Why Europe Dominates in the Fight Against Opioid Overdose

We have all seen the statistics surrounding the opioid epidemic in this country numerous times, and yet they are still alarming: upward of seventy thousand people died from a drug overdose in 2017 alone (NIDA, 2019). While this number includes all drugs, the majority is attributed to opioids and the more widespread availability of dangerous synthetic opioids such as fentanyl. But what is almost more incredible than the five-figure number is that after two gut-wrenching decades of watching much of the nation suffer because of the crisis, the rate of opioid overdose deaths in the United States is not slowing down, but accelerating (Scholl, Seth, Kariisa, Wilson, & Baldwin, 2019).

What are we doing wrong?

I would argue that how we view and treat opioid addiction in the US is an American invention. It is unnecessary, largely ineffective, and based on the myth that recovery from opioid addiction can happen using mutual-help fellowship alone, without medical care or medication, in a large proportion of patients. The relatively low number of overdose deaths in many countries in Europe where medical care is the cornerstone of treatment shows this clearly.

In Portugal, overdose deaths from drugs such as opioids and cocaine number twenty-seven per year, down 75 percent since 2001 (EMCDDA, 2019b). In Switzerland, fatal overdoses are down by two-thirds from their height in the early 1990s (CSDP, 2019). In France, a country with one-fifth of the US population, the number 370 overdoses per year (EMCDDA, 2019a).

Across the European Union (population: 512.6 million), about eight thousand people die from drug overdoses every year (Statista, 2019; EMCDDA, 2019c). According to the most recent numbers, in the US (population: 327 million), opioids alone claim 128 Americans every day, or about 47,600 people per year—a remarkable four times higher than all drug overdoses in the European Union (US Census Bureau, 2019; Scholl et al., 2019).

Research has shown unequivocally that the best outcomes for treating opioid addiction happens when people who use drugs have access to a wide range of medical services reflective of how we would treat other chronic medical disorders. In France, Portugal, and Switzerland, medical professionals address addiction using a comprehensive approach, with medication targeting the brain as a keystone of treatment.

Three FDA-approved medications are available to treat opioid use disorder: methadone, buprenorphine (both of which are recognized by the World Health Organization as essential medicines), and extended-release naltrexone (FDA, 2019; WHO, 2017). All national and international treatment guidelines support the use of medications as a central component of treatment. Yet most US addiction treatment facilities, both residential and outpatient, reject a medical model of relapse-prevention treatment and rely on more traditional, nonmedical methods and personnel, including the Twelve Step program (SAMHSA, 2014). These are the types of programs the US government currently funds.

While nonpharmacological approaches can and do work for many people with certain types of addictions, they are far less effective in the fight against opioid addiction. Once detoxified and offered treatment without medications, 70 to 90 percent of people suffering from opioid use disorder relapse within the first three months, sometimes fatally due to reduced tolerance to opioids (SAMHSA, 2016). Treatment with medication such as methadone or buprenorphine doubles or triples the chance that people with opioid addiction will survive the disorder (Fullerton et al., 2014; Thomas et al., 2014).

Most of Europe has expanded access to the medical model of treatment, including treatment with methadone or buprenorphine, by destigmatizing addiction as a criminal or moral problem. This has helped attract physicians—family doctors and others who are not addiction experts—to treating opioid-addicted individuals. Studies done in France show that primary care doctors treating opioid addiction with medications have outcomes no different than those achieved by addiction specialists (Fatseas & Auriacombe, 2007).

Stigma of addiction is universal, although in the US there is also a stigma against the medical model of treating addiction. In the Twelve Step tradition, for instance, medications such as methadone have been viewed as incompatible with sobriety. Furthermore, lack of physician education about the biological dimension of addiction leads to more incorrect views about the voluntary nature of drug addiction, which in turn leads to more negative attitudes about treating addicted patients. These views support the notion that addiction can only be treated by drug counselors who cannot prescribe medication outside of the mainstream health care system.

In the early 1990s, Zurich faced a major problem with heroin use. Their solution was to offer widespread medical treatment that includes long-term maintenance on methadone and even a heroin substitution program and other harm-reduction services for people who were using drugs. Interestingly, engaging this population in care led to a reduction of new opioid users. In just a few years, the public health crisis was mostly controlled, and the medical approach to dealing with heroin addiction was codified into law. Perception of opioid addiction in Switzerland has dramatically changed. It is now seen as a chronic medical condition, and close to at least 70 percent of patients affected with opioid addiction are treated under a medical model (Nebehay, 2010).

Portugal dealt with high rates of heroin overdoses by decriminalizing all drug use and redirecting most of the money that went to policing into medical treatment. Rather than being arrested, those people found to possess heroin for personal use are evaluated by a doctor and a social worker to explore the need for treatment. Community outreach teams educate heroin users on how to reduce risk while using and support them when they decide to try treatment. This harm-reduction approach facilitated a change in perception. In Portugal, heroin has become a health issue rather than a criminal one (Frayer, 2017).

Part of the problem in the US is that we do not treat opioid addiction as a public health issue and we do not cover the cost as such. In most of Europe, health care is based on a single-payer system. Funding assured, the government is able to implement free drug addiction treatment services for anyone interested. At present, the US government funds addiction treatment separately from the rest of medical care.

The government could change how it funds treatment by calling opioid addiction a chronic disease, which would give it the status it needs to be covered under Medicare. This would be a major improvement, but to do it we would need to treat addiction as a medical disorder using the medical model—that, for the most part, is not happening.

More than anything, a tradition in the form of outdated treatment modalities is keeping the US in the dark ages and fueling the crisis. Moving government funds toward evidence-based medical treatment and mobilizing physicians in clinics throughout the country to treat opioid use disorder may not reduce annual overdose deaths to forty, but I am more than confident that they would at least begin to drop.

References

Common Sense for Drug Policy (CSDP). (2019). Switzerland. Retrieved from https://drugwarfacts.org/region/switzerland
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). (2019a). France: Country drug report 2018. Retrieved from http://www.emcdda.europa.eu/countries/drug-reports/2018/france_en
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). (2019b). Portugal: Country drug report 2018. Retrieved from http://www.emcdda.europa.eu/countries/drug-reports/2018/portugal_en
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). (2019c). Statistical bulletin 2018—Overdose deaths. Retrieved from http://www.emcdda.europa.eu/data/stats2018/drd_en
Fatseas, M., & Auriacombe M. (2007). Why buprenorphine is so successful in treating opiate addiction in France. Current Psychiatry Reports, 9(5), 358–64.
Frayer, L. (2017). In Portugal, drug use is treated as a medical issue, not a crime [Radio program]. In Morning Edition. Retrieved from https://www.npr.org/sections/parallels/2017/04/18/524380027/in-portugal-drug-use-is-treated-as-a-medical-issue-not-a-crime
Fullerton, C. A., Kim, M. Thomas, C. P., Lyman, D. R., Montejano, L. B., Dougherty, R. H. . . . Delphin-Rittman, M. E. (2014). Medication-assisted treatment with methadone: Assessing the evidence. Psychiatric Services, 65(2), 146–57.
Nebehay, S. (2010). Swiss drug policy should serve as model: Experts. Retrieved from https://www.reuters.com/article/us-swiss-drugs/swiss-drug-policy-should-serve-as-model-experts-idUSTRE69O3VI20101025
National Institute on Drug Abuse (NIDA). (2019). Overdose death rates. Retrieved from https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
Scholl, L., Seth, P., Kariisa, M., Wilson, N., & Baldwin, G. (2019). Drug and opioid-involved overdose deaths—United States, 2013–2017. Morbidity and Mortality Weekly Report, 67(5152), 1419–27.
Statista. (2019). European Union: Total population from 2008 to 2018 (in million inhabitants). Retrieved from https://www.statista.com/statistics/253372/total-population-of-the-european-union-eu/
Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). 2013 state profile – United States. National survey of substance abuse treatment services (N-SSATS). Retrieved from https://wwwdasis.samhsa.gov/webt/state_data/US13.pdf
Substance Abuse and Mental Health Services Administration (SAMHSA). (2016). Treatment episode data set (TEDS) 2013. Discharges from substance abuse treatment services. Retrieved from https://wwwdasis.samhsa.gov/dasis2/teds_pubs/2013_teds_rpt_d.pdf
Thomas, C. P, Fullerton, C. A., Kim, M. Montejano, L. Lyman, D. R., Dougherty, R. H., . . . Delphin-Tittmon, M. E. (2014). Medication-assisted treatment with buprenorphine: Assessing the evidence. Psychiatric Services, 65(2), 158–70.
US Census Bureau. (2019). US and world population clock. Retrieved from https://www.census.gov/popclock/
US Food & Drug Administration (FDA). (2019). Information about medication-assisted treatment (MAT). Retrieved from https://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm600092.htm
World Health Organization (WHO). (2017). WHO model list of essential medicines: 20th list (March 2017). Retrieved from http://apps.who.int/iris/bitstream/handle/10665/273826/EML-20-eng.pdf?ua=1

Adam Bisaga, MD

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Adam Bisaga, MD, is a professor of psychiatry at Columbia University. He is a United Nations consultant who helps to develop drug treatment programs internationally and author of Overcoming Opioid Addiction: The Authoritative Medical Guide for Patients, Families, Doctors, and Therapists.