What are people leaving out in the conversation about the opioid crisis?
Joshua Barocas, who teaches Boston University’s School of Medicine, said the answer is embedded in the question. “Opioids themselves aren’t the crisis,” he said. “Overdoses are the crisis.”
More than 130 people in the U.S. die from an opioid overdose each day, according to the National Institute on Drug Abuse. The number of opioid overdoses is growing, increasing by 30% in 52 areas in 45 states from 2016 to 2017, according to NIDA.
Society is focusing on getting the drugs off the street, Barocas said, but the conversation isn’t putting enough attention on misuse of other drugs, such as benzodiazepines, the social determinants of drug misuse and the health effects of drug misuse besides overdoses.
Friday’s panel, “Beyond Addiction: Medical consequences for opioid misuse,” considered the different layers of health problems related to needles and drug misuse. Four panelists led the discussion, Barocas, Johns Hopkins’ Anika Alvanzo, who specializes in addiction and internal medicines; Yale’s Sarah Hull, a cardiologist and bioethicist; and moderator Martha Bebinger, a veteran health journalist who works for WBUR-Boston.
Alvanzo talked about the statistics of opioid misuse. There were 70,000 drug overdose deaths in 2017, she said, and 67.8% of them involved an opioid. Overdoses are more common than people think, she said, citing a range of 38%-68% of people injecting drugs report a non-fatal overdose.
She spoke about the benefits of medications for addiction treatment, or MATs. She daid they are cost-effective, improve outcomes and save lives. People who receive MAT are 75% less likely than those who don’t receive MAT to have an addiction-related death.
However, there are gaps in care of patients, Alvanzo said. There is inadequate pain and withdrawal management and a failure to link patients to addiction treatment, for example.
“Everybody needs to be working together in the management of these patients,” she said.
Barocas talked about the acute, sub-acute and long-term effects of drug use. Acute effects can refer to overdose deaths. However, Barocas placed more of an emphasis on the sub-acute effects.
“The thing that’s not killing not today,” he said, “but will if we don’t address it and deal with it, whether that’s in a few days or in a few weeks or in a few years.”
This is predominately the infections that come from needles and drug use, Barocas said, especially HIV and hepatitis C. According to the Centers for Disease Control and Prevention, the number of hepatitis C infections due to injection drug use increased by 249% from 2010 to 2016. In 2015, for the first time in two decades, the number of HIV diagnoses due to injection drug use increased, according to the Kaiser Family Foundation.
Barocas also spoke of the importance of understanding and thinking about the long-term effects of drug use. “This is the black box,” he said.
A major aspect of tackling opioids and drug misuse is shifting the framework, Hull said. There’s a stigma around drug users, which can breed secrecy and silence. It also can impact the decisions doctors make in treatment. Doctors have to be as objective as possible, Hull said.
Shifting the framework also falls under the ethical quandaries of the crisis. Hull said we need to consider if drug misuse patients are treated differently than other patients. Should they be? Furthermore, she also brought up the question of when doctors should declare a case too futile to treat. For example, if a patient comes into the hospital with a second bout of endocarditis, an infection of the inner lining of the heart chambers and valves, due to relapsing to drug use, do the doctors treat the patient and use costly resources? What if they treat the patient, and the patient relapses again? Where is the line? Hull discussed this debate in depth in a 2014 paper for The Annals of Thoracic Surgery and at the panel.
She explained three different aspects of doctors’ decision making ethically: the patient’s autonomy and desire for treatment, beneficence and nonmaleficence, and justice towards that patient’s treatment and towards other patients’ treatment. Is it a fair and just use of resources to treat a relapsing patient?
In the case of the patient she cited, an ethics board ruled it wasn’t. “They cite that as an example of futility,” Hill said, “and that if it happened once, if they relapsed once, they are probably going to do it again.”
In the Q&A portion, the panelists discussed the role of bias and morality in doctors’ treatment and decision making of patients with substance abuse disorders.
Hull questioned if doctors were hiding behind futility. “Is it really on us as physicians to enforce morality?” she asked. “We’re not supposed to be the judge and jury.”
Barocas maintained that decisions not to treat someone because of a relapse were based on stigma. “Addiction is a chronic disease,” he said. “It is not a moral failing.”
Alvanzo said that chronic substance use can impact a person’s impulsivity. “We know that there are chronic neurological changes that affect how somebody makes decisions and affect their response, she said.”
The panel ended with the panelists talking about needing to shift attitudes and financial incentives from prescriptions to other treatment methods and prevention.
We need to restructure our payment system, Alvanzo said. “Right now, it’s much easier to write that prescription for an opiate.”