According to the New York Times, the day before Prince died in his Minnesota home on April 21, his team made a frantic attempt to save him from his addiction to painkillers by reaching out to California addiction specialist Dr. Howard Kornfeld. The puzzling decision to look for out-of-state help was clarified by the Minneapolis Star Tribune: It turns out that Minnesota is a very difficult place to get buprenorphine, a medication that treats opioid addiction and lowers the risk of death. There are only 120 qualified buprenorphine prescribers in the entire state, a rate of 2.2 prescribers per 100,000 residents. In California, 84% of the 58 counties — even Fresno — have a higher rate than Minnesota's, even though the supply in California still falls well below the demand.
My heart goes out to those who were close to Prince and those who treated him. Along with millions of people who grew up and listened and danced to Prince's extraordinary music, I am sad about this news. But what makes me even more despondent is the growing casualty list. An average of 77 people per day die in the United States of opioid overdose, and 2014 had the most deaths on record, even though we have treatments proven to prevent death and improve recovery. Drug treatment remains widely misunderstood, and the disease remains clouded in stigma and shame.
Opioid addiction consumes its victims with cravings for ever more drugs, and it's easy to cross the line between what is enough to give relief and a dose that stops breathing. This is especially true in the early stages of recovery, when the body loses tolerance for the drug. The same dose that used to be taken daily without effect can become lethal after the process of detox (withdrawing off of an opioid), leading to high death rates for patients not on medication treatment.
Yet opioid addiction and the process of recovery don't have to be life-threatening. Buprenorphine stabilizes the brain and takes away cravings, improving function. Most importantly, buprenorphine blocks the effect of opioids on respiration, which makes it harder to die from an overdose. Unfortunately, only 1 in 10 people in the US who need treatment receive it.
This lack of access to effective addiction treatment is one reason we are losing so many people to overdose. When medications are stigmatized and unavailable, people die. The science is clear: People with opioid addiction who have access to buprenorphine are more likely to recover, less likely to overdose, and less likely to turn to heroin (and therefore also less likely to contract hepatitis C and HIV). In a Swedish study, randomized people with opioid addiction received buprenorphine or placebo (sugar pills). One-fifth of the placebo group died of an overdose within a year, while there were no deaths in the treatment group.
Another treatment trial at Yale tested the use of buprenorphine in the emergency department (ED). Randomized patients presenting with opioid addiction were twice as likely to be engaged in treatment one month later if they got buprenorphine in the ED, compared to the group who got a referral. We know treatment works, but getting enough doctors to prescribe it remains a significant challenge.
Naloxone, an antidote that restarts breathing after an overdose, is also an important tool to decrease deaths. It has been widely reported that Prince was rescued with naloxone six days before he died — sadly, not an uncommon occurrence. More than 9 of 10 people rescued from an opioid overdose continue to use opioids, putting them at ongoing risk.
CHCF Working to Improve Opioid Safety
The California Health Care Foundation, collaborating with many partners, is trying to change the situation in California:
- Supporting Opioid Safety Coalitions in 24 California counties, all working on local solutions to promote safer prescribing practices, increase access to buprenorphine, and make naloxone more available.
- Helping primary care clinics to integrate buprenorphine treatment, including a report on practical approaches to expanding access.
- Working to pilot use of buprenorphine in emergency departments.
- Supporting health plans and clinics to create integrated addiction treatment models.
No one can replace Prince, but we can find consolation in doing what it takes to build a different world. No one — famous or otherwise — should have to reach out across the country to find a doctor to save their life. I can imagine, 10 years from now, that if someone I loved had an accidental overdose, she could be revived in the ED with naloxone and meet with an addiction counselor there to talk about options. She could choose buprenorphine and receive a dose or prescription before going home. Her family and friends would be taught to use naloxone in case of relapse. A peer-support person would call later to check on her. Within a few days, she would see a clinician in a primary care office or a treatment center, and there would be no stigma associated with these visits or treatments. With this system in place, overdose death rates would drop.
It won't be simple or easy, but CHCF will continue to work with our partners to bring this vision closer to reality.
Dr. Howard Kornfeld serves as expert faculty for several CHCF programs and will present a CHCF webinar on June 8; registration is open to all. Dr. Kornfeld is a nationally known addiction specialist; a faculty member at the University of California, San Francisco; and founding medical director of the Pain Management and Functional Restoration Clinic at Highland Hospital, serving low-income patients. To learn more about buprenorphine, see Recovery Within Reach: Medication-Assisted Treatment of Opioid Addiction Comes to Primary Care.