Bubbling Up

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The opioid epidemic is one of Missouri’s most pressing health issues. To put it in perspective, roughly 64,000 Americans died from drug overdoses in 2016, with 49,900 of those deaths related to fentanyl, heroin, and prescription opioids. In Missouri, overall overdose deaths were up a shocking 28 percent from 2015. Rural communities are being hit particularly hard. We’re in crisis mode! But how have things become so dire that many police departments now carry the opioid overdose antidote Narcan? It’s essential for us to investigate the long-term factors that led to this epidemic, if we are going to respond to it in the most effective way possible.

Source: CDC – National Center for Health Statistics

The epidemic deserves sustained action and careful examination from multiple perspectives. The complex intersection of how we treat pain and the dynamics of addiction raises numerous health issues. The crisis is usefully viewed at the juncture of the societal and the personal. At a societal level, what are the conditions that allow addiction to flourish? At the personal level, how are those conditions experienced, thus contributing to addictive behavior?

The economic trends associated with the restructuring of the economy over the last several decades set the stage. Tellingly, the lag in purchasing power affected the vast majority of Americans, a precursor to the opioid epidemic’s widespread effects.

Source: The Department of Labor’s Bureau of Labor Statistics

These long-term trends reflect a crucial blind spot in U.S. economic and social policy throughout this time period. The impact on a wide swath of Americans was neglected and steps to invest in a foundering segment of our workforce have been too small and too late. In short, we had an economic situation rife for what can be called “adverse adult experiences,” analogous to the well-known adverse childhood experiences. Being fired; getting evicted; having a car repossessed; losing health insurance; family trauma like divorce, serious illness, or death – due to economic trends, all these and other everyday obstacles have become more likely to occur for many Missourians. And these events accumulate over time, reinforcing their negative effects and leading people to lose hope, to doubt their self-worth, to despair at their inability to fulfill the basic family responsibilities.

Another crucial ingredient in the epidemic has been the health care system – drug companies, doctors, payment systems, and regulators – as they fundamentally changed pain management and fostered the widespread use of opioids. The particulars are documented in-depth in books such as Dreamland, but here I will note how unusual it is for an epidemic to have as one of its primary causes the behavior of the very systems and professionals who have the responsibility to heal our citizens. Doctors prescribed 240 million bottles of opioids in 2014.The aggressive treatment of pain and the downplaying of opioid addiction fueled a devastating and destructive “answer” to the despair generated by economic circumstances. This came at time when many vulnerable citizens were seeking relief from personal pain associated with loss of hope, respect, dignity, and a vision for a better future for themselves and their loved ones.

We need to work on multiple fronts to care for people currently addicted and to prevent others from becoming addicted. Government is rightly taking the lead by enlisting a broad base of Missourians to address this multi-faceted challenge, including private sector actors like Express Scripts. Tactics currently in place include chronic care for addicted patients, prevention, education, and multi-sector coordination among government agencies from courts to prisons, to clinics to public health departments. There is still so much left to be done to keep the crisis from getting worse. We also need to address the underlying conditions that foster addiction in the first place. These societal and economic factors were decades in the making; unfortunately widespread progress will likewise take decades, even with strong action starting now.

This is a large, important issue in our state, and we will continue investigating it from a variety of angles in upcoming blog posts.