Nearly 2,000 people were gathered in Atlanta this week at the National Rx Drug Abuse and Heroin Summit. When the White House announced last week that President Obama would attend the Summit, affirming the request for $1.1 billion in the 2017 budget, it was clear that this year’s Summit would make history. It would make history not only in helping to turn the tide of the opioid and heroin epidemic but also in changing hearts and minds about all substance use disorders.
Organized by Operation UNITE (www.operationunite.org), a nonprofit begun in 2003 in eastern Kentucky by Representative Hall Rogers, the Summit brings together government leaders and people working on the ground to address the prescription opioid and heroin epidemic. Participants include federal agency leaders, Congressional leaders, state and local leaders, health care professionals, pharmacists, third party payers, law enforcement professionals, advocates, prevention experts, researchers, family members, and people in recovery. Looking around a room filled with 2,000 people (1,200 last year) dedicated to addressing the opioid and heroin epidemic inspires awe for what a small nonprofit can mobilize in a relatively short time.
As the largest conference on opioids and heroin, Representative Rogers called the Summit the shareholders meeting for drug policy in the United States. In addition to the many people working on the ground in communities, this year’s shareholders included the Surgeon General; bipartisan Congressional leaders; and directors of the Centers for Disease Control and Prevention (CDC), Substance Use and Mental Health Services Administration(SAMHSA), Office of National Drug Control Policy (ONDCP), National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA), Department of Agriculture (USDA), and Drug Enforcement Administration (DEA). It is awe inspiring to know that all of these leaders are in one place, all working together to solve the complex and devastating problem of opioid addiction.
At the same time, the need for this large-scale collective effort is heart wrenching in its demonstration of the scale of the problem. CDC Director Tom Frieden and others call the rise in opioid addiction and overdose iatrogenic. It is the result of the over-prescription of opioid medication since the introduction of Oxycontin in the late 1990s. There were 259 million prescriptions for opioids written in 2012 – enough for one bottle per person in the United States. Since 1999, 165,000 people have died from prescription opioid overdoses, and heroin overdose deaths have increased by 246%. In 2014, the latest year for which statistics are available, 28,647 people died from opioid overdoses. There are only two states where drug poisoning death rates show some decline from 2013 to 2014 – Florida and Nevada, as presented by CDC’s Frieden. Almost all other states show increases.
The ongoing loss of life was demonstrated graphically by the CDC Life Counts Clock unveiled at the Summit. The Clock is a stark reminder that about every 20 minutes in the U.S. a new family is devastated by the grief of overdose death. For individuals at the Summit who have experienced the devastating effects of opioid addiction and overdose – those with opioid use disorders whether or not in recovery, and families of those who have lost their lives to overdose or are struggling to recover – there is acute awareness of the effort required to stop the clock and the pain of loss with each rise in the count.
The Summit facilitated discussion on a broad range of approaches to changing both the “supply” and “demand” sides of the problem. Efforts to implement Prescription Drug Monitoring Programs (PDMP), and change prescriber practices (non-opioid therapies for pain, start low and go slow, exercise caution when prescribing), as well as efforts by law enforcement to close pill mills, implement prescription drug take-back sites, and interrupt the heroin and fentanyl trade from Mexico and China represent change to the supply side. The CDC Guideline for Prescribing Opioids for Chronic Pain released last week provides the framework for the responsible use of opioid medications. All states other than Missouri have PDMPs, but legislation is still needed in most states to assure use of PDMPs and the quality and timeliness of the data they contain – such as required checks of PDMPs by prescribers, required data submission by dispensers within 24 hours, closing gaps in data such as those from methadone clinics, and interstate data sharing. By mandating the use of PDMPs in Kentucky, for example, provider use skyrocketed. Also, pharmacists, third party payers, medical education (early and often) – and the public – all have a role to play in reducing access to supply. There is still much to be done to educate providers, dispensers, legislators, and the general public.
On the demand side, CDC's Frieden advocated for community awareness and support: Engaging and empowering communities, supporting patients and families, working together to prevent addiction and support recovery, and improving community structures – addressing the collective effects of zip code on life expectancy over genetics.
Relieving suffering and saving lives fall neither on the demand or supply side, except to the extent that these reduce the need to continue to use opioids. The tragedy of neonatal abstinence syndrome (NAS) was brought home by SAMHSA Acting Administrator, Kana Enomoto, in her description of her colleague’s adopted baby’s struggle with the consequences of prenatal opioid exposure. The need for 911 amnesty legislation to take the fear out of seeking medical help, and access to naloxone for overdose reversal by first responders, including families and friends who are the “first first responders” are key to reducing overdose deaths. The release of the autoinjector form of naloxone and availability through pharmacies will further this effort. Providing effective treatment, especially improved access to life-saving medication-assisted treatment (MAT) – methadone, buprenorphine, naltrexone, and leveraging the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA) to improve access to and quality of care is critical, yet in need of much greater refinement.
As NIDA Administrator Nora Volkow described, brain imaging is helping dispel false hypotheses and promote understanding of the differences in brain activity in persons affected by or vulnerable to substance use disorders. These advances help refine approaches to treatment, and are already informing the role of MAT for opioid use disorders, and relapse prevention post detoxification, post treatment, and post incarceration. However, access to MAT is still so limited and fraught with obstacles, that one could call these barriers criminal. For example, when the data demonstrate that MAT will dramatically reduce the likelihood of overdose post detoxification (when individuals are most vulnerable to overdose because their tolerance is greatly reduced), releasing individuals to their own devices – post detoxification, post treatment, post incarceration – without MAT and without the means to pay for MAT can be seen as a death sentence. There is so much work to be done.
Given the array of issues and problems presented across Summit tracks (Advocacy, Clinical, PDMP, Federal, Pharmacy, Prevention, Law Enforcement, Heroin, Third Party Payer), I longed for an effective public health model for substance use disorders, a roadmap for evidence-based implementation of prevention, screening, early intervention, treatment, and recovery supports everywhere. As an evaluator, I longed for goals and benchmarks. As someone who spent over a decade working with SAMHSA’s Children’s Mental Health Initiative, I was acutely aware of the absence of an organized family voice, and the absence of solutions to help persons with substance use disorders and their families with access to treatment. I was also acutely aware of the need to educate on the use of person-first language, awareness of stigmatizing language, and cultural and linguistic competence. I wonder, too, where the resources are for public awareness and education, and especially for reducing stigma. There is so much work to be done.
Hope is critical in recovery. Hope erodes with substance use disorders, for those using substances and for those around them. Yet hope and love are what motivate recovery. There is hope for getting the work done, for turning the corner of the opioid epidemic, and, for changing hearts and minds about substance use disorders as medical problems and not criminal or moral problems. Hope is in the $1.1 billion requested in the President’s 2017 budget. It is in the collaboration of leadership, the dedication of the 2,000 Summit attendees and their colleagues at home, and the voice of recovery by organizations such as Young People in Recovery represented by Justin Luke Riley on the panel with President Obama. This year’s Summit made history.
Summit presentations will be posted on the Summit website. President Obama’s participation in Tuesday’s panel discussion can be viewed here.
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Brigitte Manteuffel, PhD, is an independent consultant and Children’s Mental Health Network Advisory Council member. She serves on the advisory board for the National Family Dialogue for Families of Youth with Substance Use Disorders, the leadership team for the Behavioral Health Hub of the 100 Million Healthier Lives campaign, the Heroin Working Group for North Georgia, and coaches families on CRAFT for the Partnership for Drug-Free Kids Parent Support Network.