What we actually know about opioid abuse might not be what you think

President Obama's bill to expand access to treatment for prescription drug abuse and heroin use passed in the House last week and the Senate this week. (The president has said he'll sign the bill, even though it doesn't include the $1.1 billion he asked for.) But as combating the "opioid epidemic" garners strong bipartisan support, it's critical to review what we actually know about opioid abuse. It might not be what you think.


According to the Substance Abuse and Mental Health Services Administration (SAMHSA), use of most drugs, with the exceptions of marijuana and alcohol, has stabilized or declined over the past decade. The current perception of a crisis may well have more to do with a shift in the class and race of drug abusers — more "middle class" white opiate users — than with actual increases in numbers. Although a National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2012-2013 survey did show an increase in prescription opioid use since their previous 2001-2002 survey, SAMHSA's surveys, carried out annually, are more useful for understanding shifting patterns.

Broadly speaking, efforts to address opioid abuse deal with three somewhat distinct areas: prevention, treatment and emergency interventions for those who are in imminent danger of death. Let's examine each in turn.

Prevention: Little scientific information is available about prevention and the president's proposal includes little funding for it. The well-respected Coalition for Evidence-Based Policy includes only two studies in the substance abuse prevention/treatment category as "top tier." One is a smoking prevention program; the other is a life skills training curriculum for middle schools.

Public and political attention to prevention currently focuses almost solely on physicians' prescribing practices. However, according to a 2014 report, only 12.7 percent of new illicit drug users began with prescription pain relievers. While that is not an insignificant number, it certainly suggests that we should widen the scope to other factors, such as economic downturn and overreliance on medical interventions more broadly. If we truly are in the midst of an opioid epidemic, then we need to think seriously about prevention and dedicate resources to uncovering and addressing the root causes.

Treatment: Most attention and funding requests are directed toward treatment. Yet little is actually known about the effectiveness of treatment. In far too many studies, the successful outcome is simply completing the treatment program. Even the best studies, the ones that make efforts to follow up, typically cannot find half or more of the participants. So they have no idea what has happened to them or whether the half (or less) they have managed to find are representative of the full group. A recent meta-analysis of treatment studies concluded that, "Participants may drop-out and become lost to follow-up either because they are doing well and feel they no longer need formal treatment or, on the other end of the spectrum, because they have relapsed and cannot be located or do not want to reveal their condition to researchers or treatment staff."

The president's budget request includes substantial funding for methadone and buprenorphine, two medical treatments for addiction. While these have potential to be helpful, there are legitimate concerns with treating over-medication with more medication. And studies of these medical interventions are far from conclusive. For example, one of the most rigorous recent studies found that the treatment completion rate (again, not the best measure of success) was 74 percent for methadone versus 46 percent for buprenorphine, although buprenorphine rather than methadone was associated with lower continued use of illicit opioids.

Potentially more problematic, unconscionable numbers of treatment studies contain the fatal flaw of confusing correlation with causation. This is particularly true of studies of 12-step programs in which researchers find higher rates of abstinence among people who stay in the programs. These studies do not prove that the programs work. It's simply that people who go back to using do not continue to come to meetings.

Opioid-related deaths: While opioid use may not have increased significantly, the number of opioid-related deaths has. The issue is that we don't know why. This could be caused by an increase in bad drugs or stronger drugs available on the street (especially Fentanyl), more drug users entering detoxification and then overdosing because their tolerance has declined post-detox, higher rates of using multiple drugs (including prescribed psychiatric medication), a combination of these factors or something else entirely.

This piece of the problem is the easiest out of the three to study, using techniques like publicizing chemical analyses of drugs available on the streets and carefully tracking poly-drug use. The president's proposal also includes substantial plans to widen availability of the opioid overdose reversal drug, naloxone, and to train first responders and others on its use. While these interventions are not yet well-studied over significant time periods, there is compelling evidence for the effectiveness of other harm reduction measures.

Recommendations: When there is a perceived crisis, it's tempting to throw money at it in hopes that something will stick. But good policy should avoid that temptation. Current budget requests disproportionately focus on treatment, which, in light of the problematic track record of treatment research, may not be the best use of funds.

As a public health crisis, opioid abuse must be addressed at the core. We need to ask why so many Americans use pain-killing, mood-enhancing or anxiety-reducing pharmaceuticals, and what we as a society can do about our collective pain. At the level of treatment, we need to demand long-term studies that look at meaningful outcomes. And — as the lowest-hanging fruit on the opioid crisis tree — harm reduction measures need to be expanded immediately.

Sered is a professor of sociology at Suffolk University and a member of the Scholars Strategy Network.