The best way to battle addiction is to put more resources into prevention

The CDC’s National Center for Health Statistics just released some sobering news: Life expectancy in the United States dropped for the second year in a row due in large part to the 21 percent rise in drug overdose deaths to a whopping 63,600. That’s a staggering number that equates to 174 deaths everyday, just short of the number of casualties on 9/11 every two weeks.

With fatal overdoses now surpassing death rates from guns, automobile accidents, and peak HIV death rates it’s no wonder that the country has paid increasing attention to the opioid epidemic. However, it’s important to note that the opioid crisis is only the tip of the iceberg. Tobacco, alcohol, and cocaine also continue to kill Americans at alarming rates.

{mosads}Like so many other health issues, the answer likely lays upstream, that is in prevention of addictions in the first place. Fortunately, or unfortunately, many of these negative outcomes stem from the same source- adverse childhood experiences (ACEs). By turning our attention towards our children by preventing, identifying, and addressing ACEs we may begin to make headways into the opioid epidemic and other addictions.

Adverse childhood experiences (ACEs) are exactly what they sound like, traumatic events that occur in childhood. ACEs include: physical, sexual, and emotional abuse, physical and emotional neglect, intimate partner violence, a mother who has been treated violently, substance misuse in the household, parental separation/divorce, and having an incarcerated household member. They are common, tend to occur in multiples, and often have a cumulative effect.

Since the landmark CDC/Kaiser Permanente study in 1998 we have seen an avalanche of studies showing a strong correlation between ACEs and substance use (alcohol, marijuana, cocaine, and yes, opioids), incarceration, sexually transmitted diseases, suicide attempts, early school dropout as well as diabetes, obesity, cancer, and heart disease. For the record, that list is far from exhaustive.

In particular there is a “dose” response with one ACE conferring approximately a 50 percent increase in the odds of prescription pain reliever misuse, two ACEs conferring a 70 percent increase, three ACEs over 100 percent increase, and so on. Not only is this dose response informative but it also hints at possible causation. Further, individuals with five or more ACEs had a seven to ten fold increase in illicit drug use, addiction, and injection drug use.

The overwhelming evidence has led many health experts to encourage adoption of  “trauma informed care.” Unfortunately less is known about interventions either preventing or addressing ACEs close in time to when they occur and they are rarely discussed in the context of a strategy to address the opioid epidemic. That being said, several evidence-based programs have shown promising results.

These include the Nurse Family Partnership, The Positive Parenting Program, Healthy Family New York, and Seeking Safety. These programs have shown to reduce traumatic experiences, mitigate the effect of trauma, improve coping skills, improve resilience, and ultimately improve health outcomes. However, funding for prevention is often difficult as it relies on a long-term perspective, is less dramatic, and often relies on government action.

While the president’s commission on combating drug addiction and the opioid crisis does mention ACEs, few tangible, if any, results have come from this commission. In fact, Trump failed to declare a national health emergency, despite his commission’s recommendations, which would have mobilized funding for the opioid epidemic.  But worse, the Republican controlled house and senate have threatened to remove tens of millions of people from Medicaid and have currently failed to refund Children’s Health Insurance Plan (CHIP).

To be sure, not all individuals suffering from addiction fit the picture I have laid out. Many of my lectures and soapbox speeches aim at addressing this stigma by representing the many diverse faces of addiction. We know that addictions can affect anyone and everyone. In fact you likely have a family member or a friend who suffers from addiction whether you know it or not.

But what we also know is that ACEs increase your odds of using and misusing opioids, becoming addicted, overdosing, and ultimately dying from drug use. We also know that ACEs are not only a risk factor for substance use but for mental health outcomes as well as physical health problems. The correlation between ACEs and health outcomes is so consistent and strong that I find myself surprised how many of my patients have reached stability. It truly is a testament to their strength and perseverance in the setting of such adversity.

Here’s my wish list for addressing the opioid epidemic in 2018: First, Congress must immediately fund CHIP, and the president should mobilize additional funding for the opioid epidemic by declaring a national emergency. Second we need to immediately increase our allocation of resources towards evidence-based ACE prevention.

Third we must improve collaboration, as addiction is just the end result of the intersection of many psychosocial issues. With action on these three priorities I am hopeful we can begin to reverse the downward trend in of American life expectancy and make substantial progress in curbing the casualties of the opioid epidemic.  

Daniel Schatz, M.D. is an addiction medicine fellow with NYU in the Department of Population Health. Schatz’s clinical work is at Bellevue Hospital in New York City and is a collaborator with the Drug Policy Alliance.