November 3, 2017—On October 26, President Trump declared America’s opioid crisis a public health emergency. Michael Barnett, assistant professor of health policy and management, discusses the enormity of the crisis and the potential impact of the President’s actions.
Can you explain the scale of the opioid crisis? Why do you think President Trump felt compelled to declare a public health emergency?
The scale is really enormous. Preliminary estimates are that around 45,000 people died from opioid overdoses in 2016. To give a sense of perspective, that has now surpassed the number of individuals that typically die in car accidents or from gun injuries annually, both of which are causes of death that most Americans probably think are far more prevalent. In 2014, 2 million Americans either abused or were dependent on prescription opioids. And 1,000 people a day are treated in emergency departments for opioid dependence-related problems. So this is really a major, major issue.
I think exposure to opioids in the population is particularly concerning. Looking at state-level data, there are places in the country where 25%-30% of the whole population of a state gets exposed to prescription opioids at least once during the year. And in the U.S., at the astonishing height of prescribing in 2011, there were enough opioids prescribed for every single American to receive a month’s worth of hydrocodone, which is one of the more commonly prescribed opioids.
How did we get to this point? How did access to opioids spiral out of control in this country?
Physician prescribing of opioids has been one of the largest shifts in the culture of medicine over the past three decades. The volume of opioids prescribed in the U.S. more than tripled from 1991 to its peak in about 2011. I think one thing is clear: It doesn’t seem to be related to a significant change in disease burden or the burden of pain in the U.S.
There are many factors that have contributed to the increase in prescriptions*. One is that in the 1990s and early 2000s, new formulations of opioids like OxyContin, which are long-acting and particularly addictive, were approved by the Food and Drug Administration and started to be marketed to physicians as treatments for pain. And a combination of physicians, pharmaceutical companies, and specialty societies started to promote the idea that pain is under-treated, that physicians were unnecessarily scared of opioids, that patients who were in pain had a low risk of becoming addicted to opioids, and that the compassionate thing to do was to treat them. That was actually something that I learned in medical school, which was not that long ago.
One of the more famous catchphrases that really personified this era of increasing opioid prescribing was the idea of pain as the “fifth vital sign,” that we should capture every patient’s pain, and that treating pain is one of the key parts of high quality medical care. Everyone would agree that appropriate pain treatment is essential and humane. But what came along with this was the idea that opioids were the key ingredient to making sure that pain was adequately treated. That line of thinking is increasingly challenged as we realize that we’ve gotten into an enormous public health quagmire by having such easy availability to these medications.
From a practical perspective, what does President Trump’s declaration of a public health emergency do in terms of addressing the epidemic?
I think the primary effect is just the publicity and the federal designation itself. The government is saying that this addiction crisis, which is not an infectious disease, not a natural disaster, that it qualifies as a public health emergency. There’s also a greater awareness that addiction is a disease, and that it isn’t a moral failure that can just be solved with stronger law enforcement and tougher moral fiber.
In terms of actual mechanisms, it empowers the Secretary of Health and Human Services to access the public health emergency fund, which unfortunately has very little money in it right now because it hasn’t been replenished by Congress following the many public health emergencies that have been declared over the past two years.
The emergency designation also enables the federal government to potentially negotiate directly with drugmakers for necessary medications (they currently are unable to do this). The key drug here is naloxone, also known by the brand name Narcan, which is an opioid overdose reversal agent. Many observers are calling for the federal government to negotiate lower prices on Narcan so that municipalities across the country, in particular emergency medical services, can really obtain it much more easily.
In my opinion, the single most meaningful regulatory barrier that will be loosened by the President’s emergency declaration is a restriction on telemedicine. There’s currently a regulation that blocks providers from prescribing treatments for opioid addiction such as buprenorphine or methadone through telemedicine, in large part because the Drug Enforcement Agency is worried that providers could unscrupulously distribute these medications to people remotely, with little accountability, or that people would use them for recreational purposes. But there are increasing calls for psychiatrists and other addiction providers to be able to use telemedicine to reach rural areas where there are very few providers of any kind, much less addiction treatment providers, but where the burden of the opioid crisis is really quite severe.
The public health emergency really doesn’t really have teeth at all when it comes to attacking the root cause of this epidemic, in large part because it really doesn’t free up any new funds. What we really need to fight this epidemic is a lot of money and the implementation and evaluation of ideas that we think are going to work. The root causes of this epidemic are really quite complex. The way I think about it is that to really attack the opioid epidemic, you need to approach each part in the pipeline–how someone progresses from first being exposed to opioids to becoming dependent on them and being at risk for overdose. And there isn’t a single solution that will deal with all of those.
There needs to be awareness that we need to attack both the root causes of the problem itself and reduce the availability of supply. We also should enable communities to recognize that people who are dependent on opioids deserve treatment and sympathy, and to let people know that their community will try to help them, rather than shun and stigmatize them.
*Note: This story was updated on November 13, 2017
Below, listen to a podcast interview with Barnett and Howard Koh, Harvey V. Fineberg Professor of the Practice of Public Health Leadership.