When I was 13, I developed acute appendicitis on the second day of my first band camp. I can still remember standing in the late-July sun, clenching my side and fighting the urge to pass out in the middle of practice. I remember later that afternoon, recoiling as my pediatrician palpated my abdomen, and I remember the rush of anxiety when, after asking me to stand up straight and noting that I couldn’t, he sent me next door to the hospital to confirm his suspicions.
Most of all, I remember what came after: I was sent home with a neatly stitched, two-inch incision and a 10-day prescription for hydrocodone for any lingering pain. I hadn’t actually felt any pain since before my surgery — I felt fantastic, and I made sure to tell my parents that excitedly not long after waking up — but the hydrocodone was to “keep me ahead” of any pain I might feel. It worked, of course; after a week, my mom unceremoniously trashed my remaining pills and pushed me back to camp.
It’s been more than a decade, and I can still remember what a week on opioids felt like. I recall telling my mom that I felt “taller,” and I did, but I felt other things, too — blissfully unconcerned, foggy and warmly relaxed.
It may not sound like much, but seven days may be all it takes to change the brain and foster an opioid addiction, according to Dr. Carl “Rolly” Sullivan, director of the addiction program at WVU Medicine and one of a growing number of doctors railing against an “opioid first” mentality that has come to dominate pain management in the last couple of decades. It doesn’t take long to get hooked, but leaving opioids behind can be nearly impossible for the well and truly addicted — more than half of recovering addicts will relapse at least once. That’s why news that the Centers for Disease Control and Prevention had issued guidelines expressly discouraging prescribing the powerful narcotics in the first place was so welcome in West Virginia, where at one point, pain pills outnumbered people 100 to 1.
The CDC guidelines are a start, but they’re just one step on the road to a recovery that has as much to do with prescribers as it does with addicts. Doctors practicing today, and especially those trained in the last 20 years, were often taught about pain as “the fifth vital sign” and offered opioids as the solution for their patients’ woes. Attitudes have started to shift — the CDC’s guidelines are a good indication of that — and a number of initiatives at the federal level could coalesce into a backbone for the nation’s effort to combat opioid abuse.
Last week, the White House asked the Association of American Medical Colleges to urge medical schools to include a requirement that students be taught in line with the CDC’s new prescriber guidelines. This week, Marshall University and West Virginia University announced in turn that the schools hope to help lead the initiative, which now has the backing of roughly 60 medical schools, and would ultimately mean a new generation of doctors taught to avoid opioids as a first choice for treating non-palliative pain.
The CDC itself is not a regulatory agency, and its recommendations are meant to offer doctors a guidepost when navigating their own practice. As Dr. Tom Friedan, CDC director, said of the guidelines: “(W)e are not a regulatory agency. So these are guidelines. They are recommendations. States, the national governors’ association, health care systems, insurers may look to these guidelines, when they implement policies within their own jurisdictions or institutions but what our role is to provide the best available science to try to improve the care of patients who are suffering from chronic pain which is a very challenging situation for patients to have to live with and a very challenging condition for physicians to treat.”
That’s probably what’s most important to note with the WVU/Marshall announcement: the schools have put their support behind actual regulation that would change the way the universities, and other medical schools, approach teaching prescribing practices.
President Barack Obama discussed the proposal today, along with several others, during the National Rx Drug Abuse Summit. Highlights from the president’s announcements include a proposed rule to increase the current patient limit for qualified physicians who prescribe buprenorphine (Suboxone) from 100 to 200 patients, as well as a rule that would require Medicaid and Medicare to offer substance abuse treatment at the same level of insurance reimbursement as medical and surgical care.