The Children That We Are Seeing Now

Four Principles to Guide the National Response to the Opioid Crisis

Rae Brown M.D.

In the past five years, much has been made of the high rate of mortality and addiction that has ensued from the wide availability of prescription and illicit opioids. The states, with meager resources, have responded with increasing calls to the federal government for more money for more programs. Some of these programs have been effective but the distribution of efficacy is not national in scope. Almost every state has some form of a system that allows physicians and other providers to determine whether patients are receiving opioids from multiple sources, or have many concurrent prescriptions from different doctors. Some in the scientific community believe that these programs have been effective in reducing the number of prescriptions for opioids. The best available theory being that reduced exposure to opioids will decrease mortality and addiction rates.

The federal government has responded with numerous plans from multiple agencies and with no apparent central coordination. Some of the plans to reduce the burden of opioids seem to change on a monthly basis. Predictably, no group, including the recent report from the President’s Commission, offers a reasonable starting point from which the billions of dollars that the federal government has indicated are available. With the states and local governments crying out for leadership, it would seem reasonable to formulate an understanding and a process for the analysis of the problem and the use of the resources. Thus far, each statement which comes from Washington seems to further obscure a clear direction.

The report on Opioids developed by the NASM in response to a request by then Commissioner Robert Califf, M.D., offers a framework for the development of a single all-inclusive national strategy to reduce death and addiction in the US. However, comprehensive as it appears to be all areas that have been shown to affect the development and the resolution of this public health problem are not highlighted. For example, the part that the illicit drug pipeline plays in the problem received less than the weight that it likely deserves. But, it is the first comprehensive plan that examines the evidence and offers specific solutions which are possible.

What the report does not do is define specific principles to guide all programs going forward whether they are State run or Federal. I would like to offer a foundation for these programs, going forward, in four principles:

1.    Dramatically reduce the volume of illicit drugs coming across American borders

 The U.S. is facing not one problem but two, prescription and illicit opioids. These two routes of exposure are inexorably bound together and neither can be ameliorated without consideration of the other. Currently, in making a sustained and intense effort to reduce prescription drugs and to provide opioid formulations that deter abuse, we are faced with a seeming wide-open pipeline of potent opioids coming across our borders. Many of these opiates are so potent that they kill on first use. Until the problem of the opioid pipeline is solved, it is unlikely that we will effectively reduce the rate of death and addiction no matter what we do.

2.    Make medical treatment of addiction widely available and eliminate federal regulations that effectively reduce financing through the federal Medicaid program.

Medical treatment of addiction has been shown to be effective time and again.

 Yet the lack of qualified practitioners and continuous funding for treatment creates a situation that effectively stalls the development of these clinical programs. The Center for Medicare and Medicaid Services has all but regulated the full development of a comprehensive national program out of existence. The Congress provides incremental funding but has yet to see the wisdom of a long-term treatment strategy. Continuous funding for treatment through a federal program that guarantees its availability, in much the same way that the government supports the treatment of patients with chronic renal failure, would encourage program development and availability.

3.    Make comprehensive education concerning the risks and benefits of the use of opioids mandatory for all health care providers.

The FDA, through its Risk Evaluation and Mitigation Strategies, has provided a skeletonized version of the education that all providers need. Included in such a program is training about the specific problems with opioids as analgesics, but also an approach that can be used to provide pain relief with agents and techniques other than opioids. In addition, the basics of addiction medicine should be included to educate physicians and nurses about the recognition of a problem and how to begin managing it.

Of course, some patients have pain that can be treated effectively only with opioids. No one would knowingly prevent the appropriate use of opioids to treat pain. It is the wise use of these drugs that should be our quest. 

4.    Recognize that addiction is a chronic relapsing mental illness and requires treatment using the precepts that modern psychiatry has given us.

The modern treatment of depression, schizophrenia, and other mental illnesses involves the sophisticated use of drugs, talk, and continuous reevaluation of the patient’s condition. Models for the successful treatment of addiction suggest that this disease of the brain will require nothing less. We need more mental health clinicians that are capable of providing this care; currently in short supply. More important, incarceration of patients with mental illness does nothing but increase the problem. We can spend our money on prison cells, but the experience in the Netherlands suggest that our money is best spent in treatment.

Four principles to guide the distribution of a billion dollars, rather than ten separate plans from ten federal agencies and a Commission. The fundamental success of the drive to save lives and decrease addiction depends on understanding, in simple terms, where we must focus and why. These four principles are the foundation for the effective and efficient use of our scarce resources.

Rae Brown, M.D. is Professor of Anesthesiology and Pediatrics at the University of Kentucky. He currently serves as Chair of the FDA Advisory Committee on Analgesic and Anesthetic Drug Products.

The above reflects Dr. Brown’s thoughts alone and should not be considered to represent the thinking of the FDA or the University of Kentucky. Dr. Brown has no financial conflicts related to the subject of this article.