Surgeon General Call To Action Falls Short

Shame, stigma and criminalization are major obstacles to treatment in addition to cost.

Law-enforcement seizures of illicit fentanyl have soared, changing the face of drug-related deaths and necessitating new public health strategies to meet the evolving threat. The Centers for Disease Control and Prevention (CDC) reported an 80 percent increase nationally in synthetic opioid deaths from 2013 to 2014, an increase that coincides with a 426 percent rise in the number of drugs containing fentanyl seized by law enforcement.

The mortality increase isn’t all linked to fentanyl, but much of it appears to be. Fentanyl, manufactured illicitly, is a growing threat. The United States Drug Enforcement Administration (DEA) was concerned enough to issue a nationwide alert in March 2015, warning fentanyl-laced heroin is associated with a surge in overdose deaths. Illegal channels in China and Mexico are funneling the powerful and deadly drug ― the one responsible for Prince’s death and for jumps in overdose deaths in states like Massachusetts and Ohio ― into the United States from clandestine labs. At the same time, the quantity of prescriptions written for fentanyl and other opioids to treat pain are flat or falling.

As CDC behavioral scientist Matthew Gladden told Statnews.com, to meet the fluctuating threat, the response must also shift: “The markets are changing much faster than we have seen previously,” he was quoted as saying. “We need to know the basics of where are these products, and where do we mount real public health responses, to get ahead of it in states being impacted.”

Yet, rather than warning physicians of the growing illicit market, a new call to action from the U.S. Office of the Surgeon General targets instead the prescribing of opioids for pain. The pocket guide entitled “Turn the Tide: Prescribing Opioids for Chronic Pain” contains some good instructions but, unfortunately, also perpetuates the CDC’s one-size-fits-all dosage limits that may not suit all patients and sets criteria for continued prescribing ― “clinically meaningful” improvement of 30 percent from baseline in pain, pain interference and activity scores ― that appear mostly opinion based and lacking in solid underpinning science. The truth is patients differ in medication requirements due to genetic and other factors, and chronic pain, by its very nature, fluctuates. How could tapering patients from medications that are helping them and which they did not misuse be seen as progression toward societal harm-reduction goals?

In a letter to 2.3 million prescribers that accompanied the pocket guide, Surgeon General Vivek H. Murthy, M.D., writes:

Everywhere I travel, I see communities devastated by opioid overdoses. I meet families too ashamed to seek treatment for addiction. And I will never forget my own patient whose opioid use disorder began with a course of morphine after a routine procedure.

Unquestionably there is a national opioid crisis, and every case of addiction or overdose death is tragic whether it is linked to heroin, illegal fentanyl, or a prescription opioid. However, the path to prevention will be different when misused opioids are illegally produced vs. legally prescribed. If every exposure to an opioid resulted in addiction, just as if every drink of alcohol led to an alcohol-use disorder, no one would be free from the disease of addiction. That is not how the disease of addiction works: exposure is necessary but not sufficient to trigger it. Furthermore, if merely reducing the quantity of prescribed opioids across-the-board also reduced opioid-related overdose deaths, the numbers of the latter should be dropping, but they are not.

These problems are complex and need precisely targeted measures. Commonly prescribed opioids are still associated with more deaths than synthetic opioids. But cutting out or reducing needed medications to patients who are suffering is not a sufficiently targeted response. Making the target too broad could double the harm, not only in denying access to necessary medications, but in failing to acknowledge the shifting sources of the illicit drug threat, causing more people who suffer from addictions to fall through the cracks.

There is another statement in Dr. Murthy’s letter that should be emphasized: “ … we can shape how the rest of the country sees addiction by talking about and treating it as a chronic illness, not a moral failing.” This is quite true. Shame, stigma and criminalization are major obstacles to treatment in addition to cost, and this can be corrected without worsening options for people in pain. Dr. Murthy has rightly recognized a major factor that prevents timely intervention in a disease that can be fatal if not treated.

I would assert the same is true of chronic pain, which when the central nervous system undergoes changes due to pain, can become an illness in itself. It is past time to treat chronic pain as the illness it is, not a moral failing, and that includes not blaming patients for all of society’s problems with opioid misuse, particularly when the evidence indicates otherwise.

Lynn R. Webster, MD, is a past president of the American Academy of Pain Medicine and author of the award winning “The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us.” Visit www.thepainfultruthbook.com.

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