Last week, the US surgeon general sent me a letter. In fact, Dr. Vivek Murthy sent a letter to every one of the more than 900,000 doctors in the United States, asking us to help end the opioid overdose epidemic that now kills more people each year than traffic accidents. His call for us to commit to “turn the tide” on the epidemic hit home for me, both as a physician and as CEO of the California Health Care Foundation, where we are supporting a multipronged effort to fight opioid addiction in our state of 40 million people.
“We arrived at this place on a path paved with good intentions,” writes Dr. Murthy. I can attest to this, as can my colleague at CHCF, the architect of our opioid safety work, Kelly Pfeifer, MD.
For decades, we clinicians took mandatory classes informing us about the need to regularly assess patients for pain and imploring us not to undertreat pain. Today we know so much more about the biologic processes that cause pain. We also know a great deal more about the neurobiology of addiction and the impact of high-dose, long-term opioid use on the brain’s ability to manage stress, pain, and daily functions. As physicians, we want to help patients suffering from chronic pain. But while the promise of long-term benefit from these opioids rarely materialized, addiction and other opioid-related medical problems often did.
And now we’ve all experienced a wake-up call. Dr. Pfeifer’s came when she got a call from the coroner about a patient who died holding a pill bottle with Dr. Pfeifer’s name on it. Each year more than 2,000 Californians die from opioid overdoses (including heroin). The opioid epidemic touches virtually every element of our communities — from maternity wards and neonatal intensive care units to the criminal justice and child welfare systems, from living rooms to street corners to pharmacies and emergency rooms.
Our approach at CHCF has been both rigorous about the origins of the problem and respectful of patients and affected communities. We are committed to this effort and to working in partnership with clinics, experts, communities on the ground, and as part of statewide working groups that include federal and state agencies — public health, justice, disease control, health care services, drug enforcement, and others. The opioid epidemic is a complex public health challenge requiring a multifaceted response. Its further continuance is also preventable.
The problem starts with overprescribing, so educating providers and changing prescribing practices is central to the solution. We need to address pain management in a safer and more holistic way. We need to ensure naloxone, a life-saving overdose antidote, is more widely available. And we need to help people addicted to opioids gain access to proven, safe medication-assisted treatment that — along with psychosocial interventions — can help them beat addiction.
There is reason for optimism. This year we surveyed dozens of California health plans and published a paper detailing systematic health plan approaches to addressing the epidemic. Three plans in the state have reduced overall opioid prescribing 20% to 50% among providers in their networks and brought down the use of high-dose, high-risk opioids by 10% to 50% in three years.
While the medical establishment can and should change, others affected by the crisis are also critical to eradicating this epidemic. CHCF is supporting 17 local opioid safety coalitions covering 24 counties. These coalitions bring together people from health care, addiction treatment, law enforcement, local government, public health, consumer groups, and families to develop lasting local solutions.
The coalitions are hitting the streets: Clinic workers present safer prescribing guidelines at Rotary Club meetings; action teams create flyers to inform patients about pain management alternatives; family members of overdose victims share their stories with city councils, local pharmacies, and neighbors; and emergency room doctors set up clinics so patients can get started on addiction treatment.
We are starting to see change. More than 120 emergency departments (EDs) across Southern California have adopted safer prescribing guidelines (including every single hospital in San Diego and Los Angeles Counties). Some counties with high prescribing rates have cut opioid prescriptions in half. In a Monterey County hospital, all prescriptions for opioids in the ED include an accompanying prescription for naloxone. Plumas, a small county in the rural north with one of the highest death rates in the state, used to have no prescribers of buprenorphine, an effective addiction treatment. Now it has three, and it is using telehealth to get patients started on treatment. Since launching the RxSafeMarin coalition in 2014, and orchestrating all of these interventions at once, Marin County has seen overdose deaths go down by half.
Because opioid medications can take away suffering, we need to ensure that these medicines are available when people need them, especially in palliative care. But in many cases, there are safer and more effective ways to manage pain and improve function, and we need to make sure these therapies are covered by insurance and are available. The work is under way. Our Pain Care on a New Track: Complementary Therapies in the Safety Net report shows how community health centers have integrated complementary therapies into their practices.
Further, we need to stop criminalizing the disease of addiction. As the surgeon general points out, “opioid addiction is a disease, not a moral failing.” To that end CHCF is supporting a range of addiction treatment research and work, including the rollout of the county-based Drug Medi-Cal Organized Delivery System pilots, which aim to establish a comprehensive continuum of care for all drug and alcohol use disorders, including opioid use disorder.
Dr. Murthy’s message to physicians is powerful — and achievable. “Years from now, I want us to look back and know that, in the face of this new epidemic, our profession stepped up and led the way. I know we can succeed because health care is more than an occupation to us. It is a calling rooted in empathy, science, and service to humanity. These values unite us. They remain our greatest strength.”
It is that strength, of many communities united, that we rely on to sustain the work ahead. Please stay connected, and if you are so moved, join us.
Dr. Sandra R. Hernández is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. She also co-chaired San Francisco’s Universal Healthcare Council, which designed Healthy San Francisco, an innovative health access program for the uninsured.
Sandra is an assistant clinical professor at the University of California, San Francisco, School of Medicine. She practiced at San Francisco General Hospital in the AIDS clinic from 1984 to 2016. She was appointed by Governor Jerry Brown to the Covered California board of directors in February 2018. She currently serves on the Betty Irene Moore School of Nursing Advisory Council at UC Davis and the UC Regents Committee on Health Services. Sandra served on the External Advisory Committee at the Stanford Center for Population Health Sciences in 2016. Sandra is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government.