Few issues affect society at so many levels as does the current controlled substance debacle and arguably the opioid crisis in particular. It disproportionately exists within poorer and less educated communities. It draws resources from law enforcement at the federal level, including the FBI, DEA, and homeland security (whose job it is to interdict illegal controlled substances from entering our country). The multibillion-dollar drug trade also involves the intelligence community as the influx of all these highly lethal chemicals is considered a threat to national security (possibly even approaching the level of terrorism). State and local police are also critical in fighting this unending battle. All of these public officials are necessary to pursue this seemingly Sisyphean task.
Illegal opioids killed approximately 80,000 Americans per year in the last few years. A multiple of this number were harmed each year but not lethally.
Opioids include fentanyl, heroin, morphine, oxycodone, and others. Fentanyl, morphine, and oxycodone (and more) when used properly, are the drugs of choice for high-grade pain relief in medical multiple situations.
Monitoring this fundamental threat and its effect on the country is (amongst others) the JEC, the Joint Economic Committee. This committee is comprised alternately by members of the United States Senate and the House. The JEC issued a report in the early 2020’s noting that the cost of the opioid crisis reached “nearly $1.5 trillion” in 2020. This estimate does not seem to include the cost of law enforcement or lost income. One has to imagine, conservatively, that the total cost to society is closer to $2.0 trillion per year.
Hoping that that last figure drew the attention it deserves, how might one address this using the optimal medical resource utilization model (OMRUM)?
The first thing to note is that under the changes proposed in the articles above, everyone will have health insurance and work with his/her primary care physician (or with a PCP designated surrogate such as a nurse practitioner or physician assistant). On a regular basis, usually yearly, the patient will present for an annual wellness visit. One portion of that encounter will be discussing use of alcohol, tobacco, and controlled substances. If the patient uses any of those 3 categories, he/she will be offered interventions to wean from these items. These discussions with trained, dispassionate medical personnel are often quite effective at educating and dissuading patients from continued use. As a practitioner, I can confirm that. Even for those who are “not ready” to discontinue a substance, leaving the door open for a future discussion is highly effective. Additionally, I think it’s very important to check randomly a urine toxicology on all patients. Many patients are too embarrassed to admit that they have difficulty with opiates, stimulants, mood altering drugs, and so on but when presented with abnormal toxicology results dispassionately, options can be explored. Many times, patients are relieved to hear that their addiction is known and comforted that their issue is neither unique nor untreatable. Having a long-term, continuous relationship with a PCP facilitates addressing the issue.
The second thing to note is that with all medical records, including prescriptions, going to one file, excess opioid prescriptions could be flagged for the PCP. This type of screening for opiates (and other medications) could be done automatically without great difficulty. It would not matter if you bought oxycodone from all 50 states since the system would have all your prescriptions in just one file.
To summarize, by having universal healthcare with interval visits and screenings by the PCP, multiple societal benefits will be realized. 80,000 deaths per year (approximately) could be avoided (not to mention additional morbidity and mortality from cocaine, methamphetamine, PCP, and many others). Federal, state, and local law enforcement could reduce their focus on this issue releasing hundreds of billions of dollars to other priorities. Patients could avoid lost wages. Employers would note reduced tardiness and absenteeism of personnel. With less drugs on board, personnel could be more focused. Finally, healthcare resources could shift toward prevention and early intervention of patient care (think again about the ubiquitous “Markovian Mambo”; this keeps coming up). Unfortunately, our system now is replete with patients on opiates who suffer respiratory, then cardiac arrests who, if they are resuscitated at all, subsequently require extended care in the hospital in a critical care unit on a ventilator.
In the original declaration of OMRUM’s goals, this author declared that 50% of medical care (approximately $2.2 trillion) is likely wasted and unproductive and therefore needed addressing. The JEC report from 2020 (at this time of this writing 4 years ago) suggests that $1.5 trillion is lost because of just opiates (although it’s unclear from my reading of the report what percentage of that is from healthcare costs, workplace absenteeism, law enforcement costs, and so on which makes an “apples to apples” comparison difficult). If allowed slight latitude, this author asserts that society would save $2.0 trillion per year on healthcare costs + law enforcement (federal, state, local) costs + lost wage costs for the patients + business costs (avoiding tardiness and absenteeism). What is necessary for this to happen is universal healthcare coverage and a robust primary care system to prevent or intercept opioid (and indeed all other dangerous substances) use early.