Addiction in the US: The Surgeon General’s Report

The Surgeon General of the United States recently released a report on the state of our current knowledge about the etiology and treatment of drug and alcohol addiction in this country.¹ Both the complete report and a summary are available online, and I would encourage all physicians to read at least the latter.[[{"type":"media","view_mode":"media_crop","fid":"31570","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_8160595071510","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7169","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 217px; width: 240px; border-width: 0px; border-style: solid; margin: 5px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Health or Political Issue?

Substance misuse is a major public health problem, and the federal government’s official recognition of this is important. Note that the report was released while President Obama was still in office. One hopes this issue will be dealt with in a nonpartisan manner as members of all political parties are at risk for developing the problem. However, in light of the new administration’s focus on using the influx of illegal drugs as a major talking point to support the building of a wall along the Mexican border-while ignoring that almost all prescription opioids are manufactured here or are legally imported-how seriously addiction will be addressed as a health issue and not a political one is open to question.

From my perspective as a pain medicine specialist, the report contains a vast amount of information but overlooks a number of important issues. Most important is the failure to address iatrogenic opioid misuse, ie, a patient who is prescribed opioids for legitimate pain complaints ends up misusing or abusing them. The focus is only on nonmedical use of these drugs.

Leaves Readers in a Quandary

The lack of attention to iatrogenic misuse leaves readers in a quandary. Does the exclusion suggest that the problem does not exist--or that it does but is so insignificant that it’s not worth dealing with? Or, is it something else?

As virtually all of the medical professionals involved in writing the report were substance abuse, mental health, or HIV/AIDS experts, many may be unaware of or dismiss the problem as rare and not worth discussion. From my experience in discussing this issue with many mental health and substance abuse specialists, this frequently is the case.

Little Mention of Pain

The report barely mentions pain. When it does, it is to refer readers to the CDC Guideline for Prescribing Opioids for Chronic Pain released in 2016 and to note that patients with chronic pain and substance use disorder are more likely to be prescribed opioids than patients with chronic pain alone.

The report also recommends that patients with opioid use disorders and chronic pain may need multidisciplinary collaborative care but primarily focuses on integrating mental health services with general care. However, it fails to highlight the importance of providing nonpharmacologic alternatives for patients who have chronic pain to help manage it.

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Why Not Methadone and Buprenorphine

The report briefly mentions methadone and buprenorphine, explaining that they are analgesics in addition to their use as appropriate medications for the management of opioid addiction. Ignored, however, is the basic question of why these drugs should not be used as primary analgesics as they appear to be safer choices than other opioids.

The report mentions that benzodiazepines may be abused but provides little information on appropriate treatment for patients who are using them for nonmedical reasons or who were originally prescribed them by a physician who felt they were appropriate. Benzodiazepines are involved in a significant number of opioid-related deaths, and they are frequently coprescribed with opioids. I find not adequately addressing benzodiazepine misuse to be a major failing.

Addiction as “a Repeating Cycle”?

Of greatest concern to me, the report describes addiction as “a repeating cycle with 3 stages”: binge/intoxication; withdrawal/negative affect; and preoccupation/anticipation involving certain well identified parts of the brain, including the basal ganglia, extended amygdala, and prefrontal cortex.

This may well be true of addiction to alcohol and nonmedical uses of opioids and other medications, including benzodiazepines. But neither I nor anyone else, as far as I'm aware, knows whether it is true of iatrogenic substance use disorder.

Binging When Pain is Severe

Few if any patients with chronic pain and iatrogenic substance use disorder whom I have encountered in my practice begin by binging on or becoming intoxicated with opioids or benzodiazepines that have been prescribed for them. The amount of opioids used usually increases gradually over time as patients receive less analgesia as a result of several factors, including tolerance and hyperalgesia. The only time I have found these patients to binge on these drugs is when the pain is severe and they believe taking a higher dose will provide more relief.

With regard to benzodiazepines, we know that the majority of patients who become addicted to them after having them prescribed legitimately stay on the same doses for extended periods. In fact, for years many substance abuse experts did not believe that benzodiazepines were actually addictive for this reason.

Missed Opportunity

Until we recognize the existence of iatrogenic substance misuse and begin to do research on it, we can have no real idea as to its etiology or how to treat it properly. Because we may not see a revised report issued by the federal government for some time, it is sad that an opportunity to address these issues has been missed.

References:

1. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: the Surgeon General's Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016.