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Addressing opioid drug misuse in America
Editorial
Burger/Phanie/Phanie/Phanie Sarl/Corbis
Medicare opens up the end-of-life conversation
For the Institute of Medicine report Dying in America see http://www.nap.edu/openbook. php?record_id=18748 For more on the Lancet Commission see Lancet 2015; published online March 9. http:// dx.doi.org/10.1016/S01406736(15)60289-6
Nobody wants to talk about the end of life. But conversations between physicians and their patients are essential to providing the best possible quality of health care at all stages of life. On July 8, Medicare, the largest insurer in the USA of people aged 65 years and older, announced plans to cover advance care planning. This initiative will reimburse doctors for counselling patients about end-of-life care before they become physically or mentally incapable of making decisions. In 2014, the Institute of Medicine emphasised the urgent need for improvement in the quality of end-of-life care in their report, Dying in America. Among the challenges to the provision of high-quality care it identified were inadequate access to services for disadvantaged populations and a poor understanding of palliative care among health professionals. The report recommended that end-of-life care be delivered in an integrated, person-centred, family-oriented manner, and be covered by both government and private insurers. Many of the problems identified in the report are not limited to the USA, and
inadequacies in global access to palliative care and pain control are the focus of an ongoing Lancet Commission. Having these difficult conversations is crucial to ensure that all patients are treated with dignity and that treatment, whether palliative or curative, fits within their wishes. The advance care planning measures proposed by Medicare will enable patients to make better informed and better supported decisions about end-of-life care. Many physicians already provide counselling as part of routine health care for terminally ill patients and some private insurers already offer coverage for advance care planning. By reimbursing physicians for time spent counselling patients, Medicare recognises the importance of end-of-life care as part of an integrated health care system. It is time to open up the conversation about end-of-life and palliative care to ensure continuity of high-quality health care for patients at all stages of life. Preparing for the end of life is as important as preparing for its start; the new Medicare provisions should be applauded for acknowledging just that. The Lancet
Tek Image/Science Photo Library
Addressing opioid drug misuse in America
For the report see http://www. cdc.gov/mmwr/preview/ mmwrhtml/mm6426a3.htm?s_ cid=mm6426a3_w
220
America’s soaring rates of prescription opioid misuse have garnered much attention in recent years. But its increases in illicit opioid use, and the relation between the two, have been investigated to a much lesser extent. A new study in Morbidity and Mortality Weekly Report, published on July 7, assessing demographic and substance use trends in heroin users in the USA between 2002 and 2013 brings these issues into sharp focus. It shows that heroin use has increased significantly across most demographics. The overall rate of people meeting the diagnostic criteria for past-year heroin use or dependence increased from 1·0 per 1000 to 1·9 per 1000 during the study period—a 90% increase. Past-year user rates were highest in men, people with annual household incomes of less than US$20 000, those living in urban areas, and those with no health insurance or Medicaid. The age group 19-25 years experienced the largest increase in heroin rates—108·6%—between 2002–04 and 2011–13. Past-year heroin use increased in people reporting past-year use of other substances, with the highest rate consistently reported among cocaine users and the
largest percentage increase (138%) in non-medical users of opioid pain relievers. The report makes several recommendations, including a focus on action against opioid pain reliever abuse in view of the strong association between misuse of these drugs and heroin; improvement in access to, and insurance coverage for, evidence-based substance abuse treatment (eg, buprenorphine treatment or methadone treatment in opioid treatment programmes); and broader access to naloxone to treat opioid pain reliever and heroin overdoses. America has taken some positive steps to address its dual licit and illicit opioid misuse epidemics. As well as the much-needed and welcome shift away from the disastrous war on drugs, the White House launched an extensive Prescription Drug Abuse Prevention Plan in 2011. And in April, 2014, the US Food and Drug Administration approved a hand-held autoinjector for naloxone. National leadership on provision of medication-assisted treatment for people with opioid misuse problems, however, remains sadly elusive. The Lancet www.thelancet.com Vol 386 July 18, 2015
Burger/Phanie/Phanie/Phanie Sarl/Corbis
Medicare opens up the end-of-life conversation
For the Institute of Medicine report Dying in America see http://www.nap.edu/openbook. php?record_id=18748 For more on the Lancet Commission see Lancet 2015; published online March 9. http:// dx.doi.org/10.1016/S01406736(15)60289-6
Nobody wants to talk about the end of life. But conversations between physicians and their patients are essential to providing the best possible quality of health care at all stages of life. On July 8, Medicare, the largest insurer in the USA of people aged 65 years and older, announced plans to cover advance care planning. This initiative will reimburse doctors for counselling patients about end-of-life care before they become physically or mentally incapable of making decisions. In 2014, the Institute of Medicine emphasised the urgent need for improvement in the quality of end-of-life care in their report, Dying in America. Among the challenges to the provision of high-quality care it identified were inadequate access to services for disadvantaged populations and a poor understanding of palliative care among health professionals. The report recommended that end-of-life care be delivered in an integrated, person-centred, family-oriented manner, and be covered by both government and private insurers. Many of the problems identified in the report are not limited to the USA, and
inadequacies in global access to palliative care and pain control are the focus of an ongoing Lancet Commission. Having these difficult conversations is crucial to ensure that all patients are treated with dignity and that treatment, whether palliative or curative, fits within their wishes. The advance care planning measures proposed by Medicare will enable patients to make better informed and better supported decisions about end-of-life care. Many physicians already provide counselling as part of routine health care for terminally ill patients and some private insurers already offer coverage for advance care planning. By reimbursing physicians for time spent counselling patients, Medicare recognises the importance of end-of-life care as part of an integrated health care system. It is time to open up the conversation about end-of-life and palliative care to ensure continuity of high-quality health care for patients at all stages of life. Preparing for the end of life is as important as preparing for its start; the new Medicare provisions should be applauded for acknowledging just that. The Lancet
Tek Image/Science Photo Library
Addressing opioid drug misuse in America
For the report see http://www. cdc.gov/mmwr/preview/ mmwrhtml/mm6426a3.htm?s_ cid=mm6426a3_w
220
America’s soaring rates of prescription opioid misuse have garnered much attention in recent years. But its increases in illicit opioid use, and the relation between the two, have been investigated to a much lesser extent. A new study in Morbidity and Mortality Weekly Report, published on July 7, assessing demographic and substance use trends in heroin users in the USA between 2002 and 2013 brings these issues into sharp focus. It shows that heroin use has increased significantly across most demographics. The overall rate of people meeting the diagnostic criteria for past-year heroin use or dependence increased from 1·0 per 1000 to 1·9 per 1000 during the study period—a 90% increase. Past-year user rates were highest in men, people with annual household incomes of less than US$20 000, those living in urban areas, and those with no health insurance or Medicaid. The age group 19-25 years experienced the largest increase in heroin rates—108·6%—between 2002–04 and 2011–13. Past-year heroin use increased in people reporting past-year use of other substances, with the highest rate consistently reported among cocaine users and the
largest percentage increase (138%) in non-medical users of opioid pain relievers. The report makes several recommendations, including a focus on action against opioid pain reliever abuse in view of the strong association between misuse of these drugs and heroin; improvement in access to, and insurance coverage for, evidence-based substance abuse treatment (eg, buprenorphine treatment or methadone treatment in opioid treatment programmes); and broader access to naloxone to treat opioid pain reliever and heroin overdoses. America has taken some positive steps to address its dual licit and illicit opioid misuse epidemics. As well as the much-needed and welcome shift away from the disastrous war on drugs, the White House launched an extensive Prescription Drug Abuse Prevention Plan in 2011. And in April, 2014, the US Food and Drug Administration approved a hand-held autoinjector for naloxone. National leadership on provision of medication-assisted treatment for people with opioid misuse problems, however, remains sadly elusive. The Lancet www.thelancet.com Vol 386 July 18, 2015