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The Rosenthal Report - December 2016

Rosenthal Reports

The Surgeon General Has Solid Facts But A Flawed Plan To Combat Opioid Addiction

In a fact-packed and ambitious document titled Facing Addiction in America, The Surgeon General’s Report on Alcohol, Drugs, and Health, Dr. Vivek H. Murthy declares, “It is time to change how we as a society address alcohol and drug misuse and substance use disorders,” and indeed it is. But, while the report released last month is filled with useful information about drug use, treatment, and recovery, the public health strategy at the heart of Dr. Murthy's scenario for addressing rising levels of substance misuse and a nationwide epidemic of opioid addiction is fatally flawed. 

What made headlines when the report was released were the statistics—one in seven Americans at risk of addiction and the one in ten lacking the treatment they need. More Americans now use prescription opioids than use tobacco, according to the surgeon general, and more suffer from substance use disorders than from cancer.

Dr. Murthy boils down the recommendations of his 412-page report to a five-point prescription.  Three points are clear and predictable:
•    Expand access to evidence-based treatment;
•    Add more community-based prevention programs;
•    Undertake research that advances development of strategies for treatment, prevention, and support of recovery.

A fourth point—utilizing health reform and parity measures to increase access to substance misuse services—becomes questionable after last month’s election. Nevertheless, as Dr. Murthy says, “Whatever happens, continuing to expand coverage will remain key to addressing addiction.”

It is at the fifth point that the surgeon general’s plan goes off the rails, for he proposes the integration of treatment for substance use disorders with the rest of mainstream health care, which, as detailed in his report, would mean the virtual elimination of today’s network free-standing programs for substance abuse and other behavioral healthcare services.   

The rationale for this proposal derives in part from Dr. Murthy’s own professional experience as a hospitalist (an internist treating hospitalized patient exclusively) and a medical services manager.  But it mostly reflects the orthodoxies that now guide federal substance abuse policy:
•    The alleged ability of “substance use” to “hijack” the normal function of brain circuits;
•    The perception of substance use disorders as a “chronic relapsing condition” no different than such other chronic disorders as             diabetes or hypertension; and
•    The attempt to destigmatize addiction, including such efforts as banning use of the words “abuse, abuser, or addict.”

Please note that:
•    While addiction skews choice it does not eradicate free will.
•    There is more than adequate evidence that, as Dr. Sally Satel puts it, “addiction is an activity that can be altered by its foreseeable       consequences”
•    Shame and stigma are among the most useful of social mechanisms and society’s chief means of modifying negative behaviors. If       it’s okay to employ stigma against smoking, why not against illicit drug use?

“Addiction,” says Dr. Murthy, “isn’t evidence of a character flaw or a moral failure, it’s a chronic disease of the brain that deserves the same compassion that any other chronic illness does, like diabetes or heart disease.” This perception of addiction appears throughout the report. “A substance use disorder is a medical illness,” the report says and, “The primary goal and general management methods of treatment for substance used disorders are the same as those for the treatment of other chronic illnesses.” 

Separation of substance abuse services from the rest of health care, the surgeon general contends, “has contributed to the lack of understanding of the medical nature of these conditions…and the slow adoption of scientifically supported medical treatments by addiction treatment providers.”

Under Murthy’s plan, state funding and licensing policies would be employed to bring about the shotgun marriage of behavioral and general healthcare. 

The fatal flaw in all of this is the politically correct but therapeutically absurd notion that there is truly no difference between substance abuse and other chronic disorders. Nor is there compelling evidence that, save for a few black swans, addiction is in fact a chronic (i.e. incurable) condition. Chronic or not, the behavioral component of addiction goes far beyond the need for compliance in managing diabetes or hypertension. Bad behavior is a fundamental component of addiction and the past fifty years of treatment experience has taught us that changing behavior is not what mainstream medicine does. 

Medication helps, and the Murthy plan calls not only for the expansion of medication assisted treatment (MAT)—the use of methadone, buprenorphine, and naltrexone—but elimination or reduction of “restrictions on how these drugs may be prescribed or dispensed” that he maintains, “have reduced their availability for many people who could benefit from them.” 

Those of us who actually treat addiction recognize that medication is, by itself, not treatment. It is a useful adjunct for the behavioral therapies that help our patients find their way to sustained recovery.  But the most powerful ingredient by far in the treatment of addiction is the joint effort of patients, together with each other and peer counselors in recovery to take control of their own lives.  
Consistent with his call for a public health approach, the surgeon general’s plan includes “harm reduction” programs for those users “who may not be ready to stop substance use,” sanctioning needle exchange programs, overdose prevention education, and access to naloxone. These strategies, he says, “reduce substance misuse and its negative consequences… such as transmission of HIV and other infectious diseases.” They also, as the surgeon general acknowledges, “seek to help individuals engage in treatment to reduce, manage, and stop their substance use when appropriate.” 

When it comes to “the treatment gap” the difference between those substance users who need treatment and those who receive it, the report allows that, “Many factors contribute to this,” and goes on to list “the inability to access or afford care, fear of shame and discrimination, and lack of screening for substance misuse and substance use disorders in general health care settings.” In addition, the report notes that roughly forty percent of those “who know they have an alcohol or drug problem are not ready to stop using, and many others simply feel they do not have a problem or a need for treatment.”

Although it may appear somewhere in the report’s 412 pages, there is no mention in the executive summary or in any of the surgeon general’s interviews of what is surely a critical factor in the inability of our society to bring substance misuse under control. As the number of drug and alcohol users has risen over the past decade, the number of treatment admissions for substance use disorders has fallen.

The report shows illicit drug use rising from 8.3 percent of the population to 10.2 percent between 2002 and 2014. In roughly the same time frame, between 2004 and 2014, as the U.S. population increased by 10 percent, the number of treatment admissions fell by 11 percent, from 1,808,469 to 1,616,358.

Most critical was the precipitous decline of close to 50 percent in teen treatment. “The earlier people try alcohol or drugs, the more likely they are to develop a substance use disorder,” says the surgeon general’s report.  But what it does not say is that adolescents are much less likely than adults to find effective treatment.  Although the report cites one million adolescents (12 to 17) who need but lack treatment, teen admissions plummeted between 2004 and 2014 from 146,423 to 78,018. How or why this has occurred is an issue the demands investigation.

7th December 2016
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