The epidemic of accidental opioid poisoning has received increasing media coverage as opioid-related deaths have skyrocketed. But the magnitude of the problem is still largely unappreciated. The New York Times
recently illustrated that annual drug-related mortality in the United States has surpassed peak annual deaths related to AIDS, gun violence, and car accidents. What’s most troubling is that the rate of opioid-related deaths is rising faster than ever.
At the height of the AIDS epidemic, activists used rallies, marches, “die-ins”, and other targeted “actions” to draw media attention to the human cost of the AIDS epidemic. A primary complaint was that the FDA wasn’t getting experimental medications to market fast enough. Through creative and persistent protest AIDS activists fundamentally changed the way that the FDA approves new medications.
When effective antiretroviral medications were discovered, AIDS-related mortality plummeted even as the number of persons living with HIV and AIDS continued to climb.
There are several similarities between AIDS and Opioid Use Disorder (OUD).
- The illnesses are contracted through environmental exposure--AIDS through exposure to the human immunodeficiency virus and OUD through exposure to highly potent opioid drugs;
- Exposure is most often mediated by human behaviors--AIDS by sexual intercourse and IV-drug use and OUD by recreational or medical opioid use;
- The illnesses typically spread peer-to-peer;
- The illnesses, if untreated, are highly lethal; and
- Once contracted, the illnesses are typically chronic and require maintenance treatment to prevent progression and death.
There is at least one glaring difference between the AIDS and OUD mortality crises. AIDS caused record annual deaths just before effective medications were discovered and brought to market. OUD is currently contributing to record mortality rates even though life-saving medications (methadone and buprenorphine) have long been FDA-approved and marketed to providers. Methadone was FDA-approved for OUD in 1972 and buprenorphine in 2003.
What’s the catch? As of March 31, 2016, 82% of facilities that treat addiction provided outpatient treatment, but only 21% provided outpatient methadone or buprenorphine maintenance. For that reason, only a minority of persons with OUD are provided the two maintenance pharmacotherapies known to drastically decrease their morbidity and mortality risk. If pharmacotherapy for OUD were implemented as widely as antirotroviral therapy for HIV/AIDS, we would save tens of thousands of lives and begin to reverse the epidemic of opioid-related deaths.
Readers may contest the claim that medical treatment would reverse the overdose epidemic. The claim can only be tested empirically by increased access to medical treatment; but the research support for this approach is overwhelming. Consider the most recent meta-analysis of treatment cohorts, including more than 120,000 methadone patients and more than 15,000 buprenorphine patients. The methadone cohorts were followed between 1 and 13 years and the buprenorphine cohorts between 1 and 5 years. When patients were undergoing maintenance medical treatment, their all-cause mortality rates were two (buprenorphine) and three (methadone) times lower than when they were out of treatment.