Use opioid settlement funds to educate doctors

A nurse or pharmacist outreach educator can provide an interactive one-on-one conversation with a physician, like pharmaceutical sales reps do for other purposes.

A pedestrian was reflected in a window of Walgreens in Washington, D.C., on Nov. 2.BRENDAN SMIALOWSKI/AFP via Getty Images

A pair of recent developments could substantially boost the nation’s capacity to deal with the opioid crisis. CVS and Walgreens will pay over $10 billion to settle charges against them for over dispensing opioids; this will add to the $3 billion agreed to by Walmart and would bring the current sum of expected settlements to over $54 billion.

In addition, the Centers for Disease Control and Prevention revised its 6-year-old guidelines on how to prescribe these medications, adding expanded advice on the need to carefully taper these drugs in patients who are dependent on them, rather than shutting off the prescriptions (or the patients) abruptly. These recommendations would help move the country’s struggle against addictive substances further beyond Nancy Reagan’s unhelpful “Just Say No To Drugs” vision of the 1980s. The older CDC recommendations had strongly warned doctors about the risks of narcotic painkillers, but simplistic application of the guidance sometimes precipitated acute withdrawal symptoms, limited pain control for sick patients, and increased the risk of death by forcing some people to switch to street drugs, raising their chance of overdose. The revised guidelines take a more nuanced approach to lowering unnecessary opioid use while avoiding the downsides of ham-handed restrictive policies.

These new developments could be creatively combined to reduce the misprescribing of opioids and provide better care to patients in pain. As things stand, most doctors will never even see the new CDC guidelines since the government doesn’t actively disseminate its messages the way drug companies do. And our profession will continue to underuse buprenorphine, a safe and effective treatment that can wean opioid users from addiction. New reforms last year made it much easier for doctors to prescribe “bupe,” and more legislation could be in the works to make that even easier. But few practitioners understand the complexities of how to use it and many don’t know about the key rule change that made this life-saving medicine much more accessible to doctors and our patients.

It’s now clear that a major cause of the opioid epidemic was the unscrupulous but very effective marketing of these addictive drugs to doctors by companies like Purdue Pharma, which sent their sales reps (known as “detailers”) to our offices to make promotional pitches that overstated benefits and lied about risks. For several years, my colleagues and I have been using that tool in reverse, sending health care professionals to physicians’ offices to “market” non-biased information about many kinds of medications. The approach was developed in the 1980s and dubbed “academic detailing.” Such programs have been shown to work well in randomized trials; their application to the opioid crisis is a particularly good fit, since each doctor comes to these prescribing decisions with different attitudes, knowledge, and biases.

Dealing with that is best addressed when a nurse or pharmacist outreach educator engages in an interactive one-on-one conversation with a physician, as pharmaceutical sales reps do for their own purposes, rather than just sending out a copy of guidelines or a threatening memo. The drug companies know this works to change practice; that’s why they spend over $5 billion each year on their own detailing programs. De-marketing programs like the kind we’ve developed for the opioid crisis are now supported by funding from federal agencies like the CDC, Pennsylvania and other states, the Veterans Affairs health system, and the health insurer Aetna, among others. Eighteen years ago, my colleagues and I set up a nonprofit called Alosa Health that accepts no pharmaceutical funding and offers such evidence-based outreach on many topics in primary care; it’s named after the genus of fish that swim upstream, like herring.

The billions in opioid settlement dollars that are now starting to flow will be used for many pressing needs: rehabilitation of patients with addiction, reimbursing programs like Medicaid that spent millions of scarce dollars on drugs like Purdue’s OxyContin that were marketed under false pretenses, and other worthy causes. But as the massive settlement funds roll in, at least a small proportion ought to support such nonprofit re-education programs for health care professionals. That could help more doctors access the detailed clinical information we need to offer safer, evidence-based pain treatment that is not addictive and to deploy available, effective tools to help patients who have become opioid-dependent.

The knowledge base we doctors need to combat the opioid crisis is out there, but spreading the implementation of these strategies will require a boost from a delivery system that proactively transmits them to front-line practitioners who need all the help they can get in managing these tough clinical problems. And as the salespeople at Purdue Pharma knew all too well, recommendations on what to prescribe don’t just disseminate themselves.

Dr. Jerry Avorn is a professor of medicine at Harvard Medical School.