By: Norman Wetterau, MD - FMHF President
Why does the United states have a much higher drug overdose rate than other countries? Why do we have this epidemic?
As an addiction specialist and former board member of the American Society of Addiction Medicine, I have observed the whole development of this epidemic and have some strong opinions. In February an open access article was released: The Contemporary American Drug Overdose Epidemic in International Perspective by Jessica Y. Ho.
This is a detailed article with many graphs and mathematical analysis as it examines drug overdoses In other countries, changes in life expediency and various drug policies. You may find it worth reading, but here is a summary of some of its findings and additional information which is common knowledge to those in the addiction field. The information on the AAFP is not widely known but is truthful and likely common in other organizations as well. The information on the joint commission and on the AAFP is not in Dr. Ho’s article. The opioid epidemic is not all the fault of the drug companies or the patients. It is complex, but something that must be addressed or it will not go away.
Review:
I became concerned about opioids shortly after the introduction of Oxycodone, but never imagined that things would get to where they are now: seventy thousand plus deaths a year (includes all drugs, but opioids are involved in the majority). Some of my patients have had 2 or 3 of their friends die from this and others have siblings and children. What has surprised me is that in spite of Narcan and buprenorphine, the death rate continues to climb. Due partly to this epidemic, the life expectancy of the average American has decreased by over a year.
A recent article by Jessica Y Ho looks at the opioid epidemic from an international perspective. First the article documents the incidence of overdoses in various countries. The US is highest with Scandinavian countries and Canada behind. The US overdose mortality rate is 3.5 times that of other countries with a range of 1.6 to 28. The differences are illustrated in various colored diagrams. The article documents how the overdose death rate has been a major factor in the falling life expediency in the US, and one reason why Americans do not live as long as people in other developed countries.
So why is this? The previous parts of the article have extensive mathematical documentations. The second part, which to me is more interesting, is more descriptive.
A major cause was the introduction and promotion of Oxycodone and other strong opioids. In much of the world stronger opioid use is more restricted and Oxycodone is not used nearly as often. In the United States the drug companies heavily marketed these drugs to physicians and to the public. The United States allows direct consumer advertising of prescription drugs, one of only 3 countries in the world.
The article shows the relationship between how physicians are paid, opioid prescriptions and overdoses. Health systems where physicians are mainly paid salary or by capitation have the lowest opioid prescription and overdose rates. In the United States physicians are paid mainly by how many patients they see and are given incentives for patient satisfaction. So, physicians faced increased financial pressure, caseloads and time restraints, plus their employment and pay was often tied to patient evaluations. So, if a patient comes in on oxycodone 20 mg bid and the pain has increased, one can double the dose, and send the patient away in 5 min. They will likely be happy. If instead one spends a half hour discussing the pain and making suggestions but actually reducing the opioids since it was not helping the pain, the doctor might be fired.
Additional reasons which were not a major focus of that article, but well known, was that the joint commission and various state governments made pain the 5 th vial sign. Doctors who did not prescribe strong opioids for pain were penalized and, in some cases, lost their license. States required doctors to take courses on pain relief and these courses taught that we should not be afraid to prescribe opioids for pain. The courses taught that addiction to opioids when used for pain relief was rare. Indeed, from my perspective, this is the first major deadly health epidemic caused by drug companies and doctors, with the help of the joint commission.
The causes do not end here. Through advertising, Americans were taught that they should not have to experience any long-term pain or discomfort, in contrast to many other countries. This does not just apply to opioids. Now marijuana is being promoted for all types of discomfort and some doctors are freely endorsing this. Benzodiazepine usages in the US has been rising in spite of the fact that it is addicting, contributes to overdoses, and that tolerance builds up so that the dose has to be increased.
Another cause is what insurance paid for. Various studies show that long-term opioid use does not statically reduce chronic pain, but comprehensive pain treatment, including PT, counseling and even group sessions does work. insurance usually does not pay for that. The insurance would usually pay for an opioid prescription but PT, and other treatments required prior approval. Counseling is not paid for and drugs other than opioids also may require prior approval. MRI’s and surgery are paid for. So, the one thing that works the best is not paid for.
The final difference was the availability and easy access to treatment for addiction. In France buprenorphine was available and used for addiction treatment long before it was approved in the United States. Even now most American doctors will not prescribe it. Until recently drug treatment has been more available in many other countries. It is estimated that only 10% of Americans with an addiction problem are receiving treatment for this. The figure is higher for those with opioid use disorder, but still much lower than many other countries. In the United States many treatment programs refused to use medications like buprenorphine or methadone, but this is finally changing.
Can we imagine an epidemic of any other disease in which doctors would refuse to become involved? Stigma is an issue. Young people with overdoses are sent away from emergency rooms with no drug treatment except for an injection of Narcan. As expected, they may repeat the overdose until they finally die. Is there any other disease that has been treated as such? This is an epidemic caused by American Medicine and then American Medicine refuses to treat it. The national AAFP even refused to appoint a member to the buprenorphine advisory group and refused to increase their CMEs on addiction in the early 2000’s in spite of a resolution from New York that passed their national congress asking them to do this. The president of the AAFP meet with members of ASAM, including myself, and said that there were too many other issues to deal with (this information and the strong language in this paragraph are not in the article which is being reviewed).
Fortunately, things are changing. The epidemic has grown and grown. It may take years to totally subside. The AAFP is now very supportive of appropriate opioid prescribing, and treatment, including buprenorphine. Family and Emergency medicine are on the forefront of opioid addiction treatment. In a congress that can hardly agree on anything, they almost unanimously approved two bills to dramality increase drug treatment and provided financial support for this. Churches of often very supportive of those who struggle with addiction. On the whole things are beginning to change, but some of the causes, including the payment system of American doctors, drug advertising and lack of universal health insurance still exist. Most experts feel that this epidemic will kill hundreds of thousands more people, including many young people, before is subsides. Finally, if we cannot address some of the underlying causes, we will have another major epidemic with benzodiazepines or medical marijuana. The later does not kill, but it certainly does not produce an improved life. Rather than discussing which addictive drug is not as bad as others, the conversation should be around preventing and treating all addiction, including alcohol, legal and illegal drugs, marijuana and gambling, which may be the next big addiction.
The Free Methodist Church had a prohibition against the manufacture and advertising of alcohol by its members. Are we behind the times or ahead of the times?