Addiction policy must be evidence-based

Gains are possible if we focus on treatment, not stigmatizing those in need

It is late on a Friday afternoon and I am sitting with Juan, a bright young man who is the first in his family to graduate from high school. But today, the 18-year-old isn’t thinking about his future; he’s shuddering with chills and trying to comfort himself by rocking back and forth in his chair. He repeats the same phrase over and over: “Can somebody help me. I just want some help.”

Juan is addicted to heroin and suffering from his first withdrawal episode. All I can offer are words of comfort, and put him on a waiting list for detox and treatment. It’s not enough. Juan will relive his withdrawal experience numerous times as he grapples with a cycle of treatment and relapse. While struggling with his addiction, he will spend two terms in prison, nearly die of an overdose, see his connections to his family erode, and watch his dreams of a good job slip away.

That Friday afternoon encounter took place 30 years ago, when I was director of a small Western Massachusetts clinic. The resources available for treating opioid addiction were lacking, in large part because opioid addiction had yet to become a public health emergency. That’s no longer true. The rate of opioid-related overdose deaths in Massachusetts has increased 90 percent from 2000 to 2012, according to an April report from the Massachusetts Department of Public Health. There were 674 deaths in 2013 alone, according to a Massachusetts Health Council report released on October 28. This surge has spurred action that includes Massachusetts legislation—enacted in August—to enhance monitoring of prescription pain medicine, and make it easier for patients to discover and enter detoxification programs. The US Drug Enforcement Administration announced recently that one type of opioid, hydrocodone combination drugs, will be reclassified as a substance with the greatest threat of abuse.

In the years since my encounter with Juan, we have also learned that it’s possible to successfully treat opioid addition with medications such as methadone or buprenorphine/naloxone. This “opioid agonist treatment,” which substitutes safer medications to reduce the withdrawal and craving symptoms that often lead to relapse, is more effective than counseling alone. Research conducted by the University of Massachusetts Medical School’s Commonwealth Medicine division has found that individuals using an opioid agonist to help treat their opioid addiction are less than half as likely to relapse as those not using medication. These medications help many patients maintain a work and family routine that is near normal. I often wonder what Juan’s life would have been like if he had been able to access today’s opioid agonist treatment options.

But one thing that hasn’t changed in three decades is the public’s attitude toward addiction. Although most addiction medicine specialists consider drug addiction a lifelong illness in the same realm as diabetes or asthma, public opinion is often less generous. Addiction is still seen by many as a moral weakness, a failure of self-control to be viewed skeptically and sanctioned by strict legal penalties, often including imprisonment.

That public opinion often leads to the establishment of policies that are at odds with scientific evidence. Medicaid programs in a dozen states—politically red and blue alike—have imposed lifetime limits on treating opioid addiction with methadone or buprenorphine, according to a report commissioned by the American Society of Addiction Medicine published in 2013. The limits range from one year in Washington and Illinois to three years in Utah. More states have followed suit since the report was published. Thankfully, Massachusetts is not among these, and we continue to embrace a progressive, evidence-based approach to addiction treatment.

Our research shows that limiting access to opioid agonist treatment may not only increase the relapse rate among individuals with addiction, but increase costs to states as well. Care for MassHealth members who use methadone or buprenorphine to treat their opioid addiction costs $120 to $400 less per month than those who use counseling alone.

For what other illnesses would state officials impose regulations that both deny access to effective treatment and raise costs? A politician who told constituents they were only allowed three years’ worth of blood pressure medication would quickly be out of a job. Yet, many politicians seem to find support for their efforts to limit addiction treatment. One governor recently suggested that Narcan—a drug that reverses the life-threatening effects of opioid overdose—was simply “an excuse to stay addicted.”

Is taking medicine for hypertension an excuse for those with high blood pressure to continue to eat the wrong foods and not exercise?

Regulations requiring lifetime treatment limits have been implemented with relatively little public outcry in many states. This is all the more baffling because the current surge of opioid addiction—comprised largely of individuals who began by abusing prescription pain medications—cuts across income and class boundaries. Greater public recognition of this might help us understand that it is not “them” who are addicted to opioids. It is our co-workers, our friends, our family members. It is us.

Meet the Author
No doubt Juan would receive better care more quickly in Massachusetts today. And he would continue to have access to care as long as he needed it. In another state, the story might be very different. Geography is quite literally destiny for those with an opioid addiction.

While Massachusetts does have the right approach when it comes to treating those addicted to opioids, more still needs to be done here and across the nation to reduce the stigma associated with addiction. We need a society sea-change: Public attitudes about who does and does not deserve treatment are the next big barrier to better health care. Compared to that, covering the uninsured may be a piece of cake.

Robin Clark is a professor of family medicine and community health at the University of Massachusetts Medical School. He led research on health policies and health care interventions for underserved Populations while a senior director at the school’s Commonwealth Medicine division.