In a workshop talk on preventing future public health catastrophes at the Rx Drug Abuse & Heroin Summit, Andrew Kolodny, MD, opened with the comment, “I'm not playing the blame game.” Still, the co-director of the Opioid Policy Research Collaborative at Brandeis University delivered blistering criticisms for many contributors to the opioid epidemic.
Makers of powerful opioids clearly headed the list, but government regulators, state medical boards and accrediting agencies all were targeted during Kolodny's talk. At the heart of his concern is the role that pharmaceutical industry money has historically played in compromising the mission of these other entities.
“A big problem, I believe, is the revolving door,” said Kolodny, referring to the common practice of drug regulators leaving government to take jobs in the industry they had been overseeing. Kolodny, who disclosed he is assisting states in lawsuits against opioid manufacturers, placed atop his list of solutions the imposition of limits on the revolving-door practices.
He also advocates campaign finance law reform. “Congress failed in its oversight,” he said, as the Food and Drug Administration recklessly allowed opioid manufacturers, absent research evidence, to promote the idea that opioid painkillers were safe for long-term use.
Questioning accepted wisdom
Kolodny questions the general explanation for how the opioid crisis has evolved in the U.S. The account goes that a first wave of overprescribing of prescription painkillers led to a crackdown that forced addicted individuals to heroin, which then became a more deadly trend when fentanyl infiltrated the supply. Kolodny believes this explanation oversimplifies the issue somewhat. First, “We really haven't had a crackdown—we're still massively overprescribing opioids,” he said.
Also, the three-wave construct ignores that heroin use was steadily increasing in many places at early stages of the prescription opioid crisis, Kolodny said. Young, mainly white, adults started with prescription opioid use and moved to heroin because doctors grew more uncomfortable writing multiple prescriptions for younger patients, a concern they didn't apply to older patients who were able to stay on prescription opioids, he said. Another cohort that is ignored in the conventional wisdom, he said, are older inner-city adults, mostly non-white, who had a longtime heroin addiction but now faced deadly consequences of their use. In Washington, DC in particular, “Fentanyl was killing men who had survived 40 to 50 years with a heroin addiction,” Kolodny said.
He outlined the well-financed marketing efforts of Purdue Pharma and other drugmakers in assisting prescribers to grow more comfortable with opioids as a class, as they characterized any resistance to prescribe as “opiphobia” that would result in patients suffering needlessly. Helping the effort, however, were also entities such as the Federation of State Medical Boards, which sent the message that physicians would be sanctioned for undertreating pain, and the Accreditation Council for Continuing Medical Education, which failed to enforce its standard that continuing medical education be free from commercial bias, Kolodny said.
Another workshop on the second day of the conference discussed a University of Kentucky team-based initiative to link emergency medical patients with opioid use disorders to ongoing care. The First Bridge Clinic was launched in early 2018 and involves the cooperation of a multidisciplinary team that includes waivered doctors and nurse practitioners, a nurse navigator, a licensed therapist and a certified peer support panelist.
Among the panelists, and Bridge Clinic leaders, was cardiac anesthesiologist J. Thomas Murphy, MD, who said he became board certified in addiction medicine and waivered to prescribe buprenorphine after seeing an increase in patients needing surgery for complications of endocarditis.
Another outcome-focused session at the conference featured two physicians who discussed improving services for pregnant women with opioid use disorder and their families. Mishka Terplan, MD, MPH, professor of obstetrics and gynecology and medical director of the MOTIVATE Clinic at Virginia Commonwealth University, lamented the lack of evidence-based care for pregnant women, even though it has been known since the 1970s that methadone is compatible with an uneventful pregnancy and the birth of a child with manageable symptoms. From 2002 to 2009, the percentage of addiction treatment centers offering services for pregnant and postpartum women actually declined from 19% to 13%, Terplan said.
Stephen Patrick, MD, MPH, director of the Vanderbilt Center for Child Health Policy, discussed the successes of an interdisciplinary Team Hope project at Vanderbilt that has been able to reduce lengths of stay for newborns who have been exposed in utero to opioids. The effort has emphasized standardizing protocols and taking a more compassionate approach that seeks not to routinely separate the baby from the mother.