For the White House to meet its goals on stopping the nation’s opioid crisis, there are some practical steps to put in place first.
Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / Medical Economics.
Recently the White House announced its initiative to stop opioid abuse with three major goals. As an addiction medicine provider at Northland treatment center in Milford, Ohio, I prescribe medication-assisted treatment to patients with opioid use disorder (OUD) every week and share this perspective on the White House’s top goal:
Reduce demand and over-prescription: educate Americans about the dangers of opioid and other drug use and seek to curb over-prescription
Education is often the first suggestion when looking for a solution, but what’s more important is the need to concentrate on the right type of education.
Most physicians and laypeople know the dangers of opioids. Since the commission’s report, it’s been established that the compulsory numbers of prescriptions of opioids Americans use or the number of deaths is intolerable. I have patients who have watched their friends die while using heroin and they keep using despite that experience.
Educating physicians about the dangers of opioids and limiting the prescriptions written is elementary. We already know the basic premise. Curbing prescription writing, safer prescribing techniques, and finding alternatives to opioids for the treatment of pain are all important educational goals. However, most of the lay and medical community are not educated about the disease of addiction. Healthcare providers need more education to recognize that addiction is a disease and that those suffering require more than disdain and disgust. Many clinicians are not comfortable or well-versed in taking care of patients for basic medical problems who are in recovery or those who are on medication-assisted treatment. This can lead to improper treatment and an increase in relapse risk.
For example, one of my patients suffers from migraines and the only medication that ever relieved her headaches was a drug called a “triptan.” It is not mood-altering and when it was first offered, it was only available in an auto injector. When my patient started her recovery from OUD and Xanax (a sedative), she went to her family doctor asking for the injectable triptan for her headaches. Her family doctor told her she didn’t want to give it to her because it was a shot and she was an “addict.” Triptans are available in an oral form but her physician did not offer this alternative. So she prescribed a medication with a barbiturate, caffeine, and codeine. The patient went to the pharmacy and realized that the medication had codeine and refused it. So the doctor changed it to one with just the caffeine and barbiturate. Even though a barbiturate is not recommended for those in treatment for OUD, since it is a mind-altering sedative, she started taking it. Although the patient knew that she should avoid codeine, she was not aware of the other ingredients in the medication.
When I started seeing her, she was taking the migraine medication very frequently, and I suggested she move to a different medication and not take the barbiturate. As she weaned herself down from the headache medication, she was also witnessing her aunt die in hospice. Since she was her aunt’s power of attorney, her stress level understandably increased at the same time that she started taking less and less of the medication for her migraines. Since she started weaning from the barbiturate (a sedative drug like Xanax), I believe it triggered her craving for Xanax.
After an emergency meeting with me, I prescribed an oral triptan. Following the barbiturate withdrawal, the Xanax craving resolved and she rarely has headaches now. Had her primary care physician been educated on how to treat a patient who is in recovery, this may never have happened. She was at a very high risk of relapse when she was experiencing physiologic withdrawal symptoms and was going through a very stressful situation. While her cravings were for Xanax, often patients will relapse on their drug of choice (in this case, heroin).
Physician-and public-education is critical
When this epidemic started to be recognized, new regulations came out, deaths from opioid use were all over the news, and physicians stopped prescribing opioids. This may help to prevent triggering the disease of addiction. But what about those who already suffer from the disease?
When I worked in the emergency department, the state of Ohio put out a laminated one-page document that every doctor could carry showing the recommendations for prescribing opioids. Most of the providers were excited that they could show the laminate to the “drug seekers” and tell the patients, “I can’t prescribe opioids to you anymore. The state won’t let me.” The patients were then sent out the door and were not the responsibility of the ED anymore. What happened to some of those patients? They turned to the streets for heroin, a cheaper alternative to prescription opioids, and they died. If the providers had been educated about the disease of addiction and planted the seed that maybe the patient needed treatment, a few might have listened. That information is also helpful for loved ones to better understand the disease of addiction. Even if the patient is not willing to ask for or accept help, we can offer help to the suffering families and caretakers with additional resources.
Not only are healthcare professionals often uneducated about the disease of addiction, neither is the public. Comments like “How can he do that to his wife?” and “She comes from such a nice family” would never be said about someone with cancer. Addiction is not a “casserole disease.” When your neighbor’s child goes to treatment for addiction, no one brings over a casserole. But if someone goes to the hospital for cancer treatment, everyone is empathetic. Health organizations and the public need to come to a better understanding of what a disease is, including the disease of addiction.
The stigma must end since it can prevent those suffering-patients and their caregivers-from getting help. There is no doubt that convincing someone with OUD that they need help is a tall order, but it certainly won’t happen if the disease is not understood. And when a patient is educated, it is his or her responsibility to treat the disease. Caretakers can also learn how to keep themselves healthy, despite continued resistance of the patient.
If healthcare professionals and the public, including those suffering with and those at risk for the disease of addiction, are educated, we are more likely to be successful at accomplishing the President’s goals, including the goal to:
HELP THOSE STRUGGLING WITH ADDICTION: President Trump’s Opioid Initiative will help those struggling with addiction through evidence-based treatment and recovery support services.
What are some practical steps?
Right now, the White House education initiative focuses in on prescribing education. So what are some of the ways we can do better?
• Require education of middle school and high school students about the disease of addiction just as we teach them about other health issues. Include their families so they can be educated in recognizing the signs of addiction and knowledgeable about how to seek help.
• Educate the public on the resources available for the treatment of addiction for the sufferers and their loved ones.
• Require addiction medicine instruction in all medical student and resident education curricula, regardless of specialty, including treatment options and available resources and the appropriate strategies to discuss and address addiction.
• Require addiction medicine instruction to all other healthcare workers, including strategies for discussion and addressing addiction with patients.
• During opioid prescribing education, provide training on addiction medicine to practicing medical providers, including treatment options and available resources and the appropriate strategies to discuss and address addiction with patients.
What are some results we can expect?
• If pediatricians know that a patient is at risk for addiction based on family history and the family is educated in addiction, prevention and recognition of the disease can start early. For example, when a teen has his wisdom teeth removed and is at risk for addiction, mitigation strategies can be discussed and the approach to pain control can be re-directed.
• Healthcare providers can address patients with the disease of addiction as they do with other diseases and reduce the stigma.
• Families and loved ones will understand the disease and reduce the stigma.
• The medical and lay community will be aware of resources available for the treatment of addiction and for those loved ones supporting them.
The good news is that we all want the same result. We want to stem the tide of this epidemic that is taking the lives of so many Americans, regardless of demographic. Ultimately, the best result is to save lives and save money.
Leslie Rae Dye, MD, FACMT practices addiction medicine at Northland Intervention Center in Milford, Ohio, and is editor-in-chief of Point of Care Content at Elsevier, where she strives to offer resources that can assist in the diagnosis and treatment of addiction.