I had another patient overdose last week—like too many friends, children and neighbors whose addictions and deaths will break their families’ hearts. To add insult to tragedy, even as the opioid epidemic in the U.S. intensifies, access to medications that have been proven to curb cravings and save lives remains limited, largely because few physicians prescribe them.
Increasing access to those medications is now a public health imperative. The Surgeon General has called for the nation to “stop treating addiction as a moral failing” and to start treating it as a chronic disease. In a letter to doctors last week, he wrote: “We often struggle to balance reducing our patients’ pain with increasing their risk of opioid addiction. But, as clinicians, we have the unique power to help end this epidemic.”
There are now federal initiatives to expand access to addiction treatment in community health centers around the country, with a focus on opioid addiction. The idea is that by locating care of addiction in health centers, primary care providers can treat it like any other chronic condition like diabetes, hypertension or heart disease. This will give individuals suffering from opioid addiction greater access to medical care for their condition and will reinforce the understanding that addiction is a condition requiring treatment, not punishment.
But here is the challenge: while addiction may be a disease, use of illicit opioids remains a crime. No other chronic disease regularly lands its sufferers in prison or has courts and judges dedicated specifically to its management. Legal involvement interrupts and limits care for individuals with addiction in a way that would be unthinkable for other chronic diseases. If primary care is to take on this additional load, health systems will need to recognize this—and prepare.
Of course, not everyone addicted to opioids uses them illegally. But whether an individual becomes addicted through a legal prescription or begins immediately using illicit drugs, she is ultimately trapped in a condition defined by craving and withdrawal and for which there remain limited options for treatment. So, for many individuals who are addicted to opioids, relief is most readily achieved through illicit activity: borrowing or stealing someone else’s medication, obtaining opioids from multiple prescribers for multiple fictitious complaints, or buying pills or heroin off the street. This, in turn, means that many individuals addicted to opioids also have criminal histories.
In my own practice, many of my opioid-addicted patients are on parole, all for drug-related crimes. Certainly, some of their crimes include more than just the use of drugs; some of my patients sold drugs, or committed crimes in pursuit of them, or did terrible things while high. But no matter whether their crimes were petty or more serious, those patients now have probation officers involved in decisions regarding what type of care they can receive, and when. These decisions include whether or not my patients will be allowed to receive medications such as buprenorphine or methadone, both of which have been proven to reduce cravings and save lives. My patients may also be denied those medications if they return to jail, which could increase their risk of relapse and their risk of overdose upon release. In short, for many patients suffering from addiction, the legal system has the final say regarding both the type and the duration of addiction treatment they can receive.
Concerns about diversion and criminality also mean that the treatment I provide is uniquely regulated, creating obstacles to care that do not exist for other chronic diseases. Though it is safer than other prescribed opioids, buprenorphine requires a special license to prescribe. And though the drug has been proven to dramatically decrease opioid-related morbidity and mortality, the government limits the number of patients a single provider may have on the medication. This, in turn, leads to long waiting lists for care and increases the risk of diversion because people who can’t obtain it from a doctor often buy it from those who can. Physicians must track the number of patients they treat and are required to demonstrate evidence of adequate tracking to the Drug Enforcement Agency. By virtue of treating addiction, a physician becomes suspect by association.
And these concerns and constraints reinforce the perception that persons who suffer from opioid addiction are first criminals and only secondarily patients, which gives behavioral slips a salience that is much different from those experienced in other chronic conditions. When a patient with diabetes has a birthday binge, the pizza, cake and ice cream are considered in context. He may receive some gentle advice, maybe a nutrition consult, and care will continue. When a patient with heroin addiction relapses on his substance of choice, it is not just a mistake; it is a crime. And it carries a different moral weight.
In his remarkable work, Chasing the Scream, Johann Hari argues that the answer to this conundrum is to legalize drugs. And it may be. But that is a longer, more contentious discussion, and for a different day. Others, like authors Maia Szalavitz and Marc Lewis, argue that addiction is not a disease at all; they argue it is instead a conditioned habit, albeit one that can be effectively treated with medication. Again, it may be, but that, too, it is a different discussion. In the face of the current crisis of opioid-related morbidity and mortality, the discussion now must focus on how to expand access to life-saving medications for individuals addicted to and dying from opioids.
If that expansion is to occur within existing systems of chronic-disease care, it is imperative that health systems support providers as they assume care of a condition currently treated simultaneously as sickness and sin. This will mean hiring staff who understand the criminal justice system and how to coordinate care within it, investing in robust information technology to meet DEA requirements for tracking and support, and providing access to counselors, case managers and peers who will support medical providers in non-medical aspects of care. It will also mean supporting providers in recognizing their own biases and in confronting them. Without those supports in place, providers may become overwhelmed and frustrated, treatment will likely fail, and too many addicted patients will be blamed for not responding to care within systems that make adequate care impossible.