From the Editor in Chief

by U.S. Medicine

September 13, 2017

Editor-In-Chief,
Chester “Trip” Buckenmaier III, MD,
COL (ret.), MC, USA

“The current approach to the opioid epidemic is just as ineffective as managing a cholera outbreak by treating victims without ever bothering to find the source of contaminated water and provide access to safe alternatives.” —Chester Buckenmaier & Eric Schoomaker1

I am sure there is a special place in “writer’s hell” for authors who quote themselves, but I just could not help myself. In truth, the idea for this analogy was first expressed by Dr. Rollin “Mac” Gallagher, former national director (2013-16) and deputy director (2009-12) of pain management for the Veterans Health Administration, during our frequent discussions concerning federal pain management and the opioid epidemic. With the pressures of 17 years of continuous military operations in the nation’s longest war, those in federal medicine like Mac and myself recognized the opioid “train wreck” many years ago. Federal practitioners also understood the opioid issue was a symptom of a much larger medical problem in how pain was being managed in this country. I do not take any pleasure in federal medicine’s clairvoyance on this issue, for surely in this case it sucks to be right.

The ongoing prescription opioid epidemic is certainly not news at this point. One can hardly consume any news media without stumbling on a tragic story of lives destroyed by addiction or children orphaned as parents overdose on opioids. The Centers for Disease Control and Prevention (CDC) estimates that 142 people die daily from prescription opioid and heroin use.2 In terms of lives lost, that death rate is similar to a Sept. 11sized attack happening every month. Although the federal government has acted through the Presidential Memorandum—Addressing Prescription Drug Abuse and Heroin Use and the CDC Guideline for Prescribing Opioids for Chronic Pain, both documents have tended to focus on controlling opioids, with minimal attention paid to the pain management problem that is actually driving the issue. Although these measures are important, they are not commensurate with the size and scope of the opioid crisis that is literally killing Americans in astonishing numbers. This situation might soon change, though.

President Donald Trump signed an executive order on March 29, establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis, and placed New Jersey Gov. Chris Christie as its chairman. Recently the commission released an interim report to the president, urging him to declare a national public health emergency to rapidly increase the resources available at the federal and state level to combat the growing opioid crisis.

I was particularly pleased to note that the commission, within one of its recommended courses of action, called for “amending the Controlled Substance Act to require all Drug Enforcement Administration (DEA) registrants to take a course in proper treatment of pain.”2 While I would have appreciated greater detail from the commission on the link between poorly managed pain and the opioid epidemic, I was pleased that this group was calling for improved clinician training in pain management as part of the response to this national emergency.

The DoD and VA health systems have and continue to provide leadership in responding to the opioid epidemic. Through the Joint Incentive Fund (JIF), a federal program designed to resource collaborative health programs between the DoD and VA, the Joint Pain Educational Program (JPEP – http://www.dvcipm.org/clinical-resources/joint-pain-education-project-jpep-1) was established to provide a pain curriculum for both clinicians and patients designed to optimize pain management within the federal system. This curriculum has become a critical standard for provider pain education designed to ensure quality and consistency of pain management services to federal medicine beneficiaries. Developed with a primary care focus, the curriculum is intended to decrease variance in pain management care and ensure that DoD/VA providers, patients and leaders have the pain skills needed as federal medicine transforms its culture and approach to pain management. The curriculum consists of 31 virtual instructor-led training modules, five videos demonstrating proper physical exams for common musculoskeletal pain complaints and12 short videos targeting important pain management concepts facing providers and patients.

Several of the JPEP videos served as core components for the mandatory federal provider pain and opioid prescriber safety training directed by the 2015 White House Presidential Memorandum. Topics include Understanding Pain, Pain Assessment, Chronification of Pain, Essentials of Good Pain Care and Introduction to the New Pain Paradigm, among others. Developed with taxpayer dollars, the curriculum is available for free to the public.

I hope the president will heed the commission and declare a national emergency. The ongoing loss of life certainly warrants aggressive public health measures. Furthermore, I am pleased that federal medicine is prepared and stands ready to assist in this emergency with products, like JPEP, that can facilitate the cultural change needed in how our American culture responds and manages pain. Through better education of both providers and patients we can attack the opioid problem at its source, rather than just responding to the consequences of opioid addiction. This more comprehensive approach, with the president’s support, will turn the tide on this national health crisis.1http://healthaffairs.org/blog/2017/08/04/stopping-epidemics-at-the-source-applying-lessons-from-cholera-to-the-opioid-crisis/. Accessed August 7, 2017.

2https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf Accessed August 7, 2017.


4 Comments

  • John Beary, MD says:

    This initiative to make both patients and doctors wiser about chronic pain management is a good one. However, it still leaves the pump handle on the “cholera pump”.

    The opioid epidemic has now blended into the heroin epidemic, which is a $30 billion per year business, where in most Midwest cites one can order a $15 bag of heroin with a cellphone that will be delivered to the customer (similar to the delivery of a phone ordered pizza). Every Midwest newspaper has done a special section in their Sunday paper on this, since the heroin business blasted off in the past five years. Heroin victims are driving impaired and clogging our courts, jails, hospitals and homeless shelters.
    Young people under age 25 will often try stupid, risky things like heroin “just once”. It takes three years of treatment to get over the brain injury from opioid/heroin addiction, and there are not enough treatment beds for the epidemic.

    Perhaps immunology can provide a useful analogy. Thirty billion dollars will support a large amount of corruption to keep the heroin business booming.
    Since the Mexican cartel is running this high profit/low risk (to them)…. business at present, perhaps a drone delivered missile (the antibody)can take out the diseased cartel cells (with their identifiable antigens). Make a few extra drones so that when the cartel moves, they can be retargeted.
    Hope this helps.

  • scott mcnairy MD says:

    This is great and we are working on this with the integrated pain teams in MN. Please see my post to the article on telemed in regard to providing MATx support and supervision to the outstate CBOCs.

  • John Beary, MD says:

    This initiative to make both patients and doctors wiser about chronic pain management is a good one. However, it still leaves the pump handle on the “cholera pump”.

    The opioid epidemic has now blended into the heroin epidemic, which is a $30 billion per year business, where in most Midwest cites one can order a $15 bag of heroin with a cellphone that will be delivered to the customer (similar to the delivery of a phone ordered pizza). Every Midwest newspaper has done a special section in their Sunday paper on this, since the heroin business blasted off in the past five years. Heroin victims are driving impaired and clogging our courts, jails, hospitals and homeless shelters.
    Young people under age 25 will often try stupid, risky things like heroin “just once”. It takes three years of treatment to get over the brain injury from opioid/heroin addiction, and there are not enough treatment beds for the epidemic.

    Perhaps immunology can provide a useful analogy. Thirty billion dollars will support a large amount of corruption to keep the heroin business booming.
    Since the Mexican cartel is running this high profit/low risk (to them)…. business at present, perhaps a drone delivered missile (the antibody)can take out the diseased cartel cells (with their identifiable antigens). Make a few extra drones so that when the cartel moves, they can be retargeted.
    Hope this helps.

  • scott mcnairy MD says:

    This is great and we are working on this with the integrated pain teams in MN. Please see my post to the article on telemed in regard to providing MATx support and supervision to the outstate CBOCs.


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