2 posts categorized "Public Health"


The U.S. Surgeon General "Facing Addiction" report challenges myths, offers transforming vision

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U.S. Surgeon General Vivek Murthy has released a landmark public health report with a vision for transforming our behavioral health system so that we can adequately treat substance use disorders in America. Coming in the midst of an unprecedented opioid overdose epidemic, the document spells out why federal officials have shifted their approach on drug control policy to a public health approach.

Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health was released on Nov. 17, 2016 with fanfare, during a live-streamed broadcast from the Paramount Studios in California, featuring health agency officials, celebrity speakers, recovery community members, and a question and answer session with researchers (recording available on youtube).

At over 400 pages, the report provides a comprehensive review of the medical literature, makes recommendations, and notes gaps in our knowledge that need to be addressed with more research. Kana Enomoto, Principle Deputy Administrator of the Substance Abuse Mental Health Services agency, was the report editor. Facing Addiction in America states that:

  • A public health approach to the issue of addiction requires that we integrate substance use disorder services into the “mainstream” health system, a major change after decades of a segregated system of care.
  • The common belief “that alcohol and drug problems are the product of faulty character or willful rejection of social norms” is wrong, and results in damaging stigma that inhibits people from getting help.
  • Addiction is a medical disorder, a disease of the brain, that can be successfully treated with a comprehensive approach, just like many other chronic medical conditions.
  • Prejudice and discrimination have created many of the challenges currently plaguing the substance use disorder treatment field, and nothing short of a culture change will have to happen to transform the system. 
  • 1 in 7 people will misuse alcohol and other drugs, and more than 20 million people in the U.S. have a substance use disorder, yet only 1 in 10 are getting treatment. 
  • 78 people die every day in the U.S. from an opioid overdose, and those numbers have nearly quadrupled since 1999. 
  • About 25 million people are in successful recovery. Research indicates that approximately 50 percent of adults who once met diagnostic criteria for a substance use disorder are now in stable remission (1 year or longer). Even so, remission from a substance use disorder can take several years and multiple episodes of treatment, along with recovery support services, and/or mutual aid (participation in 12 step-type groups).

Health policy experts, the media, and Dr Murthy himself are making comparisons between this report, and a previous milestone in public health, the 1964 Surgeon General’s Report on Smoking and Health, released by Surgeon General Dr. Luther Terry. That groundbreaking  effort was the first federal government report to connect smoking with lung cancer, heart disease, and other detrimental health effects, at a time when years of tobacco marketing had positioned smoking as a safe, socially attractive, and even healthful. It spearheaded 50 years of tobacco control efforts that have positively improved the public health.

Dr Murthy and the other healthcare leaders emphasized in the Nov.17th summit that better screening, and earlier intervention can save lives:

 “…many people seek or are referred to SU treatment only after a crisis, such as an overdose, or through involvement with the criminal justice system. With any other health condition like heart disease, detecting problems and offering treatment only after a crisis is not considered good medicine. Integrating screening into general medical settings will make it easier to identify those in need of treatment and engage them in the appropriate level of care before a crisis occurs.”

Like hypertension or diabetes, substance disorders can and should be addressed before they reach the crisis stage. The widely held stereotype that people need to “hit bottom” before they can begin effective treatment is wrong and dangerous.

The Facing Addiction report is broken into sections that can be downloaded individually, including an executive summary, fact sheets and key findings, plus many supplemental materials. A printed copy of the full report can be ordered for free.

More key points:

  • Adolescent misuse is a risk factor for developing a severe use disorder, underscoring the need for prevention efforts, as well as early treatment.
  • Changes in specific brain circuits impact decision making, self-control, and other aspects of brain function in ways that are persistent and long-lasting, after prolonged substance use.
  • The brain can also take a long time to return to health, one reason why relapses are expected in substance disorders. Research in alcohol and other drug use shows it will be 4-5 years before the risk of relapse drops below 15%.
  • The medical consequences of substance misuse include cardiovascular and cardiopulmonary diseases, liver and pancreatic diseases, stroke, and cancers of the larynx, liver, and colon.
  • Studies show that every dollar spent on substance use disorder treatment saves $4 in health care costs.
  • Most existing substance use disorder treatment programs lack the needed training, staffing and infrastructure to provide treatment for co-occurring physical and mental illnesses.

To accomplish this behavioral healthcare transformation, the report notes that the treatment, prevention, and research sectors need appropriate funding. The legislature did not take action last year to fully fund the Obama administration’s requested $1 billion, but the “21st Century Cures Act” that just passed this week and is waiting for President Obama's signature, includes substantial new commitments towards the original funding goal.

The future of addiction health policy

Has our leadership been slow to address the widely held myths about addiction in America, the disparities in access to behavioral health care, and the need for systemic change? This new report is based on more than two decades of research which is “far more than we knew about the effects of smoking when the first Surgeon General’s Report on Smoking and Health was released in 1964.

A decade ago, in 2005, an expert panel convened by the Institute of Medicine called our behavioral healthcare system a "quality chasm" and recommended many of the same policies found in Facing Addiction in America. Still the new Surgeon General's report is intended to be the most prominent, and public effort to date to combat stigma with science, and refute the misconceptions about addiction that are deeply embedded in our culture. 

Public policy efforts to update our approach to substance disorder treatment include the 2000 passage of the Drug Addiction Treatment Act (DATA), which changed the Controlled Substances Act to allow physicians to treat opioid use disorder treatment with medications like buprenorphine in medical offices, rather than only in segregated clinics. However, this hasn't increased access to opioid use disorder as much as needed to meet the current demand.  

The Facing Addiction in America recommendations align with federal efforts under the Office of National Drug Control's public health-focused 2010 strategy to increase access to medication treatments, behavioral therapies, and recovery supports for substance use disorders. The Affordable Care Act of 2010 and the Mental Health Education and Parity Act of 2008 were significant legislative efforts to reduce inequities in behavioral health care access, although they haven't yet been fully implemented.

Dr Murthy headlined this 2016 report release with the vivid statement that “how we respond to this crisis is a test for America.”  This report is one of several initiatives at the end of the Obama administration that close out a period of major change in healthcare policy, but lead into an uncertain future.

With an incoming administration that has pledged to repeal the Affordable Care Act, credited for expanding access to substance disorder treatment for 60 million Americans, the future of these new policy recommendations and whether we can address the public health epidemic we are in today will be a test for our new leadership.

Notes on Language

Like many medical conditions, how we describe addictive disorders has changed over time. The last version of the behavioral health diagnostic manual (DSM V) changed the previous categories of substance “dependence” and “abuse” to a diagnosis of substance “use disorders” that exist on a continuum from mild to severe.  Substances refers both to alcohol and other drugs. Addiction medicine no longer uses the terms “chemical dependency" or alcohol or drug "dependence". 

Substance misuse is the use of any substance in a manner, situation, amount, or frequency that can cause harm to users or to those around them.

A substance use disorder is when prolonged, repeated misuse of a substance leads to a medical illness that impairs health and function.

Addiction is the commonly used term for a severe and chronic substance use disorder.





Big jump in PA maternal and neonatal hospital stays, need for treatment, due to opioid crisis

baby withdrawal treatment opioids neonatal abstinence syndrome drug withdrawalAddiction treatment programs in Pennsylvania generally give pregnant women first priority in access to treatment. But with the opioid crisis straining already limited budgets and program resources across the Commonwealth, more access to treatment, housing, care management, and specialized programming for mothers is needed to meet demand, according to presenters at a Maternal Care Coalition forum.

Presenters at the Philadelphia program, held in September, described the impact of the opioid crisis on maternal health to a packed room of several hundred healthcare, social services, and public health providers. Local experts presented on barriers to care, funding challenges, and best practices in medication treatment and mentoring services for pregnant and parenting women, including a moving presentation from a mother in recovery, who gave birth to a baby in jail while imprisoned due to consequences of her drug addiction. 

Now we have new data to inform policy-makers about the increasing impact of the opioid epidemic on our healthcare system in Pennsylvania. The extra costs for hospital stays connected to maternal substance use are soaring.

The increase in pregnant mothers using opioids like heroin or prescription pain medications means more babies are being born with a physical dependence that requires treatment, according to a new report by an independent state agency that studies healthcare costs in Pennsylvania: the PA Health Care Cost Containment Council (PHC4). These babies often need to stay longer in the hospital to be treated for symptoms of withdrawal.

Rates of babies in hospital neonatal units (NICUs) needing withdrawal treatment have increased four-fold from 2003 to 2013 nationwide, according to a 2015 study. The research released by PHC4 shows similar increases in newborns needing more intensive treatment in the Commonwealth.

Neonatal hospital stays connected to substance use disorders (SUD’s) increased by 250% from 2000 to 2015 in Pennsylvania. This increase in hospital days fpr babies needing extra care cost an extra $20.3 million, most paid by state and federal taxpayers, since the majority of the mothers were on Medicaid (78% of the maternal stays that were related to SUDs and 38% of other maternal stays.) Our rural western and northeastern counties had the highest rates of SUD-related maternal stays. 

Maternal hospital stays were up by 510%, and of those connected to SUDs in 2015, 51.9% involved opioids, costing an additional $1.8 million. Some positive news: maternal stays related to alcohol decreased 36% and those related to cocaine decreased 61% in the 2015 data.

We do not know what percentage of the mothers in this data might have been in medication-assisted treatment (MAT) with buprenorphine or methadone. In other words, their use of opioids was prescribed appropriately and medically monitored. The research brief doesn't break down maternal opioid use to show if it was illicit or prescribed. But in the context of the current opioid epidemic, we know that illicit use has increased at unprecedented rates and is a key driver of increased hospital costs, along with the growth in prescribing of opioids for pain management.

Treatment with prescribed methadone or buprenorphine, along with counseling and behavioral support, is clinically indicated for a mother who wants to stop illicit opioid use while pregnant, because going into withdrawal if she stopped abruptly could cause her to miscarry. Unfortunately, some of the babies of mothers on prescribed MAT may have withdrawal symptoms that need to be treated and will require a longer stay in the NICU, but the health risks to the mother and baby in a relapse to heroin use, or during a sudden withdrawal from opioid use, are significant and possibly life-threatening.

A note about appropriate language for neonatal drug withdrawal  

Almost all the media reports about this data that I saw (but not the PHC4 research brief) referred to addicted babiesin their coverage. While the journalists and headline writers may be adopting a commonly used term-- it's just wrong to describe babies with withdrawal symptoms as “addicted.”Babies with neonatal abstinence syndrome, or drug withdrawal, do not have the compulsive behavior that is a defining aspect of addictive disorders; rather, they are physically dependent and require medically-managed withdrawal. Clinically inaccurate, emotionally laden language in stories about substance use disorders increases the stigma that people with substance use disorders face -- stigma that often deters them from seeking help. 


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