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Ethics Talk: The Ongoing Opioid Epidemic

Learning Objectives
1. Identify key ethical values or principles at stake, as described in the program
2. Distinguish among factors of ethical, clinical, legal, social, and cultural significance
3. Articulate how central themes of clinical and ethical relevance in the program can influence health care practice
4. Explain at least one way in which micro-level clinical ethics questions intersect with broader macro-level policy questions in health care
0.75 Credit CME

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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.75 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.75 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.75 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

0.75 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Audio Transcript

Tim Hoff: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff.

While the COVID-19 pandemic has attracted most of the public's attention over the past few months, another epidemic has continued. Reports from around the country suggest increases in opioid related mortality in more than 20 states, and while our already stressed healthcare system works to provide relief to COVID patients, resources for treating people with opioid use disorder might be scarce. The stresses of living during a pandemic can exacerbate conditions that lead to opioid misuse.

Stephanie Zaza: What we know is that there are people who are isolated or having increased mental health challenges of all kinds and substance use disorder does fall into that category. So, we know that isolation is a real challenge for people, and we know that all of these sort of behaviors can become exacerbated when all these additional stressors are placed on people.

Hoff: That was the president of the American College of Preventive Medicine, Dr Stephanie Zaza. She'll join us later to talk about an article in this month's issue entitled “Shifting Opioid Research Priorities Toward Prevention,” which the ACPM is adopting as a policy statement.

First, we're joined by Dr Travis Rieder. Director and scholar in the Master of Bioethics degree program at the Johns Hopkins Berman Institute of Bioethics. His own experience with opioids can illuminate how we see caregivers' clinical and ethical obligations to “legacy patients,” the people who experienced the aggressive prescribing practices that contributed to the opioid epidemic. And who have been on opioid therapies for years or even decades.

Dr Rieder, thank you very much for joining me.

Travis Rieder: Thanks for having me. Great to be here.

Hoff: For our listeners who are unfamiliar with you and your story, can you begin by telling us about your experience with opioids and your expertise in opioid policy and ethics?

Rieder: Sure, I'll give you the lightning version first, then you can follow up with anything that sounds interesting. So, in 2015, I was in a pretty serious motorcycle accident. I went out on Memorial Day weekend for a ride a few blocks from my house, got T-boned by a van, and it crushed my left foot. The relevant part of that story is that, um, I was in a limb salvage situation after the injury. So, there was a bunch of bones obliterated, soft tissue damage. And so I had five surgeries in the kind of immediate aftermath of the accident and then would have one several months later. Those five surgeries meant that I was in and out of hospitals for about 5 weeks and on high doses of opioids when I got home from the hospital, I continued on high and escalating doses of opioids. And so, about two months out from the accident, I eventually saw my orthopedic trauma surgeon, and he was surprised at the dose that I was on, that I was still on such a high dose that far out, but it was the first time anyone had said anything to me about it, and so I was basically told I really needed to get off the opioids.

And so this really kind of sparked the experience that would, I mean, really change my life and in lots of different ways because I was given this very aggressive, very inappropriate tapering regimen where I was told to taper off a fairly high dose - for folks were interested, it was about 170 to 200 morphine milligram equivalents in oxycodone a day - and what that meant is I was given a four week tapering plan to get off this high dose. I went into really terrible withdrawal. And because for four weeks I struggled finding anyone who would help me. I called all of my doctors all my surgeons, all my nurses, plus anyone in the Washington, DC/ Baltimore area that I could find, and nobody would help me. And so the result was I just spent 29 days in just really awful opioid withdrawal.

Hoff: Why was the dosage that high in the first place? Was it an issue of multiple prescribing or was track not being kept over what was being prescribed or how did it get to that point?

Rieder: Yeah, so this would be one of the things I would eventually get interested in. You know, because the question that I would kind of become consumed with as I gained some distance from that withdrawal experience, and I mean, more or less from the trauma of it, was, you know, “How did I get here? How did I get to this point where I was managed so badly?” But also, “How did we get here? How did the healthcare system get to this really terrible place?”

And the answer that I think I found was that we're really bad at managing opioid prescriptions. And so, it wasn't multiple prescribers, at least that wasn't the real problem. By the time I left the hospital, my plastic surgeon had taken over and continued to increase my dosing. It's that when somebody is in really severe pain, a lot of our doctors have been trained to try to mitigate that pain, and one of the most powerful tools we have is opioids. And so, when the the prescribing is quote, unquote “appropriate,” you know kind of obviously, there's severe traumatic pain, post-surgical pain, we don't have questions about whether or not somebody is really in need of opioid therapy, then we're just kind of are okay with doctors handing it over without a whole lot of follow up.

So the big problem I would eventually come to see is that over the course of two months I had all of this, you know, interaction with the healthcare system where they say, “Well, look, you've had your foot blown apart. This is a really good use of opioid therapy,” and then just nobody thinking about what that meant long term.

And so we write prescriptions… “we,” I'm not a physician [laughs], but the health care system, right, we write prescriptions and have this mentality that they're kind of like antibiotics, that there's no further need for follow up. And so, that was the thing that really got me into this intellectually, into this space, you know I had. I had this really awful experience and for a good while, I didn't know that it mattered. You know, that that telling it would really matter. But I when I eventually decided to tell my story, the immediate feedback I got was, “Oh, you found something really important in the health care system and that is this gap, this kind of gaping chasm where we lose patients and follow up. We lose lose patients in long term care.”

Hoff: The experience of pain is an important part of the story that you tell, and it's not only the experience itself, but trying to express the need for clinicians help in remediating pain that seems to contribute to some of the problems that you went through. Why are expressions of pain experiences and asking for help important when talking about opioids?

Rieder: Pain is this really strange phenomenon, right? Because it's inherently subjective, which is to say, we don't have a pain-ometer, right? There's no device that you can hold up and scan my brain that will objectively and accurately tell you how much pain that I'm in. So, all we have is communication. You know, you see how dissatisfying this is when you think about how we actually do try to communicate about pain - we use the pain scale. Can you tell me about your pain? You rate it 0 to 10, right? With 10 being the worst pain imaginable and 0 being none. But that's a really dissatisfying sort of tool, right? Because there's no way for you to know that my 10 is anything like your 10. If I report 10, you're like, “Oh man, that sounds bad, but I don't really know what that means for that person,” right?

Hoff: And there's an inclination to discount those extreme numbers anyway, if somebody tells you 10 you think, “Well, is it really a 10?”

Rieder: Absolutely, absolutely. So, as a matter of fact, you know when you hear clinicians talk about red flags with patients about whether or not they might be malingering, right, whether they might be faking it or something. Saying an 11 on the 10 scale, saying something extreme is one of those red flags. So patient comes in, and especially if they're playing on their phone, this is a really kind of common encoding, right? “Patient reports 11 on the 10 scale and sitting playing on their phone…,” right? That's as a way of encoding to anyone who reads this, “I don't believe this patient's reports.” Yeah, so pain is this very strange phenomenon because it's inherently subjective, and so the only way that we can treat it is to actually talk about it. So communication plays this really a essential role. But that communication is really fraught because there's room for suspicion given that you cannot verify my answer when you ask about my pain.

Hoff: And patients who are members of marginalized communities often have more difficulty expressing their experiences and getting them taken seriously. And they might face unfair scrutiny, especially when pain relief is part of their primary goal. So we know that these biases influence every part of medicine, and that these extend to prescribing practices. So, what should physicians do to become aware of their bias and counteract its influence on how they might under prescribe appropriate medications to patients with minoritized identities?

Rieder: This is a really important question, you know, I didn't know any of this prior to my experience and so, you know, I think I only had two encounters with the health care system where I had my pain testimony dismissed. And so, it wasn't a big part of my own experience. And reflecting on that later, it was really striking, right? Because here are the identities that I wear really obviously: I'm a white man, you know, I speak like the professor from a middle class background that I am, right? And so, I present in a particular way that doesn't carry any of the biases, any of the implicit biases, or any of the stigma that might go along with dismissing these pain testimonies. So I think that's incredibly important. So as you say, we have data that African Americans have their pain testimony under believed and under treated. Same thing with women. Same thing with Hispanic patients.

So, what do we do about it? I think this is incredibly hard. Um, you know, there's not a ton of really successful strategy for debiasing people, like this is just something that we're not very good at. So the first thing we need to know is we just need to know that it exists, so that we're not operating in darkness. So physicians need to know that we all carry biases. This is a human thing. If they don't believe that they can go take implicit bias tests on the computer. And then know that these are the trends that have been identified, that we tend to believe women and minorities less, so that when they walk into that situation they're kind of enlightened by the fact that even with the best intentions, these might be their inclinations. So that's thing one. We just need knowledge about it, right?

But the other thing that I think that we need is, um, I think we really need to inculcate compassion and ethics with medical students and physicians in general. And I know this sounds kind of like hopelessly naive as a response, but you know, I teach in the Johns Hopkins Medical School. I teach the occasional class or lecture, and I really am always surprised at how much, kind of, cynicism builds over time - that when you get first year medical students, they're all, you know, kind of out to save the world. And by the time you get residents and fellows, they've kind of had cynicism beaten into them a little bit.

And so one of the things that I tell medical students and physicians all the time is “believe your patients. Believe your patients reported their pain.” And I immediately get them looking at me suspiciously and want to interrupt me and say, “But some of them are lying.” And someone will say, “Well, in my practice most of them are lying,” and I say, “Believe your patients because there is no harm in believing your patients because believing them does not entail any particular clinical activity.” So, here's what can happen when you believe your patients: you can build trust, you can build a relationship, you can have a real kind of solidarity with them, and you might be able to better treat all of the things that are going wrong in their life as you move forward because they trust you. And if they are lying to you, that doesn't mean that because you believe them about their pain, you ought to prescribe opioids because a whole bunch of time, opioids are not indicated. And that's still going to be the correct response, right? So there's no downside to compassion and trusting the person in front of you. As long as you still practice good, responsible, evidence-based medicine.

Hoff: So that helps us approach the issue from perhaps a, you know, individual physician working with an individual patient. What are some of the macro level tools and policies that can help promote fair prescribing practices?

Rieder: I do think that policy is very often going to be not a great tool for this sort of problem, because policy is by its nature - you know, not as a criticism - but by its nature, is hamfisted. It doesn't deal very well with nuances. And so, the really, kind of disheartening answer for a lot of people is say we need education. And here here I am as a bioethicist, you know hammer, I see nails, right? [laughs] But I do think that medical students and physicians need more ethics education. And so one of the reasons I say that is because a lot of the ethics that you get in medical school is like a brown bag lunch seminar or something, right? This isn't given a huge, a real high priority. But what if we really wore on its face what you need to do in a situation like opioid prescribing such that it be responsible and fair?

So what if instead of saying, “Oh we're in the midst of a drug overdose epidemic, which by the way was sparked by overprescribing so, hey, doctors prescribe fewer opioids,” right? Well, that's terrible advice and the reason it's terrible advice is because “fewer opioids” doesn't make any reference to the patient in front of you, and the patient in front of you might need few, they might need many, they might need none, right?

So, “prescribe fewer opioids” is bad advice which you want the physicians to do is “prescribe appropriately.” You want to give responsible prescriptions in all of your practice, right? So wear ethics on its face, and what that means is you need in every instance to be thinking kind of “thickly,” what someone like me would say “normatively.” You need to be thinking about the values and the norms relevant here. So, what are the benefits and burdens to the patient? What are the fairness considerations? You know, exactly as as you're raising here. Am I risking any kind of injustice? And so how do I avoid under prescribing, which can be a harm; avoid over prescribing, which can be a harm; and involve unjust prescribing through kind of systematic biases, which would obviously be a moral harm.

So that's that's the way I would love for clinicians to really wear ethics on its face when they're thinking about what kind of prescribing is the right kind of prescribing.

Hoff: In your article for the journal of this month, you respond to a case where it seems like that sort of intimate knowledge, and interaction between patient and clinician is particularly important. You argue that a patient's physical dependence on a medication might ethically require a physician to maintain a high dosage that created the chemical dependance in the first place. Since this might sound counter intuitive to many of our listeners at first you know the first time they hear it, can you draw what you see as the primary reasons for your line of thinking here?

Rieder: Yeah, absolutely. So the case is about so-called “legacy patients,” right? So these are patients who are a legacy of past aggressive prescribing practices in the US. And so that they can look really different, and there is no, you know, in the literature, precise definition, but generally these are patients who have not been on opioids just for weeks or months, but have been on opioids for years to decades. And because of this phenomenon of tolerance, because you have to prescribe more just to achieve the same analgesic effects in many patients, some of these patients will be on not just, you know, Mr T in my case was on 170 morphine milligram equivalents, but some of these patients will be on 800 morphine milligram equivalents or more than 1000. So, these are patients on very high doses, have been on them for a very long time. And so I say that this is one of the most morally fraught cases in pain medicine ethics today. So the first move that I think is really important to make is to notice the backdrop against which American physicians are interacting with legacy patients is that they have been told, they the physicians have been told, “Hey, you're killing people through the opioid epidemic through your overprescribing. So stop prescribing so many pills.”

And there have been all of these misinterpretations of the 2016 CDC guidelines for prescribing opioids for chronic pain where instead of just reading the guidelines as taking care in initial prescribing escalating opioids, which is what the authors have made clear was their goal, they've been interpreted to, those guidelines have been interpreted as offering ceilings on appropriate doses for all patients. So all that to say, physicians across America are interacting with these patients, legacy patients, and saying, “Oh, you're on too high a dose. The CDC or my local licensing board or the state government is saying we can't have patients on high doses anymore. I need to deep prescribe you. I need to taper you off this medication.” And that's the ethical challenge that I'm looking at.

So, are you obligated to actually taper off those sorts of patients - so the patient, in my case, is Mr T? And I think many physicians think that evidence-based medicine says yes. And the considerations that I offer are, first and foremost, that continuing opioid prescriptions are morally different from initiating opioid prescriptions because these patients are physically dependent on opioids. And so, many of them are going to be scared in the face of a taper because they know what withdrawal is like. If you've been on opioids for years or decades, you've forgotten your pills at some point, and you know how miserable withdrawal is like. And withdrawal has, as one of its side effects, increased pain - hyperalgesia - increased sensitivity to pain. So a lot of these patients think that going off the medication is going to make their life absolutely miserable.

So that's the setup of the case. What should we do with cases like Mr T, these legacy patients? And I want to say look, it's not clear from our guidelines from our evidence and from our ethos that the right thing to do is deprescribe. So I said, you know, the morally relevant feature of of these legacy patient cases is that they're already physically dependent on the medication. And so the difference between initiating and continuing is that when we're thinking about initiating a patient on opioid therapy, we've come to this - “We,” the medical community - have come to this view over the last few years that it's unlikely for the majority of patients that high-dose, chronic opioid therapy will be, all things considered, good for them. And as a result when you're initiating opioid therapy, your goal should not be that the patient is on it forever, especially not at high doses, right?

Well, if a physician thinks that you know from that kind of guidance the idea that's true is just that patient shouldn't be on high dose opioid therapy, they're missing the fact that if they're already on it, you're going to have to expose them to potential harm to get them off it. And that's because you're going to have to taper. So now there's a distinction. If they're taper badly or tapered well, and so you know my own experience of being tapered shows just how bad withdraw can be. And for anyone who's interested to you know, I did a TED talk on this or to go read the book. It's laid out in pretty excruciating detail. I mean at the end of opioid withdrawal, I was thinking about killing myself. I had my foot blown apart in a motorcycle accident, and every moment of withdrawal was the worst moment of my life. And so the first thing to know is that being forced into withdrawal and to live with excruciating unmedicated pain on top of that is is is a very serious moral consideration in its own right. That is something to be avoided.

But you might say, well, look, that's really too bad that some physicians might not know how to taper well, but let's fix that part, say, everybody should have to be able to, you know, very carefully taper their patients off opioids. And so now our question is, do we have any evidence that you can actually completely comfortably taper someone off their medication if they're on high dose of group therapy? And the answer is not really. So, the highest quality evidence we have about trying to taper high-dose, chronic opioid therapy is really heterogenous in its results. Some patients do OK. Some patients do pretty well, they lower their dose somewhat, and they have decreased pain and that looks good, but some patients don't aren't able to successfully lower their dose. Or if they do their pain goes up significantly. If you really are practicing patient-centered care and giving them what seems appropriate in the minute, you might end up after trying to taper them actually increasing their dose of opioid therapy, right? So our evidence here is really mixed that you can get somebody off high dose opioid therapy with, you know, little harm.

So now, what should we do it for? We say, “Well, it's still worth it because high dose opioid therapy is dangerous,” but we actually don't have good evidence on that either because these patients are tolerant to it. That is, kind of the the way in which they got to such high doses and so tolerances are protective mechanism. The reason they're not overdosing on their hundreds of morphine milligram equivalents is because they've built up tolerance to it. So the benefits to tapering off aren't actually all that clear, but the risks to tapering off are pretty clear. So when a patient says I'm terrified of tapering, it doesn't seem like it's good for me, we kind of have to look at them and say, “Yeah, I understand that.”

So this has been a long answer, let me wrap it up for you. So at the end of this, what I think is the benefit and burden calculus is not clearly in favor of tapering and the healthcare community, whether it was the prescribing physician that's dealing with it right now or not, the medical community has put patients into this situation where they're now dependent on opioids, and so we've kind of done this to them, and I think that that actually provides an additional moral reason to give patients a voice in their own care to kind of reestablish trust to help build a relationship with them.

And I think the end result of this argument is that it might be the case that many patients would benefit from tapering, and so we should try to work with them to develop a collaborative, careful evidence-based tapering regimen. But if they're not ready, and so they do not autonomously endorse the plan, I don't think it's permissible to unilaterally, so nonconsensually, taper a patient off their high-dose, chronic opioid therapy if they're otherwise stable. That's that's the punchline.

Hoff: This view seems to be right for this individual patient in this specific scenario, but how can it be used as a basis for making good policy that helps curtail opioid substance use disorder and excess death caused by opioid overdoses?

Rieder: Well, you know, I mentioned earlier, that policy is a bit of a blunt tool, and so it is the case that I don't think policy is going to help us much here. What we need is we need individualized, patient-centered care, and that is difficult to dictate with policy. So as a matter of fact, I think the most relevant policy consideration when it comes to deprescribing of opioids is that policy needs to get out of the game. And so, you know, there are all sorts of state mandates for opioid prescribing, and there are state licensing boards that are doing pretty aggressive tracking and reviewing of physician prescribing habits. And I think that, by and large, these blunt policy tools have the ability to do far more harm than good. So if you talk to clinicians, especially in states with more draconian sorts of regulations and policies, you'll hear all over the country that what's largely happening is patients on high-dose opioids are being abandoned by their physicians because no one will take them on and if they aren't willing to just immediately drop their dose to under 90 morphine milligram equivalents or something or maybe 60, then physicians won't work with them anymore. And so I think the policies that are leading to this sort of culture of fear are really problematic, and so the most important policy consideration is to look at the policies that we've already started to adopt, and if they have negative unintended consequences, then we need to revise those policies. So that's answer one.

But the other thing you said is, you know, we tend to think we need policy solutions to curb overdose death, right? That's kind of the goal behind all of this, so the last thing to mention is a lot of overdose death is not coming from these patients, right? We now have many years of pretty good epidemiological data in the drug overdose epidemic, and so, a couple of trends are emerging. One, overdose deaths related to prescription opioids in general are going down as a percentage of overdose deaths. Overdose deaths now are more coming from illicit drugs: heroin and illicit fentanyl and fentanyl's chemical analogs. But two, the ones that are coming from prescription opioids are still very often polypharmacy, and just because they were coming from prescription opioids does not mean they're coming from deaths by patients who are prescribed those opioids. So there are a lot of prescription opioids in the illicit market as well. So as a percentage of the kind of policy goods regarding the overdose epidemic, addressing careful pain management isn't going to end that epidemic, right? So, what we need to do is we need to address pain medicine because responsible pain medicine is just important. But doing that is not going to solve the drug overdose epidemic. And as a matter of fact, if we want to solve the drug overdose epidemic, we need to do lots of other things on the policy front that would garner far more goods. Things like get treatment on demand, you know, addiction treatment, specialty treatment, especially with medication for opioid use disorder; to institute things like harm reduction, right? So if we want policies that will solve the opioid epidemic, we're kind of looking in the wrong place if we're talking about policies that would force stable paying patients off their medication.

Hoff: Dr Rieder, thank you very much for joining me and for sharing your story and expertise.

Rieder: You're very welcome. Thanks for having me on.

Hoff: That was Dr Travis Rieder, the director of the Master of Bioethics degree program at the Johns Hopkins Berman Institute of Bioethics. His book, In Pain, recounts his own experience with opioids.

As the COVID-19 pandemic has demonstrated effective public health strategies require forward-thinking methods focused on prevention. Proactive measures can help lower disease burden and enable acute clinical focus on needs of the most vulnerable patients in adequate prevention strategy implementation, as we saw with COVID-19, can overburden clinicians result in excess death and tragic outcomes forced by resource scarcity and exacerbate health inequity.

Dr Stephanie Zaza, President of the American College of Preventive Medicine, joins us now to help us understand why prevention is key to stemming the tide of patients experiencing opioid use disorder.

Dr Zaza is also a retired captain of the US Public Health Service and a preventive medicine consultant in western Colorado.

Dr Zaza, thank you so much for joining me.

Zaza: Thanks for having me.

Hoff: The American College of Preventive Medicine is adopting the article “Shifting Opioid Research Priorities Toward Prevention” as a policy statement. What have been the research priorities around opioids up to this point, and why should we shift research priorities now?

Zaza: Yes, ACPM was very pleased that this article clearly reflects our priorities, which are focused on prevention and resilience. And because of that, our board elected to endorse this article as our own policy statement regarding research priorities in this area.

The research priorities for opioids have really been focused on finding solutions to quickly reduce the number of deaths from overdose. We now have good data that medications for opioid use disorders such as methadone and buprenorphine can reduce death rates in the community by as much as 50%. So with that, it's now time to shift our priorities to move upstream, and there are really two big reasons for that.

The first to put it simply, we cannot treat our way out of this situation. If we continue to allow the funnel to fill with more and more new cases and simply work to treat people once they are already on the path to a substance use disorder, we will never get ahead of this epidemic. The second reason is really where the ethical issues lie, and that's in that this epidemic isn't just measured in deaths. Substance use disorders are truly devastating to both the health and well being of individuals and the communities that they live in. So moving upstream to find ways to prevent the disorder itself is important.

And when we started writing this paper a few months ago, we were - obviously, this was actually back in the fall of 2019 - we really didn't see the COVID-19 epidemic coming. But one thing that this situation has brought into the open is that people and communities need a fair bit of resilience when a crisis occurs. To get to that more resilient place, we have to start thinking about health and wellness as a form of preparedness. So when a factory closes, or when a natural disaster occurs, when an outbreak or a pandemic occurs, people who have chronic diseases, including substance use disorders and people who are vulnerable because of housing or food insecurity - and these things are all connected by the way - they're almost always the people who are most affected by the crisis. When we prevent those chronic diseases or prevent substance use disorders when we prevent childhood trauma or homelessness or hunger. In other words, when people are physically and mentally healthy, we have people in communities that are far better prepared or more resilient when something unexpected happens. So when we put all these things together: this not being able to treat our way out of it, not measuring this epidemic just in deaths, and really thinking about our communities and our individuals are the people who make up these communities as being resilient, these all point to moving upstream to figure out how to stop these disorders from happening in the first place.

Hoff: The article identifies 3 focus areas for future opioid research and those are the social determinants of opioid misuse, creating and implementing prevention programs and policies, and improving risk mitigation and harm reduction strategies. Why are these three areas the most important?

Zaza: These three areas are actually all related to each other. And although we try to disentangle them a little bit to make the case in the article, it's important to recognize that they they do fit together as well. They're really on a continuum of things that we think needs to be done. And although we didn't mention this in the paper, one of the most upstream things we can do is to assure that we are maximizing our ability to prevent and treat the causes of underlying health conditions, especially chronic pain and mental health disorders, that are the big drivers of substance use and subsequent substance use disorders. So setting that aside, maximizing the prevention of the causes of this disorder, these three areas that we focused on in the paper are really important and related to each other.

So the first area: we know that we have to establish a better understanding of what is contributing to an increased demand for opioids. We know that the availability of prescription opioids in the form of pills was an important factor, but the high rates of use and use disorders suggests that there's something else going on, so we think it's very important to consider factors like social isolation, housing, jobs, education and stigma as key contributors to this epidemic. An added benefit of identifying and correcting these social contributors to substance use disorder is that any positive impact we make in this space is likely to have far reaching health impacts on health and wellness because these issues are common to so many health issues, so that's why we include the first area.

The second area when when we write about shifting toward primary prevention and finding new programs and policies, I want to make sure people understand that we are not referring to the school-based, D.A.R.E-type education programs that some of us may remember which were not only ineffective but in some cases could be harmful. I like to describe our approach as going as far upstream as we can to figure out why these disorders are happening and how to prevent that chain of events as early as possible.

So one of the big areas to investigate is how do we create an implement prevention programs and policies to shift our approach to reduce and prevent harms? By failing to pursue these very upstream prevention programs and and in some cases create them so the research that this type of intervention research that creates tests and models these programs that can then be implemented and replicated in communities all across the country remains really important. If we don't do that, we continue to be in this sort of reactionary role just trying to treat and identify and treat new and existing cases rather than preventing them upstream. So that's the second area.

The third area is reflected in what is an emerging shift in the public conversation from seeing addiction as a crime to understanding it as a chronic medical condition. Unfortunately, we still use criminal penalties to treat this medical condition. So as a medical community, it's really important that we recognize not only recognize that it's a chronic condition, but then it's incumbent on us to find to research the ways that we can help patients at every stage, the way we support patients with any other chronic condition. We have to get them the tools and the information that they need to make the healthiest decisions possible. Risk mitigation and harm reduction strategies are powerful tools that we use in all kinds of health issues, but in the case of substance use disorder, sometimes these strategies are considered illegal or patients are terrified of coming forward because the very fact of their substance use disorder is treated as a crime. So we need more rigorous testing and policy shift to make that happen.

Hoff: How does a renewed focus on prevention research rather than treatment research help motivate health equity around the opioid epidemic?

Zaza: Well, of course we know that opioid misuse impacts every strata of society, but it particularly impact people who have attained lower levels of education and who have lower incomes. So it's important to acknowledge that fact, but we have to go beyond that. Just identifying these upstream risk factors is not enough. We have to also research ways to improve living conditions and livelihoods to reduce these contributors to substance use. This is a big part of our national conversation right now in so many areas, and it's critically important in the substance use arena as well. The ultimate aim is of course to start by eliminating disparities but eventually to eliminate poor health outcomes for everybody overall.

We also think that we have an overarching ethical obligation to move upstream, and by shifting our research priorities to preventing the harm from ever occurring in the first place, we send an important signal that people's lives, their health and well being matter and with those research answers in hand, we can do so much better to inform and then turn our policies and our healthcare approach toward preventing the harm in the first place. So it's really about mustering all of our resources and all of our evidence and shifting that to making better policy and healthcare service decisions which will drive equity and eventually better health outcomes.

Hoff: That was Dr Stephanie Zaza, President of the American College of Preventive Medicine. Dr Zaza, thank you again for your time and expertise.

Zaza: Thanks again.

Hoff: That's our episode for this month. Thanks to Dr Travis Rieder and to Dr Stephanie Zaza for joining us. Music was by the Blue Dot Sessions and fact checking was by the journal's researcher, Shaun Rouser. Follow us on Twitter @journalofethics for news and updates and be sure to visit journalofethics.org to read this month's issue of the journal, Opioids and Public Health. Tune in next time when we'll be discussing behavioral architecture in healthcare. Talk to you then.

Audio Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

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