Opioid Addiction and Patient Care by Dr. Erik Steele
Peter was a patient of mine to whom I prescribed opioids intermittently for several years. I remember to this day how shocked I was to finally discover that he was not only pathologically hooked on opioids, but was so hooked he was stealing money to buy them on the street. Even more shocking to me; a patient I liked and respected, an upstanding member of the community, had been deceiving me.
Well intentioned as I was, I did my part contributing to Peter’s opioid use disorder (OUD), and by extension my part in contributing to Maine’s opioid use disorder epidemic. I was not aware enough that every patient I prescribed opioids to even once had a real risk of developing OUD. I was too easy to convince that every patient’s pain needed eradication, and that opioids were the best tool for doing that. I was intent on reducing the painful suffering of my patients, and too unaware of the suffering that might develop if my pills were used inappropriately. I failed to see that our efforts in healthcare to be more effective treating pain – efforts promoted on a national level by healthcare regulators and pain experts – was ‘opioid-dependent’ itself, and would come back to haunt us all.
For these and other reasons I contributed my small stream of unnecessary opioid pills to thousands of other such streams from physician offices, hospitals, and emergency departments across Maine. Together we created the flood of opioids that has now engulfed us, kills more Mainers each year than car crashes, wreaks OUD-induced havoc in homes and communities, and has made Maine a national showcase for the opioid tsunami.
Having helped make this mess, I now need to help fix it, by starting a different small stream. As I go back into family practice in Maine, I will take my 8 hour course and do other work to be able to prescribe suboxone therapy – one part of Medically Assisted Therapy (MAT) for OUD, and provide treatment for as many as I and my practice can capably manage. I will begin screening for OUD among my patients, and treating or referring those who need help. I will dramatically change my approach to the treatment of pain, avoiding use of opioids wherever possible, weaning patients off opioids wherever I can, and partnering with other healthcare providers and state government in meticulous management of opioid prescribing. That all amounts to a big, challenging pain in my practice, but I don’t think any of us who helped get Maine and its people into this opioid mess can, in good conscience, do anything less.
There is a growing help for those on the challenging front lines of MAT; health systems across Maine have geared up substantial efforts to support their physicians, nurse practitioners, and other caregivers in this work. The Maine Medical Association, Maine Quality Counts, Maine state government, the Maine Health Access Foundation, and many other organizations across the state are contributing educational, financial, legal, organizational, and other support. Some organizations with more expertise and resources are building hubs of advanced OUD management to which smaller practices and organizations can turn for expert consultation and other assistance. We all could do more, we all could do better, but what we are doing means that physicians and others who take on the obligation of providing MAT will feel less alone and more supported than many of them have in the past.
To that can be added the help of knowing that we are helping reduce the suffering of our patients and their families; MAT providers I speak with talk of how challenging this work can be, but also of how rewarding it can be to help turn around the lives being ruined by OUD.
Others must join this effort if they have not already. Every hospital that employs physicians must support those physicians to add to the MAT stream. Every physician who prescribes opioids on a regular basis must do his or her part; at a minimum fastidiously prescribe – and not prescribe – opioids in a responsible manner, screen for OUD and refer those who need it, and follow the state prescribing regulations, etc. Ideally, every primary care practice should develop enough MAT capacity to be able to care for its patients with OUD (and every practice has them) and a few more patients in their communities who do not have access to primary care. Every practice that fails to do that leaves their population of patients who needs MAT to some other practice to provide, potentially overwhelming those practices that step forward.
The people to whom I and others must offer this treatment for OUD are, in fact, us; they are our family members, some of our physician and other caregiver colleagues, our community members, our children’s friends in school, the people who build our bridges and serve us food. They are the ones dying in Maine at the rate of one per day, and the grief their deaths bring is a cry for help to us all.
It took years for Maine to get into this mess, and it will take Maine years to get out of it. But a concerted effort improved and sustained over the long haul will turn back this tide. The scale of the effort needs to increase rapidly – we should be establishing a statewide goal that every community in Maine has adequate MAT access by the end of some finite date – perhaps the end of 2018? The clock is ticking on our efforts, and it is a terrible human clock; every second it ticks tells another story of the misery that OUD brings all it touches, and every 24 hours it tolls the death of another one of us from OUD. We cannot move quickly enough.