The Medicalization Of America’s Latest Opioid Epidemic

David Musto, in his classic book The American Disease (1999), described a high incidence of opiate dependence in mainstream society in the late 19th and early 20th centuries, centered on patent-based medicines containing opium used for a variety of medical complaints, particularly by women. In 1914, however, the Harrison Narcotics Tax Act regulated and taxed opiates and cocaine products. The demographics of opiate addiction passed from the mainstream of society to the underground culture (Kennedy 1920).

Physicians treating addiction, as well as their patients, were made criminals in the 1920s; during Prohibition, physicians were arrested for treating opiate addiction. At that time the American Medical Association rejected the concept that addiction was a disease and did not support addiction treatment until the rise of addiction medicine in the 1960s, the formation of the precursors to the American Society of Addiction Medicine, and the subsequent acceptance of addiction medicine as a bona fide medical specialty in the early 2000s.

The current opioid epidemic can trace its origins to the medical system, and the demographics of the new addict population have shifted from the long-standing urban drug culture to a much wider socioeconomic and geographic distribution (Cicero et al. 2014). Increased acceptance of prescribing strong narcotic-based painkillers for injury-related pain and a lack of education and awareness on the part of both the medical community and patients of the potential addictiveness of these painkillers has led to the use of these powerful medications beyond their original intended use for cancer pain. This changing dynamic has put pressure on the medical profession, which is oriented to prescribing pain medication rather than preventing and treating addiction, to become more aware of these medications’ potential for addiction and to screen for potential misuse and abuse. Shifting the system to be less of the problem and more of the solution with addictive disease is a difficult policy initiative that the federal government is beginning to address (CDC 2015b, 2015b; Shear 2015).

The surge in prescription narcotics and heroin addiction has prompted the U.S. Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) to declare abuse of prescription opioids an ever-expanding epidemic in the United States (CDC 2015a; HHS 2015). Between 2002 and 2013, prescription overdose rates quadrupled (CDC 2015b), exceeding overdose deaths from heroin and cocaine (Volkow et al. 2014). Prescription rates have leveled off since 2010, and prescription painkiller-related deaths are finally starting to decline (CDC 2015a), but heroin overdose deaths are increasing as patients shift to heroin from the opioids that their physicians will no longer prescribe due to increased awareness and education about the potential abuses of opioid prescriptions (Volkow 2014). The Federal Drug Administration has increased awareness of Risk Evaluation and Mitigation Strategy (REMS) to provide a tool for managing medication risks (FDA 2014). In August 2015, the Office of National Drug Control Policy (ONDCP) announced that it would allocate funds to hire coordinators for New England and four other regions to develop plans for treating, rather than punishing, addicts (Shear 2015).

A major advance has been the healthcare reform and parity legislation, first in the form of the Wellstone-Domenici Mental Health and Addiction Equity Act of 2007, and second in the Patient Protection and Affordable Care Act (ACA) (U.S. Congress 2008, 2010). Addiction is now defined as a chronic disease to be covered by health insurance in a manner similar to other chronic diseases like diabetes and heart disease (Smith, Lee, & Davidson 2010).

The response to these policies appropriately medicalizing rather than criminalizing the opiate epidemic has produced innovative programs at the national, state, and local levels, such as the ANGEL program in Gloucester, Massachusetts, where law enforcement and the treatment community are working cooperatively to steer addicts to care (Gloucester Police Department 2015).

Faced with the opioid epidemic Northeast, the White House Office on National Drug Control Policy has funded a series of grants to facilitate collaboration between public health and public safety officials emphasizing an integrated approach at the community level. The governor of Vermont, who accepted expanded Medicaid funding under the ACA, has called for more treatment facilities utilizing medication-assisted treatment (MAT) to improve opiate treatment and capacity (Volkow et al. 2014). In contrast, the governor of Maine, who opposes the Affordable Care Act, rejected the expanded Medicaid funding needed for non-profit addiction facilities. As a result, one large treatment program in the state closed, while another has had to close a satellite facility. The decline in government support for evidence-based solutions to the addiction problem in Maine is reducing the state’s treatment capacity.

This produces a dramatic contrast between New England states such as Vermont and Massachusetts, which have a treatment-focused approach, and Maine, which has an enforcement/supply reduction emphasis. Which policy is more effective in dealing with the opiate epidemic will be an important outcome measure in directing future efforts in other states faced with the opioid epidemic and determining whether more funding becomes available to expand treatment capacity for opioid addicts.

Resources

CDC. (2015a). Injury Prevention & Control: Prescription Drug Overdose. Centers for Disease Control and Prevention. www.cdc.gov/drugoverdose/

CDC. (2015b). Today’s Heroin Epidemic. Centers for Disease Control and Prevention. www.cdc.gov/vitalsigns/heroin/

Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry 71 (7): 821–826.

FDA. (2015). FDA Basics Webinar: A Brief Overview of Risk Evaluation and Mitigation Strategies (REMS). U.S. Food and Drug Administration, updated September 28, 2015. https://www.fda.gov/aboutfda/transparency/basics/ucm325201.htm

HHS. (2015). HHS Takes Strong Steps to Address Opioid-Drug Related Overdose, Death and Dependence. Press release, U.S. Department of Health & Human Services, March 26, 2015. https://www.hhs.gov/news/press/2015pres/03/20150326a.html

Gloucester [MA] Police Department. (2015). For Addicts and their Friends, Families, and Caregivers. https://gloucesterpd.com/addicts/

Kennedy, E. J. (1920). The Pharmaceutical Era. New York: D.O. Haynes & Co.

Musto, D. F. (1999). The American Disease: Origins of Narcotic Control, 3rd edition. New York: Oxford University Press.

Smith, D. E., Lee, D. R., & Davidson, L. D. (2010). Health Equality and Parity for Treatment of Addictive Disease. Journal of Psychoactive Drugs 42 (2): 121–126.

Shear, M. D. (2015). U.S. Budgets Funds to Treat Heroin Abuse in Northeast. New York Times August 18, 2015.

U.S. Congress. 2008. H.R. 1424: Text of the Paul Wellstone Mental Health and Addiction Equity Act of 2007. https://www.govtrack.us/congress/bills/110/hr1424/text

U.S. Congress. 2010. H.R. 3590: Text of the Patient Protection and Affordable Care Act. https://www.govtrack.us/congress/bills/111/hr3590/text

Volkow, N. (2014). Prescription Opioid and Heroin Abuse. Testimony to Congress, April 29, 2014. National Institute on Drug Abuse. https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2015/prescription-opioid-heroin-abuse

Volkow, N., Frieden, T., Hyde, P. & Cha, S. S. (2014) Medication-Assisted Therapies—Tackling the Opioid-Overdose Epidemic. New England Journal of Medicine 370: 2063–2066.