Junkie. Stoner. Crackhead. We’ve all heard the terms, used to describe those individuals who struggle with drug addiction. These words are dismissive and disdainful; they reflect a moral judgment that is a relic of a bygone era when our understanding of addiction was limited, when many thought that addiction was some sort of moral failing and should be a source of shame. We need to change the national discussion. Put simply, individuals with substance use disorders are our patients who need treatment.
Scientific progress has helped us understand that addiction – also referred to as substance use disorder – is a chronic disease of the brain. It is a disease that can be treated – and treated successfully. No one chooses to develop this disease. Instead, a combination of genetic predisposition and environmental stimulus – analogous to other chronic diseases like diabetes and hypertension – can result in physical changes to the brain’s circuitry, which lead to tolerance, cravings, and the characteristic compulsive and destructive behaviors of addiction that are such a large public health burden for our nation.
Consider that every day, 44 Americans die as a result of prescription opioid overdose, and the rate of heroin-related overdose deaths has nearly quadrupled since 2002. In addition to these tragic figures, the nation is seeing an increase in opioid-related pediatric exposures and poisonings. There has been a distressing rise in neonatal abstinence syndrome as a result of women being exposed to opioids during pregnancy. Misuse by older adults also has become an increasing concern. The rate of opioid-related hospital admissions has increased significantly over the last two decades across all age cohorts. Because of higher rates of addiction in the current “baby boomer” cohort, illicit and nonmedical drug use among older adults is expected to increase in the future. The bottom line is that physicians must lead the nation in changing the tide of this epidemic.
ASAM and the AMA Task Force to Reduce Opioid Abuse want to ensure that America’s physicians, patients and policymakers take action in three ways:
First, we must change the conversation about what it means to have addiction, and we also must increase access to evidence-based treatments. This means putting an end to stigma, increasing access to medication that can treat opioid use disorder, and supporting the expanded use of naloxone – a life-saving medication that can reverse the effects of an opioid-related overdose. People with addiction deserve to be treated like any other patient with a medical disease, and physicians are helping the nation understand how to do this. That is one reason the Task Force encourages increased education and training for MAT.
Second, we encourage physicians, dentists and other prescribers of controlled substances to register for and use prescription drug monitoring programs (PDMP) – as one tool to identify when a patient may need counseling and treatment for a substance use disorder. The trend among policymakers has been to use PDMPs to identify “doctor shoppers.” This, by itself, is important, but the real work is to understand why a patient is seeking medication from multiple prescribers or dispensers – and to offer a pathway for treatment and recovery. The information in PDMPs can play a helpful role in identifying patients in need of help.
Third, consider that we must do a better job with prevention. This includes intervening early with teens who initiate alcohol and/or marijuana as well as efforts to encourage safe storage and disposal. Unused medications increase the risk of nonmedical use by adolescents who live in the home or by their friends. Unused medication also can be ingested by young children who are curious about what is inside the pill container. Implementing campaigns to educate the public on the importance of storing opioid medications locked and out of the reach of children, and properly disposing opioid medications following the end of use, can encourage these safe practices.
And this also includes recognizing that we must actively screen for and treat co-morbid psychiatric disorders in all our patients to ensure that they continue to receive the highest level of care since patients with psychiatric conditions may have even greater risk than the general population to misuse opioids. Furthermore, our patients would benefit from more active screening, brief intervention and referral to treatment (SBIRT).
There are additional issues that we must address. Pregnancy should not limit a woman’s access to opioid medications for adequate pain relief. Pregnant women should not be coerced to withdrawal from opioid treatment. And punitive measures taken toward pregnant women, such as criminal prosecution and incarceration, should be eliminated. These activities have no proven benefits and, in fact, deter pregnant women who use opioids from seeking prenatal care, leading to poor child health outcomes. The threat of punitive measures also limits the disclosure by pregnant women of critical information about their drug use to their physician. A pregnant woman should have the same freedom as others to openly discuss options with her physician, choose a course of treatment, and be monitored/supported by her physician.
We also need to guard against limiting MAT services. For example, many states have enacted limits on MAT for patients in Medicaid programs, who are incarcerated, or who have “failed” a prior treatment program. Just as an evidence-based treatment policy would not discriminate against a diabetes patient for being low-income, having been arrested, or not adhering with his or her diabetes treatment program, MAT’s proven success should not be limited by these approaches either.
As clinicians, we see the harsh reality faced by our patients with a substance use disorder. Stigmatizing patients helps no one. Our goal is to treat our patients and help them live as fully functional members of society. There are people in recovery at every level of government, the private sector and throughout our towns and communities. That is because treatment works.
For more resources:
Reducing the stigma of substance abuse disorder
Resources on the use of medication in the treatment of addiction
Issues specific to women and children
Safe storage and disposal