August 05, 2018

Medical, dental, legal professions unite, offering multidisciplinary approach to opioid epidemic

“In 2016, over 64,000 people in the U.S. lost their lives to drug overdoses, and 40,000 were attributed to opioids alone,” said Rod Rosenstein, assistant U.S. attorney general, at the ABA Annual Meeting in Chicago. “We should be curing and treating and not facilitating drug use in this country.”

Rosenstein’s comments came a day before leaders of the medical, dental and legal professions formed a panel to discuss “Opioids in America: A Multi-Disciplinary Discussion on Cause, Effect & Solutions,” sponsored by the ABA Criminal Justice Section on Friday.

“The opioid crisis is the product of several factors of the perfect storm that became the perfect storm,” said panelist Dr. Nirav D. Shah, director of the Illinois Department of Public Heath in Chicago.

Shah said the crisis started with the traditional education model of medical schools, where students are taught to aggressively treat pain. Opioids became a favorite of the medical community. “It was a magic bullet for patients as well as physicians,” Shah said.

Some of the fault lies in reimbursement programs and the way health insurers rate and reimburse physicians on how well they manage their patients’ pain. “If you want to change behaviors of doctors, you must change the way you pay them,” Shah said.

The number of opioid prescriptions dispensed by doctors increased from 112 million in 1992 to 236 million in 2016. Shah said what makes it worse is the stigma associated with opioid addiction.

“The opioid crisis is this generation’s HIV crisis in terms of how people have stigmatized the problem. When Earvin ‘Magic’ Johnson came out about his HIV diagnosis, only then did the conversation move from stigmatizing HIV to how to treat and to cure it,” said Shah. “This has yet to happen with the opioid crisis.”

Dr. David M. Dickerson, medical director of pain management services in the Department of Anesthesiology at North Shore University Health System Medical Group, said a new national strategy is in order. “The country needs a pain management strategy because physicians are faced with the broad challenge of moving away from the idea that pain equals pain medicine [opioids].”

“Opioids are not the first drug of choice for pain management. It could be a very low dose of opioid coupled with a non-opioid that begins a patient’s journey toward addiction,” said Dave Preble, senior vice president of the American Dental Association Practice Institute in Chicago.

Preble said the ADA is doing a better job of educating and monitoring the prescribing behavior of dentists, but dentists are still up against a lot of challenges. “Dental professionals want to manage their patients’ pain, while patients expect to receive medication from their dentist to manage their pain. However, this means dentists now must better manage their patients’ expectations.”

Preble said the goal is to help health-care providers understand that if an opioid is needed to manage pain, it can be prescribed in a very small dosage for a limited duration, and combined with a non-opioid such as ibuprofen. This would lower the number of opioids prescribed by dentists.

Shah said that the state of Illinois has implemented several successful programs to address the opioid crisis, including a Prescription Monitoring Program that requires physicians to check before dispensing a prescription for an opioid to patients and to perhaps identify patients who might be doctor-shopping for additional opioid prescriptions.

The state also issues medical letters to physicians showing a comparison of how other physicians who practice near them prescribe opioids to their patients to encourage physicians to better self-manage dispensing prescriptions at a higher rate to their patients.

As doctors and dentists work together to identify ways to manage the prescription of opioids, law enforcement must do its part to address the issue, said Dan Kirk, former assistant state’s attorney in Cook County.

The justice system is overwhelmed prosecuting and defending drug crimes while trying to implement appropriate programs to manage and treat chronic drug abuse with the resources available to courts. “We need to totally revamp the way we prosecute drug crimes in this country related to the opioid crisis. We cannot continue to just treat these prosecutions as mere drug offenses,” Kirk said.

Raúl Ayala, deputy federal public defender in Los Angeles, served as the panel moderator. The program was sponsored by ABA Criminal Justice Section.