What’s Missing from the National Discussion About the Opioid Epidemic

This article originally appeared on this site.

Last Wednesday, less than a week after Donald Trump declared America’s opioid epidemic a national public-health emergency, the President’s Commission on Combating Drug Addiction and the Opioid Crisis released its final set of policy recommendations. The panel called on Congress and the White House to consider fifty-six proposals, among them streamlining federal funding for addiction treatment, instituting stricter prison sentences for some opioid traffickers, and launching an “aggressive” TV and social-media campaign to dissuade children and teens from taking the drugs. (In his earlier announcement, Trump had promised “really tough, really big, really great advertising, so we get to people before they start.”) The commission also urged the Department of Health and Human Services to develop “a national curriculum and standard of care for opioid prescribers,” to supplement the Centers for Disease Control and Prevention’s existing guide for primary-care physicians.

There is no doubt that the epidemic warrants urgent, wide-ranging action. According to a recent C.D.C. report, some twelve and a half million Americans misused prescription opioids in 2015, the latest year for which reliable figures are available, and more than three-quarters of a million used heroin. All told, thirty-three thousand people died of opioid overdoses that year. The situation appears to be worsening; provisional data suggests that the over-all rate of drug-overdose deaths jumped twenty per cent in 2016, with a substantial portion of that likely coming from opioids. Trump has repeatedly acknowledged the scale of the problem, but he has yet to free up the funds to address it. For now, he seems most interested in another round of “just say no” campaigns, which will do nothing to help those already addicted. The idea of creating a curriculum for opioid prescribers is a good one—measures like it have already made the drugs harder to obtain—but the Administration must also work to confront another obstacle within the medical community. The fact is that, for many physicians, caring for drug users is a source of enormous frustration.

This truth became vividly apparent to me early in my training. As an intern at Massachusetts General Hospital in the nineteen-seventies, I was once called to the emergency room to attend to a man in his twenties whom I will call Vinny. He had a fever of a hundred and four, was struggling to breathe, and his blood pressure was falling. On physical examination, I heard a loud heart murmur, indicating that his cardiac valves were malfunctioning. Then I noticed several track marks on his arms. The diagnosis became apparent: Vinny had injected himself with heroin using a dirty needle, and in so doing he had introduced microbes directly into his bloodstream, which had landed inside the heart, causing an infection called bacterial endocarditis.

The medical team moved Vinny to the intensive-care unit and stayed up through the night, working to keep him from going into shock. In addition to antibiotics, he required numerous medications to keep his blood pressure up. By the time the sun rose, his vital signs were stable. I felt heroic, having saved this young man’s life. When I exited the I.C.U. to tell his distraught mother, she burst into tears and kissed my hands.

In the ensuing weeks, as Vinny recovered, I got to know him well. He claimed that he had shot drugs only occasionally and swore on his mother’s life that, after this brush with death, he would never touch heroin again. But, less than a month later, he was back in the E.R., spiking a fever and struggling to breathe. Though a hospital social worker had put him in touch with an addiction clinic, he had continued using drugs. Again the I.C.U. team did its best, and again Vinny survived. But I was filled with anger and resentment: my colleagues and I had been lied to, taken in by his charm, and now it appeared that our time and energy had been for naught. My supervising resident told me that I had been naïve to have any faith in Vinny’s promises; he was, in the parlance of the resident, like all addicts, an S.P.O.S.—a subhuman piece of shit.

The acronym still appalls me, more than four decades later. It was a betrayal of the spirit of compassion that good physicians must bring to the practice of medicine. But I understood then why most doctors I worked with wanted nothing to do with such patients. I later heard that Vinny had died of a drug overdose, but not before infecting his girlfriend with H.I.V. She ended up succumbing to AIDS. (As it happened, I would devote much of my career to the AIDS epidemic. Nearly all of my patients in the eighties and nineties were gay men who saw their caregivers as allies.)

As policymakers step up their efforts to check the opioid crisis, how can they best support the physicians on the front line? In August, two infectious-disease specialists at Boston’s Beth Israel Deaconess Medical Center, where I also work, took up that question in the New England Journal of Medicine. “At some point, it became culturally acceptable to treat all conditions in a patient except addiction,” Alison Rapoport and Christopher Rowley write. “It’s a diagnosis still frequently and falsely regarded as untreatable—a convenient assumption driven by the stigma against people with this disease.” The authors tell the story of one of their patients, a Mr. C., who was struggling with opioid-use disorder and bacterial endocarditis. In consultation with Mr. C. and the hospital’s social workers, Rapoport and Rowley devised a successful course of treatment—regular doses of buprenorphine, an opioid that lessens the effects of withdrawal, along with counselling sessions and weekly group meetings. Like Mr. C. himself, they write, “the medical community is also in early recovery—moving past implicit biases, stigma, and fear to connect with our patients and respond to a defining crisis of our time.” Only then, they add, can physicians begin to mend patients’ “badly damaged sense of trust in a medical system that has long treated them with judgment and neglect.”

It is fitting that this call to action should come from a pair of infectious-disease doctors. As Rapoport and Rowley note, members of their field “have historically been ardent advocates for social justice and public health, championing patients on the margins of society.” One concrete step toward addressing the epidemic, they write, is to expand the use of buprenorphine. Currently, only four per cent of all working doctors in the United States possess the necessary waivers from the Drug Enforcement Administration to prescribe the medication for opioid treatment. Indeed, according to the Trump commission’s final report, nearly half of all counties in the U.S., including almost three-quarters of all rural counties, lack access to buprenorphine. Echoing Rapoport and Rowley, the panel recommends that federally funded health centers mandate that their staff obtain D.E.A. waivers.

Let us hope that the Trump Administration listens. To be sure, many more American doctors will need training in modern methods of treating addiction. That’s actually an easy education. It will be harder to learn how to overcome our disdain for the afflicted, to see the humanity in their plight. Without that change, there is scant hope of success.