In my travels as part of my role at the AMA, it is not unusual for my airplane seatmates to discover I am a physician. And shortly thereafter—and just as often—comes a pained plea: “Doctor,” they say, “can you please fix the opioid problem?”
As chair of the AMA Task Force to Reduce Opioid Abuse, I have aimed, with the help of my colleagues, to increase physicians' registration and use of effective prescription drug-monitoring programs; enhance physicians' education on effective, evidence-based prescribing; reduce the stigma of chronic pain and substance-use disorder (SUD); and promote comprehensive assessment and treatment; expand access to naloxone in the community and through co-prescribing; and promote safe storage and disposal of opioids and all medications.
When challenges arise in medicine, we physicians take seriously our responsibility to do better and to help patients live longer, healthier lives. This is a call we reflect upon soberly and are jointly acting upon to save lives in all the big cities and little towns across the country that have felt the impact of the opioid epidemic—places like my home state of West Virginia.
I grew up in the heart of coal country there. West Virginia was blessed with resources, natural and otherwise, in the time of my youth. If you were willing to work hard, a pretty good-paying job was yours for the asking. Families and communities were connected.
Not long after I left college, my hometown’s economy worsened. Jobs vanished. Connections frayed. Many lost hope. And folks started to look for something else to help fill the emptiness left behind. As one woman in West Virginia recently remarked, “We had nothing to do here, so we got high.”
Sadly, she’s right. Deaths related to heroin and other opioids in West Virginia today are more than double the national average. The scars from this epidemic run deeper than we can possibly imagine. As I told an audience of hundreds of medical students, physicians and others at the AMA’s Inspirations in Medicine event in Chicago last week, West Virginia is not alone in this epidemic. The Windy City saw 78 deaths related to heroin or prescription-drug overdoses during one three-day period in 2015.
West Virginia’s neighbor, Ohio, saw almost 2,700 opioid-related deaths in 2015—more than half from heroin overdoses. Someone dies of an opioid or heroin overdose every 15 minutes in the U.S., making every community feel like the epicenter of this crisis.
Yet, when faced with this kind of public health challenge—no matter how distressing or wide-reaching—physicians don’t run away from the challenge, we run towards them.
Opioid-related morbidity and mortality: What every physician should know
In doing so, three simple concepts can guide our thoughts, our approach and our message to policymakers, to patients and our fellow health professionals. A fierce commitment to the principles reflected in three words—honesty, context and evidence—can help us reverse the opioid epidemic and harness the resources required to solve our biggest medical challenges.
Intellectual honesty means acknowledging the opioid epidemic is a complex public health threat with no single root cause. It means recognizing that solutions developed in silos are not enough, that the stigma against those with substance use disorders must be overcome and that people struggling with SUDs deserve treatment, not incarceration. And honesty requires understanding that physicians cannot reverse the opioid epidemic singlehandedly.
We need legislators to make decisions that result in fully funded treatments for SUDs. And we should expect that health insurers and public payers like Medicaid to pay for necessary treatment and eliminate the barriers that can delay care.
Next is context, which is so important when wrestling with any large and complicated issue. We have to examine the social determinants of this epidemic and the complexity of how pain affects each individual. We have to ensure that in our appropriate zeal to solve this issue, we don’t stigmatize patients who live with chronic pain and place barriers to their getting the care they need. And we have to confront the implicit biases that lead to people of color being undertreated for pain.
I have saved the best for last. Evidence is more important now than ever—not just in our research findings regarding approaches to treatment, but also in our broader solutions. Medicine based on reliable evidence has greatly reduced the burden of preventable disease through public health approaches, and we continue to make strides in treating chronic disease and many cancers using evidence.
But as I have said before, we in the health system cannot do it alone. As a society, we should aspire to achieve legislation that is based on evidence and public policy that is based on evidence. At the intersection of public health and public policy, there are many narratives. Some are based on fact, others not. Those that are not often lead to feel-good solutions—solutions that provide only the appearance of progress, while the underlying problems—in all their messy reality requiring multifaceted solutions—grow worse every day.
Honesty. Context. Evidence. They are three vital concepts that, if applied consistently and courageously, should help us turn the tide and carry out our mission as physicians to save lives and improve the public’s health.