The opioid crisis: What we should learn from the AIDS epidemic
There are important lessons to be learned from the successes and failures of the AIDS response that could inform our response to the opioid epidemic, according to a new paper by researchers at the Columbia University Mailman School of Public Health. Decades of HIV research have demonstrated that the existence of an effective biomedical treatment is rarely, in and of itself, sufficient to combat an epidemic, suggesting that both a social as well as a biomedical response to the opioid crisis are necessary in order to be effective. The paper is published in the New England Journal of Medicine.
"Despite the effectiveness of medication-assisted treatment for opioid use disorders, the mortality rate for opioids has surpassed that of the AIDS epidemic during its peak in the early 1990s—a time when there was no effective treatment for HIV/AIDS," says Silvia Martins, MD, Ph.D., associate professor of Epidemiology at Columbia Mailman School.
Over 2 million Americans had an opioid use disorder in 2016. The rate of opioid overdose deaths has increased by 500 percent since 1999.
"Even as efforts are under way to scale up access to medication-assisted treatment for opioid use, it is vital not to assume a position of 'if we build it, they will come,'" says Caroline Parker, Ph.D. candidate in the Department of Sociomedical Sciences. In the case of HIV/AIDS, "the benefits of scientific progress have been unequally distributed, with growing ethnic and sexuality-related disparities. This failure of equity should draw our attention to the importance of social factors in shaping who benefits from effective biomedical therapies."
To improve the population health impact of opioid use medication-assisted treatment (MAT), the researchers provide a five-point action plan:
1. Identify the cultural, social, economic, and structural barriers to care for the 80 percent of people with opioid use disorders who currently receive no treatment. "As the HIV/AIDS epidemic has taught us, the existence of effective medical treatment does not mean that people who need treatment can and will obtain it," says Parker.
2. Stop considering only one person at a time and address the structural drivers of the crisis, such as profit-driven health care, insufficient regulation of pharmaceutical markets, and eroding economic opportunity.
3. Address stigma and discrimination against people with opioid use disorder through legislation to decriminalize substance use disorders, and through training key community actors, such as police and churches, rather than just focusing on changing individual attitudes. "It is critical to directly engage affected families and communities in policymaking and changing legislation to stop the criminalization of substance use disorders," observes Parker.
4. Mobilize family and community support networks to help improve healthcare engagement. Leverage the resources and social networks that facilitated HIV treatment and adherence to improve access to MAT. Develop policies that recognize and compensate people for caring for people living with opioid use disorder.
5. Recognize that community activism is crucial to making MAT widely available just like engaging society and stakeholders was central for expanding access to antiretroviral therapy.
"As millions of dollars are appropriated at the state and federal levels for the opioid crisis, we face a choice. Committing those resources exclusively to biomedical solutions is likely to reproduce the sharp disparities that we have seen with HIV, but learning from the failures and successes of our response to HIV can help us leverage support to ensure that the opioid response benefits all sectors of society," says Martins.
More information: Caroline M. Parker et al, Facing Opioids in the Shadow of the HIV Epidemic, New England Journal of Medicine (2019). DOI: 10.1056/NEJMp1813836