The Surgeon General of the United States recently released a report on the state of our current knowledge about the etiology and treatment of drug and alcohol addiction in this country.1 Both the complete report and a summary are available online, and I would encourage all physicians to read at least the latter.
Health or Political Issue?
Substance misuse is a major public health problem, and the federal government’s official recognition of this is important. Note that the report was released while President Obama was still in office. One hopes this issue will be dealt with in a nonpartisan manner as members of all political parties are at risk for developing the problem. However, in light of the new administration’s focus on using the influx of illegal drugs as a major talking point to support the building of a wall along the Mexican border—while ignoring that almost all prescription opioids are manufactured here or are legally imported—how seriously addiction will be addressed as a health issue and not a political one is open to question.
From my perspective as a pain medicine specialist, the report contains a vast amount of information but overlooks a number of important issues. Most important is the failure to address iatrogenic opioid misuse, ie, a patient who is prescribed opioids for legitimate pain complaints ends up misusing or abusing them. The focus is only on nonmedical use of these drugs.
Leaves Readers in a Quandary
The lack of attention to iatrogenic misuse leaves readers in a quandary. Does the exclusion suggest that the problem does not exist--or that it does but is so insignificant that it’s not worth dealing with? Or, is it something else?
As virtually all of the medical professionals involved in writing the report were substance abuse, mental health, or HIV/AIDS experts, many may be unaware of or dismiss the problem as rare and not worth discussion. From my experience in discussing this issue with many mental health and substance abuse specialists, this frequently is the case.
Little Mention of Pain
The report barely mentions pain. When it does, it is to refer readers to the CDC Guideline for Prescribing Opioids for Chronic Pain released in 2016 and to note that patients with chronic pain and substance use disorder are more likely to be prescribed opioids than patients with chronic pain alone.
The report also recommends that patients with opioid use disorders and chronic pain may need multidisciplinary collaborative care but primarily focuses on integrating mental health services with general care. However, it fails to highlight the importance of providing nonpharmacologic alternatives for patients who have chronic pain to help manage it.
1. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: the Surgeon General's Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016.