While well-intentioned, the intense national focus on the dangers of opioid-based pain medication misses the mark, said Joseph Lee, M.D., Hazelden-Betty Ford Foundation’s medical director of the youth continuum. The opioid-addiction crisis is about more than opioids, Lee maintains: It’s about the larger crisis of addiction and how we identify and treat people who are at risk for developing dependence on a range of substances.
Lee’s perspective is backed up by the Hazelden Betty Ford Institute for Recovery Advocacy’s June 2017 Emerging Drug Trends Report, which is produced in collaboration with the University of Maryland School of Public Health. The report surveys a number of recent studies, highlighting findings that conclude that people with addictions to opioid-based drugs tend to also be addicted to other substances at the same time.
This finding underscores the reality that opioids are only part of the larger problem of addiction, Lee said. Too much focus on one substance distracts from the core issue.
“When we think about the opioid crisis,” Lee said, “let’s avoid focusing too much on specific drugs and make sure we prepare ourselves for the future by zeroing in on the real problem — the heightened vulnerability that some people have to substance misuse and addiction.”
Late last week, I spoke with Lee about the report, and about his firm belief that the opioid crisis can only be stemmed when Americans stop vilifying specific drugs and instead focus on building greater understanding of individual people and their addiction-risk profiles.
MinnPost: The rise in opioid-related deaths in the United States has turned the general public and much of the medical community against the use of opioid-based pain medications. Do you think this is a good shift? Should opioids eventually be banned?
Joseph Lee: It’s much more nuanced than that. I’ll start with a metaphor. Let’s say we’re talking about obesity and fast food. Say we see a group of people who eat a lot of fast food and are obese. In this case, some of the dialogue in society should be about fast food and the negative affects it has on some people’s health, but the conversation also has to be about how not everybody who eats fast food gets fat. Why is that? Maybe not everybody eats fast food so frequently, and maybe not everybody who eats French fries gets high cholesterol. A person’s obesity has to do with their body and how it processes the fast food more than it has to do with the food itself. We have the same dilemma with opioids. It’s a social allegory.
MP: So you’re saying that kind of like how not everyone who eats a hamburger will eventually become obese, not everyone who uses opioid-based drugs for pain will become addicted?
JL: Yes. People are different from each other. The way they respond to drugs is different. Because of that, many of our policy discussions about opioids are way off the mark. The questions we need to ask when we talk about prescribing potentially addictive substances are, “Who are the people who will be using that drug and are they at high risk of addiction?” or “Who are the people that are most likely to be adversely affected by this drug?” Then we also need to ask, “How do we define and identify those risk cohorts?” We are talking about end-point external variables that modulate internal risks.
With addiction we often talk about the substance, about Burger World vs. Taco Hut, but we don’t talk about the people who will be most affected by this substance. This creates a scary kind of polarization when get into policy debates.
MP: But many people in this country see the general shift away from opioids as a good thing.
JL: It’s a good move, but it’s a broad brushstroke. There’s been a serious backlash against opioid-based pain medication. Many people in hospital and clinic settings are now saying, “No opioids ever,” or, “Opioids are the devil.” The thinking that leads to that response is, “The risk for people developing substance-use disorder is just too high. We have to remove the drug from our treatment plans.”
We end up vilifying substances without really talking about the core issues that created the problem. Addiction has never really been about drugs. Addiction is about the people who are at high risk for becoming addicted to those drugs.
MP: How do prescribers identify people who are at high risk for addiction?
JL: There are many ways for physicians to identify those risks. A higher percentage of people who are frequently prescribed opioids have had documentable use of other addictive substances. We can look for those red flags. In primary care clinics, for instance, a lot of people who are prescribed addictive benzodiazepines like Xanax are often also prescribed opioids. Research has shown that this dual use can point to larger substance use issues. This is a documentable connection that can be followed in medical records.
But we also have to make sure that we are looking at the person involved and not just at the drugs they have been prescribed. If someone eats a lot of Burger World, they are probably also eating a lot of Taco Hut. When we see that, we can get caught up in this dance of, ‘What’s worse? Burgers or tacos?’ instead of looking at the real problem of the indicators of addiction. The way we talk about addiction is almost like an existential satire.
MP: When do you think the use of opioid-based medication is appropriate?
JL: If you are a person who has been determined to not be at high risk for addiction, and the context is right, say you’ve just had an operation, the use of opioid-based pain medication can be beneficial and appropriate under supervised care.
MP: Do you think a focus on one “bad” drug grants certain substances more power, creating an oversized feeling of fear?
JL: Substances don’t discriminate. Drugs don’t have innate moral properties: They don’t know who is ingesting them or what impact they will have on the user. They simply do what they are invented to do. Their impact is different on different people.
In our attitudes about the benefit of certain drugs, we’ve clearly seen a significant pendulum swing. Opioids are a good example. Some years ago, we said, “These are important drugs for pain relief.” More recently, we’ve said, “These are extremely harmful drugs.” We’ve completely vilified them. I’m saying that we need to have a deeper, more sophisticated conversation.
MP: Why is it important to focus on people?
JL: We need to prevent high-risk people from using drugs and getting into trouble. That’s always been true. The rub is that right now this nation is grieving and shocked by how serious this problem has become. There is a panicked lunacy in our approach to this crisis. If we invested in people as opposed to focusing on drugs, I think we’d have a much, much smaller problem on our hands.
It works this way in other areas of medicine. If a surgeon understands that a patient has a history of negative reaction to an anesthetic, they take that into account before scheduling an operation. Surgeons regularly conduct risk-reduction conferences before a surgery. They do their best to understand what a patient’s prognosis is before they go ahead with an operation. These risks don’t mean that we don’t do any surgeries anymore. We just take extra precautions to make sure that surgery is the best approach for each individual. This is the same approach that should be taken before prescribing potentially addictive medications.
MP: Do you advocate other risk-reduction techniques when it comes to opioid prescriptions?
JL: We have to work hard to educate the public. Most people get opioids from friends and family members, not from their physician. As part of the prescription process, doctors need to have conversations with patients that include questions like, “Where do you store your medications?” “What is your family history of addiction?” “What is your personal history of addiction?” Aside from individual risk, if you are being prescribed opioids, you should consider having Naloxone available, if not for you, for your family.
Addiction is not just about the drug itself. It is about the history of the person who will be taking the drug. To limit addiction, we have to focus on personal history and risk stratification, figuring out which people are most likely to develop a problem with these powerful medications. If we want to have greater accuracy in avoiding harms, we have to understand the risks to individual people.
MP: Do you think that some level of addiction is inevitable and unavoidable?
JL: There will always be a certain percentage of people who genetically have a predisposition for developing compulsive use. What the prescription drug crisis did was it created wider access to highly addictive drugs and that access set fire to all the risk that already was out there in the suburbs. Unfortunately it took white suburban kids passing away before we as a country paid attention to addiction as a public health issue. That’s another example of not understanding risk. There was always risk for addiction in those populations. The prescription drug crisis just lit a match and accelerated the risks that were already there.
MP: I’m guessing that many medical experts and addiction activists could find your perspective concerning. How do you respond to that?
JL: Opioids can be very dangerous. We’re not trying to minimize that. We’re just saying that we have to adopt a more sophisticated perspective, one that is science-informed. If we don’t invest in people and we focus on drugs, we end up creating another polarizing conversation about substances and people will continue to fall through the cracks.