A stunning report this week that an estimated 93,000 people died of drug overdoses in 2020 has renewed attention on the nation’s other epidemic: The drug crisis that the government, health-care workers and street-level activists have been battling unsuccessfully for more than two decades.
A wide spectrum of changes has been offered by government, academic and think tank researchers, criminal justice experts and health-care workers, and lay people to try to help the nation’s more than 8.1 million people with substance use disorders. Solutions range from completely decriminalizing the consumption of drugs, as Portugal did in 2001, to overturning the way the health-care system treats users.
“We have never fully integrated the care of addiction into the American health care system. That would be a revolution, for it to be as seamless to say to your primary care doctor, ‘I think I’ve gotten addicted to my medication’ as easily as you say ‘I think my medication is giving me heart palpitations,’ ” Keith Humphreys, a Stanford University drug policy expert, said in an email.
“And know you will not be shamed, shunted off to a program on the wrong side of town with no connection to the health care system, or told that your insurance doesn’t cover addiction because it’s not a real health care problem,” Humphreys wrote.
Just 18 percent of the people with substance use disorder who needed the anti-addiction medication buprenorphine in 2019 received it, according to the National Survey on Drug Use and Health, though it is the most effective way to battle addiction. Only 17 health-care providers per 100,000 people were approved to dispense it in 2017, according to one study.
Finding other forms of treatment — inpatient, outpatient or residential — means negotiating a thicket of obstacles erected by the nation’s uncoordinated health-care and insurance bureaucracies.
Among U.S. facilities with opioid treatment programs, more than 90 percent offered outpatient care between 2009 and 2019, according to the U.S. Substance and Mental Health Services Association (SAMHSA). But only 8 percent to 10 percent offered residential, non-hospital treatment, and just 7 percent to 12 percent offered inpatient care.
The American Medical Association has called for broader access to anti-addiction medication as well as the opioid overdose antidote naloxone. Opioids, mainly illegal fentanyl, continue to drive the overdose epidemic, as they have for years. They combined with the coronavirus pandemic last year to increase drug overdose fatalities by nearly 30 percent, according to preliminary data released by the National Center for Health Statistics on Wednesday.
On the edges of the policy debate are calls for complete decriminalization. The Drug Policy Alliance favors this approach, along with redirecting money from courts, jails and enforcement to treatment and harm reduction. Maritza Perez, director of the Office of National Affairs for the advocacy group, said except for large-scale drug smugglers, users often are also small-time sellers, and vice versa.
“I can look at the evidence, and the evidence tells me that the approach we’ve taken hasn’t worked,” she said.
Alex H. Kral, an epidemiologist with the think tank RTI International, contends that most innovative changes in drug policy are initiated by states, which should be allowed to continue experimenting and evaluating new approaches without federal oversight.
Oregon voters, for example, approved a ballot measure in November that decriminalizes possession of small amounts of drugs, from heroin to methamphetamine. As civil violations, possession would draw no more than a $100 fine, which could be waived by taking a health screening.
Sen. Charles E. Schumer (D-N.Y.) last week called for decriminalization of marijuana at the federal level.
Regina LaBelle, the acting director of the Office of National Drug Control Policy (ONDCP), pointed to the White House’s early work to adopt an approach centered more on public health. For instance, the administration is working to expand access to its drug-free-communities program for non-English speakers and is piloting an effort to integrate adverse childhood experiences into the program.
The drug policy office also announced in February that it would prioritize harm reduction, or efforts to minimize the harms of substance use — the first time the office had done so, LaBelle said.
“Eighty to 90 percent of people are not in treatment . . . and the vast majority of individuals who are not in treatment are often experiencing some kind of harm from their substance use,” LaBelle added, touting the benefits of needle exchange programs and prevention policies. “It just makes sense to ensure that we’re meeting the needs of the vast majority of people who aren’t being touched by the treatment system.”
A Philadelphia nonprofit is trying to open the first U.S. facility where drug users would be watched and revived if they overdose, an approach pioneered in Canada and Europe. The Trump administration opposed “supervised consumption,” and a federal appeals court blocked the idea in January.
LaBelle said Biden’s focus on the coronavirus outbreak wasn’t distracting from the surge in drug overdose deaths.
“I don’t see this as a competition with covid — we can do two things at once,” LaBelle said. “We can address the pandemic at the same time as we’re addressing this epidemic.”
LaBelle also listed goals she hoped the Biden administration would accomplish by the end of the president’s term.
“It would be great if we could remove the most significant barriers to treatment that keep people with opioid use disorder from getting what they need,” she said. “And if we could have every state get rid of laws that ban syringe-services programs, so we can expand those services to people who need them. And then, obviously, if we could get these numbers down.”
Outside experts said they’re pleased by Biden’s initial personnel and policy moves, crediting the president’s choice of physician Rahul Gupta as drug czar and efforts to staff up SAMHSA, which saw considerable turnover during the Trump administration.
The Senate also confirmed former Connecticut mental health commissioner Miriam E. Delphin-Rittmon as Biden’s assistant secretary for mental health and substance use last month.
“Everything we’re seeing is moving in the right direction,” said Chuck Ingoglia, chief executive of the National Council for Mental Wellbeing, citing the ONDCP’s list of first-year priorities. Those goals included supporting evidence-based prevention efforts to reduce youth substance use and expanding access to recovery support services.
“We thought it was comprehensive and pushed the nation toward a public health approach.”
Biden’s moves also have been hailed by allies on Capitol Hill.
“I appreciate that the Biden administration is taking this issue seriously, including by putting forward a nominee to lead the Office of National Drug Control Policy and working to expand access to medication-assisted treatment,” said Sen. Maggie Hassan (D-N.H.), who has lobbied the White House to increase physicians’ abilities to prescribe buprenorphine. “We must continue to work together at every level of government and across the aisle to prevent and treat substance use disorder.”
Now the question is which options Biden is prepared to embrace, if any.
“The data speak for themselves, and they are shouting,” Nora D. Volkow, director of the National Institute on Drug Abuse, said in a statement. “We need to address the social determinants of health that put some people at a higher risk of drug use and addiction. . . . We need to educate people that addiction can be treated. We need to provide access to these treatments for everyone who needs them. We need to follow the science. We need radical collaboration across sectors to create transformative and impactful changes.”