Drs. Gawande And Murthy Discuss The Opioid Crisis — And What To Do Now

When Brigham and Women's Hospital surgeon and best-selling author Atul Gawande turns his attention to a health care issue, people take notice.

But last week, during a Brigham-only event, staff packed an auditorium to, in Gawande's words, welcome another doctor "home."

Dr. Vivek Murthy left the Brigham to become the 19th U.S. surgeon general. Two and a half years into his term, Murthy was dismissed by President Trump.

"Little did I know then that I would be one in a long line," Murthy said as the audience laughed. "We joke sometimes that we should have a club."

Before he was fired last April, Murthy made the opioid epidemic a priority, issuing the first report from a surgeon general on addiction, and launching a campaign to end the opioid crisis.

At the Brigham, Gawande and other physicians were reading research that shows just a week-long opioid prescription after surgery means up to 10 percent of patients will still be taking opioids a year later.

"That is how addictive it is, and I had no idea," Gawande said. "I was fueling part of this crisis. We all were, along the way."

Much of the conversation between these two medical leaders was about what to do now.

On prevention, Murthy spelled out clear guidelines: Avoid prescribing opioids and benzodiazepines together, and avoid opioids for acute pain when possible. (Researchers are finding that for some injuries, alternative pain medications are just as good, if not better, than opioids.) If doctors do use opioids for acute pain, following an accident or surgery, for someone who is not used to taking them, doctors should limit an opioid prescription to three days.

"The point being that if you’re on opioids for more than three days," Murthy said, "there’s a much greater chance that you’ll continue to be on it at a year, compared to if you have a shorter prescription. So shorter prescriptions are better. "

For chronic pain, Murthy was blunt: Opioids don't work, don't use them. Murthy has been widely criticized by pain patients on this point -- patients with back pain, for example, who say doctors are refusing to help out of fear of prescribing opioids.

Murthy said he's worried about letting the pendulum swing too far. He's seen signs in emergency rooms that say, "We won't dispense opioids to anyone here." And Murthy notes that Medicare has moved to stop payments for long-term opioid prescriptions. Doctors, he said, should enlist patients' family members to help loved ones taper off opioids, and do so slowly.

"If somebody is on a massive dose of opioids and has been for five years and you cut them off immediately, you are actually putting them at substantial risk," Murthy said.

To move off opioids, Murthy says some chronic pain patients may need help from the same drugs used to treat those addicted to heroin.

Gawande says he's just recently learned how well medication-assisted treatments like methadone and buprenorphine work.

"They produce an 80-percent-plus decrease in drug overdose deaths. Period," Gwande said. "Imagine it’s 1995, we’re at the peak of the HIV/AIDS epidemic, te’ve got a cure that works in 80-plus-percent of people, and we’re debating whether we want to give it to people."

But, as Murthy pointed out, many people don't use these drugs because they are embarrassed to use methadone or go to Suboxone clinics, sometimes the only place where medication-assisted treatment is offered.

Murthy said he saw this during a trip to Tennessee.

"Many of the people who wanted treatment at the few centers Tennessee had were telling me that they felt they couldn't go there because they would be shamed by their neighbors and their community," he said.

Murthy says it isn't just doctors who must change the way they do business. He said companies should be funding treatment and possibly face tougher penalties as well.

"Many of the fines that we levy on pharmaceutical companies, we think they’re big, but they are a small fraction of even their marketing budgets," Murthy said. "So for many of them, these fines are just the cost of doing business."

These days hospitals are full of patients with injuries and infections that are the result of the opioid crisis. Gawande mentioned a unit at the Brigham.

"Right now, up in [the Shapiro building]," he said, "we have more patients who are here for cardiac valve surgery for endocarditis related to drug use than we have people here who are here for CABGs [a heart procedure that bypasses narrowed or blocked arteries]. That is how bad it is, in our own community."

Gawande asked Murthy why the opioid epidemic is particularly bad in certain areas of the United States. Gawande's home state, Ohio, has among the highest overdose death rates in the U.S., just a bit higher than Massachusetts'. Ohio, he noted, has high rates of unemployment, heart disease, gun violence, alcohol misuse and opioid addiction. Massachusetts, on the other hand, has better marriage rates, better education and fewer problems with gun violence. (Massachusetts does have high rates of heart disease.)

"Why is it so bad here, any idea?" Gawande asked.

"The short answer is no, this has been a vexing problem to figure out," Murthy said. The hot spots, he said, are not uniformly low income and drug trafficking patterns don't seem to explain differences or similarities between states.

Whatever the cause, most people agree the long-term solution is prevention. But here, there are mixed messages to young people. Some politicians are reviving the "just say no" to drugs campaign. But Murthy says the programs with the best record of success use a completely different approach.

"They are not beating kids over the head and telling them drugs are bad," Murthy said. "In some cases, they’re actually not talking about drugs at all. What they’re actually doing is equipping students with tools to identify, regulate and manage their own emotions."

It's a critical piece of prevention, says Murthy, because emotional pain drives many first time and continuing opioid users.

Gawande closed the conversation with a short question for Murthy: What’s next?

Murthy said he isn’t sure. He’s doing some writing and thinking about starting an institute that would focus on improving emotional well-being in the U.S. and around the world.

"I want us to build a world that is less governed by fear and that is more driven by the opposite of fear, which is love," Murthy said.

It's our fear, Murthy added later, that "prevents us from coming together effectively to address our greatest challenges -- including the opioid epidemic."