Addiction and Public Health Reform

By John Gregory | 7/23/16 8:00 AM

According to Dr. Leana Wen, only 11 percent of individuals with a substance use disorder in the United States get the help they need to overcome their addiction. She attributes that dismal statistic to a lack of treatment options and the stigma that still dogs those who abuse drugs or alcohol.

“If you are wealthy and you’re insured, then addiction is a disease because you can check yourself into a medical clinic and get treated,” Wen says. “But if you’re poor, if you’re uninsured, then addiction is a moral failing and therefore if you end up in jail or you end up dead, then somehow it’s a personal choice that you made.”

Wen is an emergency room physician and the Baltimore City Health Commissioner. She appeared on Connections to discuss the opioid crisis in America and how new views on addiction are changing approaches to treatment. The conversation is part of KET’s Inside Opioid Addiction initiative.

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The Changing Face of Addiction
Earlier drug scourges, such as the rise of crack cocaine in the 1980s, were generally seen to be a problem of poor and minority neighborhoods in the inner city. But the current opioid and heroin crisis has touched all demographic groups in urban and rural areas. In Baltimore, a city of some 620,000 people, Wen says more than 20,000 citizens use heroin, and tens of thousands more are addicted to other substances.

The result, she says, is an epidemic that affects the fabric of the entire community. And for better or worse, the issue has become part of the national conversation now that middle and upper class white families are being impacted.

“We… can’t talk about the treatment for addiction without addressing the fact that, yes, there are significant injustices that have occurred,” Wen says. “That we have been incarcerating individuals who have addiction, who have mental illness, that there are discriminatory policies around drugs, around policing, around so many other things that have gotten us to where we are, and we have to call out these injustices.”

That inequality has contributed to a slow response in building the infrastructure needed to the treat those with a heroin or opioid addiction. Wen says she’s seen many patients in her ER who are in the depths of their addiction and desperate for help. She says that she’s forced to tell those individuals that she can’t get them into a recovery program for weeks or even months due to a lack of treatment options.

“We would never say that someone with any other disease,” Wen says. “Somebody who comes in with chest pain, we would never say, ‘I’m sorry that you have a heart attack. If you’re not dead in three months, come back and see me.’”

The stigma against addiction also affects the availability of drugs known to help treat addiction or revive overdose victims. For example, Wen says some people still believe medication-assisted treatments that use pharmaceuticals to reduce addictive cravings actually promote drug use. But, she says, research shows that the opposite is true.

To help reduce overdose-related deaths Wen implemented an initiative that has trained 11,000 first responders, drug users, and citizens how to administer the overdose reversal drug Naloxone. In the first six months of the program, Wen says police have saved 30 lives. Yet she says some opponents argue that the effort will encourage continued drug use. She counters that criticism by saying no one would recommend depriving someone with a deadly peanut allergy from easy access to life-saving epinephrine.

From Prescription Pain Pills to Addiction
Scientists estimate that about 80 percent of those who abuse heroin started on their path to addiction by taking a legally prescribed painkiller. Looking back on her time as an ER doctor, Wen says she now regrets some of the prescriptions she wrote for pain relievers such as Vicodin or Percocet, yet she believes doctors aren’t totally to blame for the addiction crisis.

“The problem is that our culture has changed to one of ‘a pill for every pain,’ and the expectation by patients is also that we need the quick fix,” Wen says.

She says doctors need better training on how to help alleviate pain. Such measures would include: consulting with patients about their history with pain and addictive behaviors; offering alternative treatments for pain such as physical therapy; or simply telling a patient to take Tylenol and wait for the pain to subside.

“We’re still prescribing enough opioids every year for every adult American to have their own bottle,” says Wen. “That’s crazy.”

Wen says consumers should be encouraged to question their doctor if they prescribe a powerful painkiller, asking if they truly need that drug and if there are appropriate alternatives.

She also credits the Centers for Disease Control and Prevention for recently releasing new guidelines for prescribing opioid-based medicines. Wen summarizes these recommendations as “start low and go slow,” meaning doctors should prescribe the minimum amount of painkillers for the least number of days. She says there’s no reason to give a patient 100 pills for minor pain, especially when the excess medicine could lead to an addiction.

Another troubling trend, according to Wen, is the rise of Fentanyl, a narcotic that she says is 50 to 100 times stronger than morphine. Some drug dealers give unsuspecting customers heroin that’s mixed with Fentanyl, which can lead to an overdose. Wen says between 2013 and 2015, there was a seven-fold increase in the number of people dying from a Fentanyl-related overdose in Baltimore. Now, she says more residents die from overdoses than from homicides.

A Call for More Funding
Wen is pleased that politicians and government officials are focusing more on addiction and treatment, including a decision by Congress to lift a federal ban on funding needle exchange programs. Despite fears that such initiatives promote drug use by allowing addicts to trade used needles for new, clean ones, Wen says the exchanges are critical to reducing the transmission of blood-borne diseases like HIV and Hepatitis C.

She says that Baltimore now has 24 needle-exchange locations, and in the past 15 years the program has helped reduce HIV rates among intravenous drug users from 64 percent to 8 percent.

But Wen says much more funding is needed to address the addiction crisis.

“If we agree that addiction is a disease, we know what works,” Wen says. “It’s medication-assisted treatment, and it’s psycho-social treatment and wrap-around services like housing and employment. So what is the commitment to action? How are we going to fund these programs?”

Wen says she advocates for funding to go directly to local jurisdictions that have the greatest addiction needs to address, rather than having the money filter down through state governments or multiple bureaucratic agencies. She also hopes the nation will move to a system of addiction “treatment on demand,” whereby anyone who goes to an emergency room with an addiction or mental health crisis can receive immediate treatment 24 hours a day, seven days a week.


foundation_logo2013This KET production is part of the Inside Opioid Addiction initiative, funded in part by the Foundation for a Healthy Kentucky.