Travis Rieder’s very personal story about his journey and our nation’s fractured response to pain highlights an important narrative in our nation’s health care system. This story also highlights areas of commonality between the management of pain and the treatment of substance use disorders, both complex conditions calling for a nuanced approach.
People with pain and those with a substance use disorder suffer stigma, shame, and lack of access to effective treatments. This is well illustrated in Dr. Rieder’s essay when the ICU attending gives a “callous response” to his request for pain medication, silently judging his request as possibly indicating “drug seeking” behavior. People with substance use disorders are regularly subjected to this type of judgment throughout our health care system and in society. While such judgments are sometimes made silently, they are expressed in stark terms throughout the nation’s legal and criminal justice system. The chronic and relapsing nature of addiction—the very symptoms of addiction—are punished and criminalized. Unfortunately, both people with pain and those with substance use disorder are too often demonized and their conditions dismissed. Patients are sometimes divided into those with real pain symptoms, versus those who may have developed an addiction to opioids and are merely seeking more pain medications. The reality is far more complex. We know from surveys that people may misuse opioids to manage their own pain, and as a result some go on to develop an addiction, making treating their conditions more complicated.
Pain patients deserve more and better options to manage their pain, and abruptly stopping opioid treatment is cruel. As Dr. Rieder points out, major changes to the healthcare system are necessary to stop the swing between overprescribing of opioids and forced tapering. Major changes to the healthcare system are also needed to help the estimated 2 million people with opioid use disorder. A good place to start is by integrating the addiction treatment system into the healthcare system. Since substance use disorders have long been considered moral failings requiring a criminal justice response, the health care system is ill equipped to respond effectively to any type of substance use disorder. As with mental health, our nation’s correctional system has become the de facto treatment system for people with substance use disorders. And every day, people with opioid use disorder are incarcerated, forced into withdrawal, and denied treatment medications that would prevent abrupt withdrawal and give them a better chance of entering recovery and avoiding overdose.[i]
During my tenure as a political appointee in the Office of National Drug Control Policy during the Obama administration, we focused intently on reforming our nation’s addiction treatment system and developing a response to the rising tide of opioid overdose deaths. Decreasing opioid prescribing rates was part of this strategy, but it did not comprise the entirety of the policy response to curb overdose death rates. In 2016, the Obama administration worked with Congress to include over $1 billion in new funding to expand evidence-based treatment for opioid use disorders through the 21st Century Cures Act. This funding, coupled with increasing awareness about the risks associated with opioid misuse, the Affordable Care Act, Medicaid expansion, naloxone distribution, and support for syringe services programs formed the basis for the federal response to opioid morbidity and mortality.
The nation has only recently seen a decrease in prescription opioid involved overdose deaths.[ii] According to CDC statistics, overdose deaths involving prescription opioids leveled off in 2012 and were then followed by increases in overdose deaths involving heroin and fentanyl. Prescription opioid overdose death rates thereafter did not drop, and the drivers of overdose deaths built on one another. Opioid overdose death rates at first were driven by prescription opioids, followed by heroin and then finally fentanyl, but they built upon rather than replaced one another, and they often involved other substances.
Addiction is not a new phenomenon; rather, today’s opioid epidemic is just the latest iteration of a longer-term problem, one that requires the nation’s attention.
Recent decreases in overdose deaths are the result of a significant infusion of federal and state dollars into the nation’s treatment system and an expansion of access to medications to treat opioid use disorder. However, the disease of addiction has been so stigmatized and treated as a criminal justice and moral issue for so long, building a national treatment system will not happen overnight. The treatment system is fractured and workforce shortages are rampant. Too few medical students receive training in addiction, too few physicians practice addiction medicine, and the system that does exist falls outside the nation’s healthcare system.
Prevention efforts are also inadequate. Addiction is one of the few diseases where we expect people to diagnose themselves by “hitting bottom.” For example, despite a recommendation from the American Academy of Pediatrics, too few pediatricians talk to their patients about substance use, even though this could provide an opportunity for early intervention. Instead, the condition is ignored until it becomes chronic and more difficult to treat.
Improving the nation’s health care system to better respond to pain, as well as to substance use disorders, requires a long-term effort. People in pain, along with people with substance use disorders, can join together, build consensus, and make certain that both groups receive the type of care they need and deserve. The harm reduction services Dr. Rieder embraces should be available throughout the nation’s healthcare system as part of drug user health. Addiction can be prevented, and developing a substance use disorder, like other chronic conditions, is not inevitable. Early intervention, improving the social determinants of health, and responding humanely to people with pain and substance use disorders are all necessary to improve long-term health outcomes.
[i] See a recently released report from Columbia Legal Services in Washington state, “Gone but Not Forgotten The Untold Stories of Jail Deaths in Washington,” detailing the consequences of drug withdrawal, including opioids) in Washington state jails.
[ii] 2017 data released from the National Center for Health Statistics indicated a leveling off in prescription opioid involved overdose deaths and preliminary data for 2018 indicates a 3.4% decrease in drug overdose deaths.