Ronald Dunlap, M.D.: Doctor's perspective on opiate abuse
Across Massachusetts, lives are being wasted. State Police have recorded nearly 200 deaths from drug overdoses since November, but the actual number could be even higher, as figures from the largest three cities -- Boston, Worcester, and Springfield -- are not included in the totals.
The commonwealth is not alone. The Centers for Disease Control states that death from drug overdose is now the leading cause of injury-related death in the U.S. While drugs like heroin remain a prime cause of such deaths, CDC’s most recent figures show that most -- 60 percent -- of the more than 38,000 annual drug overdose deaths in the U.S. are related to pharmaceuticals. And of those, 75 percent involved opioids or prescription painkillers.
Thus Governor Patrick’s declaration last month of a public health emergency regarding heroin and opioid addiction was appropriate and welcome. Physicians share the governor’s concern and support his goal of reducing opiate abuse.
His directive that first responders carry Naloxone is something we have long supported. The $20 million commitment for treatment is a good initial response to increase help for addicts. His focus on youth is desirable, with teen prescription drug abuse jumping 33 percent since 2008 according to the Partnership at Drugfree.org.
The governor’s ban on a new form of hydrocodone should be the subject of legitimate discussion about its use and potential impact in clinical practice and its addiction potential. A balance must be achieved so that patients can truly benefit from its ability to control chronic pain. Opioids are important therapies to treat acute pain after trauma or surgery, as well as to manage chronic pain, including end-of-life care.
Those who follow the drug abuse issue point to physicians as part of the problem. We write too many prescriptions, they say, and are too quick to fulfill patient requests for painkillers. Balancing pain management and potential overprescribing is an area of constant physician concern. The treatment of pain is complex and individualized for each patient, and the addictive potential of any medicine that could be harmful gives any caring physician pause. And while some physicians have been found to prescribe painkillers for financial gain, these outliers represent a tiny portion of the physician population and should rightfully pay the consequences for violating ethical and clinical standards.
Physicians are not standing on the sidelines. We have had multiple discussions about solutions to the problem with legislators, patient advocates, and other professionals that prescribe pain medications, as well as with representatives of the Department of Public Health and the Board of Registration in Medicine.
Twenty years ago, the Massachusetts Medical Society helped to establish the Prescription Monitoring Program. We have consistently provided input into the program. It remains the best tool we have to combat prescription drug abuse. An accurate and accessible database can provide data on all prescriptions, including prescriber, dispenser, and patient usage. It can alert regulators to physicians who might be overprescribing or patients who might be "doctor shopping" for controlled substances.
We support the automatic enrollment of all prescribers and dispensers and call on them to participate fully in the program. We also believe improvements to the program, such as establishing real-time information and integrating the program into electronic health records, will enhance monitoring and reduce diversion of drugs.
Other actions should also be considered. As the respected CommonWealth Magazine has noted, no hard data exists on the state’s opiate problem. We need better and updated information. We must learn more about the source of these drugs: How many are stolen, taken from home medicine cabinets, obtained illegally from street dealers or out-of-state sources, or bought on the Internet? Answers to these questions will help target preventive efforts.
Pharmaceutical companies must play a role in assessing any discrepancies between the manufactured supply of medicines and actual patient demand, as their market studies usually include these estimates.
Drug take-back or return measures can be expanded. The Medical Society, for example, has advocated for legislation requiring pharmacies to have a "take back and disposal" policy for unused and expired medications.
We must also recognize the patient’s role. In the final analysis, the drugs are in the patient’s hands, and responsible use, storage, and disposal are absolutely critical. More patient education is a must.
Prescription medications are some of medicine’s best therapies, and yet they’ve become the root of one of today’s biggest public health problems. The governor’s declaration has properly elevated opiate abuse to a public health priority; his call to action should represent just the beginning of a sustained analysis and long-term effort for solutions.
Ronald Dunlap, M.D., a cardiologist in Weymouth, is president of the Massachusetts Medical Society, the statewide association of physicians with more than 24,000 members.
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