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In Reply I—Root Causes of the Opioid Crisis

      To the Editor:
      We thank Dr. Pendyal for the thoughtful and articulate response to our article.
      • Srivastava A.B.
      • Gold M.S.
      Beyond supply: how we must tackle the opioid epidemic.
      We agree that a thorough examination of opioid use disorders and overdoses includes evaluation of structural- and societal-level factors. Indeed, income inequality, social disparities, and other structural inequities are important considerations in chronic illnesses, disease management, premature deaths, infant mortality, maternal illness, and all epidemics past and present, not just the current opioid epidemic. Similarly, depression, despair, hopelessness, and suicide are not exclusively linked to the current opioid crisis but are reflective of the state of health and wellness in our society. The current zeitgeist has worsened the opioid epidemic, but it is not specific to it, nor does it necessitate drastic revisions to the proposals we addressed in our article.
      Particularly relevant is the work of the late David Musto, a Yale physician, historian, and expert on drug policy under the Carter administration.
      • Musto D.F.
      The American Disease: Origins of Narcotic Control.
      The first epidemic, occurring from 1898 to 1914, involved the purchase of then-legal heroin by rural, middle-class females and generally subsided with the introduction of the Harrison Narcotics Tax in 1914. The second is perhaps more instructive, occurring from 1960 to 1968, and it involved mostly minority young men and was linked to urban crime. In Washington, DC, response to the crisis and its inextricable link to crime, universal testing for all criminal offenders, and access to methadone treatment was provided through the Narcotics Treatment Administration, resulting in substantial public health and safety successes: heroin overdoses fell from 74 to 3, and the crime index in Washington, DC, fell by 50%. Nationally, President Nixon launched an effort to similarly attack the “demand” side of the crisis, culminating in the 1973 founding of the National Institute of Drug Abuse under Robert DuPont, MD, providing a center for cutting-edge research and policymaking that has helped curb epidemics of past years.
      • DuPont R.L.
      National Institute on Drug Abuse at its first 35 years.
      The lay news coverage of affected areas notwithstanding, the current opioid epidemic has affected rich and poor alike. Pain, access to pain medications, and failure to educate the patient of the risks of opioids have caused major consequences to patients in VA clinics, pain patients with Medicare and Medicaid, and individuals with enough capital to afford illicit oxycontin at $1/mg. Access to drugs and lack of opportunity may be more relevant to methamphetamine, cannabis, and alcohol use, which afflicted the same communities as those disproportionately afflicted by opioids today.
      • Center for Behavioral Health Statistics and Quality
      2016 National Survey on Drug Use and Health: Detailed Tables.
      Drugs of abuse are an equal opportunity destroyer of lives and families, and we strongly emphasize the importance of prevention rather than ignoring the entire scope of the problem and trying to treat the consequences.
      • DuPont R.L.
      The opioid epidemic is an historic opportunity to improve both prevention and treatment.
      Although the current opioid epidemic differs from that of the 1960s, the fundamental components of the approach—prevention, identification (in which law enforcement is an ally, not an adversary), entry into treatment, maintenance of recovery through mutual support groups, and continuing care—which may very well involve finding meaningful employment, establishing community, and focus on overall health and wellness, and ultimately a celebration of recovery—are still readily applicable today.

      References

        • Srivastava A.B.
        • Gold M.S.
        Beyond supply: how we must tackle the opioid epidemic.
        Mayo Clin Proc. 2018; 93: 269-272
        • Musto D.F.
        The American Disease: Origins of Narcotic Control.
        Yale University Press, New Haven, CT1973
        • DuPont R.L.
        National Institute on Drug Abuse at its first 35 years.
        Drug Alcohol Depend. 2010; 107: 80-81
        • Center for Behavioral Health Statistics and Quality
        2016 National Survey on Drug Use and Health: Detailed Tables.
        Substance Abuse and Mental Health Services Administration, Rockville, MD2017
        • DuPont R.L.
        The opioid epidemic is an historic opportunity to improve both prevention and treatment.
        Brain Res Bull. 2018; 138: 112-114

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