Who would argue with the goal of wanting to treat pain adequately? That’s where the opioid crisis started.
Opioids are different from the other addiction crises we have faced over the decades — crack, meth, cocaine and alcohol. Compared to these substances, opioid overdoses are more likely to be fatal. And medical providers, the pharmaceutical industry and our systems are implicated in the causes of the opioid crisis.
We all bought the line, patients and providers alike – we were neglecting our patients if we did not eradicate their pain completely. Many moved from treating acute pain effectively with opioids to using these powerful drugs to treat ongoing chronic pain. Data is sorely lacking for the latter approach.
Prescription opioids are an important treatment option for acute pain and end-of-life pain. However, opioids are a lousy treatment for chronic pain. In the middle of this crisis, we have learned how complex pain is. It includes physical trauma from injuries or surgeries, along with what each person brings, such as cultural trauma, depression, anxiety or fear of pain.
Better alternatives to ongoing opioids include physical therapy, complementary medicine, and non-opioid medications. These, combined with carefully working to lower opioid doses, are very often effective.
What can we do to wrestle this monster to the ground? Our approaches fall into three categories: preventing addiction, responding to emergency overdoses, and treating addiction.
To prevent addiction, we aim to limit initial prescribing of opioids to just enough for the worst, most acute pain. For surgery, sometimes just talking about the patient’s expectations beforehand can reframe the pain from abnormal to an expected part of the healing process.
In Minnesota, we are working with prescribers, first gently, then firmly, to let those who are too loose with opioids know that they are causing harm. Other states could do the same.
We developed Minnesota’s opioid prescribing guidelines in partnership with the medical community. Doctors receive individualized reports allowing them to compare their prescribing practices with those of similar providers. Those who continue to prescribe outside the guidelines get help, then are asked to improve. If the situation warrants, they could lose their ability to serve patients on Medicaid. We are careful to look at unique situations.
These efforts are already working. In Alexandria, Minnesota, a woman who had taken prescription opioids for pain for about 20 years worked with her doctor to reduce her use. After years of feeling hungover, she can now play with her grandchildren and remember what they tell her. Hundreds like her are flipping the script of chronic opioid use.
To help providers, our new Flip the Script outreach program arms health care professionals with the tools and resources to talk with their patients about opioids and pain management.
To protect people who are taking high levels of opioids for chronic pain or who have become addicted to opioids, we want them to stay safe and engaged. All lives have value. It’s essential we ensure the availability of naloxone, the opioid overdose reversal drug, and get it to those who need it. We cannot let judgment about opioid use limit action.
To treat those with substance use disorder, we need to take away the stigma. We need to see it as a disease that can be treated, including with medications.
Access to medication-assisted treatment, provided close to home by local treatment professionals and linked to behavioral health support, is the best way to help millions who suffer from opioid addiction. We are building this capacity in Minnesota and other states. Many providers want to help, and we are supporting them in this new, sometimes difficult work.
The opioid crisis calls for compassion and grit. It won’t always be comfortable — some will be afraid their pain will return. We will fear for the safety of people who relapse during addiction treatment. Still, when we show compassion, those on the edge are more likely to accept the grit. And when our patients, family members and friends return from this very hopeless place, there will be no better reward.
Together, we can flip the script. We can tackle this crisis, support each other and end up with stronger, healthier communities.
Dr. Jeff Schiff is the Minnesota Department of Human Services’ medical director for Medicaid. He leads the state’s Opioid Prescribing Improvement Program, which includes a multi-disciplinary group working to set standards for opioid prescribing in Minnesota, educational resources for doctors to use in communicating with patients about pain and opioids, and reports to providers about how their prescribing compares to their peers.