One pill can kill: Tackling substance use disorders

I recently had the honor of attending a White House event, “International Overdose Awareness Week.” Having not known anyone personally who has overdosed, I did not expect the impact that this event would have on me.

With that said, last year, a friend of one of my college-age sons had an incident I consider a near miss, where a drink provided to him by someone else made him extremely sick for the entire night. While it could have been something he ate, it seemed more likely that it was from the drink, with perhaps an additional substance added. I decided at that point to send my son naloxone to have on hand in case he or a friend might need it.

Then, at the White House event, I heard stories shared by those who had lost loved ones to an overdose, some via fentanyl unknowingly added to a drink or pill and others via a fentanyl-laced drug such as cocaine or heroin. There are so many substances that can be laced with fentanyl, including counterfeit prescription medications, cannabis/marijuana, and other illicit drugs, such as heroin, Molly/ecstasy, and cocaine, which means that everyone can be at risk if they choose to consume these substances, whether they have a diagnosed opioid use disorder (OUD) or not. It only takes one pill! At this point, I immediately ordered additional naloxone kits and fentanyl test strips to send to my other two young adults in college.

According to the FDA, over 6.1 million people in the U.S. ages 12 years or older have an OUD—and of those ages 18 years or older, the CDC found that only one in five receive medications to treat it. A research letter published in JAMA Network Open in August 2023 found that some groups, such as Black adults, women, those who are unemployed, and those in nonmetropolitan areas, were less likely to receive OUD treatment than others, indicating significant disparities that need to be addressed.

The CDC reports that in the 12 months prior to April 2022, more than 108,000 drug overdose deaths occurred in the U.S., with opioids accounting for 75%. Fortunately, in 2023, the country saw its first decrease in drug overdose deaths since 2018, down by 3% from 2022. While this is positive news, the problem remains a public health crisis. In fact, the DEA has reported that 60% of counterfeit pills in the U.S. contain a lethal dose of fentanyl, which is only 2 milligrams.

Recognizing this epidemic, ACP published a position paper in 2017 titled “Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs,” which states that substance use disorders (SUDs) are a chronic medical condition and should be managed as such. This paper also called for the implementation of treatment-focused programs as an alternative to incarceration or other criminal penalties for persons with SUDs found guilty of the sale or possession of illicit substances, as well as for strategies such as “implementation of evidence-based guidelines for pain management; expansion of access to naloxone to opioid users, law enforcement, and emergency medical personnel; expansion of access to medication-assisted treatment of opioid use disorders; improved training in the treatment of substance use disorders, including buprenorphine-based treatment; establishment of a national prescription drug monitoring program (PDMP); and improvement of existing monitoring programs.”

Then, in 2022, ACP built upon these policies and released a position statement on harm reduction strategies for SUDs, calling for evidence-based strategies to prevent overdose, reduce transmission of infectious diseases, encourage safe use protocols, and connect people who use drugs to medical care and SUD treatment.

As part of its policies, the College also supports federal funding for syringe support programs, including purchase of syringes/needles; recommends the decriminalization of drug-checking supplies and syringe support program equipment, including fentanyl test strips and syringes/needles; and supports pilot testing of overdose prevention sites in high-need areas. While fentanyl test strips are now readily available in much of the country and can even be purchased on Amazon, in some states they are still defined as drug paraphernalia and are therefore considered illegal, including in Idaho, Indiana, Iowa, North Dakota, and Texas. This is despite largely bipartisan efforts in some of these states to change these laws. Regarding overdose prevention sites, ACP calls for these to “be staffed and supervised by trained, qualified health professionals” and states that they “should provide a range of services, including naloxone, health and safety education, sterile supplies, screening, and referrals and/or treatment for infectious diseases, medical, and behavioral health care, including substance use disorders.”

The College has also joined with others on this issue via the development of joint principles to address the opioid epidemic. These principles were developed by ACP, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association. Together these groups represent more than 560,000 physicians and medical students.

Focusing on legislative and regulatory approaches, the principles call for aligning and improving incentives to ensure access to evidence-based OUD treatment; reducing the administrative burden associated with providing patients with effective treatment; incentivizing more physicians and other clinicians to treat SUD; advancing research to support the prevention and treatment of SUD; ensuring a public health approach to SUDs by addressing childhood stress, access to naloxone, and fair and appropriate treatment for individuals in the criminal justice system and pregnant women; addressing the maternal-child health impact of the opioid crisis; reducing stigma related to SUDs; and continuing to provide comprehensive pain management for patients.

More recent policy from ACP also goes beyond those cited above by calling for the elimination of the requirement that physicians obtain a waiver to administer, dispense, and prescribe buprenorphine for the treatment of OUD. Thankfully, this X-waiver program was eliminated on Dec. 29, 2022, when the Mainstreaming Addiction Treatment (MAT) Act was enacted into law as part of the Consolidated Appropriations Act of 2023. Now, clinicians with a current DEA registration may prescribe buprenorphine for OUD if allowed under state law. They simply need to complete eight hours of training on the treatment and management of patients with OUD.

Additionally, as noted earlier, there are significant disparities in diagnosis and treatment of SUD in several underserved populations. Given this, College policy includes related positions in our papers on “Supporting the Health and Well-Being of Indigenous Communities,” “Health Care During Incarceration,” and “Understanding and Addressing Disparities and Discrimination Affecting Health and Health Care of Persons and Populations at Highest Risk.”

In 2024, ACP's Health and Public Policy Committee also decided that the College needed updated policy related to cannabis, as well as alcohol use and alcohol use disorder. The former is particularly important and time-sensitive, as cannabis has now been legalized for both medical and recreational use in many states, even though its possession, use, and distribution remain illegal under federal law.

ACP's position is that possession of small amounts of cannabis for personal use should be decriminalized and that policymakers need to take an evidence-informed approach when considering amending the legal status of cannabis. It is also important that there be “rigorous research into the effects of legalizing cannabis on its use (including prevalence, frequency, and intensity of use) among older adults, adults, adolescents, and children; prevalence of cannabis use disorder and other behavioral health conditions; motor vehicle injuries and impaired driving; poisonings; and other adverse outcomes.”

Regarding alcohol use and alcohol use disorder, among several recommendations, ACP reiterates that alcohol use disorder is a treatable chronic medical condition and therefore should be addressed through expansion of evidence-based public health and health care initiatives to prevent and treat it and promote recovery. We also call on regulators, community groups, educators, and the alcohol industry to make a concerted effort to reduce underage alcohol use and support interventions to address alcohol-specific challenges like impaired driving. In the cases of both cannabis and alcohol, the College notes the critical importance of evidence-based education, training, payment, and delivery system policies to enable physicians and other qualified health care professionals to screen, diagnose, and treat related disorders.

As with all our policies, these come with a call to action. It is critical for all of us to engage in the prevention of these tragic overdose deaths. In most states, it is very easy and relatively inexpensive (or even free) to obtain naloxone and fentanyl test strips. There are resources out there to learn more about this yourself and to share with your patients; the organization Shatterproof is one example. Numerous areas of the country, including Philadelphia, the site of ACP's headquarters, offer locally focused information to find treatment and access preventive resources. A single pill can kill. We can and must take action to prevent these unnecessary deaths.