What led to the opioid crisis - and how to fix it
Howard Koh, professor at Harvard T.H. Chan  - Interviewed by Karen Feldscher

February 9, 2022
 

Without urgent intervention, 1.2 million people in the U.S. and Canada will die from opioid overdoses by the end of the decade, in addition to the more than 600,000 who have died since 1999, according to a February 2 report from the Stanford-Lancet Commission on the North American Opioid Crisis. In this Big 3 Q&A, Howard Koh, professor of the practice of public health leadership and a member of the Commission, discusses factors contributing to the crisis and recommendations on how to curb it.

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Q: What was the impetus behind this new report on the opioid crisis, and why was it important for this commission to issue the report at this time?

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A: The current opioid crisis ranks as one of the most devastating public health catastrophes of our time. It started in the mid-1990s when the powerful agent OxyContin, promoted by Purdue Pharma and approved by the Food and Drug Administration (FDA), triggered the first wave of deaths linked to use of legal prescription opioids. Then came a second wave of deaths from a heroin market that expanded to attract already addicted people. More recently, a third wave of deaths has arisen from illegal synthetic opioids like fentanyl. In addition to the crushing public health burden of preventable deaths, millions more are affected by related problems involving homelessness, joblessness, truancy, and family disruption, for example.

The pandemic has both masked and amplified this crisis. Rising death trends are linked to drivers such as the anxiety and isolation of COVID-19 as well as continued lack of access to quality care and prevention. The crisis seems unchecked. It demands an urgent, unified, and comprehensive response.

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Q: What were the main drivers of the opioid crisis, and what are the report’s main takeaways on how to minimize the damage?

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A:  One major conclusion is that the crisis represents a multi-system failure of regulation. OxyContin approval is one example—Purdue Pharma was later shown to have presented a fraudulent description of the drug as less addictive than other opioids. The profit motive of the pharmaceutical industry remains ever present.

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And that’s just the tip of the iceberg. Post-approval, it’s usually left up to industry—not regulators—to educate and advise prescribers on how to evaluate and mitigate risk. Donations from opioid manufacturers to politicians continue to influence policy decisions. In addition, a revolving door of officials leaving government regulatory agencies such as the Drug Enforcement Agency regularly join the pharmaceutical industry with little to no “cooling off” periods. The report details these and other glaring examples.

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The report recommends ways to curb pharmaceutical industry influence while also upholding quality care that balances benefits and risks for people with chronic pain. We must continue progress in promoting opioid stewardship—safer prescribing initiatives led by physicians.

Care, treatment, and prevention are all absolutely critical. Currently, addiction care, for example, is not only often separate from mainstream medicine but also unequal. It is also often clouded by stigma, uneven quality, and inaccessibility. Addiction remains a constant long-term threat to human health and won’t respond to only short-term fixes or short-term funding. We have to fully integrate addiction care into mainstream health care, provide enduring and sustained funding, and assure that both public and private insurance cover the full range of addiction services. Parity laws require that most private health plans cover substance use disorder services and not limit them more stringently than services associated with other medical conditions. But such laws are not always followed and that must change.

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Addiction training should be an essential part of all health professional education. The public health community can also work with the criminal justice system to move more affected people away from incarceration and towards treatment.

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And prevention, starting with kids, is absolutely key. We have to support stronger and more resilient children and families to address threats from opioids, tobacco, alcohol, and other substances that rob so many people of well-being.

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Q: When you look at the current state of this crisis, does anything give you hope?

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A: We can see progress in some vital areas. For example, more health professionals are using the term “substance use disorder” instead of “substance abuse” to recognize the condition as a medical and health issue and not a moral failing. And instead of references to people being “clean” or “dirty,” people are increasingly using the medical terms “recovery” and “relapse.” It’s gratifying to see this change in the language of addiction.

The Affordable Care Act has also helped in major ways, starting by requiring that private insurance plans cover substance use disorder services as part of essential health benefits. It also has facilitated expansion of Medicaid, the single largest payer of opioid use disorder services. The report notes that states that have expanded Medicaid eligibility have shown evidence of decreased overdose deaths and increased receipt of treatment.

It is inspiring to celebrate the estimated 25 million people who are in recovery. People in recovery are heroes for me. So many have been able to rebuild relationships with people they care for, contribute again to society, and regain a sense of purpose and meaning in their lives. It may seem to be a hopeless situation but it’s not. In the midst of this terrible crisis, that’s what gives me the greatest hope for the future.

                                                                                                              – Karen Feldscher