Over the past year, the U.S.

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1 PERSPECTIVE President Trump s Mental Health I expect that the APA will denounce and dismiss this book and its authors, but I encourage others not to do so. Dangerous Case is unapologetically provocative and political, and the authors clearly take themselves to be contributing to the improvement of the community and the betterment of public health, as the AMA (and APA) principles of medical ethics direct. Dangerous Case will have supporters and detractors for good reasons some political, some social, some psychiatric that have much more to do with views of Trump s mental health than with the Goldwater rule. I believe that An audio interview with Dr. Pouncey is available at NEJM.org the APA, in the interest of promoting public health and safety, should encourage rather than silence the debate the book generates. And it should take caution not to enforce an annotation that undermines the overriding public health and safety mandate that applies to all physicians. Standards of professional ethics and professionalism change with time and circumstance, and psychiatry s reaction to one misstep in 1964 should not entail another in Disclosure forms provided by the author are available at NEJM.org. From Eudaimonia Associates, Philadelphia. This article was published on December 27, 2017, at NEJM.org. 1. Nirappil F. Why this Democratic candidate, who has an M.D., calls Trump a narcissistic maniac. Washington Post. June 4, 2017 ( / local/ virginia-politics/ why-this-democratic -candidate-who-has-an-md-calls-trump-a -narcissistic-maniac/ 2017/ 06/ 02/ 7182a6e e7-a196-a1bb629f64cb_story.html). 2. Lee BX, ed. The dangerous case of Donald Trump: 27 psychiatrists and mental health experts assess a president. New York: St. Martin s Press, Council on Ethical and Judicial Affairs. Principles of medical ethics. In: Code of medical ethics current opinions with annotations, Chicago: American Medical Association, 2001 ( / delivering-care/ ama-principles-medical-ethics). 4. The principles of medical ethics with annotations especially applicable to psychiatry. Arlington, VA: American Psychiatric Association, Ethics committee opinion. Arlington, VA: American Psychiatric Association, DOI: /NEJMp Copyright President Trump s Mental Health 2017 Massachusetts Medical Society. Robert J. Blendon, Sc.D., and John M. Benson, M.A. Over the past year, the U.S. opioid-abuse epidemic has gained enormous visibility. President Donald Trump has identified it as a public health emergency, and a national commission and a commission of state governors have issued recommendations for action. 1,2 This concern stems from the fact that in 2016 more than 11 million Americans misused prescription opioids, and opioid-related deaths have more than quadrupled since ,4 To determine what the public believes should be done to address Public Opinion Polls on the Opioid-Abuse Epidemic. Harvard T.H. Chan School of Public Health SSRS (HSPH SSRS) poll April 7 11, 2017 Kaiser Family Foundation (KFF) polls April 12 19, 2016 July 5 11, 2016 PBS NewsHour Marist (PBS Marist) poll September 25 27, 2017 Pew Research Center (Pew) polls October 30 November 6, 2013 October 25 30, 2017 Politico Harvard T.H. Chan School of Public Health (Politico HSPH) poll November 15 19, 2017 STAT Harvard T.H. Chan School of Public Health (STAT HSPH) poll March 3 6, 2016 the epidemic, we examined data from seven national polls conducted in 2016 and Many of the findings may surprise people who have been following this issue in professional journals and the media. First, how serious a problem does the public see opioid abuse as being, and where do they rank it as a national priority? At present, Americans consider taking increased national action to reduce deaths from opioid abuse a secondtier priority for government action. On a list of 15 domestic policy issues that were possible priorities for Congress and the President for 2017, opioids ranked sixth, named by 24% as an extremely important priority (Politico HSPH, 2017; see box and table). A majority of the public considers addiction to prescription 407

2 Public s about the Opioid-Abuse Epidemic.* Perceived seriousness of the opioid-abuse problem Taking increased national action to reduce the 24 number of deaths from opioid abuse is an extremely important priority for Congress and President Trump during the rest of 2017 How much of a problem addiction to prescription pain medication is in the country National emergency 28 Major problem but not an emergency 53 Minor problem 11 Not a problem at all 5 How much of a problem opioid abuse is in your own community Emergency 16 Major problem but not an emergency 38 Minor problem 26 Not a problem at all 12 Abuse of strong prescription painkillers is an extremely serious disease or health condition 28 facing the country Prescription-drug abuse is an extremely serious 38 public health problem In the past year, the problem of addiction to prescription-drug medications in this country has Increased 63 Remained about the same 26 Decreased 2 s about government s role in responding to the problem Which level of government bears the most responsibility generally for fighting the problem of addiction to prescription pain medicine? Federal 36 State 28 Local 21 All or none (volunteered responses) 11 Which level of government should be primarily responsible for paying for programs aimed at reducing the number of people abusing prescription painkillers or opioids?** Federal 41 State 33 Local 20 Which of these bears the most responsibility generally for fighting the problem of addiction to prescription pain medicine? The medical and mental health community 47 The pharmaceutical industry 29 The law enforcement community 12 All or none (volunteered responses) 7 Public s about the Opioid-Abuse Epidemic (Continued.) President Trump s proposed program to respond to the opioid-abuse problem Does too little 27 Is about right 41 Does too much 10 Don t know 22 Spending for opioid treatment in President Trump s proposed program to respond to the opioidabuse problem is Too low 19 About right 44 Too high 18 Don t know 19 Causes of opioid abuse Who is mainly responsible for the problem of prescription-painkiller or opioid abuse? Doctors who inappropriately prescribe painkillers 33 People who sell prescription painkillers illegally 28 Pharmaceutical companies that sell prescription painkillers 13 People who take prescription painkillers 10 The Food and Drug Administration, which approves prescription painkillers before they 7 can be sold Those who are addicted to prescription painkillers have An illness 53 A personal weakness 36 Experiences with opioid abuse Do you worry that you will become addicted to 7 prescribed pain medication? Do you know someone who has ever been addicted to 49 prescription painkillers? (average of polls) Asked of those who said they have known someone in the past 5 years who has abused 20 prescription painkillers: Did that person s abuse of prescription painkillers lead to their dying? s about prevention Increasing pain-management training for medical students and doctors Very effective 53 Somewhat effective 34 Not too or not at all effective 9 Public education and awareness programs Very effective 44 Somewhat effective 40 Not too or not at all effective 14 Increasing research about pain and pain management Very effective 43 Somewhat effective 40 Not too or not at all effective

3 Public s about the Opioid-Abuse Epidemic (Continued.) Monitoring doctors prescription-painkiller prescribing habits Very effective 47 Somewhat effective 35 Not too or not at all effective 15 Encouraging people who were prescribed painkillers to dispose of extras they no longer medically need Very effective 34 Somewhat effective 29 Not too or not at all effective 36 Reducing the social stigma around addiction Very effective 30 Somewhat effective 30 Not too or not at all effective 36 Putting warning labels on prescription-drug bottles to explain the risk of addiction Very effective 25 Somewhat effective 23 Not too or not at all effective 50 Limit the amount of prescription painkillers doctors can prescribe to a 7-day supply or less Favor 45 Oppose 48 How concerned are you that new government prescribing guidelines would make it too difficult for people who need prescription painkillers for medical reasons to get them?*** Very/somewhat concerned 55 Not too/not at all concerned 42 s about treatment Is there a treatment for prescription-painkiller addiction that is effective for a long period of time? Yes 49 No 34 Don t know 17 Among those who believe there is an effective treatment: Most people who receive treatment for prescription painkiller addiction Can be successfully treated within a year 43 Treatment often required for a year or more 53 Government requiring health insurers to provide more extensive coverage for these treatment programs. (This might add to the cost of health insurance premiums for most policyholders.) Favor 48 Oppose 49 Public s about the Opioid-Abuse Epidemic (Continued.) If you or a family member had an addiction to prescription pain medications, does your health insurance cover treatment? Yes 29 No 11 Not sure 59 Think most people found possessing prescription painkillers or opioids obtained without a prescription Should be placed in a treatment program without jail time 65 Should serve jail time 28 s about making Narcan (naloxone) more available without a prescription Letting adults buy Narcan from pharmacists at chain or retail pharmacies without a prescription Favor 45 Oppose 52 * Don t know and Unsure responses are not shown if they represented less than 10% of responses overall. Data are from the responses of 485 U.S. adults, as reported by Data are from the responses of 656 U.S. adults, as reported by Data are from the responses of 1105 U.S. adults, as reported by PBS Marist, September Data are from the responses of 1201 U.S. adults, as reported by KFF, April Data are from the responses of 1504 U.S. adults, as reported by Pew, October ** Data are from the responses of 524 U.S. adults, as reported by Data are from the responses of 1212 U.S. adults, as reported by KFF, July 2016; responses of 1105 U.S. adults, as reported by PBS Marist, September Data are from the responses of 395 U.S. adults who said they have known someone in the past 5 years who has abused prescription painkillers, as reported by STAT HSPH, March Data are from the responses of 602 U.S. adults, as reported by KFF, April Data are from the responses of 599 U.S. adults, as reported by KFF, April Data are from the responses of 1034 U.S. adults, as reported by HSPH SSRS, April *** Data are from the responses of 1011 U.S. adults, as reported by STAT HSPH, March Data are from the responses of 225 U.S. adults who believe there a treatment for prescription painkiller addiction that is effective for a long period of time, as reported by Politico HSPH, November

4 pain medication a major problem nationally (53%) but does not deem it a national emergency (28%) Substantially fewer people see it as an emergency (16%) or a major problem (38%) in their own community (PBS Marist, 2017). In a list of national health problems, abuse of prescription painkillers ranks fifth in the proportion of the public that considers it an extremely serious disease or health condition facing the country (28%; KFF, April 2016). Concern about prescription-drug abuse as a public health problem has grown over time. Nearly 4 in 10 people (38%) currently believe it s an extremely serious public health problem, double the proportion (19%) who believed so in 2013 (Pew, 2013 and 2017). More than 6 in 10 (63%) believe that the problem of addiction to prescription pain medications has increased in the past year, 26% think it has stayed about the same, and only 2% believe it has decreased (PBS Marist, 2017). The public is divided over which level of government bears the most responsibility generally for fighting addiction to prescription pain medicine: 36% said the federal government was most responsible, followed by state (28%) and local (21%) governments (PBS Marist, 2017). Similarly, asked what level of government should be primarily responsible for paying for programs aimed at reducing the number of people abusing prescription painkillers or opioids, about 41% said the federal government, versus 33% for state and 20% for local. Democrats are significantly more likely than Republicans (52% vs. 29%) to believe the federal government should be mainly responsible Asked about general responsibility beyond government, nearly half (47%) said the medical and mental health community bears the most responsibility for fighting opioid addiction, while 29% named the pharmaceutical industry and 12% the law-enforcement community (PBS Marist, 2017). As to Trump s proposed national response, most of the public does not share the view of some media commentators that the proposed program does too little. Only 27% believe it does too little, 10% believe it does too much, and 41% believe it s about right. Asked about the spending for treatment in the proposal, 19% said it s too low, 18% too high, and 44% about right. A large proportion about one in five said they did not know enough to give an opinion on either of these questions Asked who is mainly responsible for the growing problem, the public placed the most blame on doctors who inappropriately prescribe painkillers (33%) and people who sell prescription painkillers illegally (28%). Only 10% believe that people who take prescription painkillers are mainly responsible A majority believe that people addicted to painkillers have an illness (53%) rather than a personal weakness (36%) (PBS Marist, 2017). Nearly two thirds (64%) of the public reports having been prescribed an opioid for pain. Although the public sees opioid addiction as a major national problem, few people (7%) worry that they themselves could become addicted to prescribed pain medication (PBS Marist, 2017). About half of people (49%, in an average of two polls) say they know someone who has been addicted to prescription painkillers (KFF, July 2016; PBS Marist, 2017). One in five people (20%) who knew someone in the past 5 years who abused prescription painkillers said it had led to the person s death (STAT HSPH, 2016). When asked how effective seven proposed policies aimed at preventing prescription-painkiller abuse would be, a majority thought only one of them would be very effective: increasing pain-management training for medical students and doctors (53%). However, more than 8 in 10 thought not only this policy (87%) but also three others would be at least somewhat effective: offering public education and awareness programs (84%), increasing research about pain and pain management (83%), and monitoring doctors painkiller-prescribing habits (82%). About 6 in 10 believed that encouraging people who were prescribed painkillers to dispose of extras they no longer medically needed (63%) and reducing the social stigma around addiction (60%) would be at least somewhat effective, while about half (48%) thought the same about putting warning labels on prescription-drug bottles to explain the risk of addiction (KFF, April 2016). Various policy groups have recommended limiting the amount of prescription painkillers that doctors can prescribe. The public is divided on this question: 45% favor limiting the amount to a 7-day supply or less, unless the pain results from cancer or conditions related to nearing the end of life; 48% are opposed to such 410

5 limits (HSPH SSRS, 2017). When asked in 2016 about new government prescribing guidelines, 55% of respondents expressed concern that the guidelines would make it too difficult for people who need prescription painkillers for medical reasons to get them (STAT HSPH, 2016). Significantly, at a time when national public figures are discussing major expansion of financial support for opioid-treatment programs, only about half of the public (49%) believes there s a treatment for prescription-painkiller addiction that s effective long-term. About half either believe there is no long-lasting treatment (34%) or say they don t know (17%) About half of those who believe there is an effective treatment (53%) think that people addicted to prescription painkillers often require a year or more of treatment. A nearly equal proportion (43%) thinks they can be treated successfully in less than a year Because many people don t know whether treatment for opioid addiction is effective, they may be uncertain about requiring insurance to cover it. About half favor a government requirement that health insurance plans provide extensive coverage for opioid-abuse treatment programs (48%), which might add to the cost of insurance premiums, while about the same proportion (49%) are opposed (Politico HSPH, 2017). When asked if their health insurance would cover treatment if they or a family member had an opioid addiction, 59% said they weren t sure. About one in three (29%) believed their insurance would cover at least part of the treatment, and 11% thought it would not (PBS Marist, 2017). A large majority of the public believes that people found to possess prescription painkillers or opioids obtained without a prescription should be treated (65%) rather than incarcerated (28%), even though many people question the effectiveness of treatment As to the opioid antagonist Narcan (naloxone), which various commissions see as key to response in emergency situations, the public is divided. After hearing a description of naloxone s function, 45% of respondents favored letting adults buy it from pharmacists without a prescription, but 52% were opposed An important finding from our review is that at a time when public- and private-sector leaders are seeking a substantial increase in government funding for opioidaddiction treatment programs and legislation requiring insurers to offer coverage for these treatments, polls show a large share of the public uncertain about the long-term effectiveness of treatment. Over the next few years, this impression could affect family referrals to treatment programs, as well as public support for them and for a government requirement that insurance cover their cost. There is a clear need for the medical and scientific communities to educate the public about the issues surrounding the potential effectiveness of treatment. Disclosure forms provided by the authors are available at NEJM.org. From the Harvard T.H. Chan School of Public Health, Boston (R.J.B., J.M.B.), and the John F. Kennedy School of Government, Cambridge (R.J.B.) both in Massachusetts. This article was published on January 3, 2018, at NEJM.org. 1. Report of the President s Commission on Combating Drug Addiction and the Opioid Crisis. November 1, 2017 ( / sites/ whitehouse.gov/ files/ images/ Final_Report_Draft_ pdf). 2. Murphy K, Becker M, Locke J, Kelleher C, McLeod J, Isasi F. Finding solutions to the prescription opioid and heroin crisis: a road map for states. Washington, DC: National Governors Association Center for Best Practices, July 2016 ( / files/ live/ sites/ NGA/ files/ pdf/ 2016/ 1607NGAOpioidRoad Map.pdf). 3. Federal efforts to combat the opioid crisis: a status update on CARA and other initiatives. Presentation by Dr. Nora Volkow, director of the National Institute on Drug Abuse, before the House Committee on Energy and Commerce, October 25, 2016 ( / about-nida/ legislative-activities/ testimony-to-congress/ 2017/ federal-efforts-to-combat-opioid-crisis -status-update-cara-other-initiatives). 4. Centers for Disease Control and Prevention. Opioid overdose: understanding the epidemic. August 30, 2017 ( / drugoverdose/ epidemic/ index.html). DOI: /NEJMp Copyright 2018 Massachusetts Medical Society. 411