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Pa. Physician General: “Opioid Stewardship” Needed to Beat Crisis

IMG_6805More than 50,000 people across the nation are expected to die this year due to opioid and heroin overdose. That’s about the same number of Americans were killed during the entire 12 years of the Vietnam War.

Rachel Levine, MD, physician general of Pennsylvania, kicked off her grand rounds on Monday in Smilow’s Arthur H. Rubenstein Auditorium with this and other sobering statistics about the opioid epidemic in America.

The numbers are surely no surprise and the analogies are starting to sound trite to anyone who’s kept up with the issue over the last few years. Headlines about the crisis have been on every health care-focused publication, every major newspaper, and even took up 20 minutes of a recent Last Week Tonight with Jon Oliver.

But what is being done? What is there to be done? Dr. Levine said it’s “all hands on deck” within the state government, but the cooperation of healthcare providers is perhaps needed most of all.

“Every law enforcement person we talk to, whether they are federal or state, whether they are district attorneys or the attorney general’s office, will state that we’re not going arrest our way out of this,” she said. “This is freshman economics. If the demand is sky high, they’ll never get a handle on the supply.”

Managing that demand is where the providers can play a role. To install that sense of mission, Levine said she’s promoting what’s being called “opioid stewardship,” a responsibility among care providers to use these essential medications in a more careful, effective way. It’s a direct translation from the antimicrobial stewardship initiative which encourages prescribers to be more reserved in using antibiotics.

To help the new class of health care professionals enter the field with a better understanding of the risks and benefits of opioids, Levine said the state is working with medical schools across Pennsylvania — including Penn’s Perelman School of Medicine — to develop a set of core competencies. Those competencies, ideally, will be tailored in the future for the needs of each profession.

Levine said the state also hopes to partner with various professional groups to help create continuing education credits specific to each position’s role in battling the epidemic.

One of the final pieces of the opioid stewardship puzzle is Pennsylvania’s new prescription drug monitoring program (PDMP), which launched in August with a speech by Gov. Tom Wolf in the Henry A. Jordan Medical Education Center. With the PDMP, each narcotic prescription is ideally logged into a database and attached to each patient.

With that tool in place, physicians are able to check a new patient’s prescription history for “doctor shopping” – patients who visit multiple physicians to obtain multiple prescriptions for otherwise illegal drugs– or other possible red flags. That information would help the doctor diagnose the patient with addiction and give the patient what Levine called a “warm handoff” to addiction treatment specialists.

The PDMP isn’t perfect right now. Only about half of Pennsylvania physicians have registered, but it’s getting better every day as more log on. Levine said they are also working on integrating the PDMP with similar systems in nearby New Jersey and Maryland and they are hoping to seamlessly involve the PDMP with electronic medical record systems as well.

Another leg of the state’s approach is to equip as many qualified people with naloxone as possible. Naloxone blocks opiate receptors in the nervous system and the hope is that by providing the drug to first responders, family members and addicts, many will be saved from overdoses. To help there, Levine has given a standing prescription to pharmacies across the state to make naloxone available to all Pennsylvanians. They’ve also given naloxone to all first responders and doses are being kept in high schools as well.

But when a person overdoses and is saved by naloxone, they shouldn’t only receive immediate treatment, Levine said. It’s also a prime opportunity for that “warm handoff” to the county’s treatment program. Reading Hospital, she noted, gets as many as two-thirds of their overdose patients directly into addiction treatment.

Levine was careful to emphasize that addiction is a disease like any other and that those suffering from the disease are as deserving of treatment as any other patient.

“We don’t say ‘Well should we defibrillate this patient? They didn’t follow their diet.’ We save that patient and work harder to get them on their diet,” she said. “Naloxone is like a defibrillator for overdoses.”

After the talk, a couple of things were clear: first, opioids are important, even vital, medications that are needed in many cases. Second, it’s going to take widespread cooperation to slow the epidemic.


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