It was 2 a.m., 22 years ago, when I answered the phone.  My friend’s brother, barely audible, asked if I wanted to buy his parents’ silverware or maybe a saltwater fish tank setup.  He would be over in less than an hour, and we could settle on the price then.  Another close friend was distraught, having just been informed that her daughter, a freshman in college 3,000 miles away, had been found unresponsive on the floor and taken to the emergency department.  A colleague’s sister was found unresponsive in a bathtub, too late for resuscitation that time.  Then there were the dozens upon dozens of men and women, from teenagers to those at least into their 60s, who were recipients of the clean needles and bleach kits we were handing out in shooting galleries (congregations of IV drug users) in Boston in the late 1990s to slow the spread of HIV prior to the establishment of a needle-exchange program.  Lastly, there was my ex.  We had been together for almost five years, apart for just about as long, when a mutual connection let me know about her fatal overdose at age 35.  Among the aforementioned, there is a highly successful corporate executive, an attorney, an elementary school teacher, a shop worker, and all are either sisters, brothers, sons, daughters, partners, parents or spouses of many others who never really understood what could be done and often became too spent to go any further and hopelessly gave up trying to help.  Nothing has changed that much.

Virtually every shift in urban, suburban or rural emergency departments requires attention to opioid and multi-substance addiction.  In the last month, I can recount the faces, ages and backgrounds of 10 people with life-threatening overdoses, too and two, young dead. This does not include the encounters referenced by colleagues, who were attending the ACEP Scientific Assembly in Chicago last month, as their biggest professional challenge.  Nothing trumps the consistency in the numbers seen with addiction, along with the incessant frustration, attached to misconceptions of what addiction really is and how many of us react to it poorly, both professionally and privately.  Refer to The New York Times, Sunday, Nov., 30, 2014, front-page story.

There is confusion amongst healthcare providers and society in general as to who addicts really are and limited knowledge or insight as to what can really make a long-lasting difference.  Paradoxically, some base their entire careers on creating wealth by writing prescriptions without any true investment in their patients’ welfare.  There are many more primary care providers, inundated with patients requiring chronic pain management, who have limited time and options to do so safely and who are hoping for more viable and tightly regulated treatment centers and resources.  There are people who are adamantly against treatment clinics being in their backyard, although the situation already is.  Fortunately, there is some necessary disruption on the horizon to share and increase information and resources.

There are dissemination of news bulletins regarding the heroin epidemic in N.H. and throughout the U.S. and more humanistic attempts to deepen awareness of addiction and that specifically “opioid use disorder is a chronic illness without a cure.”  Refer to JAMA 2014;311[14]:1393.  There is a push to accept somewhat ubiquitous availability of naloxone, including to non-medical personnel.  Refer to “Providing Naloxone to Non-Medical Personnel Can Prevent OD deaths without Increasing Abuse.” Emergency Medicine News, Sept. 2014, vol.36, No 9;12.  Collectively, there is more detailed exchange of necessary information that must occur in order to take the steam off the mirror.  We need to look at ourselves and each other as prescribers as clearly as possible to facilitate transparency and to avoid neglecting our moral compasses.

There is information to help all of us better understand fact and fiction in order to move swiftly forward with what must be done.  Fact: there is an 80/20 rule among prescribers, where approximately 80% of bad outcomes and overdoses are attributed to about 20% of prescribers.  Fiction: addicts and drug abuse are completely tied to socioeconomic backgrounds.  Without in depth awareness of what has been going on for decades and without universal acceptance of treatment guidelines through linkages between prescription monitoring programs to address multi-substance addiction with education and interventions, long-lasting successful outcomes unfortunately remain the exception.  Stigmas simply get passed on, and those in need get passed over.  A multi-factorial approach is needed to focus and expand future addiction treatment methodologies.

There is legislative discussion to increase funds for addiction recovery and treatment services.  This is the tip of the iceberg.  It will take a nation of villages, organizations and professional societies to create a sustainable public awareness forum that can uniformly deliver and govern throughout the states.  There needs to be more federal- and state-regulated treatment centers.  Privately owned clinics should not only be mandated to register with the state, but not allowed to dispense schedule ll or lll medications and have their practices routinely assessed for maintaining standards of care through unannounced site monitoring to go beyond having pain contracts with patients.  There are evidence-based practices and policies that are successful in saving lives, support many to become highly productive individuals and limit the aberrancies in prescribing practices. Refer to JAMA 2014.; 312, [17]:1733. 

Please offer feedback and resources that I and others can pursue.  The 2015 NHMS scientific forum will be “The Many Faces of Addiction.” What a great opportunity to engage our colleagues and our communities.


 Lukas Kolm, MD, MPH, FACEP

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Very timely and helpful article. The links you included lead to very useful references.