Solving the nation's opioid epidemic is no easy task. It's a problem that has sparked more than 800 lawsuits, sent thousands of children into foster care and, in 2017, killed more than 48,600 people.
Roneet Lev, MD, director of emergency medicine at San Diego-based Scripps Mercy Hospital, said real change cannot occur unless physicians, health systems, legislators and pharmaceutical companies work together to identify the root causes of the epidemic before creating solutions.
Dr. Lev, who joined Scripps Mercy Hospital as an emergency medicine physician in 1993, witnessed the roots of the opioid epidemic take hold in 1999 and grow into today's national overdose crisis.
During a conversation with Becker's Hospital Review, Dr. Lev identified the causes of the opioid epidemic, highlighted areas of progress and proposed several other solutions to curb this crisis.
Editor's note: Responses have been lightly edited for length and style.
Question: What does the public not know about the opioid epidemic?
Dr. Roneet Lev: If you're trying to deal with the epidemic, the first thing is to understand where it came from; if you understand the root of the problem you can attack it. Looking at an opioid death graph, you'll see a big upturn between 1999 to 2000 and the deaths we're seeing now. These deaths are linked to two supply chains. One chain is prescriptions; ones that I have written, and the medical community is accountable for. The other chain is the supply of heroin and fentanyl, things that are coming into the country illegally across our border.
The public may not know several laws and regulations were forced on the prescription community to deal with pain. It happened on a federal, health plan and individual level across our society. When I started my career, I had triplicate prescriptions. Overnight, we removed the triplicate forms and allowed physicians to prescribe any medicine at any quantity for any disease and any patient. All the controls went away. Pain physicians were given a golden pen by health plans to freely approve any of their pain prescriptions.
Q: What are some of the medical community's misconceptions about the opioid epidemic?
RL: The biggest misunderstanding is to call it the opioid epidemic. People die from a cocktail of medicines, not just one drug. If we focus on just opioids, which we are doing now, we are missing a lot of the problem. Physicians are co-prescribing multiple central nervous system depressants that work together. So even if you are prescribing opioids at a safe dose, if you're adding benzodiazepines and sleep aids with it, then you can have a prescription for death.
Q: How can physicians begin a conversation about treatment with patients battling opioid use disorder?
RL: When talking about patients, we need to divide them into two populations. One way to end this epidemic is by preventing a new generation from being addicted in the first place. If kids need their teeth pulled, they do not need Percocet. They don't need their developing brains exposed to opioids and addictive medications. The second population is Americans who have become victims of the past generation [of physicians'] prescribing habits. This is the population that just needs to be managed. We can't cut their prescriptions overnight, when they've been taking opioids for 15 years. We must safely manage and wean them to acceptable dosages and keep that population alive.
By focusing only on the opioid epidemic, we are missing the boat, because, again, you must go back to root causes, multiple diagnosis, and not just opioids, but the whole package. We need to be able to manage the whole person and not just a specific diagnosis.
Q: What are your thoughts on legislation that restricts opioid prescriptions?
RL: I applaud politicians' efforts to combat the problem. When there is an epidemic, people try to throw in everything but the kitchen sink. Will it end the epidemic? I don't think so, because we didn't go to the root of the problem. We always talk about the wall between patients and physicians, but we've long had a wall between traditional medical care and addiction care. The silver lining is that you have a group of people that would otherwise never talk to each other for a patient, and now they are doing that for the whole U.S. population.
Q: Could you talk about your experience with the San Diego Death Diaries project?
RL: I've heard many physicians say, "You know, if patients just took their medicines like they were told, they wouldn't die." I thought this was very interesting and maybe true, so I wanted to investigate to find out why patients were dying.
I collaborated with the San Diego County Medical Examiner's office to analyze records of 253 deceased patients, looking at the last 12 months of their prescription histories. It's here I got a great understanding that many people are dying from a cocktail of different drug combinations. Because I've lived in San Diego for 20-plus years, I knew many of these patients' physicians. They had no idea their prescriptions ended with a patient's death.
As physicians, we don't get that feedback telling us of our patient's death. There are the satisfaction scores. There are the Yelp scores, and we see all the complaints of people who want us to prescribe more. We don't see the families who are devastated by these addictions. So, I asked a group of physicians, "Hey would you want to know if somebody died, not in an accusatory way, so you could have that feedback?" Everyone said, "Yes, I would like to know."
I partnered with Los Angeles-based University of Southern California, to conduct the San Diego Death Diaries study of 800 randomized physicians who had a patient die from a prescription overdose. These deaths are certified by a medical examiner by being caused by an accidental prescription drug overdose. We sent half of the physicians letters from the medical examiner informing them of a patient's death. We studied their prescribing patterns before and after this intervention. Physicians who received a letter prescribed fewer opioids and had fewer new patients starting prescriptions. This is an important strategy to help end the epidemic for both patient populations, by not creating the next generation of users and weaning the current generation to safer levels.
Q: What is working on the local and state level in terms of decreasing opioid overdoses?
RL: Again, I think we need to go to the root of the problem. Undo some of the laws. Clean up house federally, locally and statewide; look at your laws that are promoting prescribing, because they still exist. We also need to close the faucet from the top. We've tried for years to promote safe prescribing one physician and hospital at a time. This has made a difference. You read about opioid deaths going up, and that's because fentanyl and heroin deaths are going up. Prescription drug deaths are going down. But they are not down to where they were in 1999 and 2000, and that's the goal. To do that, we need to stop paying for prescriptions that kill. Why are we paying for benzodiazepine and opioids together when we know it's a deadly combination? Why are we allowing patients to escalate to a higher dose of morphine when we know that's dangerous and not necessarily better healthcare? There's a lot that can be done on that level, and I have not seen a legislative effort.
If we understand and go to the root cause of the problem, I think we can come up with a solution to end this epidemic. We just need the will of a society to make it happen. But I think we can do it, and frankly we must get it done.