Here’s one quick explanation for why America’s opioid epidemic is getting worse: It’s easier to get high than to get help for addiction.
A new report by the Blue Cross Blue Shield Association, an insurance organization, bears that out. Analyzing data from millions of its own customers, Blue Cross and Blue Shield (BCBS) recorded a 493 percent increase in people diagnosed with opioid use disorders from 2010 through 2016. At the same time, there was only a 65 percent increase in the number of people using medication-assisted treatment — where medications like methadone, buprenorphine, and naltrexone are used to ease opioid cravings, which addiction experts consider the gold standard for opioid addiction care.
Think about this: The rate of opioid use disorder diagnoses has grown by nearly eight times the rate of the most effective treatment. That’s a lot of people not getting the standard of care for what they’re diagnosed with.
There are many other alarming statistics in the BCBS report. For example, nearly 1 percent of BCBS’s commercially insured members were diagnosed with an opioid use disorder in 2016. More than one in five members filled at least one opioid prescription in 2015. And the higher the dose and longer someone is on opioids, the more likely they are to develop an opioid use disorder.
But the disparity between how many people have been diagnosed with an opioid use disorder and how many people have obtained medication-assisted treatment really sticks out; it shows the fundamental failure in how America has responded to the opioid crisis.
America’s failed response to the opioid epidemic
In a recent conversation, I asked Andrew Kolodny, an opioid policy expert at Brandeis University, how he would stop the opioid epidemic. He drew a comparison to how New York City dealt with tobacco.
By Kolodny’s telling, New York City used a two-prong approach to fight tobacco: It made tobacco itself less accessible — by banning smoking in public spaces and raising taxes to make cigarettes much more expensive. But it also made alternatives to tobacco more accessible — by opening a phone line (311) that people can use to get in touch with a clinic or obtain free nicotine patches or free nicotine gum.
This is similar, Kolodny argued, to what the US should do with opioids. So far, it has tried to make opioids less accessible — by, for example, pushing doctors to prescribe fewer pills and going after clandestine labs, many of which are overseas, that produce the synthetic opioid fentanyl and its analogs.
But the country hasn’t done much on the other side: making alternatives to opioids more accessible. There are still places, particularly in rural areas, with no treatment facilities whatsoever, much less affordable options. There is still a stigma attached to getting help for addiction. And Congress has added some spending to addiction care (including $1 billion over two years in the Cures Act), but it’s nowhere near the tens of billions that Kolodny and other addiction experts argue is necessary to fully confront the crisis.
So say you’re someone with an opioid use disorder who wakes up one morning and feels the beginnings of withdrawal. You have a choice: Get help through a treatment program, including medication like buprenorphine, to stave off withdrawal. Or you can get heroin or opioid painkillers, fighting off withdrawal and getting high in the process.
For many, especially those in rural parts of the country, it’s much easier to get heroin or opioid painkillers than it is to get treatment. This is the key problem: They’re much more likely to do what’s easier to fight off painful withdrawal — and that often means heroin or opioid painkillers.
So we get statistics like those in the 2016 surgeon general’s report, which found that only 10 percent of people with drug use disorders get any kind of specialty treatment. And we get statistics like those in the new BCBS report, showing diagnoses for opioid use disorder have gone up at nearly eight times the rate of use of medication-assisted treatment.
The result is an epidemic that continues to get worse, largely because America hasn’t done enough to make treatment accessible.
The opioid epidemic, explained
In 2015, more Americans died of drug overdoses than in any other year on record — more than 52,000 deaths in just one year. That’s higher than the more than 38,000 who died in car crashes, the more than 36,000 who died from gun violence, and the more than 43,000 who died due to HIV/AIDS during that epidemic’s peak in 1995.
This latest drug epidemic, however, is not solely about illegal drugs. It began, in fact, with a legal drug.
Back in the 1990s, doctors were persuaded to treat pain as a serious medical issue. There’s a good reason for that: About 100 million US adults suffer from chronic pain, according to a 2011 report from the Institute of Medicine.
Pharmaceutical companies took advantage of this concern. Through a big marketing campaign, they got doctors to prescribe products like OxyContin and Percocet in droves — even though the evidence for opioids treating long-term, chronic pain is very weak (despite their effectiveness for short-term, acute pain), while the evidence that opioids cause harm in the long term is very strong.
Painkillers proliferated, landing in the hands of not just patients but also teens rummaging through their parents’ medicine cabinets, other family members and friends of patients, and the black market.
As a result, opioid overdose deaths trended upward — sometimes involving opioids alone, other times involving drugs like alcohol and benzodiazepines (typically prescribed to relieve anxiety). By 2015, opioid overdose deaths totaled more than 33,000 — close to two-thirds of all drug overdose deaths.
Seeing the rise in opioid misuse and deaths, officials have cracked down on prescriptions painkillers. Law enforcement, for instance, threatened doctors with incarceration and the loss of their medical licenses if they prescribed the drugs unscrupulously.
Ideally, doctors should still be able to get painkillers to patients who truly need them — after, for example, evaluating whether the patient has a history of drug addiction. But doctors, who weren’t conducting even such basic checks, are now being told to give more thought to their prescriptions.
Yet many people who lost access to painkillers are still addicted. So some who could no longer obtain prescribed painkillers turned to cheaper, more potent opioids: heroin and fentanyl, a synthetic opioid that’s often manufactured illegally for nonmedical uses.
Not all painkiller users went this way, and not all opioid users started with painkillers. But statistics suggest many did: A 2014 study in JAMA Psychiatry found 75 percent of heroin users in treatment started with painkillers, and a 2015 analysis by the Centers for Disease Control and Prevention found that people who are addicted to painkillers are 40 times more likely to be addicted to heroin.
So other types of opioid overdoses, excluding painkillers, also rose.
That doesn’t mean cracking down on painkillers was a mistake. It appeared to slow the rise in painkiller deaths, and it may have prevented doctors from prescribing the drugs to new generations of people with drug use disorders.
But the likely solution is to get opioid users into treatment. According to a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report found that the low rate was largely explained by a shortage of treatment options.
Some states, such as Louisiana and Indiana, have taken a “tough on crime” approach that focuses on incarcerating drug traffickers. But the incarceration approach has been around for decades — and it hasn’t stopped massive drug epidemics like the current crisis.