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Opioid crisis: Many stakeholders, common themes, Part 1

Editor’s Note: The recent Modern Healthcare Opioid Crisis Symposium reflected the broad variety of perspectives needed to address this complex problem. Stakeholders included Baltimore’s Mayor, Police Commissioner and Health Commissioner, as well as business leaders, academics, clinicians, national policy experts, a former National Drug Czar, health system leaders and health information technology companies. Dr. David Hurwitz participated in panel discussions and shares his thoughts on the themes that emerged in this two-part blog series.

There is a big difference between what we know and what we do. Josh Sharfstein, Vice Dean, Johns Hopkins Bloomberg School of Public Health, spoke extensively about this problem.

He noted, for instance, we have evidence-based treatment for opioid use disorder that is effective, saves lives and helps people return to the workforce and reunite with their families. But we do not provide broad access to these medications and treatment.

He listed the top three reasons for this disconnect, Stigma, Stigma, Stigma, which is pervasive throughout our society. Opioid use disorder is frequently viewed as a personal or moral failing, a criminal act, rather than a disease.

From a law enforcement perspective, Darryl De Sousa, Baltimore’s Police Commissioner stated, “We cannot arrest our way out of this.” He described his department’s effort to educate Baltimore police officers about the nature of opioid use disorder to reduce stigma. The department’s focus now is to respond to the crisis by directing those with opioid use disorder into treatment, not arresting them and putting them in jail.

From a public health perspective, Dr. Leana Wen, Baltimore’s Health Commissioner, echoed the importance of not criminalizing addiction, viewing that as inhumane, and instead directing resources to address opioid use disorder as a disease. Dr. Wen described writing a blanket prescription of naloxone for the city of Baltimore, making this life-saving opioid overdose antidote freely available in pharmacies to its 600,000 citizens.

Need for physician education in evaluating and treating pain

Many physicians, myself included, have had very limited training in evaluating and treating pain, particularly non-cancer pain. In response to unrealistic expectations to eliminate pain as well as regulatory and patient satisfaction pressures, physicians in recent years have been prescribing more opioids, contributing to widespread opioid addiction in the United States.

To reverse this trend, a key focus needs to be educating physicians about evidence-based approaches to evaluating and treating acute and chronic pain as well as opioid addiction risk. There are a number of approaches that can help, including more emphasis in medical training, continuing medical education and through the use of health information technology. Embedding pain assessment and opioid prescribing clinical guidelines (e.g., CDC)  in a streamlined manner in electronic health record workflow provides essential information to prescribers, who are frequently under significant time pressure and may be addressing other medical issues unrelated to pain.

Beware unintended consequences of reducing prescriptions

There is concern that the opioid prescribing pendulum may be swinging too far in the opposite direction. Paradoxically this has been associated in some regions with an increase in opioid overdose deaths, particularly where treatment availability is very limited and Fentanyl-laced heroin is easy to obtain.

There are also individuals with severe, chronic pain not due to cancer who rely on these medications simply to function, not to get “high” or divert opioids and in whom non-opioids have not been effective in controlling pain. Although treating non-cancer chronic pain with opioids remains controversial (and there is still much we need to learn through research), too rapid a reduction in opioid prescribing may deprive patients of pain relief, some who may turn to the streets and end up using illicit drugs.

(Read more about how University Hospitals is Managing patients’ pain, not their opioid prescriptions.)

Opioid use disorder is not a moral failure

Unfortunately, many people across communities and healthcare do not recognize opioid use disorder as a disease. There remains a lot of false thinking that this is somehow a moral failure. It’s not. Just as we treat diabetes or asthma as chronic diseases, opioid use disorder should be no different.

Changing this perspective will help increase access to naloxone, addiction treatment and promoting non-incarceration. This multi-stakeholder perspective will give us the holistic approach we need to combat opioid misuse and abuse. I look forward to continued community engagement on this topic.

Editor’s note: Learn more about Dr. Hurwitz’s observations about the opioid crisis in a recent blog post. You can read Part 2 here.

Comments 4

  1. Jack Collins 06/30/2018

    I’ve been on long term opioid pain therapy for several years. I’m now in NC staying with my daughter. My new doctor here writes in my chart that I’m a chronic opioid user, which in my mind is calling me a drug addict. I’ve explained my medical and pain issues. I don’t abuse or shop for medicine….yet. I’m a chronic user…to me no more than I’m a chronic user of insulin, sotalol, coumadin or anyone of the other medications I’m on. We need to deal with reality.

  2. Linda 08/13/2018

    Increased prescription of opioid medications led to widespread misuse of both prescription and non-prescription opioids before it became clear that these medications could indeed be highly addictive. Policymakers needs to create laws about substance abuse prevention and treatment needs in their communities.

  3. David Hurwitz 08/17/2018

    While I cannot speak for your physician’s use of the term, “chronic opioid user”, its meaning depends on context, whether opioids are being misused by patients (opioid user disorder) or are being prescribed for legitimate, severe non cancer pain not adequately relieved by non-opioid medication and non-medication treatment. While treating non cancer pain chronically with opioids is controversial, in my experience, those not misusing opioid do not seek a high and take chronic opioids simply to function.

    From a prescribing standpoint, it is important to know that a person takes opioids chronically, since higher doses of opioids are typically required to effectively control pain, often with long acting opioid formulations. Those with severe acute pain and who do not take opioids need short term use of lower dose opioids in order to be effective.

  4. David Hurwitz 08/17/2018

    Increased prescribing of opioids in recent years has clearly contributed to widespread misuse of opioids (opioid use disorder), opioid overdose and death. Policy makers clearly have a role to play, helping to secure resources for both prevention and treatment of opioid misuse, however, this remains difficult in some instances due to widespread stigma against those with opioid use disorder.

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