First Do No Harm: Changing Tactics in the Opioid Epidemic
The California Department of Public Health (CDPH) recently presented CHCF’s Kelly Pfeifer, MD, with the Beverlee A. Myers Award, its highest honor for an individual exhibiting outstanding leadership and accomplishments in public health in California. Pfeifer was recognized for her work leading efforts to address the opioid epidemic, which claims the lives of more than 2,000 Californians each year. This article is adapted from Pfeifer’s remarks at the April 4 award ceremony.
I am humbled and frankly shocked by this award. This honor feels like that moment when the Academy Award for best film is given to a producer, and people are watching on TV and thinking, “But what did that person do? Not any real work, like acting or directing.” To acknowledge all those fighting the opioid epidemic in California would be a very long credit reel: county health officers, addiction providers, law enforcement, nurses, doctors, people in recovery, their families, state agency staff, and more — all coming together to turn this epidemic around.
One of my favorite things about working at the California Health Care Foundation (CHCF) is playing this behind-the-scenes producer role: pulling people together and helping them get the resources they need to combat the opioid epidemic. It is deeply satisfying to see progress accelerating across the state, especially since I spent the first several years of my medical career as part of the opioid problem.
As a family doctor in a semi-rural clinic, I saw many people with chronic pain and prescribed a lot of opioids. I wasn’t alone. The number of opioid prescriptions quadrupled in 15 years. Due to marketing from pharmaceutical companies and a misleading study, most physicians believed that long-term opioid use was effective and safe and that less than 1% of our patients would become addicted. We believed we were relieving suffering.
As the years progressed, I saw people get worse instead of better. I had more than one patient die taking the medications I prescribed. Today we know that the percentage of people becoming addicted when taking opioids for pain is anywhere from 10% to 50%, not 1%. We have learned that pain relief doesn’t last long, and that higher and higher doses are usually needed to get the same effect. With these higher doses often comes hyperalgesia, where people hurt all over — citing constant 9 out of 10 pain levels — as their bodies stop making the chemicals that regulate pain sensation. We now know about the host of medical problems caused by long-acting opioids: sleep apnea, depression, anxiety, sexual dysfunction — and worsened pain. We didn’t know that once you start long-term opioids, your brain changes and it is very, very difficult to stop. Without curtailing prescribing practices, opioid overdose deaths have continued to climb.
It may be hard to imagine how a group of smart and highly educated people like doctors could have been misled by pharmaceutical marketing, and by such (now) obvious untruths.
Unfortunately, changing prescribing practices will take time and effort. As surgeon Atul Gawande pointed out in the New Yorker, some breakthroughs spread like wildfire, and some take a generation to take hold. Take the discovery of ether as surgical anesthesia. Following its first use in Boston in the 1840s, news of its efficacy quickly spread, and within eight months, surgeons were using ether around the world. Compare that to handwashing and sterile surgical techniques. While these practices prevented fatal infections, they took decades to become standard practice. What is the difference?
Quite simply, anesthesia immediately makes life better for both the patient and the surgeon. It is difficult for surgeons to perform an operation on someone who is awake and feeling the knife; patients don’t like it much either. In contrast, handwashing combats something invisible (germs), it is painful for the doctor — carbolic acid was the only option in the 1840s — and only benefits the patient through avoided infections.
As Gawande points out, it is very difficult to get clinicians to change their behavior when the change means more work, more pain, and no immediate benefit. This principle is obvious to anyone who has tried to lose weight. Unfortunately, it has become increasingly apparent that opioids are the worst of both worlds: Overprescribing spread as fast as ether, but reversing the trend looks a lot more like handwashing.
Why did we quadruple our opioid prescribing in 15 years? Simply put: Opioids solved an immediate problem for both patients and doctors. The pills take away pain and suffering almost instantly: Patients feel better, and we health care professionals feel gratified, because diminishing human suffering is one of the reasons we went into this profession. And the suffering caused by opioids? That comes way downstream, far later than a post-surgical infection.
Reversing the opioid crisis, on the other hand, is a much slower process. Changing the medical culture is hard work. We are asking clinicians to change how they treat acute and chronic pain in ways that take more time, more training, without a lot of good alternatives, and without immediate benefit to the patient in front of them. We are telling people with chronic pain to reduce doses of medications they feel they cannot live without and that, as a result, they will feel better and be at lower risk of dying. We are telling people with back pain that they will feel better if they walk and stay out of bed, and that the pills that could make them feel briefly better now will make them worse later. And we are asking the government and the public to turn around longstanding bias that drug-free addiction treatment is always the right path. The data show that for opioid addiction, 60% of people are sober at a year with medication-assisted treatment (MAT), compared to 6% of those using drug-free treatment programs.
The opioid epidemic is a problem that cannot be solved by changing prescribing habits. It is truly a public health epidemic that requires a public health response, and California has led that charge. CDPH director Dr. Karen Smith united more than a dozen state and federal agencies, along with health officers, academia, and community partners, to synchronize efforts, all pointed at the North Star: zero overdose deaths in California and widespread access to effective addiction treatment.
California’s collective impact in this work will be showcased at the National Rx Drug Abuse and Heroin Summit this month in Atlanta. California is leading the country in redesigning addiction treatment for people in Medi-Cal, a model effort now replicated in other states. And, quite uniquely, we can measure our progress in the California opioid overdose surveillance dashboard. You can compare counties over time with rates of opioid prescribing, opioid-related hospitalizations, overdose deaths, and buprenorphine access.
One of the main principles for CHCF is to find what works and then help spread it across the state. Last year we published papers on successful health plan approaches to opioid overprescribing, complementary pain therapies in the safety net, and medication-assisted treatment options for clinics and emergency departments. We are helping 25 community health centers and seven emergency departments start addiction treatment programs, and eight teams of health plans and clinics to build new services for complex patients. We launched Smart Care California — a public/private partnership — to help payers and health plans address overuse, including a focus on the opioid epidemic. This year we’re planning to look at best practices in addiction treatment for pregnant women and people released from jail.
Our biggest point of pride has been the Opioid Safety Coalitions Network. With Marin and San Diego County coalitions as our model, CHCF, CDPH, and Partnership HealthPlan launched the network 18 months ago by supporting local coalitions to make local change. Medical societies, county government, health plans, and other local leaders brought people together who typically don’t talk to each other — doctors and police officers, hospitals and health departments, drug treatment and community health centers — all united to look at data, draft a plan, and implement concrete changes to stop overdose deaths in their communities. There has been so much momentum that more than 35 counties in California now have active opioid safety coalitions.
These are just a few examples of why I accept this award on behalf of the many people across this work who push this cause forward; the credit reel is long and getting longer every day.