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I applaud the work of Gov. Charlie Baker and his Opioid Working Group in making bold moves to address the worsening epidemic, but I was alarmed by how physicians were portrayed during a recent panel on the crisis, in which Baker participated.
During the panel, physicians were portrayed both as over-prescribers of pain medications and defensive opponents to the governor’s efforts to address the opioid crisis.
Baker has talked in the past about doctors and hospitals as partners in this fight while saying he’s surprised by the cavalier attitude he hears from many physicians about their pain prescribing practices.
However, at this forum physicians were repeatedly cited for frivolous dispensing of pain medication, with no attention paid to the difficulties of balancing adequate pain control with the risk of addiction, and physicians groups were raised as some of the predominant opponents to the governor's legislation.
As a medical student, I beg to disagree.
Doctors are critical allies in halting the opioid epidemic. I would caution the governor to avoid dismissing physicians’ objections to his proposals as defensive attempts to resist oversight. I work with many doctors and medical students who feel hampered by systemic barriers to better addressing substance use disorders in our practice. Instead of calling them out, I urge the governor to call physicians groups in to the fight.
The opioid epidemic is rooted in more than overzealous prescribers. Profiteering by pharmaceutical companies, systematic failures of the FDA, widespread barriers to medical and mental health care and the poverty that so many in our population face all have important roles in the story.
And providers have a unique perspective on ways that new policies such as 72-hour limits on opioid prescriptions or involuntary commitment for people with addiction might actually challenge their ability to provide effective care to patients with addiction. Here's the president of the Massachusetts Medical Society, Dr. Dennis Dimitri, detailing that perspective.
There is a dearth of acute, transitional and long-term treatment options for people with substance use disorders. If we cannot find treatment for patients who are seeking help, how are we going to help those we involuntarily commit to treatment?
Here are some specific problems I've seen:
-- If patients seeking treatment are admitted for psychiatric diagnoses, sometimes because no substance treatment beds are available, it is nearly impossible to discharge them into a treatment program as they are now considered "high risk."
-- In Cambridge, resources such as detox and partial hospitalization programs have been eliminated in the past decade due to decreased reimbursement for these services from the state.
-- Many inpatient and transitional programs do not currently start patients on maintenance regimens. This means patients have to stay clean long enough to establish outpatient care at a maintenance treatment program.
-- There is no effective system to help patients locate maintenance providers. Patients must rely on word of mouth, or navigate an incomplete and inefficient database, calling individual providers to ask if they are accepting patients.
Withdrawing can be accompanied by agitation, and treating willing patients for detoxification is already challenging for medical teams. We must ask ourselves, in what setting are we detaining patients against their will, administering medication against their will or dealing with the potential agitation that would accompany their withdrawal?
Acute detox is only one part of the picture, and the question of continuing therapy continues to be neglected in policy discussions. Maintenance therapy consists of medication that works to prevent cravings in recovering patients, and some medications can also limit the effect of opiates if a patient relapses.
Suboxone is an excellent maintenance therapy, but access to this medication is severely lacking because physicians must obtain a special license to prescribe it; they are limited in the number of patients they can treat, and there is little or no support or incentive for practices to support prescribing. Without this important piece of the puzzle, our capacity to support full and enduring recovery is limited. Before we draw more people into treatment involuntarily, we need to do better at creating a continuum of care for patients.
Finally, the governor called out physicians groups for opposing his initiative to limit first-time opiate prescriptions to a 72-hour supply. Even amidst an opioid epidemic, we still under-treat pain, particularly in underserved patients. These are the same patients who might not be able to afford the extra co-pays that a 72-hour rule would create, or who might not be able to miss work to get to a follow-up appointment. These are the patients that are likely to return to the emergency department when their pain persists. We should hear in physicians’ resistance to a 72-hour policy the barriers to care that this rule could exacerbate.
We must be bold and imaginative to address the growing opioid epidemic in our state. Baker is right that increased education on both pain management and substance use treatment is critical. I would argue that education and incentives present more opportunity than regulation and restrictions.
As ground-level professionals, physicians are uniquely placed to understand the impacts of regulations on patients. Given the current limitations in equal access to treatment for substance use and for medical care, physicians have reason to be wary of policy that seeks to force people into treatment that can’t fully meet their needs, or curtail their access to medications they may need.
Rather than casting physicians groups as a public scapegoat, I urge Gov. Baker to foster public trust in physicians as allies in the fight against opioid misuse, and help give us the tools we need for the fight.
Anne-Marie Williams is a third-year medical student at Harvard Medical School, and a member of Med Students for Long Island, an advocacy group dedicated to improving care for patients with substance use disorders in Massachusetts.
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