FIRST, DO NO HARM
GUILFORD- Most people agree that opiate and heroin addiction is creating big problems in our society. What they don't always agree on is how to deal with those problems. There is increasing pressure in states, as well as in Washington, to pass legislation to try to solve addiction problems.
Some of the legislative fixes to addiction that I have heard indicate that lawmakers are too far removed from the problems related to addiction to make enough meaningful contributions to solutions. One example is the notion that laws should exist to set limits on prescribing of opiates.
That is a very slippery slope because it could result in denying humane treatment to people who legitimately need opiates for pain control. A debate has long simmered over the use of opiates for chronic versus acute pain as well as cancer pain. This should not be a political debate but should be a matter for scientific investigation and the development of clinical protocols.
In a January 28 piece in the New England Journal of Medicine Dr. Daniel Alford presents a cogent analysis of the opioid addiction problem. "Groups lobbying against prescribing opioids for chronic pain remind us that the effectiveness of long-term opioid therapy has been inadequately studied. I believe that this is a case of absence of evidence rather than evidence of absence. As we await scientific evidence, questions remain regarding how best to address the epidemic of prescription-opioid misuse now. Groups advocating quick fixes believe that regulations that limit opioid availability are the best plan. This strategy is well intentioned and will certainly reduce opioid prescribing, but such blunt approaches will also limit access to opioids for patients who are benefiting or may potentially benefit from them."
Many reasonable approaches are being implemented locally and around the country. Groups of prescribers at Brattleboro Memorial Hospital, as well as throughout Vermont, have been developing practical protocols and they are making excellent progress, but they know that no matter what they do it will take time before results are seen. It took a long time to create this problem and solutions will have to evolve over time.
The Brattleboro Police Department is working with a variety of community groups to address addiction related problems and that group is making it clear that problems can be solved on the local level with common sense, hard work and a long-term commitment.
What we don't need is politicians coming in to save the day and looking to make headlines and capture votes. The best that politicians can do to help deal with this crisis is to make more money available for treatment programs.
Vermont has been on the leading edge of a treatment-based approach (as opposed to punishment) with its Hub and Spoke intensive case management program, but it needs more funding and it needs more capacity. Vermont legislators have come up with sensible approaches such as diverting certain drug abusers into treatment instead of into prisons.
Dr. Alford notes that, "Many guidelines for safe opioid prescribing exist, and all include similar recommendations, including use of assessments of risk of opioid misuse, signed agreements that include informed consent, and monitoring strategies such as drug testing, pill counts, and prescription-drug–monitoring programs. But it's also essential for safe-opioid-prescribing education to include teaching of effective communication skills. How does one explain to a patient who's desperate for help that an opioid treatment must be discontinued despite the lack of alternative treatments? How does one deal with a new patient who is already taking high-dose opioids and insists that it's the only treatment that helps?"
Brattleboro prescribers have instituted most of the measures that Alford calls for. The state of Vermont has a prescription monitoring program that provides access to prescribers who can determine who has been prescribed controlled substances and other states have similar databases. Hopefully, they will all start sharing that information.
Health care professionals and thoughtful community leaders have been working on solutions to the opiate and heroin addiction epidemic. In light of the most recent political suggestions, it would seem prudent for politicians to step back for a time and talk to people on the front lines.
Opiate abuse is one area where the people who deal with this problem on a daily basis are way ahead of the politicians in terms of understanding and developing solutions. We are on the right track in Vermont and others states are also looking at the same types of solutions.
We need to support all of those efforts because if politicians start passing quick fix legislation we could end up punishing those who need opiates to manage pain and turning them into social pariahs. It is up to health care professionals to make sure that does not happen.
First, do no harm.