First and foremost, the Surgeon General's recently released report "Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health" is a tremendously informative and culturally important step in the fight against prescription drug misuse and abuse. Historically, Surgeon General reports have changed our national conversation on critically important public health issues such as smoking (34 separate reports from 1964 to 2014), HIV/AIDS (3 reports from 1987 to 1992), and mental health (2 reports from 1999 and 2001). The fact that Dr. Vivek Murthy, our current Surgeon General, has turned the attention of the public health community to the topic of addiction is certainly a sign of progress.
Among its many constructive contributions, the report attempts to re-frame our nation's struggle with addiction in 'public health' terms rather than 'criminal justice' terms. This change in approach appears to be among the precious few issues that have garnered bi-partisan support over the last couple of years, including through our most recent (and otherwise rancorous) election cycle. Delays have dangerous ends, so I'm hoping that a change in party occupying the White House won't lead to a reversion in the public health progress we've begun to make.
I did, however, find one notable omission from the Surgeon General's report.
Most readers of this blog live in the world of pain management and long term opioid use. We see our daily battle as inextricably linked to the broader issue of addiction in our society and we see, up close and personal, a lot of the underlying causes that need to be addressed (mental and behavioral health issues, unrealistic expectations of pain relief, social factors that influence healing and pain perception, etc.) But our lens on the issue is unique: what we often see is a legitimate prescription that is medically unnecessary (and, in many cases, downright harmful).
Interestingly, in Chapter 1 of the Surgeon General's report, the classes of drugs we most often encounter (pain relievers, tranquilizers, stimulants, and sedatives) are categorized under the heading "Illicits" and sub-categorized for purposes of reporting on misuse and abuse as "non-medical use." The Surgeon General relies on the self-reported statistics from National Survey on Drug Use and Health. I see this as a problem. Take an example:
Premise: Bob was injured on the job back in 2011. He perceives himself to be disabled (because everyone in his life keeps telling him he is) and began taking, as directed by his physician, 20 mg of oxycodone 2X day immediately post-injury... and is now taking 80 mg of the same drug 4X a day five years later.
Question 1: Would Bob categorize his use of oxycodone as "non-medical"? He would not.
Question 2: Is Bob's use of oxycodone medically necessary? Probably not. In fact, it's probably inhibiting his functionality and ability to recover from the original injury.
Question 3: Is this category of drug use ('medically unnecessary') an important component of the public health dialogue around misuse of drugs? Absolutely.
So why isn't it considered in the SG's report? Maybe the data wasn't there. Maybe the SG didn't want to rub the physician community the wrong way (he needs to enlist them in the fight, so why tick them off or impugn their credibility by blaming them for inappropriately prescribing in a seminal report?)
Whatever the reason, there's a category missing from the report. And it's an important one. Every time we taper a patient off of an opioid that wasn't helping him, we contribute to the progress against prescription drug misuse and abuse.
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