hen I was training to be an Air Force Pilot in 1987, one of the many things I was required to commit to memory — verbatim — and to practice religiously in a T37 aircraft was how to pull an out-of-control plane out of a spin. Thirty years later, I can still see the steps in my mind’s eye and recite them:
- THROTTLES – IDLE.
- RUDDER AND AILERONS – NEUTRAL.
- STICK – ABRUPTLY FULL AFT AND HOLD.
- RUDDER – ABRUPTLY APPLY FULL RUDDER OPPOSITE SPIN DIRECTION (OPPOSITE TURN NEEDLE) AND HOLD.
- STICK – ABRUPTLY FULL FORWARD ONE TURN AFTER APPLYING RUDDER.
- CONTROLS – NEUTRAL AFTER SPINNING STOPS AND RECOVER FROM DIVE.
The Air Force calls procedural lists like these “boldface” because, as you might guess, the critical actions that pilots need to know by heart — those the training manuals said “must be performed immediately if the emergency is not to be aggravated, and injury or damage are to be avoided” — are bolded.
After nearly a decade in the Air Force, I traded my flight suit for a white coat, and began practicing emergency medicine in 2000. I came to realize that the cockpit of a jet and my work station in the emergency department were similar environments. Both were high speed, filled with constant auditory and visual cues all competing for attention, and both had procedural boldface. In the emergency department, it was “Start an IV; Administer oxygen; and Place on the monitor” for sepsis, and “Check the airway, breathing, and circulation; Shock at 120-200 joules” for cardiac arrest.
I think a little boldface can help us ease the opioid epidemic.
My medical training occurred as the opioid crisis was taking hold. I remember being taught — and then teaching others — that the opioids used to treat pain weren’t addictive. Providers were subtly but constantly given incentives to prescribe opioids: the ascendance of pain as the fifth vital sign, pain control playing a key part of patient satisfaction surveys, and the constant parade of pharmaceutical reps. These helped nudge us in the direction of overprescribing pain medication.
Back then, signs of the developing opioid epidemic were becoming visible in the nation’s emergency departments. We saw a growing number of patients become “frequent flyers,” often urgently asking for more medications. I saw these patients, who we now diagnose as having substance use disorder, just about every day I worked in the emergency department.
One patient, I’ll call her Kelly, stands out as the tipping point in my clinical career that nudged me toward becoming involved in the daily fight against America’s drug epidemic. All of my partners knew Kelly — she was often in our busy emergency department, sometimes several times a week. Kelly’s strategy was to check in often, hoping to draw one of the doctors who hadn’t yet seen the light on taking a more careful line on prescribing opioids. We called these patients doctor shoppers.
On the days she drew me, Kelly and I would have our usual discussion about how I didn’t think it was in her best interest to prescribe more pain medications, followed by a conversation about non-opioid pain options and possibly getting treatment for addiction. She, as usual, would say she wasn’t interested.
One day as I started a shift, I saw on the board that Kelly was already in the emergency department, being seen by another provider. I decided to see how she was doing. As I approached her room, I heard the characteristic sounds of a ventilator chuffing and puffing. Upon entering, I saw that Kelly was intubated and unresponsive. She had been found, unconscious, lying on the floor in her bedroom. She died from that overdose a couple days later.
Shortly after Kelly died, our hospital designed a program to coordinate and standardize the care for our frequent flyers. Over the next year, we identified hundreds of them. We thoroughly reviewed each patient’s medical record, created an individualized care plan, and obtained a consult with a social worker.
Simultaneously, our emergency department team developed and agreed upon a consistent approach to these patients that included evaluation, treatment, and communication focusing on non-opioid pain strategies. The program was effective on almost all fronts. The one outlier was that few of our patients took us up on our offer to find an addiction treatment provider. Instead, most gradually went elsewhere for care, presumably looking for easier ways to obtain opioids.
Almost a decade later, the opioid problem has morphed into an even deadlier epidemic involving complex interactions between prescription drugs and illicit ones like heroin and fentanyl. The forces of government and private industry have mobilized in earnest, which I hope will translate into real solutions. The U.S. is in the midst of increasing its capacity to treat people with substance use disorders, and prescribing guidelines aim to reduce the number of people who become addicted to opioids.
Although much is happening, the complexities haven’t gone away. As I think about what’s needed, I’m drawn back to my pilot days and hear the boldface for how to abort a takeoff:
- THROTTLES – IDLE.
- WHEEL BRAKES – AS REQUIRED.
A pilot does that when he or she is rolling down the runway and picking up speed and notices something isn’t right. Bringing the throttles to idle stops the plane’s acceleration; applying the brakes further slows the plane. It sounds simple and perhaps even silly, but I have used it as intended several times and it has never failed me.
As I think about the uniqueness of every patient’s situation, and the rapid evolution of medicine in the U.S., this boldface seems applicable to the opioid epidemic.
We see many patients who are accelerating their use of opioids, or about to “take off” with them. When we notice those warning lights, or just get the feeling that something isn’t right, doctors should bring the throttles to idle and use the brakes as required — slow down the visit and take the time to learn what is going on and, when needed, talk about decreasing the dose of pain medication, obtaining treatment for substance use disorder, or whatever else will work for the patient’s situation.
As you can see from the boldface, it’s far easier to abort a takeoff and deal with problems early than wait until things are spinning out of control.
Jim Huizenga, M.D., is the chief clinical officer at Appriss Health, a Kentucky-based company that provides hospitals and other care organizations with a prescription drug monitoring program platform.