<\/span>Not long after Trump\u2019s announcement, the critics piled on, myself included. Most of the nay-sayers complained that he had promised to declare the opioid epidemic a \u201cnational emergency\u201d, which would have granted immediate access to <\/span>Stafford<\/span> funding<\/span>, somewhere<\/span> in the millions, rather than the paltry $57,000 purported to be sitting in the US P<\/span>ublic Health Emergency Fund. <\/span><\/p>\n <\/span>But whether it\u2019s the $57,000 in the <\/span>Public Health Emergency Fund, <\/span>millions in the Stafford fund, or even billions from an appropriations committee, an infusion of money to “fight the epidemic” is going to have little impact. The opioid epidemic is a symptom of our faltering healthc<\/span>are system, and until we see <\/span>sweeping changes in the way healthcare is delivered in this country, no amount of throwing money at the problem is going to make it go away.<\/span><\/p>\n <\/span>This opioid epidemic is first and foremost an epidemic of overprescribing. <\/span>What began in the 1980\u2019s as a well-intentioned effort to help patients with pain, turned <\/span>by the 2010\u2019s<\/span> <\/span>into a runaway train of egregious overprescribing. <\/span>Although opioid prescribing has decreased by ~15% since its peak in 2012, US doctors today<\/a> continue to prescribe three times as many opioids as they did in the late 1990\u2019s, four times as many opioids as are prescribed in Europe, and more than ten times as many opioids as are prescribed in Japan. Europe and Japan are apt comparisons for the United States, because they too are rich countries with aging populations and comparable rates of pain, yet consume far fewer prescription opioids. Indeed the United States is reported to consume over 80% of the world\u2019s opioids, while representing less than 5% of the world\u2019s population.<\/span><\/p>\n <\/span>P<\/span>erverse incentives inside of medicine driv<\/span>e<\/span> overprescribing<\/span>.<\/span> American doctors are paid <\/span>by<\/span> how many<\/span> medical<\/span> services they provide, not by whether patients get better. Services that involve writing a prescription, injecting a <\/span>medicine<\/span>, or performing a surgical procedure, pay far more than educating patients about healthy lifestyle changes, or providing them with non-opioid, non-medication alternatives for pain, such as physical therapy, psychotherapy, and massage, all of which have been shown to work better than medications for chronic pain conditions. Doctors\u2019 salary and professional advancement are tied to how well patients rate them on “patient satisfaction surveys.” Doctors are desperate to avoid bad ratings, and will write a prescription<\/span> for an opioid, even when it\u2019s not indicated, to avoid <\/span>a <\/span>dissatisfied customer<\/span>.\u00a0<\/span><\/p>\n <\/span>At the same time that doctors are incentivized to prescribe opioid medications, they are not trained or paid (much) to treat addiction.<\/span> <\/span>Despite the passage of the Mental Health Parity and <\/span>Addictions Equity Act of 2008, <\/span>which required insurance companies and other third party payer to reimburse treatment for addiction on par with other medical conditions, <\/span>getting insurance companies to pay for addiction treatment is still a bureaucratic maze of “carve-outs”, “prior authorizatio<\/span>ns”, and “fail first criteria”. Yet<\/a><\/span> addiction affects 16 percent of the US population, about 40 million people, far exceeding the\u00a0<\/span>number of people afflicted with heart disease (27 million), diabetes (26 million), or cancer (19 million). Disease burden due to addiction exceeds half a trillion dollars annually. Yet only 1 percent of the total healthcare budget goes to treating addiction, and <\/span>fewer<\/span> than 1 in 10 persons with addiction receives treatment.<\/span><\/p>\n<\/div>\n<\/div>\n <\/span>The opioid epidemic will improve <\/span>only <\/span>when doctors get paid to get patients better, including treating addiction<\/span>. <\/span>Data show that in the long run, treating addiction<\/span>, rather than<\/span> the down-stream medical complications of addiction (infection, traumatic<\/span> injury, heart disease, <\/span>cancer<\/span>),<\/span> <\/span>saves healthcare dollars. <\/span>Obama\u2019s Affordable Care Act<\/span> (ACA)<\/span> mandated that addiction treatment be an \u201cessential health benefit,\u201d creating access to <\/span>addiction treatment<\/span> for millions of Americans<\/span> for the first time in U.S. history<\/span>. Trump is set on dismantling <\/span>the ACA<\/span>, and his proposed healthcare <\/span>plan<\/span> allows insurance companies<\/span> to opt-out of treating addiction<\/span>.<\/span> <\/span>Instead, he <\/span>should make it mandatory for insurance companies to pay for addiction treatment, and promote reimburs<\/span>ement strategies that incentive<\/span> doctors to get and keep their patients <\/span>well, not continue to harm them by prescribing addictive and deadly medications<\/span>.<\/span> <\/span><\/p>\n Anna <\/span>Lembke<\/span><\/strong>, MD is an associate professor at the Stanford University School of Medicine, and author of the book<\/span><\/em> Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It\u2019s So Hard to Stop<\/span> (Johns Hopkins University Press, 2016).<\/span><\/em><\/p>\n Competing interests:<\/strong> None declared.<\/p>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":" An infusion of money to “fight the epidemic” is going to have little impact […]<\/p>\n![\"\"](\"https:\/\/stg-blogs.bmj.com\/bmj\/files\/2017\/10\/anna_lembke.jpg\")
Much hullabaloo was made last week of President Trump formally declaring the US opioid epidemic a \u201cpublic health emergency.\u201d Not that anyone was in doubt about its being an emergency, given the 140 American<\/span>s<\/span> dying each day<\/a> from drug overdoses, and the 500,000 who have died since 2000<\/a>, more than died in the Vietnam and Iraq wars combined. Four million Americans are addicted to opioids<\/a>, 11 million are using prescription opioids recreationally, and more than a million are using illicit opioids.\u00a0<\/span>G<\/span>ruesome tale<\/span>s of the epidemic\u2019s victims<\/span> are omnipresent in the media<\/span>, like the grandmother <\/a><\/span>from Ohio <\/span>passed out in the front seat of her minivan, strung out on heroin, her 5-year old grandson strapped into his car seat in the back, watchfully waiting for granny to wake up again.<\/span><\/p>\n