As a physician and healthcare leader responsible for helping to fight substance misuse across multiple state governments and health organizations, I feel a profound responsibility. Each increase in the opioid crisis’s death toll, which surpassed 112,000 lives for the first time in 2023, is a stark reminder of the challenges we face. That number, exceeding the fatalities from car accidents and gun violence combined, is an unambiguous indicator of the crisis’s severity.
The repercussions of the epidemic are staggering, not just in lives lost but also in its economic and social toll. It has siphoned $1.5 trillion from our economy and is even contributing to a decline in the national life expectancy. As the crisis intensifies, I’m compelled to ask: How are we falling short in addressing such a glaring issue?
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Will 2024 bring any change, or will we witness yet another record- and heart-breaking year of preventable deaths?
I believe the answer to that question lies in understanding that this crisis is more than a health emergency; it mirrors deep-rooted societal flaws and a failure of our systems to adequately respond. While various states and municipalities have launched efforts to mitigate Opioid Use Disorder (OUD) and the heart-wrenching overdoses it leads to, our national response remains patchy and inconsistent. A 2023 report from the Commonwealth Fund highlights the concerning reality that your zip code and cultural backdrop—rather than medical need—often determines your access to OUD treatment. And while the Biden administration has rightly made the opioid epidemic a key focus, doubts loom regarding the federal government’s ability to tackle the entrenched inequities of OUD care.
Take, for example, the undeniable racial biases in OUD treatment. A 2023 study from the Harvard T/H Chan School of Public Health found that White patients who seek care in the Emergency Department (ED) are up to 80 percent more likely to receive OUD medication (buprenorphine, naltrexone and naloxone) than Black patients. Further, evidence shows Black patients consistently face systemic barriers such as less appropriate treatment, fewer available treatment centers and limited access to private insurance.
This disparity becomes more pronounced when we consider how the crisis has shifted from predominantly affecting rural White regions to primarily impacting urban Black communities, particularly due to the rising danger of street fentanyl.
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Similarly, the justice-involved populace, especially those freshly out of incarceration, are a marginalized group. Their risk of overdose surges dramatically post-release largely due to lack of access to treatment during incarceration, yet political apathy frequently sidelines their needs.
Adding to these inequities, our healthcare system seems to harbor a bias toward physical health over behavioral health. This bias, evident in funding disparities between behavioral and physical health, affects treatment in every setting and especially in the ED. We wouldn’t dream of providing subpar care to cardiac patients post-discharge, yet overdose survivors stand a meager 16% chance of receiving comparable evidence-based care after leaving the ED.
Contributing to this dismal result, referring an ED patient to the proper behavioral health treatment is a manual process that typically involves the use of outdated inpatient and outpatient provider information. There is no incentive to do something as simple as updating provider information in a directory to facilitate the referral process.
So how do we address these challenges?
To begin, we must initiate more community-based collaborations. This means actively involving minority and justice-involved communities and their care providers. We must work tirelessly to break the barriers of stigma and rebuild trust. Successful models already exist, like initiatives in California that cater to these underserved populations with OUD education and critical medication distribution.
One hopeful sign for change in 2024 is the introduction of the Rehabilitation and Recovery During Incarceration Act by Rep. Ann Kuster, Democrat of New Hampshire. If enacted, the legislation represents a pivotal shift, allowing Medicaid to finance behavioral health treatment for eligible individuals in criminal justice settings. Effectively addressing the needs of justice-involved populations is crucial for hospitals and clinicians aiming to provide comprehensive OUD treatment at all points of care.
But any government solution is unlikely to succeed without aligning financial incentives. Without these, stakeholders, excluding state Medicaid programs, are left without a compass. Programs that incentivize quality care for broader populations can be game changers. Take Pennsylvania’s Opioid Hospital Quality Improvement Program (O-HQIP) as a case in point: it’s spurring hospitals to reshape their practices for better OUD patient care post-ED visits.
If we’re genuinely committed to halting the opioid crisis, we must confront the systemic challenges head-on. By focusing on equity and intelligent financial structuring in 2024, we can give America a fighting chance against this formidable adversary.
Photo: Moussa81, Getty Images
Nishi Rawat, MD, MBA, began her healthcare career in 2002 as an emergency medicine and critical care physician, treating a significant number of patients suffering from SUD. As a healthcare faculty member and researcher, she led quality measure development and implementation at Johns Hopkins Armstrong Institute for Patient Safety and Quality.
Using her previous years of frontline medical care experience and passion to improve care delivery, in 2015 Dr. Rawat founded and served as lead technologist for OpenBeds®, a company dedicated to improving access to mental health and SUD treatment. Following the company’s acquisition by Appriss Health (now Bamboo Health), a healthcare technology solutions company focused on fostering care collaboration and providing information and actionable insights across the entire continuum of care, Dr. Rawat continues to lead the OpenBeds® solution and behavioral health strategy as Chief Clinical Officer at Bamboo Health.
