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In Wisconsin, the prescription drug monitoring program includes patients’ convictions and suspected drug violations, straying into ethically hazy realms of social control. Patients suspected of drug seeking behavior are “fired” instead of receiving enhanced care, as compassion would dictate. Institutional, legal, and insurance architecture have robbed clinicians of time and incentives to continue care for these patients. Access to evidence-based treatment for opioid use disorder, such as methadone and buprenorphine, must be rapidly improved. The hardest hit states, such as West Virginia and Kentucky, prohibit Medicaid coverage of methadone maintenance, and insurance preauthorization prevents low threshold access among privately insured patients. The Appalachian Regional Commission recommended economic development strategies in addition to increased access to treatment services, prevention, and overdose medications. Yet, proposed federal health care reforms threaten to further exacerbate existing service gaps. Although national policy emphasizes medically assisted treatment, the social stigma of these treatments is widespread, carrying unrealistic expectations for quick fixes and a pervasive belief in “detox,” as exemplified by television shows popularizing coercive interventions. “Suffering” may be a better focus for physicians than “pain.” Others have argued for “compassion.” Health care providers have a role in reducing suffering historically and ethically. We have lost the commonsense imperative to engage those who use opioids in comprehensive care, especially during periods when access to opioids may be fluctuating. These tenets also may justify limited regimes to treat acute pain for veritable patient need. The social determinants lens lays bare the urgency of integrating clinical care with efforts to improve patients’ structural environment. Training health care providers in “structural competency” is promising, as we scale up partnerships that begin to address upstream structural factors such as economic opportunity, social cohesion, racial disadvantage, and life satisfaction. These do not typically figure into the mandate of health care but are fundamental to public health. As with previous drug crises and the HIV epidemic, root causes are social and structural and are intertwined with genetic, behavioral, and individual factors. It is our duty to lend credence to these root causes and to advocate social change. CONTRIBUTORS N. Dasgupta and L. Beletsky contributed equally to this commentary. All authors participated in conceptualization, research, drafting, and editing of the commentary. L. Beletsky acknowledges support from National Institutes of Health (NIH)/National Institute on Drug Abuse (NIDA) grants. D. Ciccarone acknowledges support from NIH/NIDA grant DA037820. N. Dasgupta is a part-time employee of the RADARS System, which had no involvement in this commentary. The RADARS System is the property of Denver Health and Hospital Authority, a political subdivision of the State of Colorado. Many manufacturers of controlled substances (including prescription opioids or stimulants) as well as federal government agencies subscribe to the RADARS System. Subscribers receive information, but do not participate in developing the System, data collection, or analysis of the data. They do not have access to the raw data. Employees are prohibited from personal financial relationships with any biopharmaceutical company. The authors thank the six peer reviewers for their insightful comments, which helped shape the final version of the commentary.
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