By Anna Lembke, MD - assistant professor of psychiatry and behavioral sciences at Stanford
My recent trip to Washington D.C. to speak before a congressional subcommittee on the problem of opioid misuse was all about unmet expectations.
First of all, I never expected to get invited to testify for the U.S. Congress. A 2012 article I wrote in the New England Journal of Medicine on the problem of doctors over-prescribing opioids to patients was picked up by Washington Post journalist Charles Lane in a piece he did, “The legal drug epidemic,” which was subsequently read by Alan Slobodin, chief investigative counsel for the House Committee on Energy and Commerce. Slobodin then sent a message to my in-box asking to “discuss the opioid abuse problem.” I almost deleted it as a hoax. But Keith Humphreys, PhD, my mentor and chief of the mental health policy section in our department, assured me it was real.
Second, not really understanding how government works beyond what I learned from the animated musical cartoon “I’m Just a Bill” when I was seven years old, and being a regular reader of the New York Times, which has almost convinced me that everyone in Washington is against everyone else and nothing ever gets done, I prepared myself for the possibility that various members of the committee might just be looking for sound bites to support their pre-ordained opinions. I was wrong.
Slobodin and his staff were curious, earnest, intelligent, and dedicated to understanding the opioid problem at the deepest level. At the hearing itself, where I and other experts testified on the problem of opioid misuse, overdose, and addiction, Congressman Tim Murphy (R-PA), and Congresswoman Diana DeGette (D-CO) didn’t go for each other’s jugular like a couple of vampires out of Twilight, which I thought might happen. Instead, they were courteous, collegial, and again, struck me as truly dedicated to ameliorating the problem of addiction in this country.
Third and finally, I didn’t imagine that my testimony would make much of a difference, yet some of my suggestions were picked up by members of the committee, including Bridgette DeHart, a senior policy advisor for Congresswoman Yvette D. Clarke (D-NY). DeHart is a whip-smart young woman who in ten minutes of conversation conveyed to me her sophisticated understanding of the opioid epidemic. She talked about incorporating one of my suggestions – mandating physician education on the use of Prescription Drug Monitoring Databases (PDMDs) at the time of DEA-licensure – into a larger bill that Clarke and her team are working on.
PDMDs allow doctors to know all the prescriptions a patient has received for a potentially addictive medication within a given time period, usually 12 months, and within a given geographic region, usually the state. When doctors access PDMDs before prescribing, they can see whether their patient has been “doctor shopping” – going around to multiple prescribers for the same or similar medication, a clear signal of prescription drug misuse, diversion (selling or giving away to others), or addiction, as well as who is getting early refills, or who might be at higher risk of overdose due to various drug combinations, such as combining opioids like Vicodin with benzodiazepines like Valium.
Data show that when prescribers use PDMDs, rates of prescription drug misuse go down. However, only 35 percent of doctors who prescribe controlled substances make use of PDMDs. The DEA license is what allows a doctor to prescribe controlled medications (addictive medications). By mandating physician education on how to use PDMDs at the time of obtaining a DEA license, usually early in a doctor’s career, we can influence their awareness of, facility with, and utility of such databases, and thereby increase the likelihood they will use PDMDs. In other words, if we’re going to give doctors a license to kill, they better know how to use it.
So my trip to D.C. didn’t meet my expectations: I went in a skeptic, and I came out inspired.