Brett Giroir, M.D., wasn't on the main stage long during the Family Medicine Experience (FMX). But in the 15 minutes that the HHS assistant secretary for health spent setting the scene for a panel discussion on opioids Oct. 11, Giroir offered a seemingly nonstop, rapid-fire delivery of sobering statistics related to the crisis our nation is facing.
HHS Assistant Secretary for Health Brett Giroir, M.D., addresses family physicians and other attendees during a main-stage presentation on opioids Oct. 11 at the AAFP Family Medicine Experience in New Orleans.
- In the past year, 11.4 million people misused opioids.
- From February 2017 to February 2018, opioid-related overdose deaths increased 6.3 percent.
- Nearly 9 percent of pregnant women used illicit drugs in 2017, up from 4.7 percent in 2015.
- The number of babies born with neonatal abstinence syndrome more than doubled from less than 10,000 in 2008 to nearly 25,000 in 2016.
But not all the news was bad, he said.
- The number of Americans misusing pain relievers declined slightly in 2016 and 2017.
- The number of first-time heroin users fell by more than 50 percent last year.
- Overdose deaths, which had increased steadily throughout 2016 and early 2017, have flattened out since the middle of last year.
"There's nothing to do a victory lap about," Giroir said, "but we are making progress."
HHS released a five-point plan last year to address the opioid epidemic,(www.hhs.gov) along with more than $800 million in grants to support treatment, prevention and recovery programs.
Giroir said family physicians can help in several ways:
- Brett Giroir, M.D., HHS assistant secretary for health, opened a panel discussion on opioids Oct. 11 during the 2018 AAFP Family Medicine Experience in New Orleans.
- Giroir outlined several ways family physicians can help with the opioid crisis, including co-prescribing naloxone for high-risk patients.
- Family physician panelists described their work with patients who have substance abuse disorder.
- Prescribe opioids only when indicated according to CDC and professional society guidelines.
- Co-prescribe naloxone for high-risk patients.
- Provide input to HHS through advisory committees and meetings.
- Screen all patients for substance use disorders.
- Establish connections with local recovery and addiction specialists.
- Obtain a waiver to prescribe buprenorphine.
Giroir said that since January 2017, the number of patients using buprenorphine has increased 21 percent. In the panel discussion that followed his remarks, family physicians with experience prescribing buprenorphine said more of their peers should be offering the medication to patients in need.
Jerry Harrison, M.D., of Haleyville, Ala., quipped that his state was competitive in both football and drugs "because we're No. 1 in hydrocodone use. I'm in a target-rich environment."
Harrison said he obtained a waiver to prescribe buprenorphine in 2003, and he encouraged other family physicians to do the same.
"You have a tool that can give patients their lives back," he said.
Ruth Potee, M.D., of Greenfield, Mass., said that when buprenorphine first became available in 2002, there was an expectation that it would be widely used in primary care because addiction is a chronic condition.
"By 2010, only 2 percent of primary care physicians were prescribing it," she said. "That was a massive failure."
Physicians owe it to patients to prescribe opioid replacement therapy, Potee said, because doctors played a role in creating the crisis by overprescribing pain medications.
"This disease is laid at the feet of those of us with prescription pads and Big Pharma," she said. "We need to be at the forefront of fixing it."
David O'Gurek, M.D., of Philadelphia, said family physicians also can help simply by changing the way they talk about the disease.
Ruth Potee, M.D., of Greenfield, Mass., (left) and David O'Gurek, M.D., of Philadelphia, (center) laugh at a comment by fellow panelist Joyce Troxler, M.D., of Silver City, N.M. The family physicians spoke about buprenorphine Oct. 11 during a main-stage presentation at the Family Medicine Experience in New Orleans.
"Let's talk about 'people with substance abuse disorder,' not 'addicts' and not about whether people are 'clean' or 'dirty,'" said O'Gurek, who is associate professor in the Department of Family and Community Medicine at the Lewis Katz School of Medicine at Temple University in Philadelphia.
Stigma, O'Gurek said, is one of the challenges of overcoming substance abuse disorder. He said buprenorphine can help by giving people more control. For example, he said a patient recently told him that he had seen "the tops of trees." Confused, O'Gurek asked the man to repeat what he said.
"I don't have to walk around with my head down anymore," the patient explained. "I literally saw the tops of trees for the first time in years."
"That is why I'm here," O'Gurek told the audience. "That's why I do this."
Joyce Troxler, M.D., of Silver City, N.M., agreed. She obtained a prescribing waiver when she inherited 25 buprenorphine patients from a physician who left town. She is the only waivered prescriber in a 50-mile radius.
"I'm giving something back to my community, because for the patient who had been in and out of jail, that's not his story anymore," she said.
Troxler said some physicians are reluctant to obtain the waiver and prescribe the medicine, but she noted that it's not that big of a challenge.
"It seems like a lot to take on at first, but family physicians love being the underdog," she observed. "Am I right? This is one way you can get that fix. Get your first patient, and that patient will be your teacher."
One important tip Troxler passed on is that because addiction is considered an impairment, treatment is covered by the Americans With Disabilities Act, and employers cannot discriminate against patients for taking the medication or force them to stop taking it.
Some physicians may be leery of patients who use buprenorphine, thinking they'll demand too much of the physician's time, but O'Gurek pointed out that there are limits on how many patients a physician can prescribe for (30 in the first year with an eventual cap at 275).
"Don't think you have to open a buprenorphine clinic," Harrison said. "These people are already your patients."
O'Gurek said some recovery programs are biased against buprenorphine use because they don't think patients should be taking any opioid-related medications. To help counter that bias, he instead offers patient-run support groups in his practice. Troxler said she also offers group visits and has received positive feedback.
"If no one is doing anything in your community, you get to make it up as you go," she said.
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