This fall I traveled a lot to Heartland areas to talk about a book I’d written about opiate addiction in America, and this provided me with a close view of the rise of Donald Trump’s candidacy.
The areas where I spoke were particularly hard hit by narcotic abuse — rural Michigan, southern Indiana, West Virginia, Kentucky, and several towns in rural Ohio.
The prevalence of Trump/Pence yard signs in these areas, particularly by mid-October, was stunning. As I traveled, it seemed palpable, this connection between Trump support and opiate addiction.
Not that there weren’t other reasons people supported him. A suffocating political correctness on the left is another factor in his appeal, I believe.
But nothing darkens your view of your present and future prospects quite as thoroughly as addiction to opiates (pills or heroin) in your family, on your street, or in your town. With opiates comes a fatalism and negativity that clouds a town or a family’s feeling about its world, even as unemployment falls and the economy improves.
In theory, addiction knows no race. In reality, though, our national opiate scourge is almost entirely white. Very few non-whites are among the newly addicted to prescription pain pills, then heroin. In three years of book research, I met one.
Though this scourge has affected every region of the country, it is felt most intensely in rural, suburban – Heartland – areas of America where Donald Trump did extraordinarily well.
Some of these areas did not fully rebound from the Great Recession of 2007 (southern Ohio). Others fared much better (North Carolina). A common denominator, I think political scientists will find, is that in these areas since the last presidential election the incidence of opiate addiction spread, grew deadlier, more public, and went from pain pills to heroin. In southern Ohio, where heroin has hit like pestilence, particularly Appalachia, Trump trounced his opponent in counties that Mitt Romney barely won four years earlier – though unemployment in many of these counties is at its lowest level in years, sometimes decades.
Shannon Monnat, a rural sociologist and demographer at Penn State I talked with, found strong correlations between suicides and fatal drug overdoses in counties where Trump’s increase was larger that the share of the vote compared to Romney’s four years earlier – this in six Rust Belt states, another half-dozen state in New England and all or part of the eight states comprising Appalachia.
One place I spoke was Hocking County (pop. 28,000). Hocking has lost coal mining jobs in recent years, though its unemployment rate dropped this fall to 4.5 percent, the lowest in more than 20 years. (It hit 14 percent in 2010.) But Hocking has also grown far more aware of its pill/heroin problem. Overdose deaths are up. Its drug court is among the first in the state to use Vivitrol, the opiate blocker. Trump earned 66 percent of the vote in the county Romney carried with 49 percent four years ago.
Opiate addiction – to pain pills or heroin — is the closest thing to enslavement that we have in America today. It is brain-changing, relentless, and unmercifully hard to kick. Children who complain at the slightest household chore while sober will, once addicted, march like zombies through the snow for miles, endure any hardship or humiliation, for more dope.
In many of these regions, folks were unprepared for it and, what’s more, believed they had done nothing to deserve it. Kids with no criminal record, star athletes, pastors’, cops’, and mayors’ kids all got addicted. Parents who’d imagined some glowing life script for their newborns years before were, as those kids reached young adulthood, confronted instead by late-night collect calls from jail, lying, stealing, conniving and that child’s body seemingly occupied by a mutant beast. Then came a felony record. Suddenly parents were co-signing for apartments, providing money and transportation for their addicted beloved, now 24, to take a GED class.
Though the number of actual addicts is small, the epidemic’s political impact has been substantial.
First because the states where the epidemic is most intense were crucial to the victor – whoever it was going to be.
Also, though, the opiate addiction rippled far beyond each individual addict. Addiction colored the lives of siblings, grandparents, uncles and aunts, friends and neighbors, pastors, teachers. As parents lost their fear of speaking out in the last two years, the problem emerged from the shadows, media coverage expanded, and now everyone for miles around was aware of it. County budgets buckled. Merchants saw theft increasing.
In several counties I visited, employers reported that more than half their job applicants couldn’t pass a drug screen. So though unemployment numbers fell, a good chunk of that was because many people were too hooked to seek work. Imagine what that does to a county’s productivity, and its buoyancy of spirit. It explains how a declining unemployment rate could create not optimism, but the foreboding that seemed to motivate many voters.
People also grew to understand that virtually all our heroin comes from or through Mexico – which is why it is cheaper and more potent than ever in our history. That did nothing to engender love for our southern neighbor in regions that had lost factories as well as kids. Nor did it make them feel that we have a serious and modern partner in Mexico when it comes to criminal justice and law enforcement.
This story plays out today with intensity in several of the states crucial to Trump’s victory – Ohio, North Carolina, Pennsylvania. It does the same in states he was assumed to win: West Virginia, Oklahoma, Utah, Kentucky, Indiana, Alabama, Georgia, Tennessee, and others. That these states – largely rural, religious, and white – are now our heroin beltways amounts to a stunning change in our national culture and one that most people in those areas became aware of only recently.
Equally stunning is that New York, California and Illinois – including New York City, Los Angeles, Chicago, once our heroin hotspots – are well down the list of states ranked by addiction rates. Hillary Clinton won each of them.
In many of the most affected regions, moreover, people, by and large, have taken as self-evident Ronald Reagan’s dictum that “government is the problem” — the starkest threat to personal freedom. The private sector and the free market are, therefore, to be exalted; government starved. (This despite a deep reliance on government programs: Medicaid, Medicare, SSI, SSDI, worker’s compensation, food stamps, welfare, farm subsidies, etc.) Confederate flags and 2nd Amendment bumper stickers were common amid the Trump signs I saw.
The irony is that behind this drug plague is a story of how the private sector introduced the most serious widespread threat to personal freedom in America today – opiate addiction. All profits from the massive prescribing of narcotic pain pills have accrued to the private sector, mainly pharmaceutical companies; all costs of addiction to those pills, and then heroin, are borne by 
the public sector. Indeed, for years, about the only people fighting the opiate scourge, my research showed, were government employees: cops and prosecutors, public health nurses and CDC statisticians, county social workers, judges and ER doctors, DEA agents, coroners and others.
The Sackler family, which owns Purdue Pharma, the company that makes OxyContin, has been estimated by Forbes magazine to be now one of the country’s wealthiest, with an estimated net worth of $14 billion, due to $35 billion in sales of the drug since it was released in 1996.
All this, I believe, helps explain the reception to Donald Trump’s populist message – including rejection of free trade and other sacred cows of Republican elites and conservative theorists. (“Worst Election Ever” proclaimed a post-election article from the conservative Hoover Institution.)
In these areas, too, the “throw away the key” approach to drug addiction was unquestioned dogma until the opiate scourge. That is changing. Democrats may still not get elected in a region like northern Kentucky, for instance, but Republicans who talk only tough on crime now have a hard time there, too – so harsh is the pill and heroin problem.
It’s likely that many of the regions where Trump enjoyed such support will require massive investment in drug treatment before they can be great again. (Ohio Gov. John Kasich realized that and went around his Republican-led state legislature a couple years ago to mandate Medicaid coverage for all Ohioans — largely because it gave people coverage for drug treatment.)
Will such an investment come from a president whose election seems to have so much to do with the opiate epidemic, yet who appears to have thought little about how to expand drug treatment?
How will people in these areas react to dismantling Obamacare, which provides coverage for addiction treatment that they didn’t have before?
In counties where half of job applicants fail drug screens, will the chambers of commerce line up to do away with the system?
Like so much that sprang from those Heartland yard signs, I guess we’ll see.
My name is Lisa I have been on methadone for 17 years never had dirty screens when I went U wanted to feel normal again well I did . But it’s getting to pay for. I need to get off of it but my daughter went and paid 10000.00 to rapid detox to get off of it It’s been a year with her and she stays depressed. I am so scared that it’s gonn b very soon that I cant pay for it anymore I have RA and other kinds of health problems and I am on Obama care..Is there suggestions wat I can do I live in Memphis Tn. I need help so bad. I pray every night for god to lead me to the right place HELP me
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I just finished reading Dream Land and want to thank you for this very informative book. I have 2 addicted children and have tried so hard to figure out why? What did we do wrong as parents? In seeing the timeline you gave, my children were born at the exact right time and place for this to occur. My children were raised in one of the small towns your book speaks of in Brown County, OH. As a teenager in the late 90’s my daughter complained of migraines, when the doctor prescribed pain meds I did not even question it. Gave no thought to addiction, we did not drink or use drugs, were active in the community and church, my children would never be hooked on drugs. I did not realize her addiction until around 2009 when I was made aware that she had turned to heroin. We are now raising her children who were removed from her care because of this addiction. She has tried at different times to stop but with no success. Not that the information makes it better it does help to understand what really was going on behind the scenes.
Heartbroken Mom: I am sorry to hear about your children. Do not torture yourself asking what you did wrong. I highly doubt you made any more mistakes than any loving parent.
I am a recovering meth addict and I can assure you that my parents and my childhood were ideal. Drugs are insidious and youth by nature are willing to take risks.
Don’t lose hope. After 13 years of active addiction I am in recovery. I know many people who have beaten terrible habits.
Your children are in my prayers.
I am a pain patient. I rely on my medications to keep me going to work. My work is electronics engineering and I design circuits and systems for guided missiles. If my medications are taken away so will my six figure salary as I’ll be on disability and laid up in bed. If not for opiates I would no longer be working. I took every medication they threw at me – Lyrics (amost killed me), Pristiq (an SSRNI anti-depressant, it caused horrible side effects), all kinds of steroids and trigger point injections. Due to steroids my hip joints are now failing. I had a bad reaction to the steroids which can cause necrosis of the bone tissue at the head of the leg bone (femur), the “ball” which fits in the hip socket. I had horrific side effects from EVERY medication I took except for opiates. I have constipation from opiates. That’s totally under control with miralax. So opiates are the only thing that help me with severe pain and fatigue, the depression caused by pain, and so on. It has saved my life – not taken it. I’ve been taking them for several years. Please don’t punish me for the illegal activities of others. It’s not fair to sick people. You cannot imagine the hell I was going through. My quality of life has vastly improved. I’m not the problem so please don’t destroy my capability to earn an income and take care of my young son and my wife. I also contribute a lot to the economy. I’m not your enemy or anyone else’s enemy. Please don’t insert yourselves between my doctor and my medications. I got this, really. Thanks for the concern but I’m doing well. I go to work and take car of my family and I need just a few courses to finish up my Ph.D. Opiates have saved my life and given a little boy his father back.
Joe,
I too am a long time chronic pain sufferer and until I was put on opiate medications my quality of life was ZERO. I’ve heard horror stories of people actually being suicidal because they can no longer deal with the constant pain. It took me two years before I realized I could no longer work as an account manager with a major telecom company. I was making decent money but leaving work everyday in pain. I finally started going to a pain management doctor who diagnosed me with degenerative disc disease. I had to go on medical leave and now am on SSDI. My doctor prescribed me opiates in the fall of 2006 and I’ve been on them ever since. I have to say, I totally AGREE with you. I don’t know how I would be able to manage without these medications. At least I’m able to clean my house now and now without being in horrible pain. I don’t know what I would do if suddenly I was told I could no longer be prescribed opiates.
Who is someone that will champion those of us who legitametly need these medications? Do we write to our senators?? I sure hope Trump takes into consideration our cases before kicking us all to the curb!
I am a pain patient that deserves to be treated by my doctor with the appropriate narcotic medication that helps me live while my insides die! why does NO ONE THINK OF US? I’m sorry people are dying but there is a huge difference between a pain patient and a drug addict!! I sit here and suffer while the drug addict goes to find a fix on the streets!! WTF?
We are the left behind, in a sea of loudly yelling healthy people. They cannot understand until they do experience it. There’s just a lack of empathy nowadays. The medication is not as strong as everyone thinks either. We still go in pain but it helps me so much. You can never stop it all. Oxycodone helps but it doesn’t make me high as a kite. It gets me through the day.
You are so right! All these do gooder politicians and DEA don’t have pain beyond what a aspirin or aleve won’t take care of. They just don’t have a clue. All they talk about on the news is the war on prescription drugs actually it is a war on pain management patients. If they were to actually focus on more than just limited to the people who sell
” Gov. John Kasich realized that and went around his Republican-led state legislature a couple years ago to mandate Medicaid coverage for all Ohioans — largely because it gave people coverage for drug treatment.)” Yeah. Great. Good for Kasich. But show me ONE treatment center that accepts Medicaid AND new patients and I’ll vote for him again. It’s a dog and pony show. The whole thing is broken. And while 3 million people walk our streets with knitted vaginas on their heads, their CHILDREN are dying. The stupidity and refusal to see what’s right in front of their faces astounds me. Go ahead, Rosie, gain what you perceive to be “equal” rights. Your vagina; your choice. I get it. But I’m really concerned about your daughter and your son more than I am you.
I was born and raised in WV. I raised my children mostly in Chillicothe OH. I remember Dreamland. I now live in Cleveland. My daughter – 22 years old – is about 260 days clean. I am fortunate. So is she. But we could get NO HELP for her when it was desperately needed. I had to drive her to Arizona to get treatment and that facility said they’d accept her insurance and then abruptly decided they did not. She was driven to the airport and flown home. It’s because her father finally decided to be involved that she wasn’t just put out on the streets of Tuscon. Mirasol. I do not recommend it.
Sam, I can’t tell you how much I appreciate your book and the knowledge I gained from it. I’m preaching it to everyone who will listen. HEROIN is our new civil war. I only hope EVERYONE will wake up and fight it.
Shelli – thanks so much for writing. i’m glad the book has meant something to you and really happy that you daughter is clean. i wish the best because I now how hard it can be….I wrote the partly for folks like her…I agree that opiate addiction is our new civil war – good way of putting it….Sam
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Dear Sam
I appreciate your coverage of our opioid\ opiate scourge in America and your take on the Midwest. We have, as a result of overprescribed narcotics and turning a blind eye to heroin trafficking one hell of a mess. Not only is there lack of treatment options for OPIOIDS and heroin abuse and overdoses skyrocketing from carfentanil, legitimate pain patients can’t get what’s needed for sufficiently controlling pain because of our inability to delineate between patients or addicts. Add lack of transparency in CDC guidelines for treating pain and a few “stakeholders” benefit while the guy or girl with chronic pain suffers. Some say no way no heroin. Others say I will use heroin if it helps with pain because I refuse to suffer and will risk felony arrest to be out of pain. That’s reality buddy, like it or not. We actually now have three epedemics. Opiate diversion, heroin addiction, untreated or undertreated pain that folx shouldn’t be forced to endure.
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Like i said a couple of days ago……lock all these good white folks up FOR BREAKING THE LAW.
Still have comrades locked up from the 80s. Why the F should i care about these turds? PC enough?
You erased my non PC comments geared at white folks. I thought you hated PCness?
I didn’t put them up because I didn’t understand them. the posts were scattered and hard to make sense of….please rewrite them and i’ll gladly put them up.
Sam, I really enjoyed your book. I want to add that the unemployment rate does not include people who have simply left the job market. Beware of statistics. As an addiction specialist and family physician practicing in Kentucky, I can tell you that the ACA does not cover addiction services. The reality is much more complicated. Medicaid “coverage” is not the same as access to care.
If you are interested in learning more about what I am experiencing day to day as an independent physician treating addiction, please contact me. If you are interested in supporting an organization that strives to raise awareness, end discrimination toward people with addiction, and to promote evidence based treatment of addiction, please consider supporting The Unbridled Project.
Molly – happy to get in touch. I think the point of the piece was that the unemployment numbers were in fact skewed because so many were out of the workforce, due to opiate addiction. i’m no expert in ACA stuff, but my impression is that it doesn’t cover that in Kentucky because the state didn’t opt in….In other states it does….that’s my understanding.
Hello. I am very interested in supporting raising the awareness of addiction and the abuse of opiates. The easily prescribed medications and the allowance of these deathly drugs that come into are country are unacceptable and heartbreaking for many people. I don’t understand how it Happens. We need to come together to stop the influx of serious drugs in our towns cities and county. Now. Before we lose anymore children.
Thanks for sharing but not sure if your points are political or awareness to the Heartland drug concerns? As a devoted Christian and born/bred Buckeye (Ohioan) my hope is that it was the latter. If correct what would be your next steps be in assisting with the overwhelming growth of these addictions you’ve noted? There’s no forsaking that God has given you a talent to write because your points are spot on however words without actions are just that “words”.
I attended the funeral of a 21 year young lady that lost her battle to a drug overdose while attending a rehab center. As I was leaving the funeral service I made a vow to myself to try and make a difference going forward someway somehow. If it’s ok I may use some of your resources noted above?
Doug – please do!
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I wonder if anyone – even as an experiment – has tried opiate maintenance as a solution.
In other words, how much of the problem is caused by the black market for drugs – fear of police and punishment, the resort to crime because of sky-high black market pricing, overdoses from adulterated or uncontrolled quality heroin, withdrawal symptoms when users can’t get their fix, lost jobs because of drug testing, etc., etc. – and how much by the opiate dependence itself?
What if doctors prescribed maintenance doses of cheap generic, quality-controlled opiates – on request?
It would kill the black market, users could keep working and afford to pay for their drug, there would be no more overdoses, dealer shootouts, or prison costs.
Has anybody even tried this? Why not?
Dave, Methadone treatment has long been available; it is effective for some addicts but obviously has little effect on the problem.
If people are buying opiates on the black market, obviously they either can’t get methadone (or legit opiates from an MD), or methadone is somehow inadequate for them.
Which bring me back to my original question – how much of the damage and misery is caused by the black market vs. the drug itself?
In the 19th century opiates were sold in pharmacies without prescription. Some people had problems, but nothing like the epidemic we see today. (Alcohol was considered a much bigger social problem.)
Has any place in the world tried simply asking doctors to write prescriptions for maintenance doses of opiates on request?
If no, why hasn’t this been tried even as an experiment?
If yes, how did it work out?
The opiate addiction epidemic is such a huge problem for so many innocent people – we need to actually do something about it, instead of simply bemoaning the situation!
Opiate users require more and more of the drug to get the same effect, even if that effect is merely a “maintenance” dose to stave off withdrawal. Methadone is not satisfying to most addicts; they have to be really motivated to get clean, and one could argue that being on methadone is not really being “clean.” For the people it helps, great.
I would love to see alternative options for pain control offered, like affordable acupuncture (perhaps covered by insurance.) I know people who have tried everything to control their pain, to make life bearable for themselves, and opioids are the only thing to get rid of pain completely. Montel Williams was determined to endure his pain without opiates. He eventually found marijuana gave him relief.
Russell Brand has a movie about this subject you may find interesting. I’m sorry, I’ve forgotten the name, but it should be easy to find.
Anne, as a long-term Chronic Pain patient I have been prescribed opioid therapy for 13+ years. I’ve been left with no alternative due to failed-back surgery where I was left with nerve damage. I’ve been on the same dosage for 10+ years and do not require more for pain relief. My doctor says most people reach an equilibrium and are comfortable at a standard dosage.
The people who constantly need more and higher dosages are those seeking to get high. I do not get high from my medication.
I never had any luck with acupuncture. I’ve had cancer pain and nausea and did smoke pot but found I needed to smoke it almost constantly to keep the side-effects at bay. It’s not for me but I know it does help some people.
I have been prescribed opioids for the past 13+ years for chronic pain due to failed back surgery. I had a herniated disc and went into surgery after trying everything to alleviate the pain. Unfortunately, I had a very bad experience and I’m left with 24/7 nerve pain in my back and down my leg to my foot. I have been on the same dosage of Rx opioids for 10+ years. I do not doctor shop or crave more. Opioids have given me a much better quality of life. This War on Opioids has made it increasingly difficult for pain patients to get prescription opioids as many doctors are now afraid to prescribe them, leaving patients to fend for themselves. This will push patients into the Black Market which is dangerous and deadly. A lot of the Opioid Epidemic is propaganda by people wanting tax money for rehab facilities. These facilities are financed by venture capitalists like Bain Capital who seek to profit off of addicts if the US Govt. votes to fund addiction recovery. I’ve found public opinion to be very against this proposition. The number of deaths in 2014 was 9,846 from Rx opioids, while 20,000+ are from illegal heroin and fentanyl. Most prescription opioid users are not addicts. There were 259 MILLION prescriptions for opioids written in 2012.
Thanks for your comments. I am sorry you have suffered and know this “epedemic” has severely limited access to opiates for those who benefit from not being bedbound. What’s really strange to me is addiction medicine and pain management doctors rarely agree. In fact, quite the contrary. If experts in addiction and pain management can’t find any middle ground, how are we benefited as a society? Now physicians are handcuffed and opiate “refugees” are everywhere. Chronic pain community UNITE!!!
I agree with you 100%!! It is all part of the political game that our government is trying to pass off as concern for the people in this country when really it is just a money making scheme for so many involved including our judicial system. People who believe the government really cares about whether or not they are healthy or who lives or dies have really been mislead. They don’t give a rats *** about us! It’s all about the money. They are causing more harm than safety to people in pain. The black market thrives and gets rich off of what our government is doing. If they took the time to really look at everyone who depends on opiates for control of chronic pain and not just the abusers, they would find that actually the percentage of problems from opiates being prescribed, and the help they provide for so many that include being able to work and have some quality of life, would show that the people who actually od and abuse is relatively small compared to the number they help. They will never do that! They only want to talk about the bad. Never the good. They want opiates to be perceived as evil and have even brainwashed society into discriminating all patients on opiates as drug addicts! People who feel normal just can’t understand what it feels like to burn and hurt all the time. Can’t stand in longer lines without agonizing pain. Maybe one day, they will understand…..
Yes. They tried it in Portugal with resounding success. The head law enforcement official there (like our attorney general), who was steadfast against the changes before they were made, says he is convinced and would never want to go back.
The U.S. is far behind much of the world on addiction.
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Not only your excellence at the craft of writing is laudable, so is your relentless investigative journalism. I was greatly informed by reading “Dreamland.” Attending your address in Columbus (N. B’way UM Church) was an additionally important educational event. Now with this piece, you assist us all in seeing a malaise that lies below the surface and breaks out infecting us not only medically and socially but politically. Thanks! Keep it up!
many thanks, ronald….very nice of you!
Why not have Purdue Pharma fund long term treatment for opiate addicts?
I don’t understand why the American taxpayer is on the hook for what this criminal organization has done. You detailed it very well in your book.
I think Trump and the Republican majorities are going to help.
But Purdue needs to pay and pay and pay.
political correctness from the right – “Who is going to shoot Obama?” – “Sieg Heil!” – “Get a brain, moran!” – is far worse, and hilariously thin-skinned.
“Free the TrumpRolled!”
Are you insane?
You stated that Obamacare covers treatment. If this is so, how and where does an addict get such help? Especially an addict who is in the prison system? There are many addicts sitting in the prison system that are not getting any treatment, and are simply waiting for release so the can get their next hit.
a lot depends on your state. if your state has not opted into this, then i don’t think it’s available. i think someone who has some knowledge about Medicaid in your state is the person to speak with. your prison most likely has a counselor of some kind who can tell you.
Before going further I want to make sure that all understand that the opinions expressed below are my own and do not represent those of any organization.
There are many concerns related to reversing the progress made in terms of addressing the current epidemic of opioid overdose, overdose deaths, opioid use disorder and opioid related adverse events. It is important for all who are looking to change the current health care delivery system to understand that this problem impacts everyone and that failure to address this will result in higher health care costs for patients on opioids, their families, and the community.
As horrific as the overdose death numbers are they are also just the tip of the iceberg. In addition to the overdose deaths there are patients with opioid use disorder, patients with medical and mental health comorbidities made worse by opioids and patients with poorly treated pain as the medical community has relied on therapies for chronic pain without the evidence to support their use while moving away from other (less expensive) therapies that are safer and demonstrated to improve pain more effectively over time.
In addition, there are false assumptions that tackling misuse and abuse is enough. In n many studies half of the people who die are taking medications as prescribed but are at risk related to being prescribed doses that are too high, prescribed with concomitant use of other medications that increase risk such as benzodiazepines, and are prescribed in doses that are risky even at low dose due to concomitant medical comorbidities. Even as we appropriately focus on the increasing problems related to illicit opioids , it is important to remember that most patients with opioid related problems still have them related to prescription opioids. In addition, 75-80 percent of patients with problems related to illicit opioids started or are still on a prescription opioid.
It is important for attempt to address this problem to understand:
1. This is not a problem that can be solved through criminal prosecution and deportation of foreign drug dealers alone without fully addressing the prescription opioid crisis that has fueled the illicit opioid crisis.
2. The relapse rate for patients with untreated opioid use disorder is very high and 90% or more in some studies. We currently do not have the infrastructure in our current health care delivery system to adequately treat all of the patients in this country who have developed opioid use disorder. Untreated opioid use disorder results in catastrophic consequences for patients, families, communities and the nation as a whole. Treating opioid use disorder (and substance use disorder in general) has been demonstrated not only to be effective but cost effective as well. To create a system which further decreases access to treatment will make this situation even harder to address.
3. All patients who receive opioids are at risk of developing opioid use disorder, overdosing or developing an opioid related adverse event. In a recent study even those on acute therapy had an odds ratio of developing opioid use disorder of 3. The odds ration jumped to over 122 in patients on long-term high dose therapy. In another study the risk of developing opioid use disorder on long term opioid therapy was over 40 percent.
4. Many patients (with and without opioid use disorder) have very costly opioid related adverse events (both personally and economically) and side effects such as increased risk of falls, cognitive problems, opioid induced hyperalgesia with worsening pain on opioid therapy, endocrine abnormalities, osteoporosis and severe constipation to name just a few.
5. Our current health care system has devalued the role and reimbursement at the primary care level leaving many primary care providers unable to deliver the important piece of care that includes disease self management, care coordination, and cautious use of specialty care. Specialty care for pain has been shown to be expensive and heavily reliant on passive modalities such as interventions, surgery and opioids. Much of the literature demonstrates that more active modalities need to be a part of everyone’s pain care plan for success.
Therefore, in order for us to tackle this effectively as a country we need to:
1. Make sure that treatment for opioid use disorder and all substance use disorder is available and reimbursed like any other chronic disease. We also need to work to address the stigma that decreases treatment opportunities.
2. Understanding that, because of reimbursement in the past and lack of understanding about the disease of addiction, we are in need of educating large numbers of health care professionals about approaches to this problem with evidence based treatment options. There needs to be increased educational efforts in all institutions that train health care professionals as efforts to educate those already practicing.
3. There needs to be improved mechanisms for treating substance use disorder in many settings, including primary care.
4. We need to address the fact that there is no evidence in the literature of effectiveness of opioids for treating chronic pain over time. Therefore, other mechanisms for treating chronic pain need to be reimbursed to offer alternatives to a therapy that has not been shown to be effective and has resulted in the greatest public health crisis that the American medical community has ever seen. In addition, research to look at alternatives to opioid therapy will need to be funded to get a better understanding of what does and does not work.
5. If we make getting insurance harder for patients with opioid use disorder we will then have large numbers of uninsured patients with a treatable disease who will continue to needlessly suffer with great personal and economic impact for everyone.
6. It is going to “take a village” to solve the problem of personal and community wide opioid related adverse events. This will require funding to improve a team based approach in health care settings, community resources to rebuild what has been lost due to the crisis and family treatment to recognize the negative impact on the family when even one family member has this very tragic disease.
7. We need to improve our health care reimbursement so that primary care clinicians can effectively perform the important tasks related to patient care that must be done in the primary care setting and have the time to do so.
As there appear to be calls to increase referrals to the private sector from the VA it is important to understand just a few of the thing going on in the VA as a health care system to address the opioid crisis.
1. There are educational efforts to increase the number of providers who are Buprenrophine waivered to increase options for this important treatment option for patients.
2. There is expansion of OUD treatment into the primary care and pain clinic setting.
3. There are regular educational programs on opioid safety for patients and clinicians
4. There are regular educational programs on pain for all clinicians.
5. There are a growing number of primary care based pain teams to improve access to pain care for patients with complex needs.
6. There are pain schools in many facilities to teach opioid safety and alternatives to opioid therapy.
7. There is wide spread distribution of overdose education and naloxone for all at risk of an opioid overdose (whether it is related to prescription or illicit opioids)
8. The VA and DoD are currently rewriting the chronic opioid therapy guidelines due to be released in early 2017.
9. There is pharmacy support for team-based approaches to pain care and medication safety initiatives in the primary care and pain clinic setting.
10. Through academic detailing support there is a wide array of educational products developed for clinicians and families.
11. There is ongoing communication between primary care, substance use disorder, pain and mental health clinicians about how we can better coordinate care and provide treatment in the most effective setting for each patient.
12. There is a primary care pain champions program that meets monthly, provides a monthly community of practice call and provides mechanisms for members to interact regularly about sharing innovations that improve pain care and opioid safety in the primary care setting.
13. There are educational programs related to the unique needs of the veteran returning from deployment.
14. There are multiple dashboards that can be used to help identify patients at risk for an opioid related adverse event in order to intervene.
15. Through the VA opioid safety initiative there is further education about risk factors for opioid related adverse event and facility based efforts to improve opioid safety. This has also resulted in a number of facilities creating opioid reassessment clinics in order to give patients on risky opioid regimens further support as decisions are made about the best approach to their pain care.
16. The VA has currently partnered with YMCA to improve access for veterans.
The current insurance reimbursement system has fueled a rapid pace style of practice with heavy emphasis on reimbursement for procedures and less reimbursement for non-procedure oriented care. It is so bureaucratically complicated it is difficult for many people to negotiate. If these issues are not addressed we will not solve our health problems related to many chronic medical conditions, not just opioid use disorder. Everyone seems to keep ignoring the fact that our current health care system does not receive high marks when compared to other health care systems in the world with our life expectancy rate at 43 and lower than most countries with universal health care options. Creating a new way to have access to a poor health care delivery system solves no problems. Whether you call it Obamacare, Trumpcare or something different it is my hope that we truly look at the issues at hand and not come up with yet another politically expedient quick fix.
Ilene Robeck, MD
Thank you for your thorough insights Dr Robeck, which as an addiction medicine and pain management specialist in a large multidisciplinary pain specialty clinic in Seattle, I agree with. I know the VA is working hard to get on top of the opioid crisis and do right by the patients.
My input here is that more physicians who practice pain management, whether in a pain specialty or primary care setting, need to get training in addiction medicine. This should include not only a buprenorphine waiver but also CME investment in addiction medicine review courses such as those offered by American Society of Addiction Medicine. If you prescribe opioids regularly, it is simply incumbent on you to be skilled and up to speed with how to screen for, assess, and treat substance use disorders. That does not happen in pain management training, and it should. Providers need to go out of their way to learn these skills. Those that do are able to help patients get the help they need and pursue safe, sustainable pain management choices, involving medication as well as other therapies and self-care strategies.
Thank you Sam for your keen insights! The link of the opioid crisis to the rise of Trump is a compelling and scary concept.
Excellent insights and writing.
There are two other concepts we must address. Doctor and patient education and the stranglehold of our current 12-step treatment facilities that simply do not work. How can any treatment that starts with convincing people they are powerless and with negated self-worth?
Patients need more than slogans, guilt based treatment and an antiquated disease concepts (debunked in just about every country but ours). Medical schools providing basic training and continuing education have to stress the need for more coursework in addiction and pharmacology. Most docs have little or no exposure to either. Except for those specialized or with additional training, docs do not have the foundation to help with either preventing or treating addiction. Sadly, a result for awhile will be a baby tossed with the bath water in terms of treating those in pain—mental or physical.
Many suggest 12-stepping is our unofficial national religion. As a culture we see nothing wrong with pumping people through sub-standard treatment over and over again. Public treatment is almost exclusively 12-step. The basics of the 12-step programs have not changed in decades and we let them get away with blaming the patient exclusively for treatment failures. There are alternatives that work much better, are cheaper, and can involve more people. While 12-step programs suggest dual diagnosed mental illness cannot be addressed at the same time as substance abuse the truth is it has to be. Collectively public and private 12-step treatment facilities will charge our system $15Billion or more this year. They almost brag about the few people that will actually benefit which has been well established by countless empirical studies to be about 3-5 percent. Put another way, that means 93-95 percent of what we spend on treatment is ineffective.
Hi Steven,
29 years 2 months and 1 day clean and sober today through the Grace of a Loving God I found through taking the 12 steps of Alcoholics Anonymous.
You seem bitter. Try the steps.
Love,
Loren
Hey Sam, how come you didn’t post my positive comments about 12 step programs? Are you another one of those biased left wing lunatic censor so called journalists? God I hope not.
It was a mistake and I’ve approved it – busy time. But in the future, keep your ad hominem attacks to yourself. You don’t know me. You don’t know my heart. Would you say that kind of rude thing to me if I were sitting in front of you? Could you not have considered human error as a cause? Why would your first impulse be to immediately attack my integrity? Don’t do it again, please! Happy Thanksgiving….
Hello Sam,
I apologize. I was wrong to call you a lunatic.
And my past experiences with censor ship does not make it okay for me to attack you.
I was wrong.
I hope you have a fantastic Thanksgiving also.
Loren
Having worked the 12 steps and having a fair understanding of them, I stand behind them as a useful and powerful path to heal a great many difficulties on the path to recovery.
That said, I disagree with the idea of abstinence only programs. NA ought to wise up about this.
I also think it is stupid to believe that the 12 steps are the best we can come up with. Why do we treat addiction differently than all other illnesses?
BTW The first step says “We were powerless…” not “We are powerless…”
Sam, you have a remarkable insight into the heart of cultural phenomena that led to America’s opiate epidemic. Connecting the dots to our recent political upheaval is incredibly insightful. You write that “Opiate addiction – to pain pills or heroin — is the closest thing to enslavement that we have in America today.” I share your questions about the new administration’s preparedness to embrace a new Emancipation Proclamation that will be necessary to abolish this slavery. Living in Ohio, I have also been stunned by the prevalence of support for the president-elect in our rural cities and towns. My fear is that this support will turn to anger if the promised change is not forthcoming. As you say, I guess we’ll see…
thanks so much Ken!
Thank you, Sam, what a terrific, insightful post.
Dear Sam-
As a Registered Pharmacist and Attorney your book Dreamland had me reliving the past 25 years of my professional life. How narcotics were rarely prescribed, then abundantly prescribed ( e.g. the ” corporate hustle” of the FDA- get a narrow approval then have people, some known, some unknown, promote it’s non-approved use ( not with the official OK of the manufacturer of course) for every ailment in the world that may cause pain, allegedly due to the commands of the stillborn jokers at JCAHO. And the societal fall out has not abated , over a thousand Americans die of an overdose every week, and the only real casualties of the “War on Opioids” are those who don’t survive an OD, physicians who prescribe buprenorphine and the pharmacies that dispense buprenorphine by the regulators that oversee its closed system of distribution. It is a great read and has enabled friends who don’t understand what I do get a grasp how devastating this act was that enriched shareholders but gutted the economy, moral fabric and the souls of millions.Thanks for the service your writing and commentary have accorded myself and others.
Sam,
I wonder if it was a perfect storm for a republican to lead the country or was it the republican congress intentionally not acting sooner? As you know CARA was passed with no funding and each day we lose 129 young people a day and yet emergency funding wasn’t put in place to afford treatment. The public seems to believe it was President Obama who didn’t act but it was a republican lead congress that removed the mandated funding of $1.1B . I don’t understand why the media doesn’t point this out. I am a parent who has lost a child to Big Pharma misleading doctors and sending their sales staff in to market Oxycotin and my son was given pain pills as a result of an adult at 14 years old. Why didn’t the doctors use extreme caution prescribing “heroin” in a pill? We kept pain pills just incase our family needed them and if the doctor instructed it was needed. Our son had access to our medicine cabinet because we didn’t know the risks no one was talking about misuse of pain pills. Unfortunately we found out he was addicted when he was 20yrs old and I thank God President Obama made it possible to insure my son be able to stay on my husbands insurance till 26 because for the 4 years he lived after we could put him back in treatment. I wanted to say this article really summed up why Trump won the electoral college. I hope he realizes he will be a one term president if he doesn’t insure mental health/drug treatment is affordable for the middle class and medical patients.
Very insightful analysis and writing. Thank you.
In Vancouver BC we have suffered a very destructive addiction history. The alarming development of ‘traditional’ narcotics now being spiked with fentanyl has caused a terrible overdose epidemic. The region is now seeing two deaths a day for those not able to be reached and treated.
The fenanyl is being smuggled in from China and cut into most street narcotics by a very entrenched drug gang pipeline. Local community agencies have been completely overwhelmed. This fentanyl development has had such stunning, tragic impact that there now seems to finally be more pressure for provincial and federal governments to take action.