An Interview with CADCA Board Member and Public Health Leadership professor at Harvard University, Dr. Howard Koh.

Recently, CADCA Board Member Dr. Howard Koh presented the keynote address at the American College of Physicians (ACP) Board of Governor’s meeting in San Diego California. The presentation centered on the opioid epidemic that is ravaging the country today. He shared with us his thoughts on the crisis and solutions in the following interview:

From what perspective and background, did you build your presentation on the opioid epidemic?

I was asked to give the keynote speech to the Board of Governors of the ACP – a national organization of 148,000 internal medicine physicians. I was honored to present from multiple perspectives:  as a physician, as a Harvard professor, as a former Massachusetts Commissioner of Public Health and as the former US Assistant Secretary for Health at the Department of Health and Human Services during the Obama Administration. I learned firsthand about addiction when I was a young intern at Boston City Hospital. So many of my patients wrestled with addiction that ruined their health, their work, their family and their overall quality of life. It’s an all-encompassing problem.

Could you share with us a few findings that you learned during your preparation?

First, it’s an epidemic that’s been ongoing for at least 15 years with very disturbing trends. In 2015, there were 52,000 deaths from drug overdoses, 33,000 were from opioids. Both numbers are the highest numbers on record for this country. The deaths keep rising steadily year in and year out. These are horrifying trends for our nation.

We have better information about who is at highest risk of dying. These deaths are seen in both sexes, but men have higher death rates. Overdose deaths occur in all age groups, but particularly in 45 – 54 year olds. Deaths occur in people from all races and ethnicities, but particularly in white populations. It is affecting every state, but has a disproportionate impact on New England, the Rust Belt—for example, Ohio, Michigan, Pennsylvania, West Virginia, the South – for example Tennessee, Louisiana, and the West – Nevada, Arizona, New Mexico and Utah.

Of opioid-related deaths, those from illicit opioids (heroin and fentanyl) have risen dramatically. We are seeing these trends in all settings but the rise in rural settings is particularly noteworthy. It is a tremendous public health challenge. In a recent survey by the Harvard Chan School of Public Health, 39 percent of people said that in the past 5 years, they knew someone who had misused prescription drugs.

In another survey from the Washington Post/Kaiser Family Foundation in 2016, people who had used prescription painkillers for more than two months were asked about reasons for use; about one-third replied they used it “for fun or to get high;” one-third of users thought they were addicted or dependent. Of those using opioids for non-medical reasons, over half reported being given opioids by friend or relative for free.

As a CADCA board member, you know that we work closely with community leaders who address substance use locally from all perspectives. What guidance would you share with them?

Prevention is the best cure. We are hearing more about this epidemic everywhere, and the discussion has focused appropriately on the need for assessment and treatment. But we still haven’t heard enough about prevention-- that’s where CADCA is critical. If we can empower young people at the earliest age, reduce the stigma and view the crisis as a public health issue and not just a criminal justice issue, hopefully we can turn this epidemic around.

Prevention is never easy but hopefully this crisis will spur action to accelerate momentum. 

What opioid epidemic solutions do you think will make an impact?

First of all, we need to change the paradigm about addiction. The way we view addiction needs to be fundamentally altered. It should be viewed as a matter of public health and not just a criminal justice one. It should be viewed as a chronic disease and not a moral issue.

We also need to humanize the epidemic. So many people affected prefer to remain anonymous because of the stigma. We need to encourage people to seek treatment and assure, as a society, that if they do, they will be treated with respect.

To address the stigma, we need to change the language of addiction. Last year, the former Director of the Office of National Drug Control Policy, Michael Botticelli and I published an article in the Journal of the American Medical Association urging use of non-stigmatizing terms in national discussions about the epidemic. For example, using the term “substance use disorder,” not “substance abuse,” and saying that a person is in “in recovery” instead of “clean” paves the way for viewing these issues as medical ones.

Do you have any concluding thoughts to share?

One point of hope is that physicians and clinicians are changing the way they are prescribing opioids. The Centers for Disease Control and Prevention (CDC) published prescribing guidelines last year that encourage limiting opioid prescribing for chronic, non-malignant pain, evaluating risk factors before prescribing, and engaging the patient in an informed conversation about risks and benefits. We have seen a drop in the number of annual opioid prescriptions in the United States from about 250 million to about 200 million. However, the US still consumes more opioids than any other country in the world. 

This crisis is with us for many more years, unfortunately. We need to establish a true system of care for people who are facing these issues. We have to maximize medication-assisted treatment, monitor misuse with prescription drug monitoring programs, strengthen treatment capacity and work more closely with the recovery community as well as the criminal justice system. And through the work of CADCA and others, we all dream of a day where we can enjoy better systems for prevention as well.

About CADCA

The mission of CADCA (Community Anti-Drug Coalitions of America) is to strengthen the capacity of community coalitions to create and maintain safe, healthy and drug-free communities globally.  This is accomplished by providing technical assistance and training, public policy advocacy, media strategies and marketing programs, training and special events.