“Prevention as Prevention”

Drug use is reaching a crisis level in Massachusetts and around the nation. Just look at the cover of today’s Boston Globe and you will see what I mean.

At MGH yesterday, Sarah Wakeman, Mark Eisenberg, Justin Alves, and Jackie Chu facilitated an excellent session about opioid use and buprenorphine. If you have 2 minutes and could answer the following question, either via email or anonymously if you prefer, I’d be grateful. I set up a survey monkey here for anonymous responses. It’s just 1 question:

“Dr. Thomas Frieden’s NEJM article on the future of public health argues that clinical medicine focuses on numerators while public health focuses on denominators. When we are thinking about opioid use, I believe that “Treatment as Prevention” is an urgent priority, with the use of buprenorphine, for example. For those of you who aren’t aware, “Treatment as prevention” is a concept from HIV medicine. However treatment as prevention is a downstream intervention. Here’s the question: what upstream, public health interventions could be implemented to reduce the supply (and use) of 1) heroin, and 2) oxycodone, hydrocodone, etc. This  strategy could be called “Prevention as prevention.” Political/ legal/ advocacy suggestions are welcome!”

A few responses:

  1. Doctor in Boston- Based on Portugal’s experience with decriminalization of drug possession and the Swiss and Vancouver prescription heroin programs, I believe that if we should legalize all drugs and sell them in government regulated stores to > 21 yo’s. I would divert the money spent on interdiction and incarceration to drug treatment and jobs programs, like is being done in Portugal.
  2. Anonymous– Tracking and publication of individual physician opiate prescribing patterns (with comparison to peers in similar practice), including number of patients receiving prescriptions, number of prescriptions per patient per unit time, number/dose of opiate per prescription, number/dose of opiate per patient. Would help physicians compare their own practice to peers, plus possibly more aggressive interventions for excess prescribing patterns.
  3. Nurse in Boston- My experience is that is much less a supply issue and more of a demand problem. Looking at the opioid epidemic in the state of Massachusetts young people are accounting for the large majority of the incidence of new users. I had a nursing professor who once said, “Sex and drugs are the after school programs of underprivileged, poor adolescents” I think this rings true throughout the epidemic. Lack of other resources (quality Early intervention programs and mental healthcare) and interests (whether it be jobs, school, or afterschool programming) are probably most culpable for the onslaught of new patients with substance use disorders. The reason for the continued prevalence of the problem lies in lack of access to quality treatment programs. Currently the Section 35 program in the state has a waiting list that is growing every day, there are just no beds to be had and you need look no further than our own ED on any given day to find that is true. Another intervention that has been looked at and tried, but has been stalled in Congress to increase access, is to have NPs rx buprenorphine, which is currently off the table.
  4. Professor Lundy Braun- These are important issues but the structural conditions leading to drug use overlooked. Need more historical framework. See my article.

I may use your responses (anonymously or named, with permission) for an article I am writing about opiates.

Thanks so much for reading! Reading/writing blog posts does take time and we all know that time is in short supply. You and I will both get much more out of my blog posts if they lead to discussion/dialogue. If you found this post useful and wouldn’t mind leaving a brief comment/sharing on social media, that would be great.Thank so much! Best regards, Phil

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