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America’s opioid epidemic has reached horrific proportions. More than 50,000 Americans died of a drug overdose in 2015, with most of the deaths involving opioids. Overdose is now the leading cause of death for those under 50.
The cost of this crisis has been vastly underestimated, argues a report published this week by the president’s Council of Economic Advisers. Previous studies focused on costs to the healthcare and criminal justice systems, or to productivity and workforce participation. If one accounts for the deaths using “value of a statistical life” methodology, the cost rises to some $504bn, the CEA says — equivalent to 2.8 per cent of national output.
The roots of the problem lie in the overuse of prescription opioids, heavily marketed by pharma companies as a safe treatment for chronic pain — despite evidence that opioids are suitable only for acute pain. Well-meaning physicians responded to the pitch, and to the incentives provided by America’s “fee for service” healthcare model: writing quick prescriptions pays better than the painstaking work of diagnosing the source of pain and monitoring complex non-drug treatments. Less scrupulous doctors ran “pill mills” that supplied the black market.
There is a broad consensus about what needs to be done. Despite a recent crackdown, doctors are still prescribing three times as many opioids as they did in 1999. Electronic prescription monitoring systems that give real-time data about patient history and physician prescribing patterns need to be made mandatory nationwide. Insurers must be required to reimburse non-opioid treatments at a level that will reverse the current incentives.
Cracking down on the supply will reduce the number of new addicts. It will not help existing ones. When prescription drugs are withdrawn many addicts switch to illegal drugs, in particular heroin and smuggled fentanyl.
Here again it is broadly clear what needs to be done. Addicts need easier access to rehabilitation programmes so they can get sober, and easier access to medication to help them avoid relapse and lead stable lives. Opioid antagonists such as naltrexone, and substitute opioids such as buprenorphine and methadone, should be in wider use.
Donald Trump has promised to make the crisis a priority, and last month declared it to be a public health emergency. But his proposals do not go far enough. Many of the measures he announced, reflecting a review led by New Jersey governor Chris Christie, are useful. But the focus was on preventing addiction, by changing medical culture, clamping down on illegal imports of opioids and “great advertising” to persuade young people to abstain. Mr Trump acknowledged the need to make naxalone, a treatment for overdoses, more easily available. But there was only a brief reference to helping addicts — and this was accompanied by a reference to “drug courts”, whose value is disputed. There was no commitment to the big increase in federal funding needed to provide treatment on the scale required.
Part of this is down to budget pressures. Mr Trump’s tax plan increases the deficit by $1.5tn, and rehabilitation programs are expensive (and do not always work). Another part is down to politics. There is still a moral stigma attached to addiction which makes it unpopular to spend significant public money helping the addicted.
Mr Trump and the country need to change that attitude and spend the money. The “forgotten” communities most deeply hurt by opioids are those Mr Trump pledged to help during his campaign. Thousands of Americans are dying. The president must make good on his promises.