In contrast to the current controversy about healthcare, there is broad agreement on the need to improve the quality of treatment for pain and addiction. The Institute for Healthcare Improvement, one of this country’s leading organizations addressing healthcare quality, is beginning to focus on this aspect of healthcare. On March 13 and 14, I participated in its first seminar devoted to this topic. Clinicians and Administrators from across the US and Canada attended the seminar, titled “The Opioid Crisis: How Health Care Can Take Action.”
I was to outline treatment approaches for opioid addiction including a detailed description of the Kolmac outpatient addiction treatment model. Many of the participants, who were already prescribing buprenorphine for addiction to opioids, were interested and responsive. As I listened to them and the other presenters, two things impressed me.
First that sophisticated models to understand and treat pain, to educate physicians about treatment, and integrate treatment into primary care settings in innovative ways already exist. Knowledge about how chronic pain differs from acute pain is expanding. While opioid medications have a role to play in managing chronic pain, using them correctly is essential. Overprescribing opioid medication can complicate an already difficult problem by causing addiction. Another potential side effect is “opioid-induced hyperalgesia,” — a poorly understood phenomenon in which opioid medications intensify rather than relieve pain. The cure for that type of pain is to stop the opioid medication.
Dr. Dan Alford of Boston University described an excellent online training program to guide physicians on how to use opioid pain medications to minimize their dangers. Dr. Joel Hiatt described how the Kaiser health system has integrated guidelines into its protocols to reduce the likelihood that these medications will be prescribed improperly.
But all was not rosy. The second issue that struck me was the lack of resources, in many areas of the country, to address the addictions that have emerged from opioid medication misuse. For example, the largest hospital in Montana does not have an addiction specialist available for patients suffering from substance use disorders. A physician in rural Tennessee said he was willing to use buprenorphine, but he could not find addiction counselors to provide the essential psychological aspects of treatment.
Promulgating our new knowledge and providing training opportunities are a challenge, as is placing clinicians across the country to implement them. Much progress has been made but more work remains. The good news is that IHI will continue to bring its impressive resources to bear on these issues. Individual states, such as Maryland and Massachusetts, are considering legislation and directing resources toward these issues.
At this moment, however, Federal efforts appear to be on pause. Online visitors to the White House Office of National Drug Control Policy find only a message: “Check back soon for more information.” Both the President and the new Secretary of HHS have identified opioid addiction as a priority. Let us hope that it is and that the proposal to eliminate addiction treatment from the list of essential services covered by all insurance companies in the failed health care reform bill was a passing aberration.