Rise and Resolution of the Epidemic
(There’s no need to rehash the statistics; the media are doing a perfectly good job of that. If you want straight from the source, here’s the CDC link.)
This post is about looking at the crisis from the viewpoint of an epidemiologist – similarly to how the CDC for example goes about figuring out what causes viral outbreaks, etc. And I’d like to suggest that the only way we’re going to see this epidemic come to an end is to adopt a similar strategy to the one we used to eradicate smallpox and polio - creating immunity.
The Epidemiologic Triangle
One of the classic ways of thinking about epidemics is the epidemiologic triangle (or triad.) Most of the time it's described as including a host population (people who can become infected with the disease), the agent (the bacteria or virus that causes the disease) and the environment. Part of the environment in classic infectious disease includes what's called a vector: that which transmits the
What’s unique about modern chronic disease epidemics, contrasted to classic infectious disease epidemics, is the unique behavioral vulnerability of the host. People have no problem adopting mosquito nets, fleeing plague-infested quarters of the city, or submitting to vaccination. And yet, they flock to Krispy Kreme, tobacco, and opioids despite the knowledge that these agents can destroy them. We are drawn like moths to a flame to that which we know to be harmful to us...
agent to the host, like a mosquito carrying the malaria parasite or yellow fever virus. It’s not exactly comparing apples to apples, but there are enough similarities between these classic infectious disease epidemics and the current opioid crisis to think about it in the same way. The host population is fairly obvious: people at risk of becoming dependent on opioids. And from what we know, that can pretty much be anyone. The agent in this scenario is the drug itself: opioids.
In this scenario (and in particular in the book I wrote on the subject introducing this paradigm for thinking about the opioid crisis) I’m considering the environment actually more in the category of the host population for purposes of discussion on how to intervene. For better or worse. In that book, and in this paradigm, I picture the vector being the third component of the triangle. And while there are certainly many different vectors including friends and family, drug dealers, etc. the one that we’ve been focusing on nationwide here lately has been prescribers.
Altering (or Eliminating) the Agent
One of the earliest strategies in our current 'war on opioids' was to try to make the drugs less addictive. So-called abuse-deterrent, tamper-resistant formulations certainly do carry logical appeal, but let's face it - people can find, and always have found ways to abuse them including simply taking more of them.
Reducing the agent's virulence (the innate ability of a bacteria or virus to attack a host and cause infection) doesn't really work in the world of microbiology. Widespread eradication of an agent doesn't work either - they are ubiquitous.
In the Opioid Epidemic, elimination isn't really possible either, and even if it was, something else new (or old) and terrible will simply step in to fill the void. I fear that what we’re seeing now is just the tip of the iceberg in terms of chemical coping. It's not just that the devastation from opioids far exceeds the deaths involved, tragic as that is. I'm afraid that unless we can confer population-level immunity to addictive substances in general I fear there will be a THC epidemic (and then another drug, and then another) the aftermath of which will make the current crisis pale in comparison. I appeal not to Dr. Robert Dupont so much as to Dr. Nora Volkow, current Director of the National Institute on Drug Abuse in voicing that concern - but more on that topic later.
Focusing on the Agent isn't the answer.
Restricting / Hampering the Vector
More recently we've been (in America) working to rein in poor prescribing practices. And of course the judicial and law enforcement community works non-stop to try to halt illicit trafficking. We're all for improving medical practice, and there's been lots of room for improvement.
Some of the recent data coming from the federal government (as well as some states) shows that restricting and refining opioid prescribing practices has correlated with a decrease in prescription opioid-related problems. And hopefully future generations will learn from our mistakes in the 1990s and 2000s.
But Prohibition didn't work, and current epidemiologic data doesn't show a decrease in opioid-related deaths, unfortunately - quite the opposite. As prescription opioids become less readily available and therefore less abused, there's been a shift to other drugs such as heroin - now more available and cheaper than ever - and other synthetic opioids manufactured outside the control of the FDA and the DEA.
Focusing on the Vector isn't the answer, either.
Conferring Behavioral Immunity
The only way epidemics end is when enough of the host population develops immunity to the agent such that transmission ceases (or the agent kills off all the hosts.)
There's a time and a place for opioids, as discussed elsewhere on this site. But that time and place have to be strictly controlled and monitored, and dependence - both physical and psychological - needs to be vigiliantly guarded against. And that can't be just the job of the physician (although the responsibility for prescribing certainly falls on us.)
Unlike historic infectious disease epidemics where people fled from the plague, or modern ones like Ebola, in the 21st century developed world most of our 'epidemics' stem from behavioral choices, and people rush headlong towards and into the agent.
If we are to end this epidemic, we need to figure out how to - at a population level - confer what the psychologists call 'behavioral immunity.' In essence, helping to cultivate within people a healthy fear and respect for opioids, much like the majority of the population has been able to develop for cigarettes. People ostensibly seek opioids for the relief of pain, but chronic use and dependence usually has more to do with seeking comfort from a complicated mixture of not only physical symptoms (including withdrawl symptoms), but also emotional distress. Replacing opioid dependence requires increasing resilience, improving biopsychosocial and spiritual health, and good old-fashioned habit replacement as well. The desire/habit of seeking instant comfort is a powerful vulnerability to this particular agent, and it's not just the physician that needs to say "no - let's try something else."
Focusing on host immunity - just like with smallpox - is the only hope for resolution of the Opioid Epidemic.
-Heath McAnally, MD, MSPH
22 Oct 2018
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