JAMA Forum: The Public Health Challenge of Drug Overdose

Joshua M. Sharfstein, MD

Joshua M. Sharfstein, MD

The surge in prescription opioid overdoses is a leading national public health crisis, says the US Centers for Disease Control and Prevention, one with a toll of more than 15 000 deaths in the United States each year. Since 1999, deaths from overdose of prescription opioids have increased 4-fold among US women and by 265% among US men.

As in the fable of the blind men and an elephant, there are many different ways to look at this epidemic—and just as many ideas on how to address it.

Academic experts and the US Food and Drug Administration (FDA) are concerned about inappropriate prescribing practices by physicians and inadequate understanding of medications by patients. The FDA is requiring that companies making long-acting opioids develop a risk evaluation and mitigation strategy, a risk management program that includes physician training, patient counseling, and other measures.

Medical boards hear the cases of physicians who are accused of incompetence, including in the area of pain management. In July 2013, the Federation of State Medical Boards adopted a model policy for state licensing boards, which “makes it clear that a state medical board will consider inappropriate management of pain, particularly chronic pain, to be a departure from accepted best clinical practices.” A substantial percentage of disciplinary  actions against physicians—about 1 of 3 in Maryland—relate to inappropriate prescribing of painkillers.

Law enforcement officials see drug diversion as a crime and physicians (and patients) as potential criminals. The Drug Enforcement Administration maintains a website of all actions against physicians, and raids of suspect practices are becoming increasingly common.

Drug policy experts argue that the disorganized nature of our health care system has exacerbated the problem. They support the adoption of prescription drug monitoring programs to alert physicians to histories of abuse and doctor shopping in real time. In Maryland, we recently launched such a program inside our statewide health information exchange.

Addiction medicine specialists are concerned that millions of individuals in the United States who are addicted to opioids do not have access to effective treatment. Even though therapy with methadone and buprenorphine has been proven effective, insurance coverage for treatment with these medications in both the public and private sector remains spotty. Moreover, in many areas, clinics that provide care for opiate dependence are stigmatized, further undermining access to care.

Moreover, data from medical examiners and directors of vital statistics support the need for interventions that go beyond targeting only prescription drug abuse. They note that in places where measures against prescription opioids gain traction, there is a risk of a switch to cheaper and more accessible heroin.

These examples of perspectives on drug overdose are far from exhaustive. Judges, psychologists, schoolteachers, clergy, family members, and others all have their own unique vantage points and ideas for action. In Maryland, a coalition of parents of children who have died was instrumental in the passage of a law to permit greater use of naloxone to reverse overdoses.

Public health officials support comprehensive action across multiple perspectives on the problem with the clear goal of lowering all overdose deaths. In Maryland, we have asked each county to develop an overdose prevention plan, involving the physician community, drug treatment centers, police, and the community. Key themes in these plans include expanding access to treatment, encouraging naloxone distribution, taking action against clinics and physicians who break the law, and educating the public about the risks of addiction. At a local roundtable attended by Maryland Gov Martin O’Malley, one elected official described her community as the “missing tooth in Maryland’s smile” because of the problem of drug overdose. She pledged to make addressing the crisis a top priority.

Recently, Gov Peter Shumlin of Vermont dedicated his State of the State address to the problem of drug addiction. He stated:

In every corner of our state, heroin and opiate drug addiction threatens us. It threatens the safety that has always blessed our state. It is a crisis bubbling just beneath the surface that may be invisible to many, but is already highly visible to law enforcement, medical personnel, social service and addiction treatment providers, and too many Vermont families. It requires all of us to take action before the quality of life that we cherish so much is compromised.

He pledged to address the challenge “as a public health crisis, providing treatment and support, rather than simply doling out punishment, claiming victory, and moving onto our next conviction.” He proposed major investments in treatment, more attention to drug abuse in the criminal justice system, better coordination in law enforcement, and greater attention to prevention.

With so many perspectives on the challenge of drug overdose, and so many possible solutions, there is no substitute for political leadership that sees the problem in full. On such a complex issue, such vision can set the stage for meaningful progress.

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About the author: Joshua M. Sharfstein, MD, is Secretary of the Maryland Department of Health and Mental Hygiene. He has previously served as the Principal Deputy Commissioner of the US Food and Drug Administration and as Commissioner of Health for Baltimore. A pediatrician, he lives with his family in Baltimore.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



Categories: Public Health, The JAMA Forum

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