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Clinical and Research NewsFull Access

What Psychiatrists Can Do to Address the U.S. Opioid Crisis

Published Online:https://doi.org/10.1176/appi.pn.2019.5b15

Photo: Marc W. Manseau and Michael T. Compton

Marc W. Manseau, M.D., M.P.H., is a clinical assistant professor of psychiatry at New York University School of Medicine. Michael T. Compton, M.D., M.P.H., is a professor of clinical psychiatry at Columbia University College of Physicians and Surgeons. They are the editors of The American Opioid Epidemic: From Patient Care to Public Health from APA Publishing. APA members may purchase the book at a discount.

More than 70,000 people died of a drug overdose in the United States in 2017, the highest number ever, according to estimates from the Centers for Disease Control and Prevention. That number represents a tripling of the drug overdose death rate in 1999 and an almost 10% increase over 2016. Most of these deaths involved opioids and, more recently, an increasing proportion involved highly potent, synthetic opioids, such as fentanyl and its analogues.

This addiction-related overdose epidemic has reached crisis-level proportions: It has surpassed other leading causes of death, such as gun violence, suicide, and motor vehicle accidents and is driving an unprecedented decline in overall life expectancy in the United States.

Clearly, to manage this public health crisis, we need an “all-hands-on-deck” approach that leverages many aspects of the health care system. Psychiatrists, as the nation’s most highly trained behavioral health specialists, have a critical role to play. And with fewer than 1,500 addiction specialty physicians in the entire United States, this means all psychiatrists.

What do psychiatrists need to know to treat individuals with opioid use disorder (OUD) and prevent drug overdose deaths? First, psychiatrists need to understand how the current crisis began. The seeds of today’s opioid epidemic were initially planted by the pharmaceutical industry’s efforts to rebrand opioid pain medications as underutilized treatments for underdiagnosed chronic pain, rather than addictive medications to be used sparingly and with great caution. Unfortunately, the American health care establishment, including many physicians, watered these seeds for years before seeing the looming, iatrogenic public health crisis. Because physicians played such a large role in causing the opioid epidemic and because of high rates of comorbidity between mental illnesses and OUD (which is also associated with worse outcomes), psychiatrists now have a moral imperative to address OUD in our clinical practice.

Next, psychiatrists, allied behavioral health clinicians, and public health practitioners need to know which populations are affected by the opioid epidemic. Because white people had greater access to prescribed opioid pain medications, the epidemic hit white, rural, and suburban areas first. However, as oversight agencies and law enforcement cracked down on prescription opioids, heroin became widely available, spreading the epidemic to urban and nonwhite populations and setting the stage for further health inequities.

All behavioral health clinicians must also learn how to treat individuals with OUD. This will entail helping our patients overcome stigma against individuals with substance use disorders by taking a person-centered, recovery-oriented, and compassionate approach to assessment and management. We also must be able to implement effective, integrated care models for clinically vulnerable populations, including those with medical comorbidities and people with comorbid psychiatric illness.

Of critical importance is one life-saving intervention that psychiatrists should offer all individuals with OUD: medication-assisted treatment (MAT) with one of three approved medications—methadone, buprenorphine, and extended-release injectable naltrexone (XR-naltrexone). Overwhelming evidence confirms that MAT prevents deaths, lowers morbidity, and helps people with OUD recover from addiction. In addition, outcomes are almost always poorer without it.

While methadone can be dispensed only in certified opioid treatment programs, physicians (or nurse practitioners or physician assistants) can be certified to prescribe buprenorphine or XR-naltrexone in office-based settings. Because of this, these two medications are the linchpins for managing the epidemic, and it is crucial to understand their indications, uses, advantages, disadvantages, and evidence bases. And while MAT is key, adjunctive psychosocial interventions are invaluable for many patients, including those with co-occurring mental health conditions, so psychiatrists should be familiar with evidence-based psychotherapies for addiction as well.

Finally, any public health crisis requires policy- and prevention-oriented responses in addition to clinical interventions. This means clinicians and public health practitioners must have a working knowledge of the philosophy of harm reduction as well as specific harm reduction–oriented strategies to reduce opioid use–related morbidity and mortality. These strategies include community naloxone access for overdose reversal, syringe-needle access programs, and supervised injection facilities. Psychiatrists should help patients gain access to these harm-reduction interventions and advocate for their expansion. Clinicians should also appreciate population-level prevention strategies, as well as population health perspectives, for managing the opioid epidemic. Experts have proposed frameworks that tie together prevention, OUD identification, treatment initiation, and care engagement, modeled after previous successful approaches to the global HIV/AIDS epidemic.

Ending the American opioid epidemic will require policymakers, public health practitioners, and behavioral health clinicians to join together to overcome numerous challenges. Psychiatrists need to learn the necessary background, clinical information, and evidence-based tools to contribute to this work. We as a field and as individual physicians cannot afford to wait; too many lives are at stake. ■

Information and training to become a buprenorphine prescriber can be accessed here.