In August 2016, U.S. Surgeon General Vivek Murthy, M.D sent a letter to 2.3 million practitioners and public health leaders seeking help to address the prescription opioid crisis; he titled the campaign, Turn The Tide.
Then, last month Dr. Murthy expanded his call to action to end what he said “was a public health crisis of drug and alcohol addiction that is both under-appreciated and under-treated."
But raising public awareness is not going to be enough to curb the problem of substance abuse in America. Health insurance companies, including Medicare and Medicaid, will have to be active participants in the solution.
If the prevalence of addiction is to be reversed, insurance companies must provide adequate coverage for treatment of both pain and addiction. That lack of coverage has contributed to the opioid crisis.
The Department of Health and Human Services provided more than 100 million dollars this year for expanded services to treat opioid addiction, and President Obama has requested an additional 1.1 billion dollars in 2017 to address the opioid and heroin crisis.
Additional funding may provide access for some who are seeking treatment, but insurance companies are the gatekeepers for the majority of people with addiction.
The problem with the insurance companies is threefold. First, they often fail to fully cover the cost of treatment for addiction. Second, even when they do provide coverage, they may require pre-authorization before allowing patients to get treatment. Pre-authorization takes time and delays treatment. Third, insurance companies frequently cover only detox which is a totally inadequate treatment. Addiction is a chronic disease and, like hypertension or diabetes, it may require lifelong therapy.
People with addiction are often in crisis when seeking help. When they have the courage to ask for help, they must be treated as if it is an emergency. They may not be able to seek help at another time, because they may find the whole process of seeking care too costly either emotionally or financially, or even a physical impossibility. Therefore, they need to have immediate and unconditional access to treatment upon their request. Boston Medical Center developed a Fast Path to Treatment that could be a model for the country.
In addition, many people with addiction are unable to work and, therefore, can't pay for any part of their treatment. For the same reason, many people with addiction don't have any insurance. Lacking insurance, or having an insurance plan that denies or delays coverage for addiction treatment, can be a death sentence.
Although the Surgeon General should be applauded for acknowledging that addiction is a disease, we as a country must do more in order to succeed in curbing substance abuse and, in particular, opioid addictions. We must not accept the misinformation many policymakers and many media outlets have promulgated which is that the crisis is primarily due to overprescribing, or excess availability, of opioids.
Clearly, overprescribing has contributed to the problem. But instead of simply blaming the excess supply of opioids, we must insist that the Centers for Disease Control and Prevention (CDC) and the medical community find, and address, the root causes of addiction. Exposure to a substance by itself doesn't cause addiction.
The ubiquitous and never-ending demand for psychoactive substances by society is largely ignored, yet it is a major factor driving substance abuse. Addiction is determined by genetic and environmental factors, including mental health disorders and poor socioeconomic conditions.
A recent CNN article provides an overview of how certain socio-economic factors can lead to addiction. Dreamland: The True Tale of America's Opiate Epidemic by Sam Quinones artfully and intelligently also describes how poverty and loss of hope for a better life are the seeds to addiction.
The desire to find emotional relief from biological, social, and environmental factors creates the demand for psychoactive substances. Reducing supply without also addressing the demand will only shift the abuse of one drug to the abuse of another drug. The move from prescription opioids to heroin is an example.
This is an opportunity for the Surgeon General to take a leadership role and pledge to "Turn the Tide," as he asked members of the healthcare profession to do. In his call to action, Murthy spoke exclusively about the opioid crisis. The statement didn't mention that, while there is no medicinal benefit to alcohol or heroin, or to other illegal synthetic opioids, there is an appropriate and beneficial use of opioids for some people. This message must be clearly articulated by everyone committed to curbing opioid addiction without sacrificing the needs of people in pain.
Placing appropriately prescribed opioids into the same category as street drugs is unhelpful and destructive. There is a large number of people who suffer from chronic pain. They are being denied access to treatment because policymakers conflate the needs of people with pain and those who are using drugs for non medical purposes. Policies that cause severe restrictions on pain medications for people with chronic pain without alternatives to opioids will cause unintended consequences.
Hopefully, any policy emerging from the Surgeon General’s initiative will consider how to fill the gap of the underinsured and uninsured. Policymakers must also recognize that under-treatment of pain is a major public health crisis and contributes to the opioid crisis. Insurance companies must offer timely and sufficient benefits to people seeking help for addictions and provide alternatives to opioids for treatment of pain. We must help the Surgeon General do everything we can to prevent insurance companies from impeding our efforts to Turn the Tide.
Lynn R. Webster, MD is Vice President Scientific Affairs for PRA Health Sciences. He is a past President of the American Academy of Pain Medicine. In addition, he is the author of the award winning book, “The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us” (Oxford University Press). Visit him online at www.thepainfultruthbook.com.
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