Via NEJM: Facing Opioids in the Shadow of the HIV Epidemic. Excerpt:
The United States is in the midst of an opioid crisis. An estimated 2.1 million Americans had an opioid use disorder in 2016. The rate of opioid overdose deaths has increased by 500% since 1999, and each day an estimated 115 Americans die from opioid overdose. Despite the proven effectiveness of medication-assisted treatment (MAT) for opioid use disorders, the opioid mortality rate has now surpassed that of the AIDS epidemic during its peak in the early 1990s — a time when there was no effective treatment for HIV/AIDS.
Given that U.S. HIV incidence and AIDS mortality declined dramatically after the advent of antiretroviral therapy in the mid-1990s, it is not surprising that the AIDS response is often celebrated not just as an unqualified success, but also as a blueprint for the response to other emerging threats to population health. However, there are vital lessons to be learned from failures in the response to HIV as well as from the successes. Learning these lessons will require a less celebratory accounting of where we stand with the current HIV epidemic than we have seen so far.
Effective treatment for HIV has been available in the United States for more than two decades, and the majority of people living with HIV in this country (86%) have now received that diagnosis. Still, less than two thirds of people living with HIV remain in care (62%), and viral suppression has been achieved in less than half the cases (49%). The benefits of scientific progress have been unequally distributed, with growing ethnic and sexuality-related disparities in new infections, dual diagnoses, and overall mortality. If current HIV diagnosis rates persist, one in two black men who have sex with men in the United States will contract HIV during their lifetime.
This failure of equity should draw our attention to the importance of social factors in shaping who benefits from effective biomedical therapies. Each of the following lessons has the potential to improve the population health impact of MAT for opioid use disorder in the United States.
First, the existence of effective medical treatment does not mean that people who need treatment can and will obtain it. Even as efforts are under way to scale up access to MAT, it is vital not to assume a position of “if we build it, they will come.” Though MAT scale-up is a necessary step for increasing access, engaging the 80% of people with opioid use disorders who currently receive no treatment also requires identifying cultural, social, economic, and structural barriers to access to care. In areas where MAT is available, studies already reveal age-based, racial, and ethnic disparities in treatment engagement and completion. If we fail to address the contextual barriers that shape engagement with MAT, biomedical advances may actually exacerbate health disparities by benefiting people who are more socially advantaged rather than the population as a whole.
Second, we need to stop considering only one person at a time and address the structural drivers of the crisis. Since the 1990s, HIV researchers have recognized that the virus’s spread is driven by structural factors such as economic inequality, sexual oppression, gender inequality, and racism.
A key lesson for the opioid epidemic is that without achieving long-term changes in the structural inequalities that render some populations vulnerable to opioid addiction, we will not be able to slow the epidemic. Structural drivers of the opioid epidemic include eroding economic opportunity, market-driven health care, insufficient regulation of pharmaceutical markets, evolving approaches to pain treatment, and limited access to effective drug treatment. Combating the epidemic will require addressing these drivers.
