How to fight the opioid epidemic

By Michael Von Korff, ScD, senior investigator at Group Health Research Institute The president of the American Medical Association (AMA), Dr. Steven Stack, has called on physicians to act now to combat U.S. deaths from opioids. In a post on the AMA news site, Dr. Stack compares the alarming numbers of opioid-related deaths to the HIV/AIDS epidemic in the late 20th century. Noting that 30,000 people died last year from opioids, Dr. Stack writes, “Each and every one of us must band together to take specific actions that will turn the tide.” Dr. Stack advocates for compassion and wisdom in treating patients with pain, which sometimes means not providing prescription opioids and exploring alternate treatments. The question is: How will we achieve these goals? A specific plan I agree with the urgency of Dr. Stack’s message. In an editorial in this month’s Medical Care, Gary Franklin, MD, MPH, University of Washington School of Public Health research professor, and I provide clear steps for physicians and an AMA task force on best practices for opioid prescribing. To help physicians gain knowledge about the problem and potential solutions, our editorial reviews the evidence on reducing opioid risks. We also offer practical steps to clinicians and clinical policymakers to respond to the opioid epidemic: Caution and consideration: Don’t prescribe opioids for acute pain if they are not needed. If they are, limit the number of pills, fully inform the patient of the risks, and make a time-limited plan for drug use. Reconsider benefits and harms before refilling. Policy change: Revise outdated state policies on opioid prescribing (as Washington state has done). Base policies on evidence that now shows: 1) significant risks of addiction and death from opioids, and 2) no evidence that opioids are effective long-term. Surveillance: Watch trends in opioid prescribing, overdose, and addiction by state and by health plan. Existing databases can help agencies such as the U.S. Food and Drug Administration, the Centers for Disease Control and Prevention, and the National Institute on Drug Abuse reduce opioid overprescribing and determine opioid effects on morbidity and mortality. Monitoring: Talk with patients at every refill visit. Clinicians must check PDMP data and document doses and patient-reported effects on pain and function. They should ask direct, nonjudgmental questions about opioid addiction (e.g., about opioid craving/preoccupation, ability to quit or cut down, loss of control of use, opioid-related harms). Patients will often report problems if asked direct, nonjudgmental questions. Taper: Clinicians should consistently offer gradually reducing dosage to patients using opioids. Good evidence supports tapering as an effective and patient-centered strategy for reducing opioid use or helping patients quit. Care alternatives: Treatment (including medication-assisted therapy such as buprenorphine) is available for addicted patients and should be offered with compassion. Taxing opioid analgesics could pay for making addiction treatment more widely available. To learn more about our plan, check out the full editorial. Gary and I look forward to hearing your response. Michael Von Korff, ScD, is a senior investigator at Group Health Research Institute in Seattle. He has led extensive research on the management and outcomes of chronic pain, depression, and other illnesses in primary care.

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