There is a great deal of interest in what the authorities and the medical community are doing about the opiate crisis in America. In her presentation as part of the Williamsburg Place Lecture Series, Martha E. Early, Ph.D., assistant professor for family and community medicine at Eastern Virginia Medical School, gave an overview of the ongoing epidemic and how medical professionals and lawmakers are reacting to it.
Dr. Early began by explaining that until recently, medical students did not learn much about addiction during their training. But that is slowly changing now. A typical medical career goes through four years of undergraduate studies, four years of medical school with third year student rotations; followed by three or more years of residency. With all that training, “family medicine is the only program with behavioral health as a significant part of the curriculum,” said Early.
Unlike most other doctors, the primary care physician (PCP) treats patients of all ages from birth to death and often gets to know them well. But while “70–80 percent of people who see a PCP present with psychosocial issues, only about 15 percent of the family medicine curriculum is behavioral,” explained Early. In many places around the country there is a lack of available psychiatrists and PCPs have to fill that gap. They are now working at the frontlines of the opiate crisis.
Between 1991–2013, the number of annual opioid prescriptions increased from 76 to 207 million with corresponding addiction and overdose deaths rates. Opioid related hospitalizations increased 50 percent 2010–15 and one in five seniors filled at least one opioid prescription. How did that happen?
It started with the now infamous one-paragraph letter published in the New England Journal of Medicine in 1980 suggesting a low risk of addiction when opioids were prescribed for chronic pain, even though no evidence for that claim was provided by the correspondents.
In 1995, the FDA approved Oxycontin, produced by Purdue Pharma, which has been owned by the Sackler family since 1952, recounted Dr. Early. Up until then long-acting opiates were only used for terminal cancer patients but Purdue started promoting Oxycontin for all kinds of pain conditions. By 2012, Oxycontin represented 30 percent of the painkiller market in the United States.
Today, more narcotics are prescribed in the United States than in any other country in the world. Dr. Early talked about a peculiar American mindset where people seem unable to handle any kind of pain without powerful meds. Patients show up in her clinic with the expectation to be treated with narcotics for pain. Due to the devastating opioid epidemic, the tide has begun to turn now. The authorities in many states have begun to limit the availability of opioid pain relievers. Physicians are required to undergo more training. Prescriptions are more carefully monitored.
In her own clinic there have been considerable policy changes. Patients no longer receive narcotics on their first visit. If opioids or similar drugs are prescribed, patients have to sign a pain management contract. The state of Virginia has implemented the Prescription Monitoring Program (PMP) which shows every prescription a patient had for the last two years. In order to be able to prescribe a narcotic, Virginia doctors are now required to check the PMP, to prevent doctor shopping and over-prescribing.
In 2016, the Centers for Disease Control and Prevention (CDC) issued new guidelines for prescribing opioid pain relievers. The dangerous pills are no longer supposed to be the first-line or routine therapy for chronic pain. Doctors are now seriously encouraged to do more than just hand out a pill.
Addiction medicine has only been recognized as a medical subspecialty for a few years. But the training for medical students now includes presentations on substance use disorders (SUD) and SBIRT (Screening, Brief Intervention, Referral to Treatment). SBIRT is an innovative, evidence-based approach that aims to catch patients at risk for addiction before they develop a full-blown SUD.
During their rotations medical interns may work in an outpatient facility to learn about medication-assisted treatment (MAT) and levels of care. Or they can spend time in an inpatient facility to learn about detox. Some, for example, come to Williamsburg to work with the medical director of the Farley Center, Dr. Jonathan C. Lee.
Dr. Early also reminded her audience that it is important to remember that opioids aren’t the only addictive substances out there. America also continues to have an alcohol problem. Alcohol is still the third leading cause of preventable deaths in America. According to CDC data, the number of deaths from alcohol, drugs, and suicide in 2017 hit the highest level since data collection began in 1999. The horrendous statistics are also driven by the prevalence of anxiety, depression, and trauma. Dr. Early has seen many patients whose substance abuse and suicidal ideation was triggered by severe trauma.
Therapists need to get to know their patients to find out what works best for them. “Know your resources, and match treatment to the level or need as outlined in the criteria of the American Society of Addiction Medicine,” Dr. Early said to conclude her presentation.