U.S. Atty. Gen. Eric Holder this week declared rising heroin and opioid overdose deaths “an urgent and public health crisis” and vowed renewed enforcement and treatment efforts.
In a five-minute televised video, the nation’s top cop referred to the 45 percent increase from 2004 to 2010 in the fatal overdoses from heroin and other opiates found in prescription painkillers. Holder called such drugs — including OxyContin, Roxycodone, Percocet, Vicodin, Dilaudid, Lortab and morphine — an increasing gateway to heroin.
“Addiction to heroin and other opiates, including certain prescription painkillers, is impacting the lives of Americans in every state, in every region, and from every background and walk of life,” Holder said. “Confronting this crisis will require a combination of enforcement and treatment. The Justice Department is committed to both.”
No Details on Treatment
Holder promised beefed up federal attention via the Drug Enforcement Agency and border patrols to halt incoming narcotics, and noted the number of drug courts designed to resolve cases in the context of substance abuse. He called for more prevention education by doctors, police and parents. He offered no details on treatment — an omission not lost on those who work directly with addicts.
“We have demonstrated only a limited capacity to enforce our borders when it comes to drug smuggling despite more than a generation of effort, and there is little reason to believe we will be more successful going forward,” said Dr. David Sack, an addiction treatment specialist and CEO of Promises Behavioral Health.
“We should focus instead on the early identification of individuals with opiate abuse problems, and expand opportunities and incentives for entering and staying in treatment programs such as drug court programs and community reinforcement that can actually increase treatment success,” Dr. Sack said.
Holder’s comments, made during his weekly videotape address, immediately revived the enduring treatment-vs.-punishment conflict since the “War on Drugs” was launched by President Richard Nixon; it continued with the Reagan Administration’s “Just Say No” campaign in the 1980s, and has unleashed billions in public funds and resources to battle narcotic trafficking.
According to a 2012 “Economic Scene” column in the New York Times, $20 billion to $25 billion a year over the last decade has been spent by the U.S. government on anti-narcotic efforts. “That is a pretty high price tag for political cover, to stop drugs from becoming a prominent issue on voters’ radar screen,” wrote The Times’ Eduardo Porter. “Almost one in five inmates in state prisons and half of those in federal prisons are serving time for drug offenses. In 2010, 1.64 million people were arrested for drug violations. Four out of five arrests were for possession. Nearly half were for possession of often-tiny amounts of marijuana.”
But the opiate and heroin abuse and deaths are not tiny and neither is the addiction.
Most medical experts now recognize that addiction is a complex medical disease, not a behavioral problem. Although addiction treatment is a relatively new field, a significant body of research shows that addiction is a chronic illness similar to asthma, hypertension and diabetes. The American Society of Addiction Medicine defines addiction as “a primary, chronic disease of brain reward, motivation, memory and related circuitry.” Consistent differences in neurophysiology between addicts and non-addicts have been observed; genetics appear to play a role, too.
About 16,000 people die of opioid overdoses every year, according to the Centers for Disease Control and Prevention; the CDC in 2011 declared painkiller abuse an epidemic, noting that enough pain pills were prescribed in 2010 to medicate every American adult around the clock for a month.
Purity Up, Price Down
Compounding the problem is that heroin is stronger and cheaper than ever. A recent study in the British Medical Journal found that between 1990 and 2010, the street price for heroin in the U.S. fell 81 percent (adjusting for inflation), while its purity increased 60 percent.
“The old-school user, pre-1990s, mostly used just heroin, and if there was none around, went through withdrawal,” Stephen E. Lankenau, a Drexel University sociologist who has surveyed young addicts, told the New York Times. Now, “users switch back and forth, to pills then back to heroin when it’s available, and back again. The two have become integrated.”
Holder said the pain pills have become the launching point into heroin. Treatment providers note the typical progression of use, and it’s mostly economic: people start with prescription opiates, but, because they often cost $30 or more per pill, a user will turn to heroin where $45 can buy a multiple-dose supply.
The attorney general’s address this week was viewed as admirable for bringing attention to the topic, if delayed. Recent high-profile overdoses involving heroin or the opiate pills have attracted new attention from the media about the continuing problem. Holder said educators, families and law enforcement need to better coordinate their efforts.
He said emergency workers are encouraged to stock naloxone, a drug to restart breathing after an overdose. Since 2001, the drug has saved lives in more than 10,000 overdose incidents.
Improved Access to Treatment Called Critical
But as the Affordable Care Act kicks in and the medical insurance landscape changes, heroin addicts in particular are finding few insurers will cover residential treatment — or not until an addict has relapsed several times. Holder made no mention of the practical matter of helping addicts kick drugs.
“Interdiction by itself cannot solve the heroin and prescription opiate problem,” said Dr. Sack. “Improved access to treatment — methadone, buprenorphine and residential treatment — along with better funding for educating the next generation of addiction treatment professionals, is critical.
“Waiting lists and limits on both public and private funding that would be unacceptable for liver disease or cancer are widespread in addiction treatment,” Dr. Sack continued. “Parity mandates are often disregarded or dismissed by insurers and an effective enforcement process is lacking.”
Dr. Sack and those skeptical about the declaration of government commitment pointed out that when it comes to providing treatment, and thus insurance coverage and payment, this week’s announcement skimmed essential details. One of them is the toothless enforcement of the Mental Health Parity Act of more than 17 years ago.
The Mental Health Parity Act was signed into U.S. law in September 1996 and requires that annual or lifetime dollar limits on mental health benefits be no lower than any such dollar limits for medical and surgical benefits offered by a group health plan or health insurance issuer offering coverage in connection with a group health plan.
“Federal programs — Medicare and Medicaid — are exempted from parity requirements the law aims to ensure,” Dr. Sack said, “except for plans offered through the new ACA-triggered exchanges. “