The U.S. Surgeon General's Report on America's Drug Problem: Too Little, Too Late!
On November 17 a Report on Alcohol, Drugs and Health was released by the US Surgeon General, whose office describes his role as " ... the Nation's Doctor ... [who] provides Americans with the best scientific information available on how to improve their health and reduce the risk of illness and injury."
This is stated to be the first report by any Surgeon General to focus on the problem of drugs in America, and indeed it is. But how is this possible? And how can one explain the unqualified endorsement of "the first-ever Surgeon General's Report presenting the science on substance use, addiction and health" by, among others, the American Society of Addiction Medicine? ("ASAM applauds release of historic Surgeon General Report ...," ASAM Magazine, Nov. 17, 2016) After all, opiate addiction has been a medical and social issue of catastrophic proportions in America and in countries throughout the world for many decades, and it has gotten steadily worse. Thus, during the past 15 years tremendous concern has been voiced - appropriately! - from coast to coast, in communities large and small, regarding the massive increase in dependence on opiates (heroin and prescription pain medications) and the number of deaths with which that increase has been associated. Most recently, a study in the current issue (Dec. 12) of theJournal of the American Medical Association-Pediatrics found that between 2000 and 2012 "incidence rates for neonatal abstinence syndrome and maternal opioid use increased nearly 5-fold ..."
In her foreword to the Report, the Principal Deputy Administrator of the Substance Abuse and Mental Health Services Administration underscores the magnitude of the problem, stating, "Seventy-eight people die every day in the United States from an opioid overdose, and the numbers have nearly quadrupled since 1999"; the Deputy Administrator then goes on to join the chorus of others in expressing her pride at the release of "this first report of its kind."
The apparent oversight of the Surgeon General's Office with respect to the problem of drugs is in stark contrast to its forceful, and laudable, role in addressing other major health issues in America. Thus, in the past 50 years there have been 34 reports issued, of which 31 have addressed the problem of smoking! It goes without saying that smoking and its consequences have been and remain enormously important clinical and public health challenges, and everything possible must be done to address them. But for the Surgeon Generals' reports to the American public over the past half-century to have ignored totally the problem of opiate use? It is truly baffling!
As for the substance of the Report, the key conclusion seems to be that addiction is a disease and not a "moral failure." This leads one to wonder where the Surgeon General - and a great many other authorities in this field - have been. The compelling call to recognize addiction as a disease and to treat it like any other was made by a New York internist, Ernest Bishop, in a book on addiction he authored almost 100 years ago - in 1920. Dr. Bishop wrote then that "One of the essentials for the ... management of the narcotic drug problem is the realization by the medical profession, legislators, administrators and laity that opiate drug addiction is a definite disease entity, to be treated as such ..." (Bishop ES, The Narcotic Drug Problem, Macmillan; New York, p. 61) Dr. Bishop's call to recognize addiction as a disease was echoed repeatedly in the decades that followed. For example:
In 1926 the Rolleston Commission in the United Kingdom concluded: "Addiction to morphine and heroin should be regarded as a manifestation of a morbid state, and not as a form of vicious indulgence."
In 1963 a Canadian physician, Robert Halliday, stated: “It is now widely accepted that the addict is a sick person…”
In 1997 the Director of the National Institute on Drug Abuse (NIDA), Dr. Alan Leschner, published a paper in Science entitled "Addiction Is a Brain Disease, and It Matters."
In 2007 the UN Office of Drugs and Crime stated, "Addiction is a disease that needs to be treated …”
In 2011 the Board of Directors of the American Society of Addiction Medicine noted, "Addiction is a primary, chronic disease... "
And in 2012 a NIDA publication stated once more that “… drug addiction is a complex disease ..."
Even the lay press has taken up the call, emphatically and unequivocally: in an editorial in 2015 the Newark Star Ledger wrote that it was time "... for state officials to proclaim in one voice this immutable truth: Drug addiction is a disease.”
So again, one must wonder where the US Surgeon General has been. Wherever it was, he has had plenty of company. For example: in a preface to the current Report the Secretary of the Department of Health and Human Services states, "One of the important findings ... is that addiction is a chronic neurological disorder and needs to be treated as other chronic conditions are."
As for the future, the Report seeks to leave readers with "hope and optimism" by stating that "effective treatments for substance use disorders are available." In theory they certainly are, and they have been - or should have been - for many decades! And yet, the Surgeon General himself, in his Executive Summary, estimates the number of Americans who in 2015 needed treatment for an illicit drug problem - treatment that seemingly was notavailable to them - at 7.7 million! And this gloomy assessment is consistent with others: just a month before the Surgeon General's Report was released, the Democratic Staff of the Senate Committee on Finance issued a report with the dramatic - and tragically fitting - title: "Dying Waiting for Treatment." The Committee noted the "... devastating lack of capacity to treat those seeking help [for substance use disorders] ... [U]pwards of 80 percent of people in need of treatment are unable to access services - with many put on waiting lists for weeks or even months before there is capacity to care for them." That report goes on to state: "More than half the counties in America - 1,678 - do not have a single physician who is approved to prescribe [medication-based] therapy..." It also cites a study of the very small number of physicians who had sought and obtained authorization to provide office-based treatment that found a quarter had never treated a single patient. How can such statistics be reconciled with the Surgeon General's statement that "… effective treatments are available"?
Perhaps most distressing is the current Report's lack of any reference to goals going forward: what proportion of the nearly 7.7 million who today, in the words of the Senate Committee's report, are "dying while waiting for treatment" will get it, by when, and through implementation of what specific strategies? ASAM certainly does not add to "hope and optimism" when it states, "Ensuring the next generation of medical professionals is equipped to screen and treat patients for addiction will require major changes to clinical professional school curricula, and ensuring patients can access these services will require health plans and insurers to pay for them ..." (ASAM, 2016, emphasis added)
Regarding ASAM's reference to the need for "health plans and insurers to pay" for treatment of drug use problems, it is discouraging - to say the least - that the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), a plan for dependents and survivors of US military,explicitly and without exception refuses coverage for opiate agonist medication used in the maintenance treatment of addiction.
And what about Medicaid, the Federal insurance program that states it is "... committed to working in close partnership with states, as well as providers, families, and other stakeholders to support effective, innovative, and high quality health coverage programs"? Consider as one example Illinois. According to ASAM, "Illinois Medicaid does not cover methadone for the treatment of opioid use disorder" (ASAM, emphasis in the original). With regard to buprenorphine, a newer medication also found to be effective in treating opiate use disorder, and that in contrast to methadone is available in office-based practices of approved physicians, the same ASAM report states that Illinois Medicaid covers such treatment, but for a "lifetime period of 12 months," and subject to prior State approval for every individual applicant, mandatory acceptance by every patient of substance abuse counseling, and strict adherence to dosage limits, established by fiat, that are completely unsupported by the evidence.
For sure, the exclusions and restrictions imposed on a treatment option widely recognized to be the "gold standard" of care, in programs operated by and with funding from government, do not bode well for eliminating barriers to care by insurance companies in the private sector. Indeed, they seem to reflect and reinforce the stigma associated with this treatment among healthcare providers, insurers and the public at large.
Yet once more: where has the Surgeon General's Office been, and what specific proposals will it offer for the future? In the interim, how many of those needing care are projected to "die while waiting"? Every American deserves and should demand answers!