Addressing the Opioid Epidemic, Part 2
The Misplaced Priorities of the Trump Administration
Widely touted as the start of this opioid crisis, the unwarranted over prescription of opioid medications over the past few decades is a reflection both of the state of U.S. healthcare, and a propensity to immediately resort to medications for treating acute or chronic pain.
Unlike most developed nations, the U.S. does not guarantee universal health care, and so Americans must acquire insurance from the government or privately.
As it turns out, many Americans cannot afford to pay for physical therapy, and would rather take the easier route of taking a pill. The unfortunate fact is that opioid prescription may, in many instances, be ineffective.
In the recently concluded SPACE randomized control trial, for common sources of pain such as back, hip, or knee osteoarthritis pain, opioid therapy was no more effective than non-opioid medication in improving pain in the long-term (Krebs et al., 2018).
While numbers of opioid prescriptions have decreased slightly in the last few years, these figures still remain much too high, particularly significant given the fact that the road to lethal opioids such as heroin and fentanyl starts for many at the overuse of prescription opioids.
Utilizing Alternative, Non-opioid Treatments of Pain
There needs to be a greater emphasis on non-opioid treatments. One alternative to opioids is the greater use of Physical Medicine and Rehabilitation to treat pain. Physiotherapy and exercise physiology could be the first line of action for cases in which opioids may not be necessary.
These lines of treatment should be covered in Medicaid and Medicare, and should not be as costly as they are at this moment. For victims of pain, there needs to be an incremental assessment for treatment options, starting with physical therapy and non-opioid analgesics such as ibuprofen. Opioids should be prescribed only if absolutely necessary; to sufferers of moderate to severe chronic pain in dire need of them.
Supplementing Medication with Therapy
Additionally, one essential avenue of treatment which is receiving a disconcertingly small amount of attention is behavioral treatment. While the immediate course of action is to utilize medications such as naloxone and buprenorphine, the most effective approach is to supplement medications with psychotherapy, such as opiate 12-step programs (Veilleux et al., 2010).
This approach at resident addiction facilities will go a long way in improving the prognoses for addiction victims. However, one major stumbling block is the Institutes for Mental Disease (IMD) Exclusion. This rule, in place since the 1970s, prevents Medicaid from covering residential facilities with more than 16 beds.
Put in place to facilitate the deinstitutionalization trend in the 20th century, this rule has proven to be a major setback in gaining access to addiction treatment. Experts on the right and left of the political spectrum have been vying to end this rule. At the moment, the best line of action is for each state to apply to a waiver for the IMD exclusion rule.
Opioids and Televised Advertising
President Trump has also proposed an advertising campaign, to raise awareness of the danger of opioid abuse. He also plans to use a new website (crisisnextdoor.gov) as a platform for families of addicts to share their stories. However, this use of advertising for drug misuse has been attempted on numerous occasions in the past, and has not had much of an effect in dissuading viewers from consuming drugs (Hornik et al., 2007).
However, staying on the topic of advertising, a more pertinent fact is that the U.S. is one of the only nations where prescription drugs are allowed to be advertised on television. This direct-to-consumer (DTC) advertising could, and has led to patients coercing their doctors to prescribe the same opioids that they saw on television.
Frankly, the Food and Drug Administration (FDA) should do away with DTC advertising, which would lessen the influence of ‘snapshot’ advertising on consumers, and lead patients to put more diagnostic control and dependence in the hands of their doctors.
As it stands, the fallacious focus on punitive measures, as well as an inefficient ad campaign, has left the actual plan for treatment, and allocation of funding and resources to treatment, shrouded with uncertainty.
The budget from Congress is nowhere near enough for the efficient combatting of the epidemic.
The current administration’s priorities for this crisis appear to be completely misplaced. There seems to be some understanding of the pertinent public health issues on the part of the administration, but the actual approach being proposed would be ineffective. This is a public health emergency much more than it is a criminal justice issue. This suggests that the administration is still treating this health crisis like a criminal justice one.
Unless there is a shift in focus, then this opioid crisis will all but certainly continue to afflict and take the lives of more and more Americans each day.
The author anticipates receiving a medical degree in 2022 from Stony Brook University School of Medicine.
DEA. (2016). (Rep.). Retrieved March 20, 2018, from https://www.dea.gov/docs/Counterfeit Prescription Pills.pdf.
Hornik, R., Jacobsohn, L., Orwin, R., Piesse, A., & Kalton, G. (2008).
Effects of the National Youth Anti-Drug Media Campaign on Youths. American Journal of Public Health, 98(12), 2229–2236. http://doi.org/10.2105/AJPH.2007.125849
Krebs, E., et al. (2018). Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain. JAMA Network Open, 319(9), 872-882. doi:10.1001/jama.2018.0899
Mattick, R. P., Kimber, J., Breen, C., & Davoli, M. (2008).
Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd002207.pub3
Mumola, C. J., Karberg, J. C., & United States. (2007). Drug use and dependence, state and federal
prisoners, 2004. Washington, D.C.: U.S. Dept. of Justice, Office of Justice Programs, Bureau of Justice Statistics.
Piehl, A. M., Useem, B., & Dilulio, J. J., Jr. (1999). Right-Sizing Justice: A Cost-Benefit Analysis of Imprisonment in Three States. Center for Civic Innovations (CCI) at the Manhattan Institute, 8.
Pollack, H. A., & Reuter, P. (2014). Does tougher enforcement make drugs more expensive? Addiction, 109(12), 1959-1966. doi:10.1111/add.12497
Sordo, L., Barrio, G., Bravo, M. J., Indave, B. I., Degenhardt, L., Wiessing, Pastor-Barriuso, R. (2017).
Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. Bmj. doi:10.1136/bmj.j1550
The White House. (2018, February). BUDGET OF THE U.S. GOVERNMENT (Rep.). Retrieved March 21, 2018, from The White House website: https://www.whitehouse.gov/wp-content/uploads/2018/02/budget-fy2019.pdf
Veilleux, J. C., Colvin, P. J., Anderson, J., York, C., & Heinz, A. J. (2010).
A review of opioid dependence treatment: Pharmacological and psychosocial interventions to treat opioid addiction. Clinical Psychology Review, 30(2), 155-166. doi:10.1016/j.cpr.2009.10.006
Mani,, R. (2018). Addressing the Opioid Epidemic, Part 2. Psych Central. Retrieved on April 22, 2018, from https://pro.psychcentral.com/addressing-the-opioid-epidemic-part-2/