Last month the Centers for Disease Control and Prevention announced that our country is facing a major public health epidemic.

Hint: it isn’t Ebola or SARS. And it isn’t avian flu or any of the other scary sounding public health threats that so often raise alarm bells in the media.

What is it? Drug addiction. An epidemic largely hidden from view and generally ignored by the media, yet an epidemic that far too many families across the country have been painfully aware of for some time. The particular drug that has risen to epidemic levels of abuse at this time is heroin. Heroin led to more than 8,000 overdose deaths in 2013 alone; rates of heroin addiction have quadrupled in just over a decade.


A Historical Perspective on Opioids

Heroin is an opioid drug derived from the poppy plant. It has no medical use and is typically injected to produce a time-limited high. It also produces a rebound withdrawal sickness in those who become addicted to it. Heroin is no longer a drug that is just abused in cities. Overdose deaths and new cases of addiction are particularly prominent in some of our most rural states, such as Vermont, Indiana, and New Mexico.

But heroin is not the only opioid drug – and this is not the only opioid epidemic we have ever faced. Just three years ago, the CDC and four other federal agencies officially designated prescription opioid abuse and overdose to be a national epidemic. Prescription opioids such as OxyContin, Lortab, and Dilaudid are now the largest class of prescribed medications. These opioid medications are legally – and usually appropriately – prescribed by physicians for relief of pain. Yet these drugs are opioids too. They have the same pharmacological properties and they can have the same negative consequences as heroin, including lethal overdose and addiction.

Historically, most opioid overdose and addiction epidemics have come courtesy of wars. Opioids are widely used in time of war to treat wounds and injuries. Opium prescribed to Civil War soldiers produced our most serious national opioid addiction problem (See White et al., 2003), but illicit heroin and prescribed pharmaceutical opioids in the Vietnam and Iraq/Afghanistan wars were also devastating to young,service veterans, and later to their families and their communities. The history of our federal response to these epidemics is also interesting. Always seen as a legal problem, the response to these epidemics has typically come directly from the Justice Department. The United States typically decides to “crack down” on those who bring drugs into the country and those who sell or distribute them using expanded interdiction, policing and criminal penalties as the major instruments of a federal response.

But these most recent U.S. opioid epidemics are different - no war and no foreign country to blame. This one is “Made in the USA.” The dramatic increases in opioid overdose incidents (over 200,000), overdose deaths (over 16,000) and opioid addictions (15 million) are a clear result of the extraordinary increase in prescribed pharmaceutical opioids to treat pain: more than a 700% increase since 1997 (Paulozzi et. al., 2011; Atluri et. al., 2014). The origins and course of both these opioid epidemics (heroin and prescribed opioids) were summarized by CDC Director Thomas Frieden: “Heroin use is increasing at an alarming rate … driven by both the prescription opioid epidemic and cheaper, more available heroin.”


Taking a New Approach

This time the federal response is different as well, coming from the director of the CDC - our major public health office – and not just the directors of Homeland Security or Justice. Frieden called for "an all-of-society response – to improve opioid prescribing practices to prevent addiction, expand access to effective treatment for those who are addicted, increase use of naloxone to reverse overdoses, and work with law enforcement partners like DEA to reduce the supply of heroin." This says a lot to me – particularly that our country has begun to take a full-fledged public health and public safety approach to the epidemic of opioid use problems. I agree with Dr. Frieden: "it is time we use all the resources we have."

This is not just political rhetoric or wishful thinking – science has given us many effective prevention, early intervention and treatment options that have never been a significant part of our nation’s response to opioid drug problems. For example, there are two Food and Drug Administration-approved medications that can prevent or reverse opioid overdose, four that can effectively treat opioid addiction, and one that can prevent re-addiction. But because drug abuse has long been cast as purely a legal or law enforcement issue, most physicians have never been trained to prescribe these medications; not all pharmacies carry them; and many insurers (both governmental and private) will not offer reimbursement for them. Similarly, there are research-tested community prevention programs that have demonstrated 25-40% lower rates of teen-age use and comparably lower rates of related problems of school drop-out, and delinquency in communities that use them. But again, there has been no coordinated federal or state effort to bring these proven prevention programs to scale.

Opioid epidemics will continue to occur with increasing regularity in this country unless we get serious, get scientific and get organized. But the good news is that this and future drug epidemics can be effectively faced and stopped. We have the means; we just haven't used them:

Better physician training combined with broader use of existing technology can reduce improper prescribing of opioids. That's one part of the problem.

States and communities can stop ineffective, uncoordinated prevention and implement tested, cost-effective programs that will alert, educate and equip families, schools, law enforcement, and healthcare agencies with the tools they need to prevent or intervene early at signs of any drug problem. That will help too.

But healthcare providers and insurers must also stop willfully ignoring the addiction problems throughout healthcare settings and decide to finally provide the research-derived medications, behavioral therapies and therapeutic monitoring that can make recovery an expectable result of treatment for opioid addiction.

These latest calls from the CDC suggest that we have finally begun to move past an ideological approach to drug abuse and towards policies based on the best science. Maybe soon we will also find the public and political will to demand the full complement of our public health and public safety tools to combat these deadly epidemics.

A. Thomas McLellan, PhD, founder and chairman of the board of the Treatment Research Institute in Philadelphia, is a former deputy director of the White House Office of National Drug Control Policy.

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