The opioid crisis: How did we get here?

Rarely does a day pass without a headline about opioid abuse and addiction. While safeguards like prescription guidelines and alternate pain remedies have been put into place, it’s still estimated that about 90 Americans lose their lives each day due to an opioid overdose.

But how did we get here?
It began innocently enough. Reporting requirements for patient satisfaction led hospitals to begin monitoring pain levels, asking patients to rate their pain on a scale of 1 to 10. The expectation of absolutely no pain was born. Prescriptions drugs like OxyContin, Vicodin and Percocet became the gold standard to pain control. But since pain is subjective, it is also hard to treat. This led to overprescribing opioids drugs that are proven to be easily addictive, particularly to people with a predisposition toward drug dependence. Unfortunately, this persists, as reporting requirements like pain control are tied to value-based care, leading hospitals and physicians to acquiesce to demand to get paid by managed care.

According to The Centers for Disease Control and Prevention (CDC), sales of opioid pain medications quadrupled across the country between 1999 and 2014. And last year, the CDC released new guidelines for physicians to treat pain, citing no medical evidence that opioids combat chronic pain and encouraging physicians to try interventional techniques like medical injections, physical therapy and other proven tactics before resorting to an opioid prescription.

While we are seeing the impact of these recommendations in fewer prescriptions written for opiates, taking out this giant is not likely to happen overnight. As emergency physicians with American Physician Partners, we see opioid overdoses in our EDs every day. We find ourselves in a catch-22 – treating an opiate-addicted patient, knowing that we can prescribe something that will keep the patient from heading back to the street and overdosing on an illegal drug, but acknowledging that this is a stop gap measure at best. The ED is not the place to manage and counsel patients on the dangers of opioid abuse. In our role to combat opioid abuse and addiction, we have two goals. The first is to get patients with chronic pain on a better treatment path and the second is to get patients who are addicted to opiates the help they need to fight and defeat this adversary.

And therein lies another problem: patients who are desperate for treatment are getting caught up in the bureaucracy of managed care, and even if they manage to wade through that red tape, many treatment centers have months-long waiting lists – a testament to the depth of the problem with which we are dealing. Physicians who treat opiate addictions with medication strategies are out there, but they are so overwhelmed there’s no capacity for new patients. Pain management clinics offer some support but their mission does not center around the needs of the addict.

The need for provider education
Another problem we believe has led to lack of treatment options for addicted patients is the lack of education for medical students, residents and fellows on the basics of addiction. Physicians are coming out of training ready to take on the world, only to soon learn that this problem is beyond their understanding. Without solid medical education on both the biological issues that can lead to addiction as well as solid treatment options that work, physicians soon become frustrated at their inability to tackle and defeat addiction in their patients.

That’s one of the reasons we have opened outpatient treatment centers – outside of our responsibilities as emergency physicians – to address, in a safe medical approach the need for more, better treatment options. Our vision is to treat our patients with a combination of medication-assisted treatment and behavioral therapy. We’ve seen great success within our program and our scope of treatment, and we believe wholeheartedly in our approach and its benefit to our patients. And while today, many of our medically underserved areas like rural communities and inner cities are in desperate need for similar programs, we are taking a step in the right direction. Simultaneously, we know that addiction recovery must involve a continuum of care. We ask our patient care colleagues across specialties and spectrums to link arms with us to combat this problem and support these patients through addiction, treatment and long-term recovery.

We’ve realized the medical community helped create this problem. Now, as part of that community, we are setting our sights on solving it.

Tony Briningstool, M.D., is the Senior Vice President and Chief Medical Officer for American Physician Partners, an Emergency Department medical service organization.

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