America, we have a problem:
Two Princeton economists startled Americans recently when they discovered that between 1999 and 2013, white, middle-aged, high-school-educated men in the United States died at an increasing rate from prescription and illegal drug overdose, alcohol and liver-related disease and suicide. Fortunately there is the impression that government and media are paying attention to this national epidemic. Earlier this month, President Obama announced his plans to invest more than $1.1 billion over the next two years to expand access to treatment for abuse of heroin and other drugs, avail the overdose-reversal drug naloxone to first responders, and support targeted enforcement activities. Also Congress passed the Comprehensive Addiction and Recovery Act (CARA), revising punitive drug policies, promoting best medical practices and strengthening data sharing among states’ prescription drug monitoring programs.
The Princeton study also forces us to recognize that drug abuse is not, as previously thought, a malady afflicting only poor, minority, inner-city communities, but rather is an across-the-country phenomenon, affecting in particular rural white adults. Interestingly, as the mortality trend demonstrates, the under-treatment of pain in minorities has inadvertently ‘protected’ them from overdose, reducing a decades-long death-rate gap between whites and non-whites. But will increased access to care for those already harmed by addiction; addressing the enduring shortfalls in prescriber education; and research for alternative abuse-deterrent medications actually reverse this deadly epidemic?
I think not.
Turns out the overdose epidemic is a social, not just a medical, problem.
First, researchers are struggling to understand why whites, in particular, are doing so poorly with drug abuse. Although there are no definite answers, many speculate that it is the combination of stress and lack of social support (risk factors for drug abuse in general) and acute job loss that are causing these deaths. Recession alone does not increase mortality, however when recession is associated with job loss, the rate of heart attacks, strokes and deaths rises. This may suggest that the increase in stress, despair and financial insecurity combined with engaging in unhealthy behaviors (like inactivity, smoking, drinking alcohol, and drug abuse) may be the cause of these deaths.
Second, and even more surprising, is that although awareness of the harms of opioid abuse is rising, the overwhelming majority of patients who survive an overdose continue to be prescribed high-dose opioids, often by the same prescriber. It is easy to attribute these results to poor care, bad decisions or sloppy prescribing, but many of these prescribers simply do not know that their patients are overdosing. Given the fact that there are no widespread systems in place to notify prescribers when overdoses occur, it is highly unlikely prescribers will suddenly increase the level of care for these patients.
Third, the notion that there is a small group of prolific prescribers that are driving the opioid overdose epidemic is not accurate. The bulk of prescriptions are made by general practitioners trying to help patients with a broad array of health conditions, and the distribution patterns of prescribing opioids between Medicare and Medicaid patients are no different than other drugs given for chronic diseases. These statistics suggest that adding law enforcement resources to address improper prescribing is not warranted. Fourth and most disappointing is that despite a plethora of local, regional, state and federal efforts to curb the overdose epidemic, things are actually getting worse. More people died from prescription and illicit drug overdoses over the past year than during any previous year on record.
Clearly there is a need to develop safer drugs and do a better job in prescribing and intervening before prescription drug misuse or other substance use progresses to addiction. But are these responses a big enough step in the right direction?
Under-assessment, the overlooked problem
The 18th century French philosopher Voltaire had many amusing quotes about medicine, such as: “common sense is not so common” and “the Art of Medicine consists of amusing the patient, while nature cures the disease”. However there is one particular quote that might provide an overlooked solution to the overdose epidemic. Voltaire said that “Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing”. How does this statement reflect on current practice?
Obviously, nowadays we know much more on how to prescribe and how to cure diseases, but what about “knowing our patients”? How well do healthcare providers ‘know’ their patients and how does this intimate, context-sensitive, unbiased knowledge contribute to the decision to prescribe (or not) drugs? When was the last time a healthcare professional used an online multidimensional, patient-reported outcome tool during a routine office visit incorporating data on sleep, movement and diet based on a wearable FitBit-like device? When was the last time a prescriber was able to show a patient their longitudinal treatment outcome on a dashboard in real time, to justify continuing or stopping treatment?
Well if your answer is never, you probably understand that the problem of medicine in general is not the over- or under-prescription of drugs, or the over- or under-treatment of anything, but rather a fundamental under-assessment of patient’s complex physical condition and nuanced life narrative.
One billion dollars of funding devoted to appropriate, cost-effective treatments can be expected to help many. But in order to halt and not just attempt to reduce rising death rates from drug overdoses, prescribers really need to get to know their patients. Beyond human contact, professionals need to start quantifying human social traits (“phenotypes”) at every clinical encounter in addition to the routine use of lab tests and imaging. Insurance companies need to pay for this, so that lack of time will not be an excuse for not measuring behavior, and patients need to have this actionable information (‘health data’) available. Not measuring pain interference, mood, diet, activity, exercise and sleep limits the understanding of the effects of any therapy, and makes prescribers unable to guide patients and their families to cope with, and remove, the obstacles that deny them the health and wellbeing they seek.
As for patients, my recommendation is: “next time you see your doctor, ask to see your data”.
Dr. Alex Cahana is Director of Medical Affairs at the Center for Lawful Access and Abuse Deterrence and theme developer for ARK Investment Management. He has over 15 years of experience in policy and healthcare redesign and serves as a consultant for the Department of Defense and the Veterans Health Administration.
 Case A, Deaton A. PNAS 2015; 112(49):15078-15083
 http://www.cdc.gov/media/dpk/2015/dpk-eoy.html. Accessed on 2.3.2016
 https://www.whitehouse.gov/blog/2016/02/01/preventing-epidemic-opioid-abuse-and-heroin-use. Accessed 2.4.2016.
 https://www.govtrack.us/congress/bills/114/s524/text. Accessed 2.4.2016
 Noelke C, Avendano M, Am J Epidemiol 2015; 182(10):873-882
 Rudd RA, Aleshire N, Zibbell JE et al. CDC. MMWR. 2016; 64(50):1378-1382
 Francois Marie Arouet Voltaire (1760). In: Robert Allan Weinberg, The Biology of Cancer (2006), p. 726
 Ausielo A, Lipnick S. Big Data 2015; 3(3):203-208