On the first day of my summer fellowship, I almost stepped on a used needle. The road was littered with needles and syringes, a byproduct of widespread intravenous drug usage and a physical embodiment of a much larger problem. The United States is in the midst of an epidemic that takes over 115 lives per day.
The opioid crisis has risen to a level reminiscent of the AIDS epidemic that ravaged the nation in the 1980s and 1990s. At its peak, about 50,000 people died from AIDS in 1995 in the United States. Similarly, around 50,000 Americans died from opioid-related overdose in 2017. Frustratingly, the comparisons do not end with the numbers. The country’s mobilization to respond to the AIDS epidemic was largely hindered by the immense stigmatization of the disease, and we see the same problem today with the treatment of patients suffering from opioid use disorder (OUD) because substance abuse disorders are part of the DSM-V.
Because substance use disorders are classified as mental health disorders, often, they are not viewed as legitimate medical issues. From my experience, this is evident in medical practice by the stigmatized language health care providers sometimes use–such as addict, frequent flyer or drug-seeker–clinicians’ lower expectations for OUD patients and the decreased access to medication assisted treatment (MAT) for incarcerated patients. Given the magnitude of this crisis and the barriers to progress it faces, we need to pay special attention to the most effective methods of treatment and use them to standardize efforts to combat this epidemic.
Massachusetts is one of the top ten states by number of drug overdoses. In 2015, Massachusetts passed a bill christened “An Act relative to substance use, treatment, education, and prevention,” also known as the STEP Act, which largely targeted opioid-prescribing practices. The STEP Act requires prescribers to undergo pain management and addiction training, check the prescription monitoring program before any schedules II or III controlled substances are prescribed and allow patients to request only a partially-filled prescription.
In the three years since the STEP Act was adopted, Massachusetts has finally taken another move towards battling the epidemic. The CARE (Combating addiction, Accessing treatment, Reducing prescriptions, and Enhancing prevention) Act was passed in August 2018. This bill was supported by physicians and lawmakers and notably received praise from the Massachusetts Medical Society and bipartisan state government officials.
The CARE Act not only addresses more issues in prescription practices, but has also improved treatment and prevention methods of OUD. Interestingly, the CARE Act statistics show that of the 962 deaths due to opioid-related overdose, less than twenty percent of patients had prescription opioids in their systems while over ninety percent contained non-prescription fentanyl.
In the creation of this policy, the physicians’ reactions were significant especially regarding components not included in the final bill. The Massachusetts Medical Society supported many provisions but opposed creation of a physician-sanctioned seventy-two hour involuntary hospital commitment. This provision was not bolstered by any research that supported its efficacy, and physicians were concerned that hospitals would not have the appropriate infrastructure. Before the bill was finally passed, this condition was removed largely due to the strong physician argument against it.
Of the passed provisions, one major area of progress focused on overdose treatment. The CARE Act required that every Massachusetts pharmacy have standing order for naloxone, the first-line treatment for opioid overdose. Naloxone, a potent opioid receptor antagonist, can be administered nasally to quickly restore regular respiration in patients who have overdosed on prescription or non-prescription opioids.
The bill also calls for civil immunity for those who use or prescribe naloxone in a move intended to encourage more widespread use of this medication. According to Michael Botticelli, head of the Grayken Center for Addiction Medicine at Boston Medical Center, “Increased access to naloxone across Massachusetts is one of the main reasons overdose deaths are down in the state.”
The standing order is a significant move to increase naloxone accessibility, and hopefully, future policies will also address its cost which has risen to over 35 dollars per dose. In addition, the bill called for creation of a commission to review evidence-based treatment approaches to substance use disorders: This was done in an attempt to gather more data and increase knowledge on the most effective treatments for addiction and substance use disorder.
There are other provisions in the bill aimed at increasing access to medication assisted treatment (MAT) such as methadone and buprenorphine to help patients wean off opioids in a safe and controlled manner. Emergency departments are now required to follow MAT and refer patients who have over-dosed to long-term rehabilitation centers.
Furthermore, MAT access will be expanded to incarcerated populations in Massachusetts’ prisons. Specifically, this allows access for the first and last ninety days of incarceration in state prisons and access for the thirty days prior to release in county correctional facilities. Incarcerated persons are at a uniquely high risk of overdose after being released. A recent study in North Carolina indicated that the risk of overdose was forty times higher in previously-incarcerated patients than the remaining population.
Medical schools are increasing awareness of the opioid epidemic to their students. At Tufts University School of Medicine, all second-year students will be completing naloxone administration training in the spring of 2019. After this one session, over 200 future physicians will be able to recognize and respond to an overdose crisis. With this knowledge, they will be able to teach their patients to do so as well.
As a medical student, I am excited to see the effects that current policies will have on medical practice in the future. While the medical field may have been slow to organize in response to the opioid epidemic, the future looks promising with movements like these. Propelled by physician and medical student advocates, the opioid epidemic will likely continue to remain at the forefront of the nation’s attention until it is no longer an issue.