Opioid abuse has some roots in the physician community, but it will take a much larger effort than physicians alone to combat the growing crisis.
Ted Parran, MD is a board-certified internist, addiction medicine specialist, and the Isabel and Carter Wang Professor and Chair in Medical Education at Case Western Reserve University School of Medicine.
A 1982 graduate of CWRU School of Medicine, he completed his residency in internal medicine at the Baltimore City Hospital of Johns Hopkins University School of Medicine. Parran pursues several areas of interest in medical education including doctor-patient communication, faculty development, continuing medical education, and addiction medicine.
Q. From 1999-2014 there was a 400-percent increase nationally in prescribed opioids, with similar increases in opioid-related ER visits, addiction treatment admissions, and accidental fatal overdoses. What are some of the reasons for today’s crisis, the largest opioid-abuse epidemic in our nation’s history?
A. For over 90 years, physicians were taught to avoid using narcotic pain medications for chronic pain unless absolutely necessary, such as in cancer patients. As a result, accidental overdose from prescription opioids was a negligible cause of death in the United States.
Beginning in the early 1990s, this began to change. There were many reasons:
Q. You have made it a point to speak about the physicians’ role in the upsurge of opioid abuse. Can you explain that role?
A. Tragically, my colleagues and I were too receptive to these factors, often failing to balance our obligation to “do no harm” with a sincere —but necessarily secondary—desire to reduce pain and relieve suffering. Consequently, much of today’s illegal heroin and fentanyl crisis can be directly tied to physician over-prescription of legal opioids: up to 70 percent of patients who turn to heroin (and unknowingly, heroin laced with illegal fentanyl) at first started taking opioids by prescription.
But physicians are not alone in bearing responsibility. Regulators, healthcare institutions, and the pharmaceutical industry all made serious mistakes. And if we’re going to solve the problem, we also must clearly say that patients also have a big share of responsibility.
Q. Various steps have been taken to address the crisis. Can you describe some of these?
A. The Centers for Disease Control and Prevention has developed opioid prescription guidelines. A national prescription drug monitoring database has been established, with 49 states—all except Missouri—participating. It allows physicians and pharmacists to quickly pull up a person's history with prescription narcotics and other controlled drugs in order to spot signs of potential and actual abuse. Many communities are equipping first responders with the opioid antagonist naloxone, saving lives. The Affordable Care Act has provided many Americans in chronic pain with access to health care and improving their access to both quality pain management treatment and addiction treatment.
Q. What are some of your suggestions for making further inroads against the opioid crisis?
A. All physicians in training (medical students and residents) should be fully educated on safely prescribing opioids in particular and controlled drugs in general. This includes weighing the pros and cons of controlled drugs, assessing patient risk, and monitoring for and responding to problems. We at the CWRU School of Medicine have been teaching these principles for the past two decades to physicians with a history of problematic prescribing who are referred to us by state medical boards and hospitals around the country. Based upon this experience we have made this same education available to all senior medical students and are extending it to our affiliated residency programs. This training needs to be provided to all senior medical students and residents nationally.
Health systems should incorporate controlled-drug prescribing algorithms into their inpatient and outpatient electronic health record systems, including automatically notifying doctors when daily safe levels for individual patients have been reached. This will also allow medical quality assurance programs to identify over-prescribers and take intervening action.
Government and professional regulatory organizations should develop and enforce additional standards for prudent prescribing of controlled drugs and ensure that these measures are well represented on national board exams, specialty board exams, and state licensure requirements. The federal government should consider a compulsory certification examination and periodic re-certification for all clinicians applying for a DEA number.
Pharmaceutical companies must follow the letter and spirit of all laws and FDA regulations for marketing controlled drugs. Failure to adequately disclose potential dangers should be considered negligent, with attendant consequences.
Patients should have realistic expectations about pain relief from medications. Therefore, with their physicians, they should seek out well rounded, complementary chronic-pain management strategies, such as yoga, meditation, acupuncture, and counseling. And they must ensure that their medication is secured from all young people in the household.
Finally physicians have a moral duty to ensure that we are vigilant in determining who should receive opioids and under what conditions. If we don’t do this job right, nothing else will matter.
Q. A few weeks ago, Governor John Kasich signed a bill limiting opioid prescriptions for acute pain conditions to a maximum of seven days for adults and five days for minors. President Trump signed an executive order establishing a federal commission led by New Jersey Governor Chris Christie to try to reverse America’s opioid epidemic. His proposed budget includes a $500 million increase from 2016 levels to expand prevention efforts and increase drug treatment. What is your assessment of these state and national steps?
A. The Ohio initiative will give further guidance to physicians, dentists, physician assistants and advanced practice nurses in their management of acute pain issues. Re-evaluating patients with acute pain after a week, and making subsequent prescribing decisions seems prudent and appropriate. Additional funding for local treatment programs and drug courts would have been even more helpful in Ohio. The federal initiative based on the recent executive order is still fairly undefined, so it is difficult to assess at present. I can say that the 2016 CARA Act did provide somewhat more funding for addiction treatment nationally as well as changed administrative policies to expand access to opioid addiction treatment. This was a good start, but only a start. Currently proposed federal laws to better track and interdict illegal potent opioids mailed from overseas (like the current fentanyl and carfentanyl) would also be a very helpful intervention. There still remains much to be done locally, regionally and nationally to address what the CDC has termed the worst man-made epidemic of the 21st century.