Feature War on Drugs

US surgeon general: doctors have central role in solving opioid epidemic

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j715 (Published 15 February 2017) Cite this as: BMJ 2017;356:j715
  1. Richard Hurley, features and debates editor, The BMJ
  1. rhurley{at}bmj.com

Vivek Murthy, the US surgeon general, has highlighted prescription opioid misuse as a serious public health problem. Richard Hurley spoke to him about what he thinks needs to be done

“If we’re really going to address not just the opiate crisis but addiction in America we need the medical profession to be a key part of the solution,” implores Vivek Murthy, the US surgeon general, when I interview him for The BMJ.

Describing the country’s epidemic of drug addiction as a “crisis” and a “moral test for America,” he calls for “a cultural shift in how we think about addiction.”

Clinicians have an important role, he says, not just in their prescribing practice but also because “they have the ability to reframe how our country thinks about addiction.

“For far too long addiction has been looked at as a character flaw or a moral failing,” he says. “It’s been looked at differently from other illnesses like diabetes and heart disease—with more judgment. Many people with addiction have not felt comfortable coming forward and asking for help.”

America’s addiction epidemic in numbers1

  • 48 million Americans used an illicit drug or misused a prescription medication in 2015

  • More than 20 million US residents have a substance use disorder

  • Associated healthcare, lost productivity, and criminal justice drain more than $400bn (£300bn; €370bn) a year

  • 47 055 people died from drug overdose in 2014, with 28 647 deaths associated with opioids including prescription painkillers and heroin—the most ever recorded

“This is a public health problem that requires a public health solution. We now have evidence based treatment strategies that work,” he says. “The challenge is ensuring that we get these to the people who need them.”

He wants more clinicians to have training to screen for, recognise, and treat substance use disorders because, he says, “Only one in 10 people actually gets treatment. That’s a massive gap that we have to close.”

To this end, in November he published the first surgeon general’s report on alcohol, drugs, and health Facing Addiction in America.1 The surgeon general reports, which reflect key current public health concerns, are highly regarded and have prompted major public health initiatives. The latest report offers evidence based strategies to help healthcare professionals and policy makers and is accessible to the general public.

Prevention programmes

Education about drugs and preventing their use are central to Murthy’s report. “Some of the most effective prevention programmes save up to $64 for every $1 we invest in them,” he says. He also calls for more evidence to be gathered about prevention, treatment, and recovery.

As an internal medicine physician in Boston, Murthy saw the damage that opioid dependency inflicts on patients and their families. And as surgeon general he has seen people affected by substance use disorders in “every community he has been to, all around America.”

Legitimate increased prescribing for untreated pain also led to inadvertent overprescribing of opioid painkillers such as oxycodone, fuelling the epidemic, Murthy confirms. “We urged doctors and nurse practitioners to be more aggressive about treating pain without giving them the tools or the training to do so safely and effectively,” he explains. “And the result is that we had an increase in the treatment of pain that was appropriate but also an increase in inappropriate prescribing."

“We’ve seen the prescription opioid epidemic feed into what has become an even larger heroin epidemic. We’ve seen it contribute to the spread of HIV and hepatitis C through the sharing of needles.” Now, he says, “we are losing thousands and thousands of people each year to prescription opioid and heroin overdoses.”

Pledges for prescribing

In 2016 Murthy wrote to 2.3 million healthcare professionals, including doctors, dentists, and nurse practitioners asking them to pledge to lead efforts to turn the epidemic around and highlighting guidelines for the rational prescribing of opioids (http://turnthetiderx.org).

“Since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly—almost enough for every adult in America to have a bottle of pills,” he wrote.

Murthy also thinks healthcare professionals should be advocating for and speaking up for patients and calling for more investment in treatment and prevention programmes.

“More often than not clinicians are reluctant to step up and make their views known,” he says. “They’re reluctant to meet with policy makers.”

This is not going to get the result Murthy wants: “If we only operate in the clinics, and if we don’t have a larger voice in the public sphere to call for changes to our healthcare system, then we’re not going to be able to help our patients as much as they need.”

Murthy proposes a multisectorial approach, with educators, faith leaders, and law enforcement also helping to shift attitudes.

The pharmaceutical industry also needs to “be much more responsible,” he says. Aggressive marketing of opioid drugs to consumers “did not fully apprise patients or clinicians about the risks,” and Murthy notes the difficulties for clinicians who try to help misinformed patients.

Crime and punishment

But how can stigma surrounding drug dependency be removed while possession of even small amounts of some substances is a crime and punishable? Murthy’s report makes little mention of growing calls, including from The BMJ,2 to consider decriminalisation of “small scale drug possession.” Evidence from Portugal, for example, has indicated that such a move can help reduce harms associated with drug use.3

Murthy points to existing US programmes that circumvent the criminal justice response. “We have more than 3400 drug courts in operation across the United States which serve more than 55 000 people annually, connecting people with addiction who are engaged in non-violent offences, to treatment as an alternative to incarceration,” he explains. “These programmes have reduced drug use, incarceration, and recidivism—and they cost taxpayers less.”

But this is a drop in the ocean, Murthy acknowledges: “One million offenders with substance use disorders pass through the United States criminal justice system each year. So we have more to do.”

He thinks President Trump’s new government will continue support for his approach. “It’s been an issue that Democrats and Republicans very much care about.

“[Drug dependency] affects people of all racial and ethnic groups and certainly people of all political persuasions, and people have seen a great deal of coverage in the media about addiction.”

But repeal of the Affordable Care Act puts 20 million people’s coverage at risk, including for treatment for substance use disorders.

“We have to make sure that we don’t lose ground when it comes to coverage,” says Murthy, but he admits that he is “encouraged” by the bipartisan support he’s received for tackling America’s addiction.

Real people

The humanity of Murthy’s approach is clear: “We can never forget that the faces of substance use disorders are real people. They are a beloved family member, a friend, a colleague, and ourselves,” his report says.

“How we respond to this crisis is a moral test for America. Are we a nation willing to take on an epidemic that is causing great human suffering and economic loss? Are we able to live up to that most fundamental obligation we have as human beings: to care for one another?”

Of doctors, he tells me, “Our role is not just to care for the individual patient but also to care for the entire community. And the more we’re able to embrace that role the more we’re able to advocate for system changes that will serve them and their families.”

The report’s foreword seeks comparisons with the first surgeon general’s report published in 1964 on smoking, which preceded half a century of tobacco control efforts helping US smoking rates plummet from 42% to 16%.3

“I’ll leave it up to history to determine whether our current report has as much impact,” quips Murthy.

Who is the surgeon general?

  • Vice Admiral Vivek H Murthy was confirmed as the 19th surgeon general on 15 December 2014. He has a bachelor’s degree from Harvard and MD and MBA degrees from Yale. He completed residency training in internal medicine at Brigham and Women’s Hospital and Harvard Medical School in Boston before joining the faculty.

  • As “America’s doctor,” the surgeon general’s mission is to communicate scientific information to advance personal and public health. He or she also leads the US Public Health Service Commissioned Corps, 6700 uniformed health officers worldwide

  • The surgeon general is nominated by the president and reports to the assistant secretary for health. Once the nomination is confirmed the term lasts four years.

  • The surgeon general’s reports are landmark scientific publications that highlight urgent public health concerns. The first, in 1964, on smoking, is revered as having prompted a new era of tobacco control

References

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