Why isn’t the US treating the overdose epidemic like the public health emergency it is?

For the past 20 months, the drug overdose epidemic has been overshadowed by the COVID-19 pandemic, which has also fueled it.

An estimated 100,306 Americans died of drug overdoses in the 12-month period ending April 2021, according to figures released recently by the Centers for Dis- ease Control and Prevention. This was an increase of 28.5 percent from the year be- fore, making it the highest drug death toll ever, and surpassing the toll of gun deaths and car crashes combined. The vast majority of these cases involved polysubstance use, including alcohol.

Clinics, hospitals, and drug treatment programs must be incentivized and required to provide medication treatment for substance use disorder.

Many of these people did not need to die. Law enforcement and public health officials know how to prevent drug overdose deaths and create better access to treatment. They just need to do it.

The Police Assisted Addiction and Recovery Initiative was founded in 2015, when fatal overdoses peaked at 52,404. Recognizing that we cannot arrest our way out of a public health crisis, PAARI has created a model for lifesaving public health and public safety partnerships. Since PAARI’s founding, more than 700 law enforcement agencies in 40 states have prevented overdoses by creating non-arrest pathways to treatment and recovery. Our evidence-based programs are saving lives and opening doors to recovery, and our experience has taught us valuable lessons.

Yet, given the continued increase in overdose deaths, America’s response to the drug overdose epidemic is clearly flawed and lacks the urgency necessary to save lives. Are we meeting people where they are at, only to then leave them there to die?

Five years ago, overdoses occurred more frequently in those who became addicted through often fraudulently marketed and over-prescribed pain medications or from heroin than from other substances. But with Fentanyl, the synthetic opioid now found in most illicit drugs, overdose deaths are rising sharply among users of cocaine, methamphetamine, and other drugs and spreading death to new parts of the country and new populations. People of color now make up a rapidly rising percentage of all overdose deaths. What is needed is extensive outreach and education efforts, including with health care providers, to address stigma and increase demand for access to treatments.

There have been and continue to be effective treatments, such as methadone, buprenorphine, and extended-release naltrexone Vivitrol for some substance use disorders. However, our systems of care have failed to take urgent steps to employ them, and hospital emergency departments continue to lack the capacity, or the desire, to treat patients with substance use disorders.

While there are effective medication treatments for opioid and alcohol dependence, as exist for other chronic diseases, there remains an urgent need to put over- dose blocking naloxone, commonly known as Narcan, in the hands of every first responder and family with a loved one suffering with opioid addiction — while we also develop therapies for stimulant dependence. Our law enforcement partners tell us that for every overdose death there are 9 to 10 overdose reversals with naloxone. There would have been about 1 million deaths instead of the more than 100,000 overdose deaths last year without naloxone.

America’s response, albeit delayed, to the HIV/AIDS epidemic resulted in the HIV Cascade of Care Continuum, which has had extraordinary outcomes at reducing stigma and driving down infection and death. More recently, the response to COVID-19 has been similarly extraordinary. In relatively short order, vaccinations were developed, and our systems of care adapted. Health care providers, from primary care to neurosurgery, quickly trained in the fundamentals of the disease.

Our health care system can react similarly to substance use disorder but has chosen not to. The health care and health insurance systems are a significant barrier to access to treatment and medications. Almost 4 in 5 Americans with the disorder receive no treatment, and even fewer receive medications for treating it.

Shockingly, those with substance use disorder are increasingly more likely to access treatment and receive medications while they are incarcerated than while in the community. That is unacceptable. Access to medication-assisted treatments in the community must be expanded, because we know that those receiving medications have a significantly reduced risk of fatal overdose.

Clinics, hospitals, and drug treatment programs must be incentivized and required to provide medication-assisted treatment for substance use disorder. In fact, existing and unenforced federal law already requires such level of care. Hospitals and other medical providers must stop shirking their responsibility to help people in need. Restrictions on Medicaid for people who are incarcerated should be waived so there’s no gap in coverage when they return to the community. Research has shown that people with SUD who are released without treatment are 50 times more likely to overdose and die.

In 2017, PAARI was invited to the White House when a public health emergency was declared. Since then, despite overdose deaths breaking records and fentanyllaced methamphetamine deaths rapidly rising, we are still waiting for the urgency and resources required to fully address this crisis.

The United States must declare meth- amphetamine an emerging threat, swift- ly research treatment therapies, and urgently renew the public health emergency declaration of 2017. The institutions of public health and public safety have adapted; our health care systems and the highest levels of government must do the same.

While new funds to treat substance use disorder have been appropriated in the American Rescue Plan, PAARI law enforcement partners and public health professionals across the country fear that they will be expended by states on the same old flawed systems of care, and overdoses will continue to rise.
What we do, or fail to do, now, will have real life and death consequences.

– John E. Rosenthal is cofounder and board chair of the Police Assisted Addiction and Recovery Initiative.

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