Update on opioids

Here is an open letter from Dr. Steven Stack, President of the AMA, to physicians and the public that recently appeared in the Huffington Post (http://huffingtonpost.com/steven-j-stack). My short comment follows:

Steven J. Stack Emergency physician and the 170th president of the American Medical Association

The medical profession must play a lead role in reversing the opioid epidemic that, far too often, has started from a prescription pad.

For the past 20 years, public policies — well-intended but now known to be flawed — compelled doctors to treat pain more aggressively for the comfort of our patients. But today’s crisis plainly tells us we must be much more cautious with how we prescribe opioids.

At present, nearly 2 million Americans — people across the economic spectrum, in small towns and big cities — suffer from an opioid use disorder. As a result, tens of thousands of Americans are dying every year and more still will die because of a tragic resurgence in the use of heroin.

As a profession that places patient well-being as our highest priority, we must accept responsibility to re-examine prescribing practices. We must begin by preventing our patients from becoming addicted to opioids in the first place. We must work with federal and private health insurers to enable access to multi-disciplinary treatment programs for patients with pain and expand access for medication-assisted treatment for those with opioid use disorders. We must do these things with compassion and attention to the needs of our patients despite conflicting public policies that continue to assert unreasonable expectations for pain control.

As a practicing emergency physician and AMA President, I call on all physicians to take the following steps – immediately – to reverse the nation’s opioid overdose and death epidemic:

  • AVOID initiating opioids for new patients with chronic non-cancer pain unless the expected benefits are anticipated to outweigh the risks. Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred.
  • LIMIT the amount of opioids prescribed for post-operative care and acutely-injured patients. Physicians should prescribe the lowest effective dose for the shortest possible duration for pain severe enough to require opioids, being careful not to prescribe merely for the possible convenience of prescriber or patient. Physician professional judgment and discretion is important in this determination.
  • REGISTER for and USE your state Prescription Drug Monitoring Program (PDMP) to assist in the care of patients when considering the use of any controlled substances.
  • REDUCE stigma to enable effective and compassionate care.
  • WORK compassionately to reduce opioid exposure in patients who are already on chronic opioid therapy when risks exceed benefits.
  • IDENTIFY and ASSIST patients with opioid use disorder in obtaining evidence-based treatment.
  • CO-PRESCRIBE naloxone to patients who are at risk for overdose.

As physicians, we are on the front lines of an opioid epidemic that is crippling communities across the country. We must accept and embrace our professional responsibility to treat our patients’ pain without worsening the current crisis. These are actions we must take as physicians individually and collectively to do our part to end this epidemic.



Bob Clare ·

University of Pittsburgh

Blamed for not prescribing, blamed for prescribing. Every physician I know is already doing everything Dr Stack recommends in his open letter. Although well intentioned, it fails to address the root cause. This “epidemic” is the result of “do-gooder” policies gone bad. To address this means disincentivizing physicians from their current practices. A good first step would be the abandonment of the “1 to 10” pain score at triage in the nation’s ERs, This is not a “vital sign” and was never intended for use outside of research settings. Next, remove the question regarding how well pain was controlled form HCAHPS. Third, remove questions of how well a patient’s pain is controlled from Press-Ganey scores. Physicians have been browbeaten for more than 2 decades to prescribe more and more opioids. When simple scolding failed, hospital reimbursement and physician jobs were placed at risk for those failing to comply. This epidemic was entirely predictable. Opioid seekers take up an inordinate amount of my day, every day. Assure me that I won’t be fired for turning away that drug seeker, no matter how bad my Press-Ganey score, and I’ll be happy to stop prescribing opioids for trivial pain complaints. Physicians, and especially emergency physicians, are keenly aware of our patients’ pain–we do everything we can to relieve it responsibly. I resented then being told that I was ignoring my patients’ pain but not nearly as much as I resent now also being told that I am to blame for the nation’s opioid epidemic. Saw a heroin OD death yesterday and intubated a multidrug OD last week. This issue will not go away until physicians are provided assurances that addressing their patients “needs” rather than their “wants” will not garner censure, peer review, loss of revenue, or loss of employment. Simply telling physicians to “do better” isn’t going to cut it.


One thought on “Update on opioids

  1. You know, this is very interesting. A lot of good points have been made in this blog and anyone with any common sense would agree. However; when it comes to patient satisfaction scores and viewing healthcare as a customer oriented business, it seems that this could create a little problem. As you know Dr. Clare, you are damned if you do and damned if you don’t. You will be placed on the naughty list by the “leaders” if you prescribe too many narcotics and in the same sentence you will be reprimanded on how you withheld pain medicine to someone “in need” and that this dropped the patient satisfaction scores to an all time low. At least in my experience this seems to be the case. You just cannot win.

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