Effective treatments for opioid use disorder exist, but tackling the epidemic requires education, support, and coming to terms with (and addressing) some of our society’s shortcomings. American Psychiatric Association president Dr. Petros Levounis, M.D., M.A., offers his insights on the state of the opioid epidemic, and what can be done to curb rates of addiction and overdose.
Dr. Petros Levounis, M.D., M.A.
President, American Psychiatric Association
“When it comes to opioid use disorder, the person will most likely need medication in order to thrive and do well, which is something that a family member cannot really provide. But what the family member can provide is support.”
How urgent is the need to develop a response to the opioid use crisis in America?
The opioid epidemic is very much with us, alive and terrible as it is, devastating communities throughout the country. What’s particularly concerning is that there are some populations that are disproportionately affected. The death rates for Black men have tripled over the past few years and over the past decade.
Altogether, men are more vulnerable than women when it comes to opioid overdose. Although the country as a whole may be seeing somewhat of a plateauing of the deaths from opioid overdose over the past 12 months, there are regions of the country that are still being hit very hard: the middle of the country, the northeast, and the northwest most prominently.
Is there a reason men are more vulnerable than women?
Men are more vulnerable to addiction in general, so it goes hand in hand that opioid overdose will also affect men preferentially. It’s the way we’re socialized, the way we’re brought up. Men have more opportunities and expectations to take more risks. So, there are many ways and many reasons why we see addiction as being skewed somewhat on the male side.
That being said, alcoholism in women is greatly under-diagnosed, underappreciated, and undertreated — there are many areas in which women have been underserved by the addiction treatment system.
Are there any other underserved populations that are particularly affected by the opioid crisis?
Incarcerated people make up one of the most discriminated against populations. Quite often, incarcerated people do not have access to buprenorphine, a life-saving medication for the treatment of opioid use disorder.
Addiction is a chronic relapsing illness, very similar to diabetes, hypertension, and depression. While incarcerated people get medical treatment for their diabetes, it’s outrageous that they don’t get the treatment they need for their opioid use disorder. The fact that you’re incarcerated and may not have access to opioids does not make you immune to the incredible cravings that you may have for opioids, and there’s a tremendous risk of relapse right away when you get released from a prison.
What can we do to address these disparities?
One good thing that has already happened was the removal of the X-waiver. Before, you needed a special license to prescribe buprenorphine, a life-saving medicine for the treatment of opioid use disorder. As of December 2022, you no longer need the X-waiver, and we applaud that development.
The second thing is telehealth, which has helped those in vulnerable populations who are not to come to a clinic. The relaxation of rules during the COVID pandemic very much helped these vulnerable populations. We hope, strive, and fight for the extension of these emergency allowances to help these vulnerable populations.
The other thing was making naloxone (with a commercial name of Narcan) available as widely as possible — you can now get it over the counter. But that’s not enough: We need to make it available to everyone, so that if you see a loved one nodding off or overdosing, you can administer a couple squirts of naloxone in the person’s nose and save a life.
What are some signs that someone might be struggling with substance use disorder?
There are four major categories. The first one is a physiological dependence, meaning you develop a tolerance to the drug, and you need higher and higher doses in order to achieve the same effect. Under a physiological dependence, if you abruptly stop using, you may feel terrible and have physical symptoms, such as terrible aches and pains.
The second part is an internal preoccupation: You constantly think about the drug, you have cravings about the drug, and you spend tremendous amounts of time buying the drug or getting high, coming down from it, and finding the money, and then you start the whole process all over again.
The third category has to do with external consequences. Your relationships start going south, you start not performing well at work, you do not attend to your responsibilities, you may get in trouble with the law, you may have medical consequences — all of these are external aspects of addiction.
And then the final category is the one I consider to be the most telling of all the signs of addiction: continued use despite knowledge of adverse consequences. You know it’s bad for you, you want to quit, and you cannot do it; you’re just bound to continue using.
What are some things people can do if they see a loved one struggling?
Talk to the person, open the door, start the conversation, start that initial step of actually understanding where the person is. But very often, that’s not enough. You do need to try the best you can to get the person to a professional.
When it comes to opioid use disorder, the person will most likely need medication in order to thrive and do well, which is something that a family member cannot really provide. But what the family member can provide is support.
A lot of patients are highly reluctant to go and see a doctor. So, a loved one can provide support and seek professional advice themselves on how to best motivate the patient to take that step to get help from a doctor.
What is the biggest misconception people have about opioid use disorder?
Quite a few people feel that addiction is a matter of willpower, that if you are strong enough and really work on it, then you can beat the disorder and you don’t need professional help. Not true. The best analogy I can think of is diabetes. If you have insulin-dependent diabetes, no matter how much you are white-knuckling it, you cannot will your way through it without insulin. You need to have a doctor help you with your illness. Opioid use disorder works the same way.
We’re incredibly fortunate to have a powerful, safe, and effective medication that can address opioid use disorder: buprenorphine. We also have alternatives to buprenorphine if that doesn’t work. But just trying to do it yourself is not an effective strategy.
