Bold Steps to End the Opioid Epidemic – The Physician Contribution to the Solution

Dr. Dennis Dimitri By Dennis M. Dimitri, MD
President, Massachusetts Medical Society

An epidemic of opioid use and the associated overdose deaths has been slowly building across the nation and Massachusetts for the last decade, and has now reached a crisis point. It is affecting nearly every city and town in the Commonwealth. In some communities, the crisis is unprecedented.

State officials estimate that more than 1,000 Massachusetts residents died of opioid overdoses last year – 33% percent more than in 2012, and nearly three times more than in 2000.

A Harvard School of Public Health survey found that nearly 4 in 10 state residents personally know someone who has abused prescription pain medications.

While the total numbers may be startling, we should also remember that each individual overdose death has a human face. Each tragedy has changed a family forever. It has to stop, and the time for action is now.

Physicians must step forward immediately to do everything we can to help bring this devastating problem under control. How can we do this? It starts with education.

According to the Centers for Disease Control and Prevention, more than 80% of people who misuse prescription pain medications are using drugs prescribed to someone else. These drugs are most often obtained from a friend or relative – for free, purchased, or stolen.

This tells me that there are too many doses of opioid medications in circulation. By limiting this supply and ensuring that opioids are available only to patients who truly need them, we can make a big impact on the Commonwealth’s opioid crisis.

That is why the Massachusetts Medical Society is launching a comprehensive campaign to educate prescribers and the public about the safe and responsible prescribing and handling of these medications.

The campaign has three components:

  • Guidelines to help physicians make the right decisions for their patients
  • Free education resources for prescribers to help inform their judgments
  • Storage and disposal information for patients and their families

Prescribing Guidelines

We have reviewed guidelines already developed by many states and medical specialty societies on this topic. There has been a lot of good work done in the area already – it is, after all, a national epidemic. We are recommending this set of guidelines for use by all physicians.

They are not designed to micromanage care, but to provide guidance and information based on evidence that will improve the care of our patients and lessen the risks associated with opioid prescribing. At the same time we recognize that each patient is different, and in all cases, a prescriber’s sound clinical judgment is important. However, we also believe that several principles should govern the exercise of this clinical judgment.

First, the guidelines emphasize that physicians and patients should discuss family and personal histories of substance abuse disorders and behavioral health concerns, before the prescription is written.

Second, patients and physicians are encouraged to mutually develop agreements that outline the expectations and goals of the treatment, along with the conditions for continuing opioid therapy for chronic pain after initial treatment.

Third, there are exceptions for hospitalized patients, those in hospice and palliative care, and for those being treated for cancer. These patients have special circumstances that do not yield readily to hard and fast rules. Their care must be based upon the long held medical principles of relief of suffering.

We’re offering these guidelines with the hope that they will be adopted by physician practices throughout the state. We are also sharing them with the state Board of Registration in Medicine, in the event that the Board will consider incorporating them into its prescribing guidelines for physicians.

You can see the details of our recommendations here.

Prescriber Education

The Massachusetts Medical Society has long been a leader in providing continuing medical education to physicians and other clinicians about pain management. Today, we are announcing that we are making these pain management courses available to all prescribers – for free, until further notice. This includes not only our current suite of courses, but those currently in the pipeline that are due to be released in the coming weeks and months.

The urgent interests of the community are paramount, and we will remove as many barriers to this prescriber education information as possible.

Public Education

An effective first step to reduce non-medical opioid use is through education. Therefore, in an effort to curb the supply of prescription opioids in the community, we are partnering with the Partnership for Drug Free Kids and its Medicine Abuse Project to broadly disseminate information about the safe storage and proper disposal of opioid medications.

Most people are probably unaware that their medicine cabinets are attractive targets for those who would misuse opioids, and that they could be an unwitting supplier. Our education program will provide guidance on how to safely store and secure medications, and how to get rid of them when they are no longer needed.

In early June, our website will host all of these materials. We will make these materials available to anyone, including physicians, who wish to put them in their offices or share them electronically.

There is no more important public health issue today than the opioid epidemic. It is devastating communities, families, men, women, rich and poor, and most tragically, children and adolescents. It has to stop – and we are ready to do our part.

  1. The 1000 overdose deaths in MA are sentinel events of a much larger problem. The root cause of the opioid crisis is a result of the chronic pain epidemic. The reason there is so many opioids in circulation is because physicians want to help the pain & suffering of their patients but have few other options in their “tool box”.

    According to 2011 IOM Pain Report, 20% of adult US population live in moderate-to-severe chronic pain. Unfortunately,this has led to unintended consequences.For example, SAMHSA has estimated that 336,000 seniors are misusing or dependent on prescription pain relievers.

    A comprehensive strategy to stop the pain-opioid epidemic cycle should include development and promotion of safe, effective, non-pharmacological approaches to treat pain that physicians can deliver and get reimbursed.

  2. James Recht says:

    Dr. Starer’s comments could not be more apt or more urgent. I agree that Dr. Dimitri’s and MMS’s attention and concern are to be applauded. But one crucial aspect of this epidemic is missing from Dr. Dimitri’s statement, and addressed only obliquely by Dr. Starer: our responsibility as physicians to treat patients with substance use disorders. Despite the passage more than 15 years ago of federal legislation aimed explicitly at facilitating and normalizing the office-based treatment of opioid-use disorders, the overwhelming majority of physicians still effectively refuse to provide this treatment. The following statement may sound dramatic, but unfortunately, it is a fact: the death count will not slow until more physicians succeed in recognizing their own biases against individuals with substance use disorders. The more that our professional sisters and brothers make personal progress in this area, the more we will find colleagues willing to join us in providing the safe, effective, evidence-based, life-saving treatment that is so desperately indicated here.

  3. I forgot to add my name and credentials at the end of my comments a move:
    Jacquelyn Starer, MD, FACOG, FASAM
    Diplomate, American Board of Addiction Medicine
    President, Massachusetts Society of Addiction Medicine

  4. I applaud Dr. Dimitri and MMS for their attention to the opioid crisis affecting Massachusetts and its citizens.
    The numbers certainly support the concept of too many opioid prescriptions contributing to the supply of opioids available for misuse.
    We must tackle the excess prescribing with extreme caution, however. There is consensus in the addiction medicine physician community that efforts to reduce the availability of prescription opioids and reformulation of certain medications to reduce misuse by crushing and inhaling or injection has shifted the crisis from a prescription drug problem to an marked increase in the use of illicit heroin. Additionally, the heroin today is increasingly potent and mixed with fentanyl in varying degrees of purity and potency, all of which contributes to the increasing mortality we are seeing from opioid addiction.
    The pool of patients now opioid dependent has increased during the 10 -15 years over which the crisis has developed. If physicians now simply attempt to reduce access to prescription opioids, many will turn to the much more dangerous opioids available on the “street”.
    It is critical that physicians identify their opioid dependent patients and seek appropriate consultation and treatment, including dose reduction when possible but also referral to providers who can assess the addiction and initiate treatment with buprenorphine/naloxone products or refer to methadone programs. Evidence show that “detoxification”, or medical assisted withdrawal (MAW) leads to reduced tolerance and increased risk of overdose death with even a single use of opioids after MAW.
    Opioid agonist treatment is shown to be the best way to reduce the risk of death from the deadly disease of opioid addiction. Preconceived notions of successful treatment equaling opioid abstinence must change. Success should include those patients who are stable on opioid agonist treatment, not using or misusing illicit drugs, prescription drugs, or alcohol, and return to function into the community, family, and workplace. We may need to accept that for some or many of these patients, opioid agonist treatment may be a long-term or lifelong treatment.

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