Addiction is a chronic, treatable disease, like diabetes and high blood pressure. Unlike most other chronic diseases, though, addiction comes with the burden of stigma. This stigma presents enormous problems.
It can limit access to evidence-based care and may prevent those with addiction from feeling comfortable disclosing their history. Sharing that information is as vital and as relevant to getting good medical care as a patient revealing that she has heart disease or had surgery several years ago. Relapse to active substance use can happen at any point in the recovery process, even after years or decades of sobriety, and care providers should be aware and ready to support all patients in all steps of recovery.
As we have seen firsthand in our work developing Massachusetts General Hospital’s new guidelines for using opioids, the situation becomes particularly complicated for individuals with a substance-use disorder, or in recovery from one, who experience an acute, painful medical episode like recovering from surgery.
Such patients and their health care providers are challenged to strike a fragile balance between undertreating pain and giving the patient opioids. Both of these pathways come with the risk of disease recurrence for someone with addiction. Negotiating this balance with a patient is essential. Yet it is not something most physicians have been trained to do.
The medical community has spent the past two decades focused on treating pain. Now we need to learn how to balance the sometimes competing needs of compassionate pain relief and addiction prevention, treatment, and recovery management.
Recently on STAT, Seth Mnookin shared a personal story of managing a painful episode of kidney stones from the perspective of someone in long-term recovery from a substance-use disorder. Throughout his medical journey at Massachusetts General Hospital, he was open and forthright with his caregivers about his history of addiction.
Given the stigmatization of patients with substance-use disorder, that took courage. Mnookin’s frankness enabled his medical team to factor his history into treatment decisions. A troubling — though sadly not surprising — point he raised in his article was that with his history of addiction, he didn’t get adequate counseling about how to manage opioids for pain upon his discharge from the hospital.
The national opioid epidemic continues to strain the health care system in many ways, and hospitals and physicians today are struggling to figure out the most effective ways to care for patients with addiction who come through their doors.
At Massachusetts General Hospital, we have made addressing addiction the hospital’s top clinical priority. More than a year ago, we formed a multidisciplinary addiction consult team, one of only a handful of hospitals across the country to have such a resource. We integrated addiction treatment within our community health centers and other primary care practices. And we hired seven recovery coaches who have experienced firsthand the struggles of addiction and are there to support patients in the community on their path to recovery.
In the emergency department, we have an addictions advanced practice nurse and social workers to help patients with substance-use disorders. We are also piloting a transitional clinic that provides short-term care for patients from the hospital and emergency department who need ongoing treatment but are not yet connected to outpatient and community services.
For nearly a year, our opioid task force has worked to develop guidelines for the safe and compassionate treatment of pain in all care settings. These guidelines, which are being released Wednesday, provide strategies for prescribing opioids for both acute and chronic pain. Specific recommendations include:
- prescribing opioids only for severe pain not relieved by other treatments;
- screening patients to determine who might be at risk for problems with opioids;
- counseling patients on the potential risks of opioids, including addiction and overdose;
- regularly monitoring and reevaluating patients on long-term opioids for chronic pain;
- and, when appropriate, prescribing nasal naloxone for patients at increased risk of overdose.
Once fully integrated into the MGH community, these guidelines will address the gap that Mnookin described in his narrative.
Health care providers have the responsibility of safely managing their patients’ pain while devising new and innovative ways to treat those suffering from substance-use disorders. Mnookin’s story highlights the need for greater screening and counseling, not just for patients with active addiction but also for those in recovery.
The challenge has never been greater, and our commitment to it has never been stronger.
Sarah E. Wakeman, MD, and Eric M. Weil, MD, are chairs of Massachusetts General Hospital’s Opioid Task Force.
Even before this policy, the unassisted prescribing of an opioid to a patient that communicates his status and concern seems unwarranted. How does MGH explain that and how frequently does it occur?