Friday, May 13, 2016

AMA Task Force to Reduce Opioid Abuse

Patients with a substance use disorder need treatment — not stigma


Junkie. Stoner. Crackhead. We’ve all heard these terms, used to describe individuals who struggle with drug addiction. These terms are dismissive and disdainful; they reflect a moral judgment that is a relic of a bygone era when our understanding of addiction was limited, when many thought that addiction was some sort of moral failing and should be a source of shame. We need to change the national discussion. Put simply, individuals with substance use disorders are our patients who need treatment. Mental Health Month — in May — is a good time to remember this important fact — and to ensure we carry the message throughout the year.

Scientific progress has helped us understand addiction — also referred to as substance use disorder — is a chronic disease of the brain. It is a disease that can be treated, successfully. No one chooses to develop this disease. Instead, a combination of genetic and environmental factors — similar to other chronic diseases like diabetes and hypertension — can result in physical changes to the brain’s wiring, which lead to tolerance, cravings, and the characteristic compulsive and destructive behaviors of addiction that are such a large public health burden for our nation.

Every day, 78 Americans die as a result of prescription opioid and heroin overdose, and the rate of heroin-related overdose deaths increased dramatically and claimed 10,574 lives in 2014. In addition to these tragic figures, the nation is seeing an increase in opioid-related exposures and poisonings in children. And there has been a distressing rise in health problems in newborns as a result of women being exposed to opioids during pregnancy (known as “neonatal abstinence syndrome”). Misuse by older adults also has become an increasing concern. The rate of opioid-related hospital admissions has increased significantly over the past two decades across all ages. Because of higher rates of addiction in the “baby boomer” generation, illegal and nonmedical drug use among older adults is expected to increase in the future. The bottom line is that physicians must lead the nation in changing the tide of this epidemic.

The Texas Medical Association and the American Medical Association Task Force to Reduce Opioid Abuse want to ensure that America’s physicians, patients and policymakers take action in three ways:

  1. We must end substance use disorder stigma, increase access to medication-assisted treatment (MAT) for opioid use disorder, and support the expanded use of naloxone — a life-saving medication that can reverse the effects of an opioid-related overdose. People with a substance use disorder deserve to be treated like any other patient with a medical disease, and physicians are helping the nation understand how to do this. That is one reason the Task Force encourages increased education and training for MAT.
  2. We encourage physicians, dentists and other prescribers of controlled substances to register for and use prescription drug monitoring programs (PDMP) — as one tool to identify when a patient may need counseling and treatment for a substance use disorder. The trend among policymakers has been to use PDMPs to identify “doctor shoppers.” While this is important, our point is to understand why a patient is seeking medication from multiple prescribers or dispensers — and to offer a pathway for treatment and recovery. The information in PDMPs can play a helpful role in identifying patients in need of help.
  3. We must do a better job with prevention: Intervene early with teens who start using alcohol and/or marijuana; and encourage safe storage and disposal of drugs and alcohol. Unused medications increase the risk of nonmedical use by adolescents who live in the home, or by their friends. Unused medication also can be ingested by young children who are curious about what is inside the pill container. Educating the public on the importance of storing opioid medications locked and out of the reach of children, and properly disposing opioid medications following the end of use, can encourage these safe practices. 

And physicians should actively screen for and treat accompanying psychiatric disorders in all our patients to ensure that they continue to receive the highest level of care, since these patients might have even greater risk than the general population to misuse opioids. Furthermore, our patients would benefit from more active screening, brief intervention and referral to treatment.

There are additional issues that we must address. Pregnancy should not limit a woman’s access to opioid medications for adequate pain relief. Pregnant women should not be coerced to withdrawal from opioid treatment. And punitive measures taken toward pregnant women, such as criminal prosecution and incarceration, should be eliminated. There are no proven benefits and, in fact, doing so deters pregnant women who use opioids from seeking prenatal care, leading to poor child health outcomes. The threat of punitive measures also can cause pregnant women to withhold critical information about their drug use to their physician. A pregnant woman should have the same freedom as others to openly discuss options with her physician, choose a course of treatment, and be monitored/supported by her physician.

We also need to guard against limiting MAT services. For example, many states have enacted limits on MAT for patients in Medicaid programs, who are incarcerated, or who have “failed” a prior treatment program. Just as an evidence-based treatment policy would not discriminate against a diabetes patient for being low-income, having been arrested, or not adhering with his or her diabetes treatment program, MAT’s proven success should not be limited by these approaches either.

As physicians, we see the harsh reality faced by our patients with a substance use disorder. Stigmatizing patients helps no one. Our goal, as physicians and dentists, is to treat our patients and help them live as fully functional members of society. There are people in recovery at every level of government, the private sector and throughout our towns and communities. That is because treatment works.

Resources that the task force encourages physicians to use include:



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