From risk reduction to implementation: Addressing the opioid epidemic and continued challenges to our field

In the United States, the opioid epidemic has been characterized by unprecedented increases in prescription and nonmedical pharmaceutical opioid use, heroin and pharmaceutical opioid use disorders, and associated deaths.^1–4 As a result, on a daily basis, practitioners in a wide range of clinical settings are now confronted with the difficulties of managing opioid medications and opioid use disorders, often in conjunction with chronic pain syndromes. Unfortunately, practitioners may not have been taught the skills necessary to integrate risk reduction, addiction assessment, and treatment into routine clinical practice. Further, there is an inadequate number of providers with the inclination and expertise to treat opioid use disorders to meet the current need for treatment.⁵

Practitioners may not gain skills in the prevention and management of opioid use disorders for numerous reasons, starting with their education. For instance, many medical students and residents do not envision addiction medicine as an appealing and rewarding career option. As co-editors, we were both trained in large academic internal medicine residencies. In these residencies, we read the results of elegant and well-powered cardiology trials with acronyms that made us sound knowledgeable when we mentioned them on rounds. These trials had “hard” outcomes that no one doubted were important: death, hospitalization, stroke, myocardial infarction. There were major—and sometimes even competing—guidelines about who should have what treatment, when, and even where. There was research that documented the gaps in care, counted the time from symptom to intervention in minutes, and documented disparities in outcomes so we could strive to deliver care that was better than average. Cardiology and many other medical specialties were respectable, well-paid, and competitive.

In contrast, we recall few discussions in residency about addiction prevention and treatment trials. Bringing up the substance-related issues our patients faced did not provide us the same benefits as noting other medical problems on the wards. It was not clear that treatment for substance use disorders would be effective. The outcomes of interest were often confusing. Unlike on our cardiology rotations, we were not trained on “addiction units” that were striving to achieve well-delineated metrics for high-quality care. There were few role models for a career in addiction medicine and research—although those we had were vital and inspirational.

These experiences have driven us to seek to improve the scholarship regarding identification, assessment, referral to treatment, and management of opioid use disorders and its complications. As co-editors on this special section, “From Education to Implementation: Addressing the Opioid Misuse Epidemic,” we are pleased to collaborate again with the American Academy of Addiction Psychiatry (AAAP) and their Providers' Clinical Support System for Opioid Therapies (PCSS-O) to present the latest research regarding the opioid epidemic. Our previous collaboration with AAAP resulted in a special issue on pharmacotherapies to address opioid misuse and was one of our most popular section.⁶ After a call for submissions in the summer of 2015, over 55 articles were considered for inclusion in the current special section. The accepted articles represent the broad range of scholarship regarding interventions to address the opioid epidemic. The number and breadth of submissions we received demonstrates the extent to which diverse practitioners and researchers are contributing to opioid practice and policy change, are evaluating their efforts, and are eager to disseminate their results. Many articles in this special section address the intersections of policy, practice, science, media, and advocacy. Further, this special section highlights the powerful impact of community-based advocacy and harm reduction on the field. Together, these articles suggest a landscape in rapid evolution, with robust interdisciplinary partnerships well beyond the medical subspecialties.

One example of the progress made is in the expansion of overdose prevention and management programs distributing the opioid antagonist naloxone. When we were medical students and residents, the implementation of overdose prevention and naloxone programs funded by state and US federal agencies was only a dream. Yet Oliva and an interdisciplinary group of researchers—including a prominent legal expert—describe a new large-scale national naloxone distribution program sponsored by the Veterans Administration.⁷ Winstanley and colleagues describe rapid expansion of public health and foundation-funded programs distributing naloxone in Ohio from 2012 to 2014.⁸ Ashrafioun et al. provide results from pre- and post-naloxone training assessments using a knowledge and a confidence instrument.⁹ This article highlights 2 key questions for the widespread implementation of naloxone programs. First, what is the minimal essential knowledge required for effective administration of naloxone by both providers and lay bystanders? Second, is there adequate research in the current era to inform this “essential” knowledge?

The article by Haug and colleagues about provider social media “naloxone” postings raises important questions about the relationship of provider burnout and stigma, as well as whether public social media venues such as Twitter are the appropriate outlets to discuss patient care experiences.¹⁰ There are significant emotional costs associated with the opioid epidemic—for patients, their families and friends, and the practitioners who treat them—costs that are rarely addressed in the scientific literature. These emotional costs include shame, uncertainty, fear, loss, guilt, burnout, and grief. Providers may need other, more private venues in which to interact and share their sometimes difficult experiences caring for people who use opioids.

A second series of articles in our special section focus on risk assessment and mitigation among patients prescribed opioids for pain. Although risk assessment and mitigation strategies are increasingly included in opioid prescribing guidelines, there is a limited evidence base supporting their use.¹¹ The articles in our issue suggest relatively limited uptake in primary care and dentistry practices, as well as differences in the doses of opioids prescribed and monitoring imposed based on racial/ethnic group.^12–14 Together, these articles implicitly raise several provocative questions about the role of bias and race/ethnicity in opioid prescribing and management practice: Have African Americas, Latinos, and Asians been paradoxically “spared” by more “judicious” prescribing? Or, do they suffer from “underprescribing” for pain and disproportionate “monitoring”? Qualitative articles in this special section also challenge and expand widely endorsed approaches to risk mitigation. Starrels and colleagues describe conflicts between risk mitigation approaches (i.e., reduction in dose and monitoring) with human immunodeficiency virus (HIV) management goals (i.e., retention in care).¹⁵ Stumbo and colleagues use qualitative methods to illustrate the ways family members assist patients in opioid medication management.¹⁶ The role of families is a new kind of “risk mitigation” that warrants greater attention.

Despite recent progress on overdose prevention and management of opioid use disorders, we started at a disadvantage and were unprepared for the crisis we now face. Although opioid overdose has been a problem for a long time, the current opioid overdose epidemic in the United States is unparalleled in terms of scope and lives lost.^1,3 As physicians in internal medicine and addiction medicine, our practices have been deeply impacted by this epidemic, and we face significant practice challenges, which have been detailed below.

First, we struggle with the management of both pain and addiction—each one separately and together. For instance, we find that the application of the diagnostic criteria for opioid use disorders does not always resonate with the experiences and complaints of our patients who have started opioids for pain. Our diagnostic dilemmas seem to mirror disciplinary boundaries between pain and addiction, boundaries that drive contentious public discourse on pain, opioids, opioid use disorders, and overdoses and may not serve our patients well. The implicit and explicit assignment of blame for this complex problem to groups of professionals, industries, regulators, and patients is unlikely to help us achieve our mutual goals to reduce deaths while improving quality of life and function.

Second, we struggle with employing paternalistic strategies to reduce harm, strategies that may be inconsistent with patient engagement and shared decision-making. It is not always clear how to apply risk assessment and mitigation strategies in balanced and unbiased ways that do no alienate, disempower, and abandon our patients. The low levels of uptake of the risk mitigation described in articles in this special section¹² may reflect valid concerns among practicing providers and patients. We have particular reservations about the use of criminal sanctions against patients who use opioids (e.g., pregnant women) and the providers who prescribe to them. Opioid use disorder is a complex condition with medical, socioeconomic, and, importantly, legal facets. As we have discussed before, the stigma associated is strengthened by the pejorative language often used in practice when referring to patients with addictive disorders.¹⁷

Third, our young patients tell us heroin is “everywhere.” A defining life event—the death of a friend, family member, or colleague from overdose—is now commonplace. In our medical practices, we see people with opioid use disorders who are young and old, who are pregnant and have small children, who are homeless and isolated, who are supported by loving and attentive families, who have complex medical problems, who are otherwise healthy, and who are in a multigenerational family struggling with opioids. The patients who seek care from us crush every stereotype we can conjure. We worry that the risk of death among our patients is higher among these patients than the risk from many other common conditions we treat in internal medicine: diabetes, hypertension, and even some cancers.

Fourth, our patients with opioid use disorders have chronic, life-threatening, and debilitating conditions with only a small range of effective treatments currently available. For our patients who clearly meet diagnostic criteria for opioid use disorders and want treatment, we worry that their families and partners will tell them not to take the effective pharmacologic treatment we have to offer. At the same time, as physicians, we have little credibility when we cannot provide satisfactory and evidence-based answers to patients' and family members' common and basic questions. As a few examples, here are some questions we have struggled to answer for our patients and their loved ones:

• What is my prognosis?

• What is the risk of dying from my condition in the next year if it is untreated?

• What is the chance of success from each of the treatment options you are recommending?

• I am ready (or I am desperate). What is the best thing to do first to jump-start my treatment? Should I go inpatient? Outpatient? For how long? And then what?

• Is this treatment (or treatment setting, or modality) worth the money?

• Why can't I get this medication from my primary care provider?

• Why do I have to go to a special clinic every day (or every month) for this medication?

• How long do I have to take this medication?

• Will my baby be born sick if I take this medication? Will he or she be taken away from me?

• What is the best way for me to taper off this medication? Won't I be in pain?

• Where will I get my treatment when I turn 26 and am no longer covered on my parents' insurance?

• What happens if I want to take a semester abroad or go back to school? How will I get my medication then?

• How come I did not know about this medication before?

• When will there be a cure?

• Is a cure possible?

• In the meantime, how do I know if I am getting high-quality care for my condition?

Our inability to provide credible, evidence-based, and clear answers to many of these basic questions concerns us. Between us, we have years of training and experience in diverse and geographically dispersed practice settings. We wonder: Do our questions accurately reflect wide and deep gaps in our epidemiologic and outcomes research related to addiction? Or, do they reflect inadequate dissemination of prior findings into our practices? Or, do they reflect inadequate medical training at academically oriented internal medicine programs, issues we would not have experienced in psychiatry training?

Finally, from an editorial perspective, we are concerned about the potential for (mis-)use of research findings, particularly during a crisis. Although we are desperate to avoid more deaths among our friends, patients, and the general public, the implementation of policies to address associations seen in observational data alone should be met with a healthy dose of scrutiny and skepticism. As an interdisciplinary scientific community, we have important research challenges to address in this field: statistical power, patient engagement and centeredness, disclosure of behaviors, recruitment, loss to follow-up, and meaningful and well-specified outcomes. In this spirit, we strongly encourage your comments in the form of letters to the editor and comments on our Twitter account (@substanceabusej) on all the articles in our special section and the perspectives we have shared above.

Acknowledgments

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, Kaiser Permanente, the United States government, or the authors' affiliated institutions. The authors declare that they have no conflicts of interest.

Funding

Funding for this initiative was made possible (in part) by Providers' Clinical Support System for Opioid Therapies (grant no. 5H79TI025595) from the Substance Abuse Mental Health Services Administration (SAMHSA). The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the US government.