Today President Trump finally declared the opioid epidemic a national emergency. For years our nation has been in the midst of its most significant drug addiction crisis. The number of annual opioid overdose deaths has quadrupled since 1999. The Center for Disease Control and Prevention reported that 64,000 people died from drug overdoses in 2016 alone. An estimated 142 people die from drug overdoses every day in the United States. A recent joint investigation by 60 Minutes and The Washington Post, which aired last week, shed light on what fueled the epidemic.
According to Joe Rannazzisi, a whistleblower who previously ran the DEA’s Office of Diversion Control that was charged with investigating the pharmaceutical industry, the epidemic was fueled by three main pharmaceutical companies. These companies were permitted to operate with virtual impunity in their distribution of dangerous prescription opioids throughout the country for billions of dollars in profit. Essentially legalized drug dealing was allowed to spread through the efforts of lobbyists that were paid hundreds of millions of dollars to convince congress not to act against fortune 500 companies selling highly addictive drugs.
By the way, in many cases the prescriptions were paid for by health insurance companies who did not bother to ask questions since filling a medication is far less costly than covering the expense of actual treatment.
Eventually, pain pill mills that distributed prescription opioids were cracked down on in numerous states by local law enforcement. However, by then most individuals prescribed opioids (mostly Oxycontin) had developed severe substance use disorders. No longer able to "doctor shop" to fulfill the compulsion to use due to the extreme sickness of withdrawal that develops from cold turkey cessation; many switched to street drugs of Heroin or available synthetics such as Fentanyl or the even more dangerous derivative Carfentanyl. Most opioid overdose deaths in the country are actually occurring because pure Heroin is rarely available any more since creative entrepreneurial drug dealers mix it with Fentanyl or Carfentanyl to sell more product and hence making the drug up to 100 times more lethal.
So we have a drug epidemic that was fueled by pharmaceutical companies and exacerbated by law makers and health insurers. According to the most recently published data from the National Survey on Drug Use and Health (2016), 19.9 million adults (8.1% of those aged 18 or older) needed treatment for illicit drugs or alcohol while only 2.1 million (10.8% of those in need) received specialty care. An estimated 17.7 million adults needed treatment, but did not receive it. The most common stated reason for not receiving treatment was a lack of insurance coverage and the inability to afford treatment. Millions of Americans with healthcare insurance have no idea that coverage will be minimal or even denied when they are in desperate need. What the large carriers do not want Americans to know is that the insurance industry is doing everything possible to avoid paying the cost of drug and alcohol treatment and have taken active steps to fight the very providers that are here to save lives.
Even those covered by insurance rarely have a decent benefit to get help when trying to use it. At the treatment center that I operate at least 75% of our treatment related inquiries find that they have no ability to pay for treatment. While we treat upwards of 20% of our patient’s pro-bono, it is heart wrenching for me to see so many individuals in need who are unable to receive treatment while we have many open treatment spots. When there is a natural disaster such as a hurricane, generators and battery operated fans sell out, but treatment beds remain open everywhere when the natural emergency pertains to human beings in need of drug treatment.
Many of those calling for treatment are shocked that their health insurance plan does not cover the cost of treatment or requires unattainable out of pocket costs. Even more are shocked that they have deductibles that can reach as high as ten thousand dollars. Then there is the individual who has a benefit and comes into treatment only to find that the managed care entities within their insurance company only authorize a few days of treatment before dropping them down to a level of coverage that only affords insufficient outpatient treatment. As a treatment center we spend an enormous amount of time fighting insurance companies on behalf of the patients we treat only to be reimbursed pennies on the dollar after waiting months. It is a daily fight to remain in operation and yet insurance companies act as if they are being victimized by simply being asked to provide the benefit their member in need has paid for.
Health insurance companies are utilizing the same tactics that the pharmaceutical companies have by funding lobbyists to allow them to operate with impunity. They were implicit in starting this epidemic and now do not want to fund the treatment of it. Even more disturbing is that discussions regarding the answer to the opioid epidemic have turned to MAT. MAT stands for Medication Assisted Treatment through drugs such as Suboxone, Methadone, or Naltrexone/Vivitrol. Without getting into a long dissertation of the pros and cons of these medications I will simply say that the first two are abusable, can lead to a dependency on them, and require substantial withdrawal to come off of while Vivitrol does not. Suboxone and Methadone also have accompanying euphoric effects. Vivitrol is a 30 day injectable form of Naltrexone, which is a safe medication to completely block all euphoric effects of Opioids while reducing cravings for the drug. Vivitrol has been shown to be evidenced based in significantly reducing relapse. We utilize Vivitrol at Evolutions Treatment Center for appropriate situations in which the individual has a history of relapse and has productively engaged in behavioral treatment.
Vivitrol is expensive so, not surprisingly, many health insurance companies will not pay for it. Conversely, health insurance companies seem more than happy to pay for Suboxone and Methadone, as a much less expensive alternative to paying for behavioral health treatment. One large health insurer even rejected our in-network application citing that we did not provide MAT treatment by only offering Naltrexone and Vivitrol.
In my opinion Suboxone and Methadone often just transfer drug dependencies from one drug to another. This is not to say that there are no appropriate situations for their prescription, as there are always individualized cases in which they may be appropriately utilized and helpful. However, do not be fooled by the national push towards MAT, as this is not good therapeutic treatment that will get somebody better for the long term. It is an inexpensive way to transfer the problem for the short term with substantial long-term ramifications if the individual ever attempts to get off the drug.
The answer to the opioid epidemic and the national emergency we face is complicated, but involves solid evidenced based behavioral health addiction treatment along with the consideration of certain MAT approaches on a case by case basis.
The regulation of insurance companies to require the necessary coverage of treatment and payment is essential. Other forms of funding are also essential to treat addiction and the underlying contributing difficulties. A government issued voucher system, in which those with a proven need may utilize to cover reduced fee care at accredited facilities, is one such system that I recommend for consideration. With the right legal interventions such vouchers could be covered by the pharmaceutical companies deemed responsible for circulating prescription opioids. It is entirely illogical that 1000’s of treatment beds sit open every single day while people die in the streets without receiving help. Every day I hear of another treatment center going out of business rather than receiving the funding required to save lives.