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US Surgeon General writes to all US doctors about opioids

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4723 (Published 31 August 2016) Cite this as: BMJ 2016;354:i4723
  1. Owen Dyer

The Surgeon General of the United States, Vivek Murthy, has written to 2.3 million prescribing healthcare professionals—the first time the government’s chief physician has sought their support to solve a public health crisis—urging them to help tackle America’s problem with opioids.

He wrote, “Everywhere I travel, I see communities devastated by opioid overdoses. I meet families too ashamed to seek treatment for addiction. And I will never forget my own patient whose opioid use disorder began with a course of morphine after a routine procedure.”

Murthy’s letter asked doctors to take a pledge on a website and to follow a set of enclosed prescribing guidelines. He noted that opioid prescriptions had quadrupled since 1999—enough to give every adult in the US their own bottle of pills—but overall reported pain had not declined. Meanwhile, deaths from overdose had overtaken road accidents as the leading cause of accidental death, and heroin use had seen a resurgence, feeding addictions that often began with prescriptions from doctors.

The letter came after a week of grim headlines from opioid blackspots. In Huntington, West Virginia, a city of 49 000 people, 27 overdoses in four hours stretched emergency services to the limit. All misusers survived because of the widespread availability of naloxone, but some needed several doses of the opioid antidote. Cincinnati, in Ohio, saw 178 overdoses in six days, with at least three fatalities.

Similar spikes occurred around the US and were blamed on a new practice of lacing heroin with carfentanil, the most powerful commercial opioid. Carfentanil was the drug released as an aerosol by the Russian military in the 2002 Moscow theatre hostage crisis. It was later linked to the death of 125 hostages.1 In the US, heroin was already routinely laced with carfentanil’s weaker but still potent cousin fentanyl.

In West Virginia, the state hardest hit by opioid misuse, a group of former addicts have brought a class action suit against multiple doctors, pharmacies, and drug wholesalers. They argued that the entire distribution chain conspired to develop a business model based on mass addiction. Several of the doctors named in the case have already been imprisoned or stripped of their license, or have fled the country.

Some of the pharmacies named were closed after federal raids. One pharmacist, James Wooley, who was later imprisoned, ordered three million doses of hydrocodone for his pharmacy in Kermit, a town of 400 people. It was one of several pharmacies known for long lines of cars with out-of-state license plates snaking past its drive-through window.

Six drug wholesalers earlier this year paid $6.7m (£5.1m; €6m) to settle state claims that they flooded West Virginia with opioids, but the biggest chains still contest those allegations. West Virginia law demands that wholesalers report suspicious orders.

Lawyers for the defendants in the class action suit last week failed to stop the case proceeding at the West Virginia Supreme Court after arguing that the plaintiffs caused their own problems through criminally misusing drugs. One of the state’s senators, Democrat Joe Manchin, told the Guardian that he had heard similar arguments from cigarette manufacturers.

Manchin said, “It’s an epidemic because we have a business model for it. Follow the money. Look at the amount of pills they shipped into certain parts of our state. It was a business model.”

But while unethical doctors and pharmacists have grabbed the headlines, research has shown that more addictions grew out of honest attempts to control pain by doctors using lax guidelines and relying on misleading claims from manufacturers.

The Surgeon General’s letter was conciliatory toward this group, saying, “It is important to recognize that we arrived at this place on a path paved with good intentions. Nearly two decades ago, we were encouraged to be more aggressive in treating pain, often without enough training and support to do so safely. This coincided with heavy marketing of opioids to doctors. Many of us were even taught—incorrectly—that opioids were not addictive when prescribed for legitimate pain.”

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