Last week the Philadelphia Department of Public Health reported the first glimmer of hope after many dark years of the opioid crisis: an 8 percent decline in drug overdose deaths last year, from 1,217 in 2017 to 1,116 in 2018.
The crisis has been so devastating that it strains comparisons. Nationally, more lives lost in a single year than lost in the entire Vietnam War. The only man-made health problem big enough to cause a decline in life expectancy. In Philadelphia, three overdose deaths for every homicide. An epidemic in which children have lost parents and parents have lost (often multiple) children. A drug crisis mostly hidden in homes but also overflowing onto the streets in the form of strewn syringes, homeless encampments, and men and women nodding off on sidewalks.
This ongoing tragedy arose from decades of over-prescribing painkillers by medical providers — leading to tens of thousands of Philadelphians dependent on these prescription opioids — combined with aggressive street marketing of heroin and, more recently, the ultrapotent opioid fentanyl.
The new hope comes not from the size of the drop in overdose deaths, but that it represents a radical change from steep increases in the five preceding years. And there are three solid reasons to believe that the reversal may mark a long-term turning point.
First, many doctors are finally learning to stop feeding the problem with unnecessary opioid prescriptions. In just the last two years, opioid prescriptions to patients covered by Medicaid have fallen by more than half.
Second, we’re seeing a surge in medication-assisted treatment for opioid addiction. The number of people on Medicaid with a diagnosis of opioid use disorder who received buprenorphine (Suboxone) surged sixfold from 2015 to 2018. That’s because Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services has improved access to medication-assisted treatment and hundreds of primary-care doctors are offering buprenorphine treatment themselves rather than relying solely on specialized drug treatment programs. The Philadelphia Department of Prisons is now routinely offering buprenorphine to inmates with opioid addiction, and hospital emergency rooms seeing patients for drug overdose are starting the medication on the spot.
And third, more Philadelphians are carrying and administering the opioid antidote naloxone to save the lives of those who overdose. Over two years, the city has distributed nearly 80,000 doses, and residents themselves are buying an additional 20,000 doses a year from pharmacies.
Still, this progress could stall or the decline in overdose deaths could be agonizingly slow unless we do more. The doctors still prescribing opioids for low back pain or arthritis must stop, and those doctors should help their patients who are dependent on opioids gradually shift to safer forms of treatment. The medical-care system must fully and permanently embrace drug-abuse treatment as a core part of primary care. And the residents whose family members are quietly addicted to opioids at home should encourage their loved ones to get treatment, and be prepared with naloxone to save those family members until they are in recovery.
Also, as part of the solution, Philadelphia’s Resilience Project will continue to work in the Kensington area, which has been hardest hit by the epidemic, to increase access to treatment and reduce overdoses as well as improve quality of life for residents. Philadelphia must also continue to move forward with the proposal to open one or more overdose prevention sites — locations to keep people who are not quite on the road to recovery alive long enough for them to take that road. This must include a public safety plan and a community dialogue on potential sites.
If we take these steps, the crisis will still not be over. Too many people are addicted; many will need medication-assisted treatment for years. But if we take these actions we can, in the next few years, further reduce overdose deaths, help tens of thousands of Philadelphians rebuild their lives, and reclaim the streets in the most hard-hit neighborhoods.
Now is not a time for self-congratulations but merely a moment to take a breath of hope to sustain us as we all work harder to end this tragedy.
Thomas Farley, MD, MPH, is the commissioner of the Philadelphia Department of Public Health.