"Rarely will the Senate be called upon to deal with an issue more complicated by prejudice, fear, and emotion, nor more presently or potentially destructive." That was the observation of then-U.S. Senate Chaplain Rev. Richard C. Halverson in 1990 on the day the body began to debate what would be known as the Ryan White Act. Then, the issue was AIDS, a deadly disease that was claiming tens of thousands of lives — including, that year, the bill's namesake, an 18-year-old Indiana hemophiliac who contracted HIV through a blood transfusion. One of those rare occasions is upon us again, and the parallels between the AIDS crisis and the present opioid overdose epidemic are striking. Prejudice, fear and emotion have again prevented us as a nation from taking the steps necessary to counter a disease that is taking tens of thousands of lives every year in cities and suburbs, small towns and rural communities. For that reason, we are heartened that Rep. Elijah Cummings and Sen. Elizabeth Warren of Massachusetts are taking the Ryan White Act as their inspiration for a sweeping new proposal to combat opioid abuse and overdoses. That landmark legislation from a generation ago provides not only a useful model for how the federal government can effectively counter a public health emergency but also for how public attitudes about a disease wrapped in stigma can and must change.
The Ryan White Act was revolutionary in its time as an attempt by Congress to tackle a single disease — then-President George H.W. Bush initially opposed it for that reason, though he later signed the bill — but it has served as an effective demonstration for how federal funding can be channeled through state and local governments and non-profit groups to address a complex public health challenge. The AIDS epidemic manifested itself differently from one part of the country to another, and so has the opioid crisis. The kinds of interventions that work best in one place might not be well suited for another. The approach also fosters experimentation with new models — for example, the effort Baltimore is launching to divert those whose primary problems stem from substance abuse from emergency rooms to a stabilization center where they can be steered into treatment and other services. It's a promising idea with limited funding; an infusion of federal money could help expand it across the city and beyond. A federal commitment of $100 billion over 10 years could make that happen.
But beyond the money, we need to look at the debate over this legislation as an opportunity to reassess our attitudes about opioid addiction and the people who suffer from it. In 1990, those living with HIV and AIDS were often still treated as untouchables, pariahs — even deserving of their fate. Today, the same kind of moralism hobbles our response to addiction, as we too often blame substance abusers for bad choices and weak wills rather than treating them as we would sufferers of any other disease. Over time, we have increasingly accepted the importance of measures like needle exchanges and distributing condoms to prevent the spread of HIV, but we are not there yet on opioids.
Many have difficulty accepting the effectiveness of medication-based treatment for opioid addiction (methadone, buprenorphine and the like) and consider a treatment that requires the daily use of a synthetic opioid to be no solution at all. Consequently, we have laws that limit physicians' ability to prescribe such drugs and policies that limit their availability where they're needed most, for example in prisons. Here, again, the HIV metaphor is apt — our best treatments require daily use of drugs to control that virus, just as diabetics or heart disease patients have to use medications every day of their lives. We do not expect to "cure" those diseases or conditions, just to manage them. Why must we reject the same goal for opioids?
Ultimately, the answer to stemming the deaths from overdoses may require steps that many find deeply uncomfortable, such as safe injection sites where addicts use illegal drugs under supervision. But we won't be able to seriously consider such interventions until we stop treating addiction a legal or moral issue and start treating it as a disease. The Ryan White Act helped us get there with HIV/AIDS. We can and must get there with opioids, too.
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