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Response to Letter from the Surgeon General

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Reprinted with the kind permission
of the PAINS Project
In late August, Surgeon General Vivek Murthy, MD wrote to 2.3 million physicians asking for their help in solving the opioid epidemic. By doing so Dr. Murthy joined a distinguished list of Surgeon Generals who have spoken out about critical public health issues. Some of America’s “top docs” who stand out in my mind are Luther Terry who in 1964 spoke about the dangers of tobacco; C. Everett Koop who in 1988 helped America understand the AIDS epidemic and quieted some of the panic that was surrounding it at that time; and David Satcher who in 2000 drew much needed attention to mental illness in the U.S. Let us hope that Dr. Murthy’s letter and his “Turn the Tide Campaign” will have the positive effect that those I’ve mentioned had on the health and well-being of our society.
Without question, physicians and others who prescribe opioids need better education about the safe use of opioids. They also need tools and resources to help them do a better job of treating pain. I completely agree with Dr. Murthy that substance use disorder/opioid addiction “is a chronic illness, not a moral failing.”  I believe the very same statement is true about chronic pain — another public health epidemic which is not mentioned in the Surgeon General’s letter other than to suggest that efforts by physicians to improve pain care have caused the opioid epidemic.
There are no data to substantiate this claim. Nor is there data to inform policy makers and other advocates about the rate of iatrogenic addiction, i.e., addiction that results from medication prescribed for legitimate medical reasons, although various rates are being pitched about irresponsibly in my opinion. Furthermore, I do not believe it is helpful to even suggest that efforts to improve pain care in the U.S. are the cause of the opioid epidemic.
We have research validating that a comprehensive chronic pain management model is called for; however, public and private insurers have been unwilling to fund this model because it is expensive on the front-end even though there are tremendous long term cost savings. This is understandable from the perspective of private payers who are subject to plan “members” rotating out of plans frequently but short-sighted and inexcusable for the Centers for Medicare and Medicaid.
Just reducing opioid prescribing will not resolve the opioid epidemic. These efforts are already making it more difficult for those who struggle to live with chronic pain and rely on opioid therapy to receive the care they need. As reported by various sources, prescriptions for opioids have declined for each of the past three years. It is noteworthy that, at the same time, the rate of addiction has continued to rise.  I’m well aware that the Centers for Disease Control and Prevention (CDC) Director, Dr. Tom Frieden, has claimed that “prescription opiates are a gateway drug,” but again, we have no data to substantiate that claim.

It is a shame that as national leaders like Drs. Murthy, Frieden and Secretary of Health and Human Services Secretary Silvia Burwell continue their important efforts to address the opioid epidemic, they do not, at the same time, talk about the chronic pain epidemic that leads to disability, poverty and even death for tens of millions of Americans. Several years ago, PAINS leaders were encouraged by former Health and Human Services Secretary Kathleen Sebelius and her leadership team to recognize the correlation between these two public health problems, i.e., chronic pain and opioid addiction, and to address them in a coordinated manner. We believe that she was absolutely right and have worked to develop relationships with substance use disorder advocates.
Let me be clear. PAINS is not advocating for the status quo. We know that opioid therapy alone is woefully inadequate for addressing pain. These medications are life-saving for some who live with chronic pain; there are also significant risks associated with them, and they must be used prudently. As one national leader in pain and addiction said recently, “Opioids are powerful medications; they are powerful in healing and powerful in harm.” Furthermore, it is well known that opioids do not work for many to whom they are prescribed and that the reduction of pain for those who do receive benefit from them is only about 30%. That benefit, however, may be the difference between life and death for those for whom pain consumes their every waking moment.
PAINS calls on Dr. Murthy to pledge to use the power of his office to educate the American public about chronic pain as a disease, the relationship between chronic pain and opioid addiction and the need for comprehensive chronic pain care. We also call on others at HHS to include moving from a biomedical chronic pain care model, i.e., opioid therapy, interventional procedures and surgeries, to a comprehensive chronic pain care approach as a major strategy in their efforts to address the opioid epidemic.
Comprehensive chronic pain care will improve the quality of life for millions of Americans, save billions of dollars each year, and reduce opioid prescribing.

The PAINS Project is a program of the Center for Practical Bioethics dedicated to transforming the way pain is perceived, judged and treated as called for in the IOM Report, Relieving Pain in America:  A Blueprint for Transforming Prevention, Care, Education, and Research

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