Last week, at my home address, I received a letter with a pocket card enclosed, from Vivek H. Murthy, MD, MBA, our current United States Surgeon General in the Obama Administration. The Surgeon General’s position and role is often used to reach citizens about their health and the measures they can take to protect or improve it (among many other responsibilities). But this letter, dated August 2016, was addressed “Dear Colleague.”
True to his salutation, in the most collegial of ways, Dr. Murthy wrote “I am asking for your help to solve an urgent health care crisis facing America...” He was referring to the opioid addiction epidemic that has spread like a terrible virus across our country, affecting people of all colors, socio-economic stations, ages and geographies (from rural communities to small towns to big cities). Deaths from opioid overdoses, which are surely underreported in older people as well as because of the limited capacities of medical examiners in about every city, have quadrupled since 1999. The great increase in the prescription of opioid pain pills (like OxyContin, Vicodin and Percocet) has not only been a tragic route to dependence on this analgesics to relieve physical and mental pain it has also helped to create a resurgence of heroin use when the pills become too expensive or difficult to access. Yet there is no evidence that the collective pain experienced by Americans, at least physical pain, is any greater than it was in 1999.
When the Centers for Disease Control and Prevention (CDC) issued guidelines for opioid prescribing, it was the first time a federal agency so forcefully declared the problem and took action towards its remediation. I covered this release in US News & World Report in an article called “Better Than a War on Drugs.” I wrote that guidelines, like these, are welcome but seldom prove sufficient to change doctors’ practices. Nor are they likely to alter the demand from users already addicted.
Dr. Murthy’s enclosed pocket card was titled “Prescribing Opioids for Chronic Pain,” and was noted to have been adapted from the CDC publication. The card, like the original guidelines, advised doctors (really anyone who can prescribe these medications) about what they could/should do before prescribing, when prescribing, and after initiating treatment with an opioid medication. The Surgeon General’s card made plain that these guidelines were for people over 18 years of age (because too little is known about youth) with chronic pain, and not meant for patients with active cancer, or palliative or end of life care. The counsel the card provided was clear and will be useful if it will find its way into everyday practice, which the Surgeon General was beseeching.
To add to Dr. Murthy’s call for change was a link to “Turn The Tide,” a website where doctors could make a “pledge” to do what is right. I made the pledge – though my clinical work today does not call for the prescription of this category of medications – though many of my colleagues are in a position to adopt its recommendations.
Changing social attitudes and individual reactions towards people with addictions, including alcohol, tobacco and drugs, is one of the great barriers to changing the course of the opioid epidemic. People with substance use disorders and their families face and feel shame. Many doctors and other clinicians feel out of their comfort zone, untrained and unconnected to addiction services, and thus eschew asking patients about addiction, screening for it in practice, and being part of a medical team caring for someone with an addiction. In the article I wrote after Prince’s death, “Painful Shadow of Prince’s Death,” I illustrated how his route to addiction started with the prescription of opioids following hip surgery and then progressed to dependence, coupled with his need to hide this problem ― thus giving him little chance of being saved.
The Surgeon General’s letter called on doctors to be “leaders” in saving lives lost to opioids. He did not say but I am confident he also meant we doctors need to help mitigate the impact of this epidemic on families who are devastated, and communities ravaged by crime and the social costs of untreated addictions.
Drug use, abuse, and dependence are, I believe, one of a handful of major societal issues we face in the 21 Century, along with immigration, terrorism, climate change and poverty (including disparities and injustice). The opioid addiction epidemic can be brought under control ― if responded to with the types of strong public health approaches that achieved great success with TB, polio, HIV/AIDS and many other diseases. Doctors must help but they cannot do it alone. They need to be part of a larger effort involving youth, adults, families, communities, media and government. Complex problems require complex solutions, “teams of teams,” and adequate resources. When that happens we can change the world for the better.
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The opinions expressed herein are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
My new book, Improving Mental Health: Four Secrets in Plain Sight, Foreword by Patrick Kennedy, will be available this November, 2016.
My book for families who have a member with a mental illness is The Family Guide to Mental Health Care (Foreword by Glenn Close) — is now available in paperback.
My website is http://www.askdrlloyd.com
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