Travis Rieder’s essay is hard to read from a physician’s perspective as it highlights multiple times when the health care system failed him. We can do better.
The pain trajectory to opioid misuse, addiction, and overdose is unfortunately real and tragic.
Long term opioid use often begins with the treatment of acute pain. Shah and colleagues[1] studied a random sample of commercially insured, opioid naive individuals who received an opioid prescription. They found that with one day of use, the probability of use at one year was only 6%, but it rapidly increased to 13.5% for those prescribed for > 8 days, and 29.9% with > 31 days of use. Thus, educating physicians about safe prescribing and supplying the correct amount of pain reliever depending on the injury or illness is one of many steps that we need to do to save lives. However, chronic pain is highly prevalent in the U.S. population, affecting over 100 million people, or one in three individuals, with 25 million Americans suffering from daily pain.[2] It is estimated that 10% of patients with chronic pain misuse opioids.[3] Consequently, the NIH is investing substantial dollars in developing new medications and treatments for pain; the Center for Disease Control has offered guidelines for safe prescribing; and the number of opioid prescriptions has decreased.
There is enough blame to go around for the creation of the perfect storm.
Physicians were being told in the mid 1990s that they undertreated pain, and they became more than willing to prescribe more pain medications with little scientific evidence. The American Pain Society and other advocacy groups lobbied for pain to be included as the fifth vital sign, along with temperature, pulse, respiration, and blood pressure. Purdue Pharma aggressively marketed the longer acting sustained release opioid formulation OxyContin with few facts related to its addictive potential, and it targeted primary care practices and areas of high prevalence of pain, such as the rural Appalachian Valley. Regulatory bodies, such as the Joint Commission for Hospital Accreditation, released new pain standards in 2001, and finally in 2006 CMS linked reimbursement to patient satisfaction with pain management.
In retrospect it was the perfect storm. However, today the overdose rates from prescription opioids are decreasing, and more and more deaths are attributed to heroin and increasingly use of synthetic opioids such as fentanyl. This is even more frightening, as synthetic fentanyl is cheap, easily purchased through the mail, often sold and marketed as other illicit substances such as heroin or cocaine, and it’s strikingly more lethal. In 2017 synthetic opioids have become twice as common in overdose deaths as prescription opioids or heroin.[4] Thus, we need to learn from our mistakes and develop prevention, treatment, and harm reduction strategies partnering with law enforcement and public health.
Stigma is a large factor preventing access to treatment.
Once we all—including health professionals, the public and the judicial system—understand that opioid addiction is a chronic, relapsing disease that can be treated with proven medications and is not a moral failure, we will be closer to saving lives. Opioid agonist treatment with methadone or buprenorphine does work and has proven to reduce illicit use, craving, HIV and hepatitis C transmission, crime, and contact with the judicial system; it also increases retention in treatment and improves quality of life. So why is it that so many patients refuse treatment, and why do physicians fail to treat? First, the stigma associated with opioid addiction is profound both in the lay population and the health care field, and it is one of the major reasons individuals with OUD do not seek treatment. The lack of knowledge surrounding addiction is pervasive and disheartening. Words matter,[5] and individuals are often labeled as “addicts” instead of individuals with a disease, opioid use disorder (OUD); their urines are termed “dirty or clean” instead of positive or negative; care is often terminated if the individual “fails treatment” instead of returns to use, where treatment should be escalated, not withdrawn.
An individual with diabetes would never have their care terminated if they presented one or many times with high blood sugars. No one would contemplate not offering another prescription for insulin. But this is exactly what we do with OUD. While diabetes has many behavioral treatments as part of the care, including weight loss, dietary restriction, and nutritional guidelines, we know that the treatment is medication (insulin or oral preparations). With OUD the term medication assisted treatment (MAT) continues to be used instead of the more accurate terms of opioid agonist treatment (OAT) or medications for opioid use disorder (MOUD). Countless studies[6] and reports[7] have emphasized that medications are as effective with or without counseling and should never be withheld, but we continue perpetuating this falsehood that medication is merely optional.
Many individuals with OUD end up in the judicial system, which lacks the will and ability to treat the underlying disease. In Connecticut alone, there were approximately 1,000 deaths in 2017 from overdose, and 55% of these individuals had been previously incarcerated in a Connecticut prison or jail.[8] Yet few departments of correction offer methadone or buprenorphine. A National Academy of Medicine report states that “withholding or failing to have availability of all classes of FDA-approved MOUD in any health care justice setting is denying appropriate medical treatment.”7
Physicians, patients, and family members often think we are replacing one opioid for another, or one addiction for another. This is simply not true. MOUD are prescribed/administered specifically by physicians. The hallmarks of addiction include craving, consequences, and lack of control. When an individual receives MOUD they return to work, have meaningful relationships, and no longer engage in destructive activities despite knowledge of their consequences.
Strategies for saving lives.
Families and friends need to encourage their loved ones to seek help. Health professionals must recognize OUD and identify patients in need of assessment, treatment, and referral, using signs that are often obvious. OUD is estimated to be present in 3-17% of primary care practices,[9] and opioid-related emergency department (ED) visits increased 30% from 2016 to 2017.[10] Patient and healthcare system challenges exist and must be overcome. Physicians currently must obtain a Drug Addiction and Treatment Act of 2000 (DATA 2000) waiver, requiring 8 hours of training, to prescribe buprenorphine. This is truly laughable when a physician can prescribe countless opioids for pain without any further training. However, the law is an Act of Congress and most likely will be in place for the foreseeable future. Thus, we should all be required to obtain the training.
At Yale School of Medicine, with help from SAMHSA, as well as several others around the country, this training is being initiated for medical students, physician assistants, as well as to the advanced practice nurses in the School of Nursing. Residents are now receiving training in many primary care specialties including emergency medicine. After all, do we refuse to treat, or are we unprepared to care for, patients with other life-threatening illnesses, such as heart attacks or strokes? Should this preparation be optional? Shouldn’t obtaining a DATA 2000 waiver be a requirement for hospital credentialing?
Hospitals and pharmacists need to stock buprenorphine and have systems in place for patients to fill their prescriptions seven days a week. We know from a study conducted at Yale-New Haven Hospital emergency department that ED-initiated treatment with buprenorphine more than doubles engagement in treatment at 30 days when compared with receiving a referral alone,[11] is cost effective,[12] and saves lives. So why not require this evidence-based practice? The cost of the medication is less than an ED visit, hospitalization, or the staggering increase in heart valve replacements due to endocarditis. The overall economic cost of the U.S. opioid crisis is estimated to be more than $500 billion per year.[13]
Identifying community opioid programs and providers and partnering with them to provide timely referrals and other services is essential. State laws that require extensive counseling that precludes primary care offices form prescribing buprenorphine need to be eliminated. As many individuals have unstable housing, shelters should be monitored and drug-free so that individuals in treatment feel safe using them.
Harm reduction strategies are also imperative. We should be dispensing naloxone to patients with OUD or at risk for OD, and their families or friends. Insurance companies should include naloxone in all plans without copays, and pharmaceutical companies should not be overcharging for this medication or other MOUD.
We need to increase the workforce for addiction treatment.
Sadly, Travis Rieder did not have the benefit of an addiction specialist involved in his care from the beginning. Multiple surgeries require thoughtful and effective pain management. Developing a physical dependence on opioids due to these surgeries does not necessarily mean that one will develop an addiction. Cancer survivors and individuals with sickle cell disease may develop physical dependence, meaning they require more medications due to tolerance, or may develop withdrawal symptoms when the medication is withdrawn, but they do not meet the other criteria for addiction. Having an addiction specialist consulted will aid the physician in appropriately prescribing the opioids, adding other treatments for pain, and recognizing when a patient may have developed an addiction and need treatment.
Addiction Psychiatry has been a subspecialty since 1992 but is limited to physicians who have completed a psychiatry residency. Fortunately, Addiction Medicine has recently been formally recognized as the first clinical multi-specialty subspecialty recognized by the American Board of Medical Specialties (2016) and is administered by the American Board of Preventive Medicine (ABPM). Any physician with primary board certification such as Internal Medicine, Family Medicine, Emergency Medicine, Pediatrics, Preventive Medicine, Obstetrics and Gynecology, Anesthesia, or others can apply through June 2021 for Addiction Medicine subspecialty certification via the ABPM Practice Pathway.
As is true for all new ABMS recognized fields, this pathway will close, and then a twelve-month, full-time Addiction Medicine fellowship will be required after primary residency completion. The Accreditation Council for Graduate Medical Education (ACGME), the entity that accredits all physician training after medical school, recognized the subspecialty in 2018 and then began accreditation of fellowships. ACGME provides the gold standard accreditation for physician training. As of June 2019, there were 54 ACGME accredited addiction medicine fellowships, 20 programs previously accredited by the American College of Academic Addiction Medicine which are transitioning to ACGME accreditation, and another 15 emerging programs in development.
It is anticipated that we need 7,500 full-time addiction medicine specialists by 2025 and into the future; there are currently about 2,000. This will require at least 125 training fellowships with 2-3 fellows graduating from each annually. Policies that can assist in paying hospitals for these fellowships and encourage physicians to take this additional year of training are needed. This could include working in rural or underserved areas and with underserved populations both in rural and in urban areas.
End the opioid crisis with a multifaceted approach.
A multifaceted approach involves partnering with health care providers, public heath, law enforcement, and the judicial system. The stigma of addiction needs to be removed, and individuals need to come forward to tell their story and not be ashamed or afraid of repercussions. Treatment capacity and harm reduction strategies need to be increased so that access to care can be available and affordable in all communities, rural or urban. Patient and system barriers to treatment must be broken down. Lastly the Addiction Medicine workforce must be increased to help improve the health of the public through this epidemic and other escalating substance misuse and disorders.
Notes
[1] Shah A, Hayes CJ, and Martin BC. (2017). “Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015.” Morbidity and Mortality Weekly Report (MMWR), 66(10):265-269.
[2] Loeser J, D., (2012). Relieving pain in America Clin. J. Pain,28pp.185-186
[3] Garland, E. L., Froeliger, B., Zeidan, F., Partin, K., & Howard, M. O. (2013). The downward spiral of chronic pain, prescription opioid misuse, and addiction: cognitive, affective, and neuropsychopharmacologic pathways.Neuroscience and biobehavioral reviews,37(10 Pt 2), 2597–2607. doi:10.1016/j.neubiorev.2013.08.006
[4] Hedegaard H, Miniño AM, Warner M.Drug overdose deaths in the United States, 1999–2017. NCHS Data Brief, no 329. Hyattsville, MD: National Center for Health Statistics. 2018.
[5] Botticelli, M. P., & Koh, H. K. (2016). Changing the language of addiction.Jama,316(13), 1361-1362.
[6] Mattick RP, Breen C, Kimberly J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014 Feb 6;(2):CD002207. Doi10.1002/14651858.CD002207.pub4
[7] National Academies of Sciences, Engineering, and Medicine. (2019).Medications for opioid use disorder save lives. National Academies Press.
[8] State of Connecticut. Office of Policy and Management monthly indicators report https://portal.ct.gov/-/media/OPM/CJPPD/CjResearch/MonthlyIndicators/2014-2018/2018MonthlyIndicatorsReport/MonthlyIndicatorsReportSEPT2018DRAFTpdf.pdf?la=en September 2018
[9] Vowles, K.E., M.L. McEntee, P.S. Julnes,et al.2015. Ratesof opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis.Pain156:569–57
[10] Vivolo-Kantor, A. M., Seth, P., Gladden, R. M., Mattson, C. L., Baldwin, G. T., Kite-Powell, A., & Coletta, M. A. (2018). Vital signs: trends in emergency department visits for suspected opioid overdoses—United States, July 2016–September 2017.Morbidity and Mortality Weekly Report,67(9), 279.
[11] D’Onofrio G, O’Connor PG, Pantalon MV, Chawarski MC, Busch SH, Owens PH, Bernstein SL, and Fiellin DA. (2015). “Emergency Department-Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial.” JAMA, 313(166):1636-1644.
[12] Busch SH, (2017) Fiellin DA, Chawarski MC, Owens PH, Pantalon MC, Hawk K, Bernstein SL, O’Connor PG, D’Onofrio G. Cost Effectiveness of Emergency Department-Initiated Treatment for Opioid Dependence. Addiction 2017, doi: 10.1111/add.13900.
[13] Council on Economic Advisers. The underestimated cost of the opioid crisis. Accessed November 26, 2018.https://www.whitehouse.gov/sites/whitehouse.gov/files/images/The%20Underestimated%20Cost%20of%20the%20Opioid%20Crisis.pdf