Will Declaring a National State of Emergency Solve the Opioid Epidemic?
“The opioid crisis is an emergency, and I’m saying officially right now it is an emergency,” the President informally stated on August 10th, directly after the publication of an interim report released by the president’s Commission on Combating Drug Addiction and the Opioid Crisis recommending the opioid crisis be identified as a national state of emergency. Despite President Trump's announcement a few months ago, there has been no formal declaration from the administration at this time.
A formal declaration was made on Thursday, October 26, 2017.
The opioid crisis has been at the forefront of the national consciousness since the election revved up in 2015. Sensational headlines have dominated the news cycle and words, such as naloxone, that were once parlance for those in the field are now commonly known throughout the general population. Before, opioid may have been a nebulous word, jargon referring to a class of drugs, but now most people can tell you that an opioid includes prescription pain relievers, heroin, and fentanyl, among others. National Institute on Drug Abuse (NIDA) estimates that more than 90 Americans die every day after overdosing on an opioid, and Sheelah Kolhaktar wrote in the September 18th issue of the New Yorker that some estimates put a $78.5 billion price tag on the cost of the opioid epidemic on the national economy. There is no doubt that something needs to change, that we are not providing the help and care individuals need in order to combat Opioid Use Disorder. But is declaring a national emergency the solution?
What would a state of emergency mean?
Well, first of all, it depends on which laws the administration uses to declare the state of emergency. There are two obvious options: the Stafford Act and a Public Health Emergency. The Stafford Act is enacted by a declaration from the current president and is typically used in the case of a natural disaster in order to support local and state governments in providing resources to the people. Invoking power under the Stafford Act allows for an increase in funds to treatment and/or law enforcement. The Public Health Emergency is declared by the Secretary of Health and Human Services and would increase treatment providers, either through mobilizing medical staff or training providers in underserved areas. Both options would make logical sense for different aspects and populations of the opioid crisis, however neither provides the whole picture support that is needed.
The interim report is unclear as to which route it would take in their national declaration, in part due to the different recommendations it makes. A final report will be issued this month. Hopefully, in that report the recommendations will be more definitive as to which approach (Stafford Act or Public Health Emergency) will be taken if a state of emergency is declared. Even Michael Botticelli, former head of the Office of National Drug Control Policy, has commented on the vagueness of the current administration’s plan, asking: “I think the question really becomes, not that you just say it, but what are the actions behind it? What are the series of actions that you’re going to take as a result of that declaration? There is some merit to it, but only if that brings along with it real meaningful action.”
This chart outlines various recommendations made by the president’s opioid commission and which invocation of power would enact the recommendation, with the third column highlighting that some of the recommendations are unclear under which legal umbrella they would fall.
Would this be unprecedented?
Well, yes and no. Declaring a state of emergency for a behavioral health issue on the national stage is unprecedented, but it is following the lead of actions taken by six state governments: Maryland, Massachusetts, Alaska, Arizona, Virginia, and Florida, all of which have taken unique approaches to the crisis tailored to their state’s needs. Alaska issued a disaster declaration, pointing out that, just like a natural disaster, their population is sustaining a loss of life, a threat to property (they specifically cited due to crime; however, if you look at the economic breakdown of the New Yorker article cited above, there are numerous factors influencing threat to property), and limited capacity from local agencies. What is interesting and unique about a disaster declaration is that it expires after 30 days. Despite the tight timeline, this call to action inspired state agencies to team up for more of a collaborative model of treatment versus the siloed approach many agencies across the country are taking.
Virginia took another approach, Virginia decided it wanted to ensure everyone had access to Naloxone so the State Health Commissioner, Dr. Marissa Levine, declared a Public Health Emergency in order to provide a statewide standing order for the overdose reversal drug.
These are just two different approaches states have taken to handling the unique ways the opioid crisis is affecting their population. All six states declared states of emergency in order to implement specific solutions that reflect their specific needs. The solutions outlined in the president’s opioid commission’s interim report are broad sweeping and reflect much of what is already happening on a state basis. It is not clear that these would solve any of the current needs and concerns of this epidemic. Instead of continuing to look at population of individuals abusing opioids as a homogeneous group, we need to break down the different cultures of use and tailor supports based on individualized needs.
Wait, wait, wait... what do you mean there's different cultures of use?
When I think of patterns and cultures of use, usually the last thing I think about is the drug itself. Questions of frequency, context, route of administration, time/effort/energy spent, co-current substance use, etc. are often what first come to mind when trying to understand someone’s habit. That’s because these things, along with social supports, ability to function independently, and mental health tell me much more about a person’s usage and where my concerns lay.
It is worth noting that while the DSM-5 differentiates between various substance related and addictive disorders (Alcohol Use Disorder, Cannabis Use Disorder, Inhalant Use Disorder, etc.), much of the diagnostic criteria is similar (taking larger amounts and for longer than intended, wanting to cut down or quit but not being able to, spending a lot of time obtaining, craving or strong desire to use, repeatedly unable to carry out major obligations, continued use despite persistent or recurring problems, stopping activities due to use, recurrent use in hazardous situations, consistent use despite persistent difficulties, withdrawal, and tolerance). The main tenets of diagnosing a substance use disorder focuses on not the drug or its psychoactive effects, but how the substance impacts their daily functioning. So when we discuss treatment, we need to not focus solely on the drug that we are targeting, but global issues facing the individual and their culture of use because this is crucial to understanding the specificity of their substance use.
Okay! What are some of the different cultures as it relates to the opioid crisis?
One of the cultures of use is hiding in plain sight. “Drying out from drinking lean is probably the worst feeling in the world," said the rapper Gucci Mane in ESPN’s Highly Questionable. Lean (also known as purple drink or sizzurp) is made using cough syrup with codeine, codeine being an opioid.
You can find references to it throughout rap lyrics. It is not a covert use of opioids that we usually associate with addiction, but in broad daylight. Gucci Mane has been vocal about his unhealthy relationship with the drink and it’s a topic he explores in his new memoir, yet few have made the connection between the rapper’s struggles and the national conversation. Often times when we discuss the opioid crisis, the groups we refer to are white and rural or suburban, yet here is a clear example (and not an isolated incident, but representative of a larger trend) of a cohort of opioid users who do not fit the narrative currently being constructed. Some elements that make this cohort unique: route of administration is oral (versus intranasal, intravenous, or smoked), which is a less extreme means of ingesting the drug and it has a tendency to be used socially, so there is reason to believe one of the most effective treatments for this group would be simple psychoeducation on what lean drink is and the potential consequences. Simply by being open about his own struggles with lean, Gucci Mane is acting as an agent of change. This would be a minimal intervention, however declaring a state of emergency doesn’t really seem to address this group. By not involving the lean drink in the same, compassionate conversation that is being had around what we more traditionally consider to be opioid use, we are continuing to guarantee a perpetual cycle of opioid misuse among these populations.
While women have not been left out of the conversation (or at least white women haven’t), much of the solutions offered by the president’s commission are not responsive to the unique experiences of women and how they access treatment (or oftentimes, don’t). It has been widely reported that the face of the opioid crisis is young, white women from middle class backgrounds and yet walk into any opioid treatment program or hospital detoxification program and you will find an overwhelmingly male population; anecdotally, Bellevue Hospital Center will quite often not even have a woman on the detox unit. What barriers keep women from seeking help from these traditional treatments? Well, to begin with, coed rehabilitation centers are not always the most welcoming for female service recipients. Many women have revealed being approached or on the receiving end of predatory behavior by their male peers, which creates an environment that feels unsafe to the women and can lead to retraumatization. There are also a number concerns related to legal repercussions that keep women from seeking treatment. There is a significant population of female opioid users who engage in sex work and for mothers the threat of child protective services can keep them from seeking the help they need. The stigma of being a mother or sex worker who uses drugs that is then reinforced by the authorities and punitive measures can keep women from seeking treatment.
These concerns are particularly true for women of color, a population that has been made practically invisible during the national conversation on opioid use disorder. In an article for Glamour, Lula Beatty, Ph.D, now senior director of health disparities at the American Psychological Associate and who spent 20 years as the director of special populations at NIDA, states: “It can be more difficult for African American women to admit it and try to get help than for white women because of the stigma.” Women of color in general, have to struggle with the overlapping stereotypes of criminality and violence that plagues both individuals with substance use issues and minority communities, in addition to the barriers that women overall must deal with. In the Leah Samuels article for STAT News on the opioid epidemic and families of color, Dr. Helena Hansen, a New York University psychiatrist and anthropologist, elaborated on this stigma and how it relates to black women: “I’m a black person...and if I were to die of an opioid overdose, my mother would not say anything about my overdose death, because she is working against stereotypes of black women as addicts and sex workers.” And this is just the tip of the iceberg about why women, especially women of color, will not benefit from the policies laid out in the interim report.
One of the most effective ways to help women engage in treatment is the low threshold, low barrier intervention of drop-in centers. Facilities where women don’t necessarily need to get clean, they don’t need to enter treatment, they don’t even need to divulge information about themselves. They can just show up for a safe place to come down, for a place to get food or drink, clean needles, and start to feel out the treatment landscape without having to jump in feet first. This has proven time and time again to be one of the most effective ways of treating women with opioid use disorder and is in line with one of the main tenets of harm reduction: meet the client where they’re at. Yet, despite this clear and obvious solution that would target a significant portion of opioid users, the culture of being female and a drug user, of being a woman of color and being a drug user is neither acknowledged nor represented by the interim report.
Another group that gets left out of the discussion is a surprising one: the baby boomers. A report by the Office of Inspector General for the US Department of Health and Human Services found that medicare was spending $40 billion on opioid prescriptions for long-term, chronic pain and the CDC found that 44% of adults who overdosed between 2013 and 2014 were ages 45 to 64. Ages 50 to 69 are the fastest growing users. Some point to the generation’s comfort with illicit drug use (much more mainstream than their parents’ generation) as a potential reason why the numbers are so high, a continuation of their mood altering experimentation that was put on pause to raise families and start careers. Others consider the generational unaddressed trauma (both experienced and vicarious) of growing up during the Vietnam War as potential reasoning for their high numbers of use. Regardless of the reason, this group is unique in a number of ways, including the trajectory of their addiction. Their use begins in the doctor’s office and typically remains there until the habit is kicked one way or another; this group is not moving on to heroin, which is a path that younger populations commonly take.
What are the solutions?
And this is where I wave my magical wand, throw some glitter, clap my hands and poof: answers. Or maybe not. The opioid crisis is complex and is going to take long term solutions beyond what declaring a state of emergency might do. Dr. Georges Benjamin, executive director of the American Public Health Association, put it best when he said: “It’s a PR stunt if it doesn’t come with money, and doesn’t come with a total government commitment to give people the best access to health care to resolve this issue. Unless you do that, all you’ve done is made a statement.”
An interesting fact that many have been fast to point out is that there seems to be a correlation between opioid abuse and the effects of the great recession. While I think there is no singular reason why we are seeing a drug epidemic of these proportions, what this point highlights is important: this is beyond just the power of the drug. Dr. Carl Hart, a leader in the field of substance use research, has pointed to three risk factors for developing a substance use disorder: being young, being unemployed, and having a co-occurring psychiatric illness. A declaration of a state of emergency would do nothing to increase the likelihood that supports for the issues of unemployment and mental health care.
Opioid Use Disorder is oftentimes likened to diabetes, a disease that needs ongoing maintenance and treatment and monitoring. However, maybe thinking about Opioid Use Disorder as the disease that we are targeting is the mistake. We need to recognize who uses, why they use, and that what they need is diverse and more often than not a symptom of a bigger issues. The problem with the proposal for a declaration of a national emergency is that it is stuck on opioids as the problem, as if getting people off drugs is the solution, and for some that may be the case, but for many their use is connected to a need for social supports, for mental health treatment, being connected with resources. It’s time to re-think our idea of treatment as being black or white, sober or not sober. The focus needs to be on the individual’s ability to function and cope in the world. Treatment and recovery exist in shades of gray and call for a multi-systems approach. Until we look at overall access to health care and social welfare programs, we will continue to do a disservice to substance using populations and set them up to face unrealistic expectations. By centering the individual in a holistic treatment, supporting their strengths and integrating them into their communities we have a better chance of creating lasting change.