Leana S. Wen is an emergency physician and a visiting professor at George Washington University Milken Institute School of Public Health. She was Baltimore health commissioner from 2015 to 2018 and chief executive of Planned Parenthood Federation of America from November 2018 until July.
Every day, more than 130 Americans die from opioid overdose, and Baltimore has not been spared. In 2017, nearly 700 city residents died from this preventable tragedy. Even though I had written a blanket prescription that made the opioid antidote naloxone readily available, limited funding forced first responders to ration this lifesaving medication. Science is unequivocal that addiction is a disease that can be treated. But in Baltimore, and throughout the United States, only a fraction of patients with addiction are getting the treatment they need.
So many more lives could be saved.
Thankfully, we now have an opportunity to secure this funding. Last month, an Oklahoma judge ordered Johnson & Johnson to pay the state $572 million for deceptive marketing practices that fueled the crisis. Purdue Pharma has tentatively reached a $12 billion deal with 24 states and nearly 2,000 cities and counties, and more than 20 state attorneys general are pressing for an even larger settlement. Thousands of other cases are pending against multiple pharmaceutical companies. Taken together, all this could reach the scale of resources needed to treat and prevent opioid addiction once and for all.
All to the good. But there’s one more big hurdle: Will settlement funding be used for its intended purpose?
Recent history is not reassuring. The 1998 Tobacco Master Settlement Agreement shows what can happen when funding decisions on public health matters do not employ a public health approach. That settlement required major cigarette companies to pay an estimated $246 billion over 25 years. The payouts were supposed to be used to fight tobacco-related disease, but only 2.4 percent of revenue collected ended up being spent on prevention and cessation. Instead, states have used funds to subsidize tax cuts and cover budget gaps. In North Carolina, money was even used to help tobacco farmers grow more tobacco.
To prevent a similarly egregious diversion, today’s policymakers should commit — at the outset — to a strong public health framing for the opioid settlement. This starts with tight controls to guarantee that all funds support evidence-based methods of prevention and treatment.
Three key points:
First, there is broad medical consensus that the gold standard for opioid addiction treatment is medication-assisted treatment, combined with psychosocial counseling and other wraparound services such as supportive housing. Rapid “detox” programs do not work, and, in fact, lead to higher rates of overdose deaths. Yet, these detox programs still get government funding, and many states force people to comply with these methods. That needs to change.
Second, resources should be allocated based on severity. In a disease outbreak or natural disaster, funding should be aimed at hardest-hit areas. The Ryan White HIV/AIDS Program, for example, employs a formula that takes into account HIV prevalence and proportionally distributes funding. To ensure efficacy, a similar formula should be used for opioid funding.
Third, that formula must include the core public health principle of equity. Specifically, this means that policymakers must ensure that funds go not just to areas with high rates of prescription opioid usage, but also to places hit hard by heroin and other street opioids.
This critical point brings me back to Baltimore, so I want to elaborate a bit. We know that prescription opioid overuse fueled the street drug epidemic. Patients with opioid addiction frequently switch to heroin because it is cheaper and can be easier to obtain. Effectively addressing the epidemic requires taking stock of the problem as a whole.
A funding distribution that focuses only on one face of the disease would violate public health best practices. It would also worsen racial disparities. Already, many in my city and around the country are angry that opioid addiction was not deemed an epidemic until decades after it claimed the lives of countless people in minority communities.
When the face of addiction was black and brown — and associated with heroin — addiction was seen as a crime and a moral failing; when it became white and associated with pills, addiction became understood as a disease. To be sure, it is an important development that much-needed resources are finally coming to address this crisis. But unless street drugs are given equal weight to prescription opioids, the response will not only be ineffective, it will perpetuate systemic injustice and structural racism that have long undergirded opioid addiction.
The decisions soon to be made in our courts, legislatures and statehouses will answer critical questions. Even now, do our policymakers fully grasp the scale and breadth of their constituents’ suffering? Will they do what’s needed to end this epidemic once and for all?
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