Surgeon General’s Report on Opioids Emphasizes ‘Gold Standard’ Treatment

The U.S. surgeon general issued a report last month calling for a “cultural shift in the way Americans talk about the opioid crisis.” He also called for health care professionals to become qualified to prescribe buprenorphine, follow “the gold standard” for treatment, and address substance use with the same sensitivity as other chronic health conditions.

“Addiction is a brain disease that touches families across America, including my own. We need to work together to put an end to stigma,” wrote U.S. Surgeon General Jerome M. Adams, M.D., M.P.H., in the report’s preface.

His family experience with addiction involved his brother. His brother’s illness started with untreated depression, which led to opioid misuse. Like many individuals with co-occurring substance use and mental illness, his brother cycled in and out of correctional institutions.

The report, titled “Facing Addiction in America: The Surgeon General’s Spotlight on Opioids,” was prepared by the surgeon general’s office in collaboration with the Substance Abuse and Mental Health Services Administration (SAMHSA). The intent behind the report is to allow people from a broad range of backgrounds to obtain opioid-related information cited in the surgeon general’s previous report on addiction, “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health,” in one document.

In 2017, overdose deaths climbed to more than 72,000, a nearly 10 percent rise from the previous year, according to provisional government estimates issued in August. More than two-thirds of those deaths involved opioids. The surgeon general’s report attributed the rise to three trends: an uptick in prescription opioid overdose deaths, a fourfold increase in heroin overdoses since 2010, and a tripling of the death rate from synthetic opioids such as fentanyl since 2013.

Despite the existence of effective treatments and the promise of integrated care to reach more individuals, only 1 in 4 people receives treatment for opioid use disorder (OUD). The report pointed out why that’s the case: “The substance use disorder treatment system is underprepared to support care coordination; the primary care system has been slow to implement medication-assisted treatment (MAT) a as well as prevention, early identification, and other evidence-based recommendations; the existing health care workforce is already understaffed and often lacks the necessary training and education to address substance use disorders; and the need to protect patient confidentiality creates hurdles for sharing of information.”

“Now is the time to work together and apply what we know to end this epidemic once and for all,” wrote Elinore McCance-Katz, M.D., Ph.D., assistant secretary for mental health and substance use in the Department of Health and Human Services, in the report’s foreword. “Medication-assisted treatment, combined with psychosocial therapies and community-based recovery supports, is the gold standard for treating opioid addiction.”

In a section on treatment and management of opioid use disorders, the report noted that treatment is effective and improves an individual’s productivity, health, and overall quality of life. “Incorporating treatment for multiple substance use disorders could also be beneficial.” For example, integrating tobacco-cessation programs into substance use disorder (SUD) treatment is associated with a 25 percent increase in the likelihood of maintaining long-term substance abstinence, the report explained.

The report listed the “components of care” as follows: personalized diagnosis, assessment, and treatment planning; long-term disease management; administration of FDA-approved medications; behavioral interventions delivered by trained professionals; coordinated care for co-occurring disorders; and recovery support services.

Andrew J. Saxon, M.D., chair of APA’s Council on Addiction Psychiatry, praised the report overall, calling it a “positive, strong, and important report that codifies some of the most important aspects of opioid use disorder treatment.” However, he said, while the report enumerates the gold standard “components of care,” it falls short of explaining how patients can access this type of comprehensive treatment, which would cost at minimum $10,000 to $15,000 per patient per year.

“I wish every patient, every person in the country with OUD could get this kind of health care. But how is this all going to be paid for?” Saxon asked. “I worry that the way this is pitched in the report, primary care physicians may say, ‘My practice can’t provide all that, so I’m not going to do it at all.’ ”

Saxon advises physicians who cannot provide all the elements to at least offer MAT and meet with patients regularly, citing several recent studies showing that buprenorphine treatment alone provided in a primary care setting can be just as effective for many patients, even without additional counseling and services.

Substance users face many barriers to care, including a shortage of treatment providers and the reimbursement policies of many state Medicaid plans; most do not cover all of the FDA-approved medications for treating OUD. Saxon called on the federal government to begin providing physicians incentives to take on the complicated work of providing MAT by offering higher compensation and by taking action to eliminate the myriad prior authorizations that prescribers must fight through to get patients the medication they need.

“Ultimately, the federal government should call on private insurers to step up to this crisis and cover MAT and reimburse providers who use these medications at a higher rate,” he said.

Saxon said he is also concerned that the federal mental health parity law—on the books now for 10 years—is still not being well enforced. “We need government support and intervention to reduce the stigma surrounding substance use disorder in practical ways. One way to do that is to enforce parity laws,” he said. The administration’s expansion of “skimpy,” short-term, limited duration health plans that took effect October 1—a move the APA is fighting in federal court—is an affront to that, he said, and will most likely strand more individuals with no coverage for OUD treatment.

The report also highlighted the proven benefits of “harm reduction strategies,” such as outreach and education programs, needle/syringe exchanges, overdose prevention education, and access to naloxone to reverse potentially lethal opioid overdoses. But Saxon pointed out that needle exchange programs are not supported by the federal government. In addition, the Justice Department has threatened to prosecute the state or city officials who open “safe injection sites,” a harm reduction strategy now being contemplated across the country to prevent overdose deaths and disease transmission. ■

“Facing Addiction in America: The Surgeon General’s Spotlight on Opioids” can be accessed here.