Landmark Surgeon General Report Tackles Addiction

Nancy A. Melville

November 18, 2016

The US surgeon general has taken on the nation's addiction crisis, issuing a landmark report on substance misuse and related disorders.

"Today I am issuing the first-ever report on alcohol, drugs, and health," Surgeon General Vivek Murthy, MD, told reporters in a conference call.

"With this report, I'm calling our country to action around one of the must underrecognized and underaddressed public health issues of our time," he said.

Dr Murthy detailed the staggering figures that speak for themselves in underscoring the severity of the problem ― 20.8 million people in the country with substance use disorders, which is approximately the same number of people with diabetes and 1.5 times the number of people with all cancers combined.

"Despite this, only 1 in 10 people with substance abuse disorders are getting treatment," Dr Murthy said. "That is unacceptable, and we have to close the gap."

The report, Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health, addresses a broad array of issues, ranging from illicit drug abuse to prescription drug addiction, alcohol use, binge drinking, and teen alcoholism. It is being compared in its significance and potential impact to the surgeon general's 1964 Report on Smoking and Health, which put a spotlight on the health risks of tobacco.

Cultural Shift

Dr Murthy said that, similar to the 1964 report, the new report strives to set the wheels in motion for a "culture shift." However, in contrast to the smoking report, which sought to stigmatize a practice that was socially acceptable at the time, the new report seeks to destigmatize addiction and change negative perceptions that stand in the way of addiction being regarded as a chronic disease.

"I am calling for a cultural shift in how we think about addiction, recognizing that it is not a moral failing or evidence of a character flaw but a chronic disease of the brain that deserves our compassion and care," Dr Murthy said.

The report outlines key findings on the neurobiology of substance use and addiction, the benefits of prevention, treatment strategies, and the essential role of healthcare systems in addressing substance use disorders.

Among the many misconceptions regarding addiction are misunderstandings about the roles of methadone and buprenorphine that have hindered their availability.

"Similar attitudinal barriers hinder the adoption of harm reduction strategies like needle/syringe exchange programs, which evidence shows can reduce the spread of infectious diseases among individuals who inject drugs," the report states.

Dr Murthy spoke of the need to increase investment in alternatives to opioids for pain management.

"We are urging clinicians right now to treat pain with nonopioid medications and strategies whenever possible, but that toolbox is more limited than I would like it to be," he said.

"We need pharmaceutical companies and academia and government to work together to expand the tools we have to treat pain that are not opioid-based."

Education, Communication

He also noted the importance of patient education and the need for communication of addiction issues in clinical practice.

"Clinicians and patients need to work together to solve this problem," Dr Murthy said.

"We've seen that a combination of clinician and patient education has been helpful in other areas, such as antibiotic overuse, for example, with more parents understanding that having antibiotics is not always helpful, and in fact sometimes it can contribute to harm, and we need the same public information effort around prescription opioids."

Although the issuance of the surgeon general's report was not intended to coincide with a change of administrations in the White House, Dr Murthy addressed the issue of working with the incoming Trump administration.

"The issue of addiction affects everyone, regardless of political party, and addressing this is a bipartisan issue," he said.

"I've been happy to work with members of both parties on public education efforts and on advancing other measures of addiction that we're taking on as a country, and I plan to continue that. I'm looking forward to working with the new administration for the rest of my term to ensure we're going to be doing everything we can."

The report has been applauded by various medical societies involved in the treatment of substance abuse and addiction.

Report Support

The American Psychiatric Association (APA) issued a statement in praise of the report.

"We are encouraged by the focus on the nationwide substance use epidemic and the many ways we can collectively work to address it," said APA President Maria A. Oquendo, MD, PhD.

"The disease of addiction affects people from all backgrounds across our society, and we have the knowledge and tools to provide effective treatment.

"It is important to have effective policies and programs to help prevent alcohol and drug misuse as well as make addiction care both more acceptable and more accessible to all people needing treatment," Dr Oquendo said.

Addiction specialist Shawn A. Ryan, MD, president of BrightView Health, a chemical dependency treatment program in Cincinnati, Ohio, likewise welcomed the release of the report, saying its impact could be far-reaching.

"It's been a long time coming, and I think it has the potential to have an even more substantial effect than the tobacco report did," Dr Ryan, who is also an assistant professor in the Department of Emergency Medicine at the University of Cincinnati, told Medscape Medical News.

"I don't think we've historically done a good job of treating substance abuse disorder, so it's my hope that this will be a step forward in contributing to advances in science as well as treatment of patients."

Clinical Decisions Play a Key Role

Dr Ryan agreed that clinical decisions in the course of everyday practice can play a key role in either contributing to or preventing addiction.

"We know for some people it just takes a single or very few exposures to the opioid medication that can elicit the trajectory to a substance use disorder," he said.

"We discuss risk and benefits of a medication every day – you don't put someone on a blood thinner, for instance, and say, 'Hey, good luck' – we discuss that the patient has a condition that requires a blood thinner, but it's also dangerous to be on blood thinners, and here are the reasons why.

"We are accustomed to having conversations with patients like that every day, and we just need to learn how to also do it with opioid pain medications."

Richard N. Rosenthal, MD, a professor of psychiatry at Icahn School of Medicine at Mount Sinai and medical director of the Mount Sinai Behavioral Health System, New York City, further commented that the surgeon general's report is significant in raising the issue of addiction to the forefront of health policy concerns in the United States.

"This is a fitting follow-up to the previous surgeon general report [on tobacco and health] in the sense that it is looking at the broad conception of substance use disorders and the public health peril that is occurring in this epidemic, which needs to be addressed by policy makers, clinical systems of care, insurers, and many others," he told Medscape Medical News.

"I think it does a great job at showcasing the problem and the opportunities to take action."

In terms of opioid addiction, Dr Rosenthal noted that a key issue emphasized in the report is that illicit use of street drugs and prescription drug addiction are more closely related than many may believe.

"What we're seeing is a conversion of people who started out as addicted to prescription pain medications but, either because of prescription monitoring programs or because they can no longer afford to pay for the pain medications, ended up moving to something cheaper and more available, such as heroin or other street opioids," he said.

"It’s all the same epidemic."

The American Society of Addiction Medicine (ASAM) released a statement in support of a cultural shift with respect to addiction.

"The report released today confirms what we have known for a long time: addiction is a disease of the brain that can and should be treated with evidence-based, compassionate care," Jeffrey Goldsmith, MD, ASAM president, said in the statement.

"For too long, policy makers, the public, and even healthcare providers have misunderstood this disease as some sort of moral failing. We hope this report will put an end to that misperception once and for all," he added.

Facing Addiction in America. Full text

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