WASHINGTON -- Although the government can do its part to reduce the opioid abuse crisis, the underlying problem is a cultural one that can't be solved solely through government actions, several speakers said Wednesday at a discussion sponsored by the American Enterprise Institute (AEI), a right-leaning think tank here.
"This crisis is not a failure of government; it's a failure of culture and other things," said Danny Seiden, deputy chief of staff to Arizona Governor Doug Ducey (R). "Government alone is not going to save us."
Nicholas Eberhardt, the Henry Wendt chair in political economy at AEI, noted that those parts of the country with a higher proportion of religious adherents generally didn't seem to have as high a mortality rate among middle-aged white men -- one of the groups getting hit hardest by opioids, as well as by alcohol and suicide -- as other areas. "This obviously is not something that's amenable to government policy -- I hope we don't have a Department of God -- but we have to recognize some of the civil society and social capital aspects of the crisis in mortality that we're in."
Medicaid's Role
One study found that in 2013, among unemployed white men, ages 25-54, with a high school education or less, 75% were enrolled in a disability program -- something that established their eligibility for Medicaid, said Eberhardt. And once they got onto the Medicaid program, "they could go to a 'pill mill' and get a 90-day supply [of opioids] for $3 up front and Medicaid would pay the rest," although those rules are being tightened up, he said, calling it a "horrible deadly consequence" of Medicaid enrollment.
On the other hand, Medicaid is also being used by both parties to help treat those with opioid addiction, said Harold Pollack, PhD, professor of social service administration at the University of Chicago. "The Affordable Care Act's Medicaid expansion is the model for successful bipartisan [work] on health policy ... If you call someone in a random state, the conversation you have is that they're trying to get people into residential treatment and get Medicaid to pay for that. It's about the work, not about the politics. I find that very encouraging."
Pollack described a program he is working on in the Cook County jail, where 80% of the prisoners involved with drugs are in the Medicaid expansion program. Many of them are at their maximum level of vulnerability, in terms of relapse, when they leave the jail, "and they [often] slip through our fingers" and don't show up for treatment the next day, he said. So the researchers set up trailers to give these newly released prisoners "three hots and a cot" and then take them to someone who provides addiction treatment.
"This costs about $168 per night, and Medicaid expansion is what makes that possible ... Everyone around the country is trying to do stuff like that," said Pollack.
A Difficult Problem
One audience member, an intern at another conservative think tank, took issue with that approach. She explained that her family was fairly well-off and got very engaged in helping her father with his addiction -- but he died from it anyway. "He went into treatment multiple times and it didn't do any good," she said. "If my dad didn't care when I held his hand taking him into treatment ... Why would it do any good for a stranger [taking a released prisoner there] with no hope and no job?"
Sally Satel, MD, a resident scholar at AEI and a psychiatrist at an addiction treatment facility, said that people such as the intern's father are among the hardest to help. "They must have some inner pain," she said. For some people, it's useful to teach them tricks for preventing relapses, such as making sure they don't walk home on the same street where their drug dealer hangs out, and having them get their paychecks direct-deposited instead of in check form, "but your dad knew how to do all that. This is very tough."
Pollack also called for more data. "We know less than we should about what's happening out there," he said. "We need a solid epidemiological system that actually gets at the people who are using," not just those who dutifully fill out the surveys.
Seiden listed several steps the state of Arizona has taken, including Monday's declaration of the crisis in Arizona being a public health emergency. "That gives us rulemaking authority and advanced surveillance," he said. The state is also requiring that its doctors check the Controlled Substance Prescription Monitoring Program database before prescribing, and it has limited all first prescriptions for opioids among Medicaid beneficiaries and state employees to no more than 7 days.
On the interdiction side, Arizona partnered with the federal government and has so far intercepted 176 lbs. of heroin, "which translates into millions of hits," said Seiden. "Attacking that won't solve the demand problem," but at least it's something.
Encouraging Prevention
Prevention is another aspect of the solution that has kind of fallen by the wayside, Seiden said. "There are pilot [prevention] programs we started that we're very excited about," including one program in junior high schools. "Wouldn't it be much better if we could prevent people from becoming addicted?"
The state also has an overdose review panel to review any death from an overdose, to evaluate whether state and local officials could have intervened. "Our Medicaid programs; are we enabling this? Does access to opioids get them started? I think people don't think of this as an epidemic ... It has almost become OK to see people taking pills, and that's part of the problem," he said.
In response to a question from the audience, Pollack said he liked an initiative the Canadian government has started in which people are given safe, clean locations in which to inject the drugs they are taking. "That's an interesting harm reduction intervention, and there is some evidence it's valuable for people," he said. While he would never oppose such a program if it came to the U.S., "I've got a bunch of things on the list that I'd want to do first that are much more consonant with the norms of American drug policy," such as needle exchange and medication-assisted treatment.
As for the idea of legalization, the opioid crisis "is a kick in the pants for legalization in such an interesting way," Pollack told ڴŮ. On the one hand, "we've got these legal products that are killing people ... One side of the argument is if you legalize the drugs and provide them through the medical system with known quality and dosing [it will help solve the addiction and violence problems]; we did that with opioids. Nobody's being killed selling opioids, it's just that people are dropping dead using the opioids." At the same time, "The 'drug warrior' type of approach is also not going do it, because we're shifting people into the street substances ... which are too prevalent and too cheap."