I spent a lot of time in 2018 reporting on complex systems and policies that could help end the opioid epidemic, which is now the deadliest drug overdose crisis of the United States.
But behind all my reports, there was a simple idea: the US must consider addiction as a health problem and address addiction treatment as any other form of health care.
This simple idea was at the heart of every problem and solution on which I wrote: Virginia Reworks Medicaid Program to Address Opioid Crisis, private insurers neglect drug treatment, prisons do not provide drugs for opioid addiction, and special training programs helping doctors to get involved in the treatment of drug addiction. It's also at the heart of other stories I'm currently working on, including an upcoming article on California's efforts to provide addiction treatment in emergency rooms.
Understanding this simple idea will help you solve the opioid crisis in America. Once addiction is seen as a condition requiring health services, many of the solutions begin to appear obvious: of course, people with addictions should have access to proven drugs. Of course, they should be able to access care in emergency rooms, urgent care or the doctor's office. Of course, health insurance should pay for their treatment.
It is useful to make comparisons with other chronic diseases.
Consider a statistic: according to the 2016 Surgeon General reportonly 10% of people with substance use disorders receive specialized treatment for their addiction, largely because local treatment options do not exist, or if they exist, they are unaffordable or have waiting periods of several weeks or months.
Imagine for a moment if this was true for another health problem, such as heart disease. Imagine a world in which 90% of Americans with heart problems are allowed to suffer and even die without access to health care. Imagine a person who has a heart attack can go to an emergency room to be told that the emergency service has no way to treat it. Imagine that the emergency department has a way to help, but the patient who just has a heart attack will have to wait weeks, if not months, for treatment. Imagine that this patient goes to the doctor for treatment, but the providers do not see it.
It would be a public health disaster. US leaders would do everything in their power, at the public's urging, to address these huge gaps in health care.
Yet this is the reality of addiction in America, even as the current overdose crisis breaks all records of death numbers year after year.
Stigma remains the main obstacle
The main reason for this problem is a mixture of stigma and misconceptions about addiction.
For a long time, dependence in the United States was considered not as a medical condition, but as a moral failure. That's how I understood emails such as this one, that drug addicts deserve to die: "Darwin's theory says" The survival of the fittest. " Let these lost souls pay the price of their criminal choices and crimes. acts. Society does not owe them multiple medical resuscitation due to poor judgment, criminal activities and self-inflicted injuries. "
It would obviously be ridiculous for anyone to claim that this is the case for other health problems, such as heart disease, diabetes and lung cancer, which can also be caused by unhealthy actions and behaviors. But with addiction, it's something I've heard many times throughout my reporting – the result of a culture, society, and legal system that treats addiction as a moral issue and criminal.
There is no clearer example in this regard than the misconceptions surrounding buprenorphine and methadone, which prevent withdrawal and cravings to stabilize a person's drug use. They are very effective drugs for the treatment of opioid dependence: studies show that they reduce the all-cause mortality rate in patients with opioid dependence by: half or more and do a much better job of keep people in treatment than non-drug approaches.
In Richmond, Virginia, Fawn Ricciuti m said how buprenorphine helped her put her life back on track. After years of fighting pain and heroin consumption, buprenorphine has helped her to stop consuming. She told me how her healing had helped her "improve her relationship with my daughter, my mother" and about her dream of creating an ice cream shop at the water. "I had a business idea. I just want to do some classes and make sure everything is set so that I do not jump into something above my head, "she said.
Fawn Ricciuti plays with his son Aiden in the yard of his home outside Richmond, Virginia. Julia Rendleman for Vox
If you took medicines that could halve the death rate of heart or cancer patients or produce results similar to those of Ricciuti, it would be scandalous not to make them available to people in need. And if it turns out that the drug is better than other treatment options, it would be totally unethical and immoral not to provide it through the health system.
But with addiction, things are not so simple. Many people, including leading providers of addiction treatment and the former secretary of health and social serviceswonder if a person taking a medicine, including a medicine, is really recovering. Taking buprenorphine or methadone is often perceived as "substituting one drug for another". By considering a person's addiction problem as a moral problem, it suddenly becomes possible to challenge the basic concept that drugs can treat diseases and medical conditions.
This stems in part from a misconception of addiction: the myth that a person is addicted simply because they use drugs. But the problem of addiction is not drug use per se. The problem is that drug use becomes compulsive and harmful – create health risks, cause someone to neglect his family and children, push someone to commit crimes, and so on.
As Ricciuti's story shows, buprenorphine tackles these problems by allowing it to control its drug use without negative consequences, even if it has to be taken indefinitely. Medications do not work for everyone, with data from la France and Vermont suggesting that almost half of those with opioid dependence will not take the drugs even though they are widely available. But helping only half of opioid-addicted Americans would mean hundreds of thousands of lives saved in a decade.
However, the stigma persists, making these drugs inaccessible. Federal data suggests, for example, that less than half of treatment centers offer drugs for opioid dependence. These facilities are primarily responsible for providing drug treatment in the United States, and a majority of them do not offer the best-known treatment for opioid dependence in times of opioid crisis.
Health systems still do not do enough
The stigma and misconceptions are deep and lead to a poorly equipped health system to deal with addiction.
This applies to health care providers who, under federal law, must take special courses to prescribe buprenorphine. According to the White House Commission on Opioids 2017 report47% of US counties – and 72% of rural counties – have no doctor who can prescribe buprenorphine. Only about 5 percent Country doctors are allowed to prescribe buprenorphine.
It applies to emergency rooms, the vast majority of which do little to nothing to treat addiction. The result is the equivalent of bringing in someone with a heart attack and telling them they are alone – because the hospital does not have a cardiologist or other specialists on staff.
This applies to health care in other contexts, such as prisons. When I interrogates State prison agencies to find out whether or not they offer drugs for opioid addiction, for example, only Rhode Island – a single state – said offering all three drugs (buprenorphine, methadone and naltrexone). This remains true to this day, although some states are now experimenting more with the idea.
This applies to health insurers, who often resist paying for drug treatment. In Virginia, addiction treatment programs were notoriously underpaid by Medicaid, a company that covers low-income people, until recent program reforms increase reimbursement rates – leading both an increase in the number of people treated and a decrease in the number of emergency visits for opioid use disorder, suggesting that there previously existed a population not negligible number of people subcontracted and subcontracted.
Mandy's recovery from opioid addiction, in Photos.Pictures of Mandy; collage of Javier Zarracina / Vox
In Illinois, I also spoke to a patient, Mandy, who had trouble charging his buprenorphine prescription to his private insurer. As a result, Mandy had to shell out more than $ 200 a month – until, after a long appeal process, Blue Cross and Blue Shield of Illinois finally agreed to pay.
Of course, insurance companies refuse to pay for what they are supposed to do all the time, even outside the field of addiction. But with addiction treatment, the problem is particularly serious, as evidenced by the fact that these problems arise again and again, even after the federal and state governments have Adopted laws effectively obligate insurers to cover the treatment of drug addiction.
The same problem is at the heart of each of these examples: often, the health system does not even do the bare minimum for the treatment of drug addiction because we did not expect it to do anything to this subject – because of stigma and misconceptions – as long as it exists.
Once this expectation has really changed, the United States will begin to see significant progress in resolving the opioid crisis. (Indeed, some of the states that have experienced a decrease in drug overdose deaths in 2017, such as Vermont, Rhode Island and Massachusettsmoved in that direction.) It will not be easy; Policy making remains difficult, health care systems are complex and the way everything works in the field can become complicated.
Ultimately, however, there is a simple concept: addressing drug treatment as any other form of health care.
Back to my 2018 stories about opioids
I have spent a good part of the year traveling, reporting and writing about the opioid epidemic. If you want to dig deeper into the subject, here are some of the main stories I wrote this year:
- We really have a solution to the epidemic of opioids – and a state shows that it works: I traveled to Virginia to see how the state has reformed its Medicaid program to improve access to addiction treatment. The big finding: by increasing reimbursement rates, Virginia Medicaid seemed to attract more people to addiction treatment and seemed to see fewer emergency room visits related to opioid addiction.
- How US prisons fuel the epidemic of opioids: I interviewed the 50 state penitentiary agencies to find out if they offered full access to opioid addiction medications. Only Rhode Island has done so, and a recent study has indicated that the program has reduced the number of overdose deaths among released inmates by more than half.
- US doctors can defeat the opioid epidemic. Here's how to ship them: I went to New Mexico to see how the ECHO project is helping train health care providers to provide treatment for opioid addiction, especially buprenorphine. Some of the barriers are stigma, but many of the problems are more common misconceptions about addiction and the difficulty of doing this kind of work.
- Needle exchanges help fight the opioid crisis. But the stigma remains: Needle exchange is one of the best supported public health interventions, supported by decades of evidence and by leading health care organizations. But in Orange County, California, government officials forced the closure of the only needle exchange. The whole story offers a very important lesson on the stigma towards drug users and addicts.
- A syringe exchange in Vermont is not just about dispensing syringes. It's offering on-site treatmentAs the epidemic of opioids continues, more and more places are seeking to make addiction treatment as accessible as possible. In Vermont, a needle exchange even offers on-site treatment – a rare and innovative approach. This is an example of how the current crisis requires an effort with bare hands.
- Solving the paradox of analgesics in America: One of the root causes of the opioid epidemic was the proliferation of prescriptions for analgesics. But how to remove painkillers without hurting the pain patients who actually benefit? I spoke to a group of experts who came up with a mix of solutions that involved less pressure on health care providers to prescribe less and offer better alternative treatments for long-term pain management.
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