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    Vivek H. Murthy, M.D., M.B.A.
    N Engl J Med 2016; 375:2413-2415

    December 22, 2016

    On August 24, 2016, I mailed a letter and pocket card (see figure Turn The Tide Rx Pocket Card, Mailed to 2.3 Million Clinicians.) to 2.3 million doctors, nurses, dentists, and other clinicians asking them to help address America’s escalating opioid epidemic. It was the first time in the 145-year history of the Office of the Surgeon General that such a letter was issued specifically to medical professionals calling them to action.

    The letter and pocket card are part of a larger campaign — Turn The Tide Rx — that also includes an online pledge for clinicians, educational resources, and an invitation to share experiences with colleagues about how to address opioid-use disorder, commonly referred to as addiction. The campaign is also a precursor to the first Surgeon General’s Report on Alcohol, Drugs, and Health, which will be released November 17, 2016.

    I chose to take these actions because of the magnitude and trajectory of the opioid epidemic. The annual number of overdose deaths involving prescription and illicit opioids has nearly quadrupled since 2000, and this increase parallels marked growth in the quantity of opioid pain relievers being prescribed.1,2 In addition, more than 2 million people in the United States are addicted to prescription opioids and more than 12 million report having misused these medications in 2015.3 Prescription opioid addiction and misuse are also contributing to a resurgence in heroin use and the spread of HIV and hepatitis C.4

    As I visited communities throughout the country as part of our Turn The Tide Rx tour, I heard the heartbreaking stories behind these statistics. In Oklahoma City, a mother and father shared the tragic experience of their son, an all-American athlete, whose fatal disease began with prescriptions he received after sports injuries. In Napaskiak, a remote fishing village in Alaska with fewer than 500 people, residents lamented that their clinic had been broken into multiple times by people seeking prescription opioids. In Knoxville, people of all ages told me they could not admit they had an opioid-use disorder for fear that they would be fired from their jobs or ostracized by their friends, their neighbors, and even their doctors. In each place I visited, I saw the complexity of causes driving an epidemic that cuts across boundaries of economic status, race, and education level.

    But I also encountered many reasons to be hopeful. I saw firsthand that when given access to evidence-based treatment, people can recover and rebuild their lives. Right now, however, we estimate that more than 1 million people who need treatment lack access to it.5 I also saw how putting the opioid antagonist naloxone in the hands of first responders saves lives. Police officers I met in Seattle began carrying naloxone in the spring of 2016 and saved 10 lives within a few months. They described this as some of the most rewarding work they have done. And I have been heartened to meet clinicians all across the country who are taking steps to reduce unnecessary opioid prescriptions by using prescription-drug monitoring programs and starting prescriber education programs for their peers.

    The Obama administration has played an important role in addressing the opioid epidemic. The Department of Health and Human Services has invested millions of dollars in treatment programs, access to naloxone, and prescription-drug monitoring programs, and the Centers for Disease Control and Prevention has developed opioid prescriber guidelines. Going forward, it will be essential for Congress to adequately fund efforts in this area. It will also be necessary to continue efforts to expand insurance coverage, which is essential for obtaining access to prevention and treatment services. Although 20 million people have secured health care coverage through the Affordable Care Act, there are still millions more who need it, particularly in states that have yet to expand Medicaid.

    But the opioid epidemic cannot be solved by government alone. It will require the engagement and leadership of all segments of society, particularly clinicians. As clinicians, we have a unique responsibility to address this epidemic. We can sharpen our prescribing practices and use prescription-drug monitoring programs to reduce the risk of opioid misuse and overdose. We can ensure that the recognition and treatment of opioid-use disorder is a universal aspect of training and part of every clinician’s toolbox. We can use our voices to call for a more effective approach to opioid-use disorder in our health care institutions, in our communities, and in our government. And perhaps most important, we can use our position as leaders in society to help change how our country sees addiction — not as a personal failing but as a chronic disease of the brain that requires compassion and care. Eradicating the bias against addiction that too many people — including some clinicians — still harbor will be essential to creating an environment where people feel comfortable coming forward and asking for help.

    Our ability to address the opioid epidemic will also depend on our willingness as a society to be clear-eyed about what is working and where gaps still exist. For example, as we urge clinicians to consider nonopioid pain-treatment alternatives in their practice, we must also acknowledge that more needs to be done to make these alternatives affordable. The pharmaceutical industry, payers, academia, and government will have to work together to develop additional safe alternatives to opioids and to ensure that they are accessible to patients.

    It is also important to recognize that though the Mental Health Parity and Addiction Equity Act of 2008 was a major step forward in ensuring that health insurance plans treat substance use disorders the same way they treat other medical conditions, more accountability is required to ensure that this promise is fully reflected in payer practices. And we need to be willing to grapple openly and honestly with the fact that we have paid too little attention to the physical and emotional factors that are driving pain for millions of Americans. Among other things, that means making prevention and emotional well-being a higher priority, not only in the clinical setting but also in our communities at large. Finally, we have to do all these things without allowing the pain-control pendulum to swing to the other extreme, where patients for whom opioids are necessary and appropriate cannot obtain them.

    Society still looks to the medical profession for help and for hope during difficult times. This is one of those times. This is a moment for clinicians — who have dedicated their lives to providing compassionate care to others — to be not only caregivers but also the leaders and advocates that our communities need.

     

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