Bigger than Trump’s 5-point plan for the opioid crisis. A 10-point plan in 2 blogs. Part 1

igger than Trump’s 5-point plan for the opioid crisis – a 10-point plan in 2 blogs. Part 1
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In 2013, I wrote a blog for the Huff on the need to adopt a dual pronged approach of new regulation and improved education to effectively address the opioid epidemic in the USA. I was hopeful. With death rates rocketing and successful law suits being brought against Big Pharma and expanded treatment options like office based buprenorphine coming on line I hoped things would change for the better. They have not. More Americans are dying from opioid overdose than ever before.

In response to soaring death rates the US government without any additional funding has announced a 5-point plan. The points are valid but I doubt they’ll bring about the change that is so desperately needed. When you have a problem of this magnitude, where change will be resisted by so many vested parties (health insurance and pharma, dealing doctors and other interested lobby groups) it’s time nail the elephants in the room and grab the chance to think a little outside the box.

I have thought about the chain of decisions that has led to the current situation and propose interventions at each point. In this first part I will look at possible responses to points 1 to 5. In part 2 I’ll cover 6 to 10.

1. Drug companies make medications which get licensed by the FDA

2. Drug companies advertise drugs

3. Drug companies educate doctors

4. Doctors prescribe drugs and make money

5. Insurance companies make money

6. Patients/people take the medications and some get high

7. Some patients/people get dependent and need more medication

8. Some people other the intended patient take the opioid medications

9. Doctors stop prescribing the medication so patients seek heroin

10. Patients die

1 No more new opioids

The range of opioid pain killers available is the USA is staggering. To provide effective pain relief you do not need an inexhaustible supply of new opioid preparations. You don’t need more super potent opioids. Solution FDA places a 5-year moratorium on the approval of any new opioid analgesic unless it has been developed, evaluated and is only licensed for the treatment of opioid dependence. Make addiction treatment pay better than the peddling of drugs of abuse

2 Advertising

You would not let cocaine dealers advertise on billboards so ban all direct to consumer advertising

3 Education of doctors

Stop or severely curtail industry funded education of doctors on pain management. If Big Pharma wants to help let them donate to a non-tied pooled educational grant run by independent clinical groups. In 2012 80% of medical education was pharma funded. You can’t have groups who want sales to go up educate doctors about what is best for the patient. It’s a conflict of interest. Mind you there is so much conflict of interest in the current presidency that this point seems almost trivial

4 Doctors are dealers

a) Doctors don’t often go out of their way to do harm. Most mean well. But a combination of poor education on assessment and management of pain, historical patient expectation (helped along by pharma’s advertising), perceived normative behaviour among their peers and financial reward, combined with limited punitive consequences mean shifting automatic licensed drug dealing is hard. But you can change it and get outcomes that are preferable to the rise in heroin use that occurred as a consequence of the reflex response of many physicians to accusations of irresponsible prescribing which was to just cut patients off their script. Some possible options are below:

b) Change the norm

Many doctors who prescribe lots of opioids in high prescription areas of the US

probably think they are just being an average prescriber. The chances are that

the worst offenders normalise their behaviour more than less aberrant groups.

Use ‘nudge theory’ and ‘behavioural economics’ to create a regional register of

doctors opioid prescribing showing in confidence where that doctor sits in terms

of opioid prescribing rates (adjusted for population) compared to their peers. This

could help outlier prescribers to recognise the need to change and may help

nudge their excessive prescribing down and maybe seek help on the

management of these patients who have genuine health care needs. It would

also show dodgy doctors that they are being monitored. We all tend to behave a

little better when we know we are being watched, it’s human nature (Trump is a

truly special exception to the rule, he is exceptional!)

c) Prosecute doctors

Most of the opioid medications that people overdose on are prescribed by doctors, although fentanyl and its analogues are challenging that. Doctors are the gateway. We can cause death and disability by irresponsible prescribing. Doctors should first do no harm. Those who prescribe in reckless and inappropriate ways (multiple different opioids, high doses, long term, no review, no risk assessment, no assessment for abuse and dependence) should be challenged and have their license to prescribe reviewed.

d) Limit prescribing until pain management courses are completed

We don’t let people drive big trucks until they pass a special test, so before you can treat pain above certain thresholds of prescribing get on a course.

e) On line support forums to help doctor negotiate challenging patient groups and give them strategies manage pain in other way and where appropriate how to say ‘no’.

f) A single doctor for a single patient with shared prescribing data bases so people can reduce the incidence of availability of doctor shopping (seeking out multiple prescribers)

5 Insurance companies

This huge and immensely profitable and influential industry need to get back to prioritising the health and well-being of patients not shareholders. They need to a code of ethics and practice. They need to change the way they reimburse and support those with chronic pain and increase funded options for other pain interventions and those addressing drug dependence.

If you want us to get better information out to people who use drugs and prescription medications please share your expertise with us by completing the world’s largest drug survey now at https://www.globaldrugsurvey.com/GDS2018

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