The opioid epidemic has been declared a public health emergency, allowing for access to public health funding, in an effort to raise awareness and deploy public health initiatives. This declaration was in response to the growing numbers of overdoses and overdose deaths in the United States.
In 2016, there were approximately 42,000 deaths from opioid overdose, and this is likely an underestimate. To put this into perspective, there are approximately 115 deaths per day in the United States from prescribed and illicit opioids. By comparison, there had been 120 deaths by the yet unknown HIV virus when the Center for Disease Control raised the concern for an impending epidemic in 1981 in the June issue of Morbidity and Mortality Weekly Reports.
An emergency is often defined as “an unforeseen combination of circumstances or the resulting state that calls for immediate action.” The opioid epidemic, however, is a culmination of issues that healthcare providers are well aware of: trauma, mental health issues, and the disease of addiction. There is nothing unforeseen regarding the volume of opioids that flooded the market, the influx of cheap synthetic opioids, and the lack of access to treatment that has culminated into this epidemic. This epidemic isn’t just an emergency, it is a humanitarian crisis, and there is a need to apply the tenets of humanitarian care to policy and practice to combat it.
Humanity is a guiding principle of humanitarian response to crisis. Humanity means both allowing one to live a life with dignity, and the act of addressing human suffering wherever it is found. There is a prevailing negative view and stigma about people with substance use disorder, often labeling them as weak or morally inept. There is a perception that people with substance use disorder are “just getting high” and that they could “stop at any time.” As a result, individuals with substance use disorder become marginalized, isolated, and demoralized.
The truth, however, is that addiction quite frequently stems from trauma. In many cases, the use of substances is a means to mask the trauma, be it from interpersonal violence, sexual assault or post-traumatic stress. Isolation, shame and stigma often results in these individuals being incredibly vulnerable. Lack of access to healthcare, lack of insurance, and homelessness are also common. There is a great deal of suffering among this population and yet, when they need care the most, they are often neglected.
It is imperative to prioritize a restoration of dignity, to re-establish a sense of self-worth and to take a trauma-informed approach to caring for those who suffer from addiction. Policy and practice need to reflect these principles that are the core of a humanitarian response.
Impartiality, in a humanitarian response, is the concept that those who need the care most get it first. It prioritizes the most vulnerable, the most in need to getting the care they need. In the United States, access to substance use and mental health treatment is prioritized to the insured. Individuals with adequate insurance have access to programs that are not available to those on the margins or who are uninsured. There are more than forty-four million people uninsured in this country, and there is a significant intersection between poverty, trauma and substance use. While there are means to access care without insurance, these programs are overburdened and underfunded. The result is that those who are most in need are likely also least likely to have access to care.
In a humanitarian response, the first priority would be to those very individuals, those most in need, who lack access and resources and who will suffer needlessly without aid. And yet the approach to the opioid epidemic has been ineffective in reaching these individuals. There is again, an imperative to provide care to the marginalized and uninsured, to provide access to important programs and treatment and to ensure access to those most in need.
The declaration of a public health emergency was a good first step. A public health approach to the opioid epidemic is important. There is a need to gather epidemiological data, as well as institute evidence-based educational programs and harm reduction methods. There is a need to better understand the disease, its implications, and to improve access to treatment. There is a need to develop evidence-informed policy and to institute best practices.
This epidemic, however, goes beyond that. It isn’t just an emergency, it is a humanitarian crisis. The opioid epidemic is affecting some of the most vulnerable and marginalized individuals in this country. There are millions of individuals in need of help, but without access to care, and they are in our own backyard.
A humanitarian thought process and approach can help to focus policy and action on prioritizing care to those most in need. As such, it can be neutral, not taking any political, religious, or ideologic side with regard to its response. The response will provide care to those who are suffering the most, the under-insured, uninsured, and homeless populations.
Harm reduction and access to treatment can be at the core of the response. Improving access to clean needles, filter needles, safer injection sites, medication assisted treatment and mental health support can be administered unimpeded. Policy and practice should reflect the principles of humanitarian response. It should engage a trauma-informed approach, engage in restoration of dignity, and provide access to care to those most in need.
With this approach, more people will have access to care and with hope, in time, there can be healing and recovery.
Stephen P. Wood is a nurse practitioner for Lahey Health and works in the emergency department at Winchester Hospital and Lahey Medical Center. He is a fellow at the Harvard Medical School Center for Bioethics with a focus on the opioid epidemic and human trafficking. He is the chair of the Winchester Hospital Substance Use Task Force and a member of the ED Mental Health Working Group. He is co-chair of the Southern MIddlesex County Mental Health Working Group. His focus is on harm reduction and access to care.