Lives We Can Save

It is a public health crisis that kills hundreds of Americans a day. Effective treatments could bring down the death toll. But many doctors and patients are not using those treatments.

Regular newsletter readers might think I’m talking about Covid. But the description also applies to drug overdoses. They don’t get nearly as much attention, but they’re a similarly major public health problem, and they have neglected solutions.

More than 100,000 Americans die each year from overdoses, mostly from opioids, according to C.D.C. data released last week. That is higher than the toll from gun and car crash deaths combined. While medications like methadone and buprenorphine can sharply reduce deaths among opioid addiction patients, only about a quarter of people who could benefit from these treatments receive them.

Decades into the overdose crisis, tens of thousands of people whose lives might be saved are instead dying from opioids.

Extra barriers

America’s addiction epidemic did not have to unfold this way, and it highlights the health care system’s continued resistance to providing addiction care.

Treatment can be very expensive, and it’s often not covered by insurance. Addiction doctors have complained to me that they can spend hours of their workday on the phone with insurers asking them to pay for a medication, and sometimes insurers say no anyway. Patients have shared similar experiences.

The federal government has sometimes exacerbated the problem. Until last year, doctors had to go through special training and obtain a waiver to be able to prescribe buprenorphine, the medication for opioid addiction. At the same time, federal officials have failed to enforce laws requiring that insurers cover addiction treatment.

A comparison to France, which faced its own opioid crisis in the 1980s and ’90s, is instructive. In 1995, French officials deregulated buprenorphine so more doctors could prescribe it. Over four years, overdose deaths fell 79 percent.

It is a sharp contrast to the U.S. Rather than impose extra requirements for addiction care, French officials greatly relaxed rules during a crisis. And through the country’s government-run health care system, officials made sure that the treatment was widely available and paid for.

On top of America’s bureaucratic problems are more personal ones.

Some doctors hold stigmatizing views about addiction and the patients afflicted by it, and refuse to provide treatment. Many doctors say they lack the confidence to treat addiction because they don’t have enough training or access to specialists who can help guide them. Drug users can also resist treatment. Some think of medications for addiction as merely replacing one drug with another, though experts reject that framing because the medications replace drugs that do harm with drugs that can help.

All of these problems lead to the underuse of effective addiction treatments in the U.S., and so it is easier to get high than it is to get help.

The bigger picture

Some of the problems are specific to addiction. But others are broader. Obesity and mental health conditions are often undertreated, too. Flu seasons are consistently worse than they have to be because not enough people get their annual shots. While Americans’ overuse of health care frequently receives attention, underuse is a problem in many situations as well.

Why is this the case?

Often, people, including doctors, have outsize fears about the downsides of some treatments, especially new ones. With Covid, doctors worry about Paxlovid’s interactions with other drugs — a real problem but largely a manageable one. With opioid addiction, patients make the mistake of thinking of a prescribed medication, like buprenorphine, as just another drug, even though it can save their lives.

The American health care system’s fragmented nature also makes it easier for problems to fall through the cracks. In France, officials can leverage the country’s universal health care system to overcome hesitancy to new treatments by guaranteeing they’re widely available and by strongly pushing for their use. In the U.S. system, there is no centralized authority, so medical authorities struggle to coordinate care even when the best practices seem clear.

As a result, drug overdoses are both a major public health problem in their own right — they are one reason U.S. life expectancy fell in 2020 and 2021 — and representative of the system’s larger struggles. The U.S. spends far more per person on health care than any other country and also has lower life expectancy than Canada, Japan, South Korea, Australia and much of Western Europe.

Related: Opioid overdoses are killing thousands of people in New York each year. The surging death toll is the city’s “new normal.”

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