Former President Bill Clinton and researcher G. Caleb Alexander discuss why opioid-related deaths are still increasing and the best solutions.
Opioid-related deaths continue to increase in the U.S. despite growing awareness of the epidemic’s threat. Former President Bill Clinton has made stemming the epidemic a priority for the Clinton Foundation. After leading a related 2014 event at the Bloomberg School, President Clinton returns on October 30 to discuss the issues with key policymakers and researchers. In this conversation, he and G. Caleb Alexander, MD, MS, co-director of the Center for Drug Safety and Effectiveness, explore what needs to be done, why the epidemic exploded in recent years and how to best meet patients’ long-term needs.
This article originally appeared in the fall 2017 issue of Hopkins Bloomberg Public Health magazine.
GCA: Here we are more than 20 years after the first uptick in prescription opioid sales, and yet injuries and deaths are still increasing. Why haven’t we turned the corner yet?
WJC: First, we haven’t done enough to prevent people from becoming addicted to opioids in the first place—from reducing overprescription, to integrating alternative therapies to treat chronic pain, to keeping drugs from people who use them without prescriptions.
Second, while the opioid epidemic is largely seen as a public health crisis, the capacity to deal with it as such, with proven treatment and rehab programs, is too often inadequate, uneven, and unaffordable.
Finally, often people who are hurting economically sometimes turn to pills and heroin as ways to alleviate some of their emotional pain. We need to figure out ways to address these basic causes, while also helping those who have fallen into addiction to escape them.
This is the time to strengthen our efforts and our commitment, and we need to make sure that in the years ahead when we do see progress, that we don’t let up on our efforts.
GCA: I have a trainee from Italy who is a physician. She can’t even prescribe opioids in an outpatient setting for her patients there. Is the opioid epidemic a uniquely American phenomenon?
WJC: There are characteristics of America’s health care system that have exacerbated this epidemic. For instance, our health care system gives pharmaceutical companies more leeway to advertise their products and more freedom to market to doctors than most other countries.
Americans are prescribed the most opioid prescriptions of all developed nations by far. Unfortunately, more countries are now taking the path that the United States has. Worldwide, there was a 200 percent increase in opioid overdose deaths from 2000 to 2014. A recent survey by Columbia University’s Mailman School of Public Health looked at teenagers and young adults in Europe, Asia, Latin America, the Middle East and the U.S., and found that even as younger Americans used opioids less and less recreationally, their counterparts abroad used them more and more. In nations where the medical community may not have as much education on addiction, they’re particularly susceptible to opioid manufacturers who want to develop markets for their products.
We should be looking for model policies around the world—as well as interventions that are having a positive impact here in the U.S.
GCA: Health care systems are indeed an important part of the puzzle, and one that we think about a lot around here. We recently published a paper suggesting that as many as two-thirds of patients have prescription opioids remaining after hospital discharge following surgery. Why has the health system been so slow to reduce the quantity of opioids dispensed after common procedures like tooth extraction or joint replacement?
WJC: I don’t know. Perhaps our health care system is too responsive to patient demand for the immediate pain relief opioids provide, even knowing that the costs of short-term relief to a patient’s health and to the health care system will be far higher.
The Affordable Care Act is helping health systems move away from this policy. By reframing them, looking at episodes of care, and testing things like bundled payments and lowering readmissions, the ACA has changed the market incentives. We’re moving away from the idea that you go to the hospital and get five different bills from five different people who’ve seen you, toward looking at each patient’s treatment as a whole. Delivery system changes are part of the ACA.
Additionally, because of the ACA, states were able to expand Medicaid to cover much of the population most at risk for opioid addiction. States that have expanded Medicaid have been able to give more access to treatment and get [people] into recovery.
GCA: What are two or three most important things that the general public should know? How about policymakers?
WJC: First, this is an epidemic of stunning magnitude. Whenever I ask people that I’m addressing to raise their hands if they know someone who’s been hurt by the opioid problem, nearly every hand goes up. Five friends of mine have lost children in the past few years. Last year was the worst year in American history for drug overdose deaths, with an estimated 59,000 to 65,000 deaths—that’s higher than the worst year of car deaths, the worst year of HIV deaths, and the worst year of gun deaths in America.
Second, there must be no stigma or shame in dealing with this epidemic. It is hurting Americans of all stripes—no matter your age, race, gender, economic status or zip code. We must embrace those reaching out for help, recognize the courage it takes to take that step, and help them on what’s sure to be a hard road ahead. We also need to make sure people recognize the danger in all opioids. People who use needles are more commonly seen as having a drug problem, but in the case of opioids, pills can be just as addictive and dangerous.
Third, people must also know what resources are out there for help—and how to access them. The Clinton Foundation does a lot of work making Naloxone, an opioid overdose reversal drug, widely available to schools and first responders across the country. One of the biggest challenges we still have with Naloxone is normalizing access—making sure people know that in the event of an overdose, there’s a life-saving drug available.
GCA: That’s interesting—I think many people wrongly assume that everyone knows that Naloxone is out there. So in addition to barriers getting Naloxone distributed, you are also facing barriers ensuring that people know how to, and are willing to, use it. How much progress have you made?
WJC: I think we’ve done a lot, but there’s still a long way to go. Working with Adapt Pharma, we’re making Naloxone nasal spray available free of charge to every single high school and college in this country. Others are working on this too, getting Naloxone to local emergency responders and law enforcement. More people in hard-hit areas know what Naloxone is and how to use it. People’s lives have been saved because someone in law enforcement or a paramedic or even a friend got there in time.
Even though Naloxone is now more widely available and almost every state has passed enabling legislation that removes barriers to access and usage, some areas still don’t understand how it works or don’t want it. This is another example of the stigma around addiction—people think that making Naloxone available will encourage drug use. Having Naloxone available isn’t going to make someone at the point of overdose more likely to use. And saving a life is worth the risk.
Normalizing access and decreasing stigma increases the chances of lives being saved and creating the will in survivors to come out of addiction.
GCA: You’ve highlighted stigma—an important issue. When it comes to heroin or illicit fentanyl, the stigma may be greater still. And this is a huge issue, partly because while opioid sales have declined modestly since 2010, heroin and fentanyl deaths have surged, leading to an overall increase in drug overdose deaths. Are we facing two epidemics in one?
WJC: The prescription opioid and heroin/fentanyl addictions are dangerous in different ways, but they’re part of the same family of addictions, so it’s easy for the former turn into the latter. People with legal prescriptions often start to get extra pills from other sources. When those pills become too expensive, those sources can usually supply you with heroin too. Then fentanyl, which is much more powerful, makes it even more challenging to help people free themselves from addiction.
Our responses can’t be limited to one set of circumstances, and we need everyone to be a part of the solution: governments at the local, state, and federal level; law enforcement and health care professionals; hospitals and pharmaceutical companies; civic organizations and nonprofits; everyone who can provide treatment, recovery and follow-up at affordable cost. We’ll have to address economic, health and personal issues that can drive people into addiction.