Updated May 26, 7: 40 ET
U.S. Surgeon General Dr. Jerome Adams on Wednesday called for emergency physicians to take a bigger role advocating for evidence-based opioid abuse treatments including harm reduction.
Speaking at an American College of Emergency Physicians forum in Washington, D.C., the nation's top doctor urged physicians to do more to engage community stakeholders and help them understand why harm reduction could be an effective strategy. He said community-based conversations could range from basic education to syringe services programs to safe injection sites. Communities need to assess their situations and the science and determine the best approach for their residents.
"We have to understand that these policy interventions look different in different parts of the country," Adams said. "We have to understand that public policy means public, and that we have to be able to go there and show them that we care before we can share what we know."
Adams said the government should do everything possible to make it easier for ED doctors to prescribe medication-assisted treatments like buprenorphine. He noted that France experienced a 79% reduction in overdose deaths over four years in the 1990s after allowing doctors to prescribe buprenorphine without training requirements or limits on how many patients they could treat.
More than 50,000 of the more than 950,000 physicians active in the U.S. are certified to prescribe buprenorphine, according to the U.S. Substance Abuse and Mental Health Services Administration. Currently, physicians who wish to prescribe buprenorphine are required to apply for a waiver and undergo an eight-hour continuing medical education course.
Physicians are initially allowed to prescribe buprenorphine to as many as 30 patients, and they can apply to distribute to 100 or 275 patients under regulations implemented in 2016.
Many public health experts have contended the requirements limit access to medication-assisted treatment and make it cumbersome for physicians to get certified, which they claim has discouraged many from applying.
"As you look at France, they were able to drive down their opioid rates and their heroin usage by making it easier for folks to get access to MAT," Adams said. "So, we know that this can work."
But Adams wouldn't advocate eliminating training requirements for buprenorphine prescribers entirely, noting it's difficult to set a blanket policy since each part of the country has its own challenges in responding to the opioid crisis.
"We have to understand that public policy is complicated and we need to make sure we're designing programs that are optimally beneficial where we minimize the downside," Adams said.
He said ED physicians need access to community resources to refer patients to long-term recovery programs, which could help break the cycle of patients overdosing, stabilizing at EDs, undergoing detox and being discharged with no recovery support if they cannot enter a treatment facility.
Buprenorphine abuse is another issue that may prevent expanding MAT prescribing efforts. Suboxone, a MAT that combines buprenorphine with the overdose reversal drug naloxone, has become the No. 1 contraband drug found in prisons.
Indeed, the number of cases involving buprenorphine abuse have increased as the drug has proliferated. A 2013 study by the U.S. Substance Abuse and Mental Health Services Administration found buprenorphine-related ED visits rose from 3,161 in 2005 to 30,135 in 2010, and 52% of cases stemmed from non-medical use of the drug.
By comparison, there were more than 142,000 opioid-related ED visits across 45 states between July 2016 and September 2017, according to a March report the Centers for Disease Control and Prevention.
Correction: A previous version of this article said the surgeon general support safe injection sites. A spokesperson sent the following state clarifying his position:
The Administration and the Surgeon General do not support so called "safe" injection sites as a means to combat the opioid epidemic and its consequences. In addition, there is no evidence to demonstrate that these illegal sites reduce drug use or significantly improve health outcomes for those with opioid use disorder. So called "safe" injection sites lack the necessary scientific support to be considered a standardized evidence-based practice in the U.S.