In August of 2016, former surgeon general, Dr. Vivek Murthy wrote in a letter addressed to every doctor in the United States “I am asking for your help to solve an urgent health crisis facing America: the opioid epidemic.” He wrote “First, we will educate ourselves to treat pain safely and effectively.”1 This letter marked the first time America's top doctor had reached out to every physician. Yet, despite all the attention this letter received, little has been done to address one of the largest groups of opioid prescribers in the United States: residents.
As per the Centers for Disease Control and Prevention (CDC), sales of prescription opioids in the US nearly quadrupled from 1999 to 2014. To put this in context, in 2012, providers wrote 259 million prescriptions for opioid pain killers. That number translates into roughly a bottle of pills for every adult in the United States. As the number of opioid prescriptions increased, so did the number of lives lost to painkiller overdoses. In 2015, around 15,000 patients died from prescription pain killers.2 That is more than double the number of people whose death was attributed directly to HIV/AIDS.
Despite what the numbers may suggest, some (doctors included) still argue against any physician contribution to addiction and the opioid crisis we face today. I recently read an article written by a physician who went as far as calling any physician contribution “a myth of guilt.” Most physicians, including myself, have strong opinions in regard to what caused the crisis. Yet, that is not the point of this article. My goal is to unite us all in this fight. At this point, the Titanic is headed straight toward the iceberg and arguing over anything short of a cure is a waste of time that will only translate into higher casualties and an epidemic turning into a pandemic.
Medicaid remains the single largest source of health coverage for patients with substance use disorder (SUD). After Medicaid expansion by the Affordable Care Act (ACA), 1.2 million Americans with SUDs had gained access to health care by 20163 and repealing it today could lead to 2.8 million individuals with SUDs losing some or all of their coverage.4 Now, with the future of ACA in jeopardy and the uncertainty of what will or will not be covered in the current administration's health care bill, relying on such programs to solve the current crisis is quixotic ideal.
As a surgeon who has spent the last 6 years of his life training in the field of general surgery and as a doctor who has written for thousands of opioid pain killers, I can tell you one thing with full certainty: when it comes to the quantity of painkillers needed to control patients’ pain, my education has failed me and in return I may have failed many of my patients (This is not easy to admit). I have spent many sleepless nights learning the mechanistic, cellular, and chemical interactions of opioids. I have been tested on these topics more than I can remember. Yet, my formal training on the number of pills I should prescribe to different patients with different pain tolerances and different diseases is almost NONE.
Dr. Richard Barth and his colleagues at Dartmouth University recently published an article in the journal of Annals of Surgery demonstrating the desperate need for such educational programs. They showed a 53% drop in the number of opioids prescribed by surgeons after a simple educational intervention.5 In 2016, an article titled “Improving Residents’ Safe Opioid Prescribing for Chronic Pain Using an Objective Structured Clinical Examination” was published in the Journal of Graduate Medical Education. The article described an opioid prescribing educational intervention that included a lecture followed by immediate skills practice. The results were not surprising, better education led to better prescribing practices and improved residents’ confidence.6 At this point, the number of such studies are a handful, but the results are promising, and in the world of science, promising data are and should be respected.
The Accreditation Council for Graduate Medical Education's (ACGME) mission is to improve health care by assessing and advancing the quality of resident physicians. They envision a world where trainees become physicians “who place the need of their patients first.” Furthermore, they address patient safety and health care quality as 2 of their 6 areas to improve resident education. The ACGME is one of the few organizations who can implement and mandate a general opioid education program for all accredited residency programs to address this large group of physicians.
Resident fatigue was a major problem, but we recognized it, ACGME formed a task force on Quality Care and Professionalism, they enforced work hour restrictions and mandated educational programs; then things got better. Although a few departments have employed educational curricula such as lectures and guidelines on opioid prescription practices,7,8 the vast majority of residency programs have failed to take action. What we so desperately need today is a task force with the mission to study the available research and to construct and implement data-driven educational programs and guidelines in every hospital that is training our residents for what is to come.
If the ACGME is not to implement such educational programs on a national level, as surgeons, we should take on this challenge on our own and at least do our part toward better prescribing practices. The mission of the American College of Surgeons (ACS) is to improve the care of the surgical patient and to safeguard standards of care in an optimal and ethical practice environment. In the absence of any action from the ACGME, now more than ever, it is time for the College to take this matter in to its own hands and assemble a task force on opioid education to design and implement a yearly educational program for surgical residents across the nation. After all, we are the captains of our own ships.
Imagine Dr. Barth's work on the national scale. Imagine an army of fresh, bright, and young doctors now equipped with the right education to take on this epidemic. If we are sending our residents to the front lines, then we should provide them with the appropriate armor, we owe this to them. The results might not end the opioid crisis, but it will surely be a right step in avoiding the iceberg. I know many physicians share this belief with me and call for implementation of formal opioid education. The time to act was yesterday but today is still not too late.
“I know solving this problem will not be easy. We often struggle to balance reducing our patients’ pain with increasing their risk of opioid addiction, but as clinicians we have the unique power to help end this epidemic. As cynical as times may seem, the public still looks to our profession for hope during difficult moments. This is one of those times” Dr. Murthy wrote in his first and last letter as the surgeon general of the United States.1
1. Murthy VH. Letter from the Surgeon General. [Institution for Health Improvement website]. August 26, 2016. Available at: https://turnthetiderx.org/#
. Accessed November 4, 2017.
2. Frenk SM, Porter KS, Paulozzi LJ. Prescription Opioid Analgesic Use Among Adults: United States, 1999 – 2012. National Center for Health Statistics Data Brief; Atlanta, GA, February 2015.
3. Beronio K, Po R, Skopec L, et al. Affordable Care Act Expands Mental Health and Substance Use Disorder Benefits and Federal Party Protections for 62 Million American [Department of Health and Human Services website]. February 20, 2013. Available at: https://aspe.hhs.gov/report
. Accessed December 6, 2017.
5. Hill MV, Stucke RS, McMahon ML, et al. An educational intervention decreases opioid prescribing after general surgical operations. Ann Surg
6. Alford DP, Carney BL, Brett B, et al. Improving residents’ safe opioid prescribing for chronic pain using an objective structured clinical examination. J Grad Med Educ
7. Howard R, Waljee J, Brummett C, et al. Reduction in opioid prescribing through evidence-based prescribing guidelines. JAMA Surg 2017 [Epub ahead of print].
8. Hill MV, Stucke RS, Billmeier SE, et al. Guideline for discharge opioid prescriptions after inpatient general surgical procedures. J Am Coll Surg 2017 [Epub ahead of print].