The Orphaned Patient: Treating Chronic Pain with Opioids

By Peter Grinspoon, M.D.
February 1, 2018

The commonly cited proverb, “The road to hell is paved with good intentions,” was coined in the twelfth century by a French abbot named Bernard of Clairvaux. In no case is this adage more apt than as applies to chronic pain patients, who have been cut off from their longstanding and stable supplies of opiates by physicians who have been convinced, cajoled, intimidated, mandated, and cowed into no longer prescribing high-dose opiates for chronic pain patients in response to the current opiate epidemic. Continue reading “The Orphaned Patient: Treating Chronic Pain with Opioids”

Clinicians Leading Change in Health Care

By Ted A. James, MD, MHCM
January 25, 2018

“The Only Thing That Is Constant Is Change”
― Heraclitus

The United States health care system has the dubious distinction of ranking last in outcomes and first in cost compared to most other Western countries. Much of this is due to Continue reading “Clinicians Leading Change in Health Care”

The Opioid Crisis and Physician Burnout: A Tale of Two Epidemics

December 14, 2017

[The following post by Steven A. Adelman, MD has been shared with us by Harvard Health Publishing where it originally appeared in June of 2016. In light of increasing pressure on physicians to become part of the solution to the opioid epidemic, we invite you to share your thoughts on physician burnout, and the role it plays, in the comment section after reading this post.]

In April [2016], the U.S. Surgeon General, Dr. Vivek Murthy, attended a meeting of the Association of Health Care Journalists. In an exclusive interview with MedPage Today, he shared his mounting concerns about two matters: the impact of burnout on physicians and our society’s current opioid crisis. Dr. Murthy stated that he views physicians as being an essential part of the solution to the epidemic of drug overdoses, which have exceeded motor vehicle accidents as one of the leading causes of death.

Dr. Murthy correctly linked the well-being of health professionals with that of the general public, stating, “As I think about the emotional well-being for our country, I am particularly interested in how to cultivate emotional well-being for healthcare providers. If healthcare providers aren’t well, it’s hard for them to heal the people for whom they are caring.”

As the director of Physician Health Services (PHS), an independent non-profit dedicated to promoting and supporting the health and well-being of some 45,000 physicians and medical students in Massachusetts, I have witnessed first-hand how stress and burnout among practicing physicians may play a role in the opioid epidemic.

In the past, physician health programs across the country focused on assisting doctors with drinking problems, drug addiction, and mental illness. Although these conditions continue to challenge a subset of practicing physicians, the rising tide in the physician health world is occupational stress, burnout, and an overall failure to thrive, which may be both personal and professional. Indeed, a recent study on physician burnout published in the Mayo Clinic Proceedings demonstrated that more than half of all physicians are experiencing professional burnout. As burnout increases, satisfaction with work-life balance drops. The data indicate that internists and family medicine physicians, those who prescribe the lion’s share of opioids, are particularly beleaguered — and this conforms to my own experience assisting distressed physicians who are failing to thrive.

Many physicians in busy primary care practices feel like they are playing a never-ending game of “Whack-a-Mole.” They answer to a growing cadre of masters: faceless managed-care bureaucrats; managers; IT consultants; quality measurement gurus; and…patients. As time grows scarcer and the rewards leaner, being an excellent physician while managing one’s life outside of the office has become increasingly challenging. Given these pressures and demands coming from so many quarters, some adult primary care physicians may not possess enough time or the requisite emotional fortitude to fully explore non-opioid alternatives when, for example, a patient with chronic lower back pain reports that 80 mg of oxycodone (Oxycontin) per day has allowed him to continue working and providing for his family. Scenarios like this raise the possibility that physician burnout may be playing a role in the opioid epidemic.

Solving the burnout crisis of adult primary care physicians is beyond the scope of this blog post. But until our society and the medical profession begin to address this crisis in a vigorous and meaningful way, our quest to put an end to the opioid epidemic remains daunting.


Register for Free Opioid Use Disorder Education

The Opioid Use Disorder Education Program (OUDEP) is an accredited, free, online medical education program from Harvard Medical School for the identification and management of opioid use disorder. This program is designed for nurses, nurse practitioners, physician assistants, physicians and other healthcare professionals collaborating to treat patients with substance use disorder and offers up to 24 CE/CME credits.


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“Should international medical graduates do research?”

Medical researcher with vials of blood.

Kenneth B. Christopher, MD, SM,
November 29, 2017

Dr. Kenneth Christopher is the associate director of global education at Harvard Medical School and the course director for Introduction to Postgraduate American Medicine, an online course that prepares international medical graduates for careers in the American health system.

Dr. Christopher has written for and about international medical graduates for many years, and has agreed to share some of his blog posts with our Lean Forward audience.

The topic of today’s reblog is whether or not research has any value for international medical graduates seeking careers in the American health care system.

Internal Medicine Residency for IMGs

I get asked the “should I do research” and “where can I do research” question often. From my look at the NRMP data about half of those who match have research which means half do not.

If you are going to do two years of research and delay your application and increase the distance from your year of graduation you better produce something like this. High quality research is difficult and takes a lot of time to produce. You need to join a productive group and bring something to the table. Few IMG applicants who do any research time without previous training (MPH, MSc, PhD) have much to show for it. Performing research to get into residency is not worth the effort. Pursuing research because your passion to become an academic is a laudable act in my opinion.

If you think about it, most successful IMG applicants will match…

View original post 262 more words

Gun Violence as a Public Health Issue

By Ajay K. Singh, MBBS, FRCP, MBA
November 21, 2017

An interesting viewpoint about gun violence was recently advanced by Nicholas Kristof (with Bill Marsh) in the New York Times.

Kristoff argues that a blanket opposition to guns hasn’t worked and that an alternative approach of regulating guns should be considered. He advocates a “public health approach.”

The article cites some staggering facts:

  1. Guns per 100 people—for the US, 88.8; the next closest Switzerland at 44.7; Canada comes in at 30.8 and Japan 0.6.
  2. Murders per 100,000 people—the US 3.0; the next closest Italy at 0.7; Canada comes in at 0.5.
  3. Research on guns: from 1974 through 2012, the NIH funded just three research awards.

The Kristof article makes some sensible recommendations that seem to resonate with Americans. Here are three that caught my eye:

  1. Background Checks—93% of Americans surveyed agree and yet 1 in 5 guns are obtained without one. Nearly 90% of Americans agree that the mentally ill shouldn’t be buying guns.
  2. Safe storage—making sure guns are inaccessible to children and have trigger locks.
  3. Banning under-21-year-olds from purchasing guns—we don’t let them drink, but allowing a teenager to buy a semi-automatic gun seems sensible?

Other ideas that we could consider with a public health approach include taking a systems approach. How can the health system help reduce gun violence?

  • Could the primary care doctor ask patients about gun ownership, and perhaps even counsel them about safe gun use?
  • Does integrating educating patients about safe storage and making sure guns can’t be fired accidentally seem to make a lot of sense?
  • Could research be funded that predicts which individuals are prone to gun violence? Perhaps, high-risk individuals could be screened and then offered help by the health system?
  • Could sensible controls be built-in that, on the one hand preserve privacy, but at the same time regulate access to guns in people with mental illness? Should people with personality disorders or a history of psychotic illness be allowed to buy guns without undergoing some secondary screening? On a related note, merging databases that screen people as a part of a “background check” with databases that record diagnoses around mental health could be developed.

Whether gun violence abates in the US is a complicated question. At one level, solutions are a function of societal trends, politics, and the power of the gun lobby. Still, thinking about novel ways to frame an important problem isn’t a bad idea. Gun violence kills people, and as Kristof suggests, emphasizing and framing it as a public health issue makes sense. Has anything else worked?


Learn more about Health and Health Care Disparities from a panel of HMS experts.


Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

Share your thoughts on solving America’s gun violence crises in the comment section below.

A Primary Care Doctor Delves into the Opioid Epidemic

November 14, 2017

[The following post by Monique Tello, MD, MPH, has been shared with us by Harvard Health Publishing, having originally appeared on their website in February 2017.]

Our nephew Christopher died of a heroin overdose in October 2013. It had started with pain pills and experimentation, and was fueled by deep grief. He was charismatic, lovable, a favorite uncle, and a hero to all the children in his life. His death too young was a huge loss to our family. I have always felt that I didn’t do enough to help prevent it, and perhaps, in a way, even contributed.

Good intentions with unintended consequences

My medical training took me through several big-city hospitals where addiction and its consequences were commonplace. Throughout all of it, great emphasis was placed on recognizing “the fifth vital sign,” i.e., pain, and treating it.

I distinctly remember as a medical student wearing a little pin with the word “PAIN” and a line across it. One was considered a bad doctor if they didn’t ask about and treat pain. And so, treat we did. This medical movement, combined with the mass marketing of OxyContin and a swelling heroin trade, has created the current opioid epidemic.

It generally starts with pain pills: Percocet, Vicodin, Oxycodone or OxyContin, either prescribed or given or bought. Quickly, a person finds that she or he needs more and more of the drug to get the same effect. Almost overnight, they need the drug just to feel normal, to stave off the horror of withdrawal. Street heroin is cheaper and easier to come by than pills, and so, people move on to the next level. Just like Christopher.

Recent data from the Centers for Disease Control (CDC) and the National Institute for Drug Abuse (NIDA) show that deaths from overdose of opioids have been rising every year since 1999. (OxyContin came to market in 1996). Deaths from heroin overdose have recently spiked: a 20% increase from 2014 to 2015. And most recently we’re seeing fentanyl, an extremely potent synthetic opioid, where even a few small grains can kill.

So, if we doctors helped everyone get into this mess, we should help them get out of it, no?

Needed: Treatment that works

As the opioid epidemic has exploded, so has the demand for treatment. But treatment is almost impossible to come by. The U.S. is short almost 1 million treatment slots for opioid addiction treatment. And not all treatments offered are that effective.

The “traditional” treatment of detoxification, followed by referrals to individual therapy or group support (think Narcotics Anonymous), may work well for some, but the data suggest that there are more effective approaches. In fact, a growing body of evidence very strongly supports medication, combined with therapy and group support, as the most effective treatment currently available.

“Detox” followed by therapy has consistently shown poor results, with more than 80% of patients relapsing, compared to treatment with medications, with only 15% relapsing. Medications, specifically methadone and buprenorphine, can help prevent withdrawal symptoms and control cravings, and can help patients to function in society. Suboxone (a combination of the drugs buprenorphine and naloxone) has many advantages over methadone. It not only prevents withdrawal and controls cravings, but also blocks the effects from any illicit drug use, making it more difficult for patients to relapse or overdose. In addition, while methadone can only be prescribed through certified clinics, any primary care provider who completes a training course can prescribe Suboxone. That means treatment for opioid use disorders could be much more widely available.

Basically, treatment with medications, and especially Suboxone, is effective, and safer than anything else we have to offer. Yes, relapses can occur, but far less frequently than with traditional treatment. And death from heroin overdose? Far, far less.

Biases against treating opioid use disorder with medications

Despite their effectiveness, there is stigma associated with treating substance use disorders with medication. I admit that I had my own doubts as well. People say, as I did, “Oh, you’re just replacing one drug with another.” But a lot of hard science has accumulated since 2002, when the FDA approved Suboxone for the treatment of opioid addiction.

Think about it. Is shooting street heroin that’s cut with God knows what, using needles infected with worse, really the same as using a well-studied, safe, and effective daily oral medication? Some may claim “Oh, you’re just creating another addiction.” Would you tell someone with diabetes who depends on insulin that they’re “addicted”? Then why say that to someone with opioid use disorder who depends on Suboxone? This is literally the reasoning that played out in my head as I have learned about treating opioid addiction, or, more correctly stated, opioid use disorder.

Stepping up

I’ve decided that it’s time to do something. There’s a great need for doctors willing and able to treat opioid use disorder. In 2016, surgeon general Vivek Murthy issued a strident call to action to all U.S. healthcare providers, asking them to get involved.

This issue has been on my mind and soul since Christopher’s death, so I started educating myself, and contacted our hospital’s substance use disorders specialist with my motivation and concerns. In the few months since then, I’ve taken the training course to become a licensed prescriber, and am working with the team to begin treating a small group of patients.

In my 16 years of clinical training and practice, I have witnessed all of this firsthand: the blatant, medically rationalized over-prescription of pain meds, the stigma and undertreatment of opioid use disorder, and the unnecessary, premature death of a really good kid. I’m just starting off on this, and I’m still learning, but my hope is to keep another family from experiencing unnecessary loss.


Register for Free Opioid Use Disorder Education

The Opioid Use Disorder Education Program (OUDEP) is an accredited, free, online medical education program from Harvard Medical School for the identification and management of opioid use disorder. This program is designed for nurses, nurse practitioners, physician assistants, physicians and other healthcare professionals collaborating to treat patients with substance use disorder and offers up to 24 CE/CME credits.


Sources

  1. Generally Medicine: Ripped from the family
  2. Generally Medicine: Drugs, Violence, and Tragedy in our Family
  3. Mularski R.A., White-Chu F., Overbay D., Miller L., Asch S.M., Ganzini L. Measuring Pain as the 5th Vital Sign Does Not Improve Quality of Pain Management. Journal of General Internal Medicine, 31 May 2006.
  4. http://www.huffingtonpost.com/kristine-scruggs-md/the-opioid-epidemic-how-d_b_9865680.html
  5. https://www.cdc.gov/drugoverdose/data/statedeaths.html
  6. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
  7. https://www.cdc.gov/drugoverdose/data/heroin.html
  8. Jones, C.M., Campopiano, M., Baldwin, G., and McCance-Katz, E. National and state treatment need and capacity for opioid agonist medication-assisted treatment. American Journal of Public Health, August 2015.
  9. http://www.theatlantic.com/health/archive/2015/10/why-80-percent-of-addicts-cant-get-treatment/410269/
  10. Wakeman S.E. Using Science to Battle Stigma in Addressing the Opioid Epidemic: Opioid Agonist Therapy Saves Lives. American Journal of Medicine, May 2016.
  11. Bart, G. Maintenance medication for opiate addiction: the foundation of recovery. Journal of Addictive Diseases. October 2012.
  12. Connery H.S. Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harvard Review of Psychiatry, March/April 2015.
  13. Mattick, R.P., Breen, C., Kimber, J., and Davoli, M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 6 February 2014,
  14. Mauger S., Fraser R., Gill K. Utilizing buprenorphine-naloxone to treat illicit and prescription-opioid dependence. Neuropsychiatric Disease & Treatment, 7 April 2014.
  15. Colson J., Helm S., Silverman S.M. Office-based opioid dependence treatment. Pain Physician, July 2012.
  16. Schwartz, R.P., Gryczynski, J., O’Grady, K.E. et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. American Journal of Public Health, May 2013
  17. Subutex and Suboxone Approval Letter. U.S. Food and Drug Administration (October 8, 2002). fda.gov.
  18. Murthy V.H. Ending the Opioid Epidemic — A Call to Action. New England Journal of Medicine, 22 December 2016.

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Ending America’s Gun Violence

By Ajay K. Singh, MBBS, FRCP, MBA
November 7, 2017

…it is imperative, now more than ever, that we approach this public health concern in an evidence-based and apolitical manner so as to better understand the complex social, economic, and political factors associated with firearm-related injuries. – Faiz Gani

Gun violence is a leading cause of premature death in the US, killing approximately 30,000 people and causing about 60,000 injuries each year.

In the midst of writing an article about a blog post on gun violence by Faiz Gani, I heard breaking news about 26 people tragically killed in a Texas church.

Senator Chris Murphy (D-Conn) issued a statement after the Texas church mass shooting: “As my colleagues go to sleep tonight, they need to think about whether the political support of the gun industry is worth the blood that flows endlessly onto the floors of American churches, elementary schools, movie theaters, and city streets. Ask yourself—how can you claim that you respect human life while choosing fealty to weapons-makers over support for measures favored by the vast majority of your constituents.”

While the motive for the Texas mass shooting (or for that matter, the tragic mass shooting in Las Vegas) remains elusive, one factor that has been common among some earlier mass shootings is that the perpetrator(s) suffered from mental illness.

Besides the mental instability part of the problem, there is also the economic cost. The post by Faiz Gani in Health Affairs discusses the price of gun violence:

Thousands of individuals incur firearm-related injuries daily, leading to approximately 36,000 deaths each year from a firearm-related injury. The number of nonfatal injuries is estimated to be three times that number…we estimate that the annual financial burden associated with the ED and inpatient care for firearm-related injuries to be $2.8 billion in hospital charges. Taking into account the costs of rehabilitation, repeat admissions, and lost work, the CDC estimates that each year, approximately $46 billion are lost due to firearm-related injuries. This figure is comparable to the $49 billion spent to treat patients with chronic obstructive pulmonary disease, the third leading cause of death in the United States…it is imperative, now more than ever, that we approach this public health concern in an evidence-based and apolitical manner so as to better understand the complex social, economic, and political factors associated with firearm-related injuries.

Setting aside constitutional right issues around gun ownership and the huge and tragic human cost of gun violence, there is the economic cost. Isn’t it worth asking if better access to mental health services to perpetrator(s) would reduce the current rate and extent of mass shootings?

Gani’s post suggests that from a purely economic perspective, the government investing in more mental illness treatment (programs and facilities) might make the difference. Even if mental illness is not formally diagnosed, most of us would agree that this type of mindless, despicable violence has a component of mental instability.

Share your thoughts with Harvard Medical School in the comment section below.

Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.