First, Do No Harm
Marshaling Clinician Leadership to
Counter the Opioid Epidemic
NATIONAL ACADEMY OF MEDICINE • 500 FIFTH STREET, NW • WASHINGTON, DC 20001
NOTICE: This publication has undergone review according to procedures established by the National Academy of Medicine (NAM). Publication by the NAM signifies that it is the product of a carefully considered process and is a useful contribution worthy of public attention, but does not represent formal endorsement of conclusions and recommendations by the NAM. The views presented in this publication are those of individual authors and do not represent formal consensus positions of the authors’ organizations, the NAM or the National Academies of Sciences, Engineering, and Medicine.
Support for this activity was provided by the National Academy of Medicine.
Library of Congress Cataloging-in-Publication Data
Names: National Academy of Medicine (U.S.), issuing body.
Title: First, do no harm : marshaling clinician leadership to counter the opioid epidemic.
Other titles: First, do no harm (National Academy of Medicine)
Description: Washington, DC : National Academy of Medicine, 2017. | Includes bibliographical references.
Identifiers: LCCN 2017052761 (print) | LCCN 2017053059 (ebook) | ISBN 9781947103115 (Ebook) | ISBN 9781947103108 (pbk.)
Subjects: | MESH: Prescription Drug Misuse--adverse effects | Opioid-Related
Disorders--prevention & control | Pain Management--adverse effects | Physician’s Role
Classification: LCC RC568.O58 (ebook) | LCC RC568.O58 (print) | NLM WM 284 | DDC 616.86/32--dc23
LC record available at https://lccn.loc.gov/2017052761
Copyright 2017 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
Suggested citation: National Academy of Medicine (NAM). 2017. First do no harm: Marshaling clinician leadership to counter the opioid epidemic. Washington, DC: National Academy of Medicine.
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
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SUSAN M. ADAMS, PhD, RN, PMHNP, FAANP, Professor of Nursing, Vanderbilt University, Nashville, TN
CARLOS BLANCO, MD, PhD, MS, Director, Division of Epidemiology, National Institute on Drug Abuse, Bethesda, MD
HUMAYUN J. CHAUDHRY, DO, MACP, President and Chief Executive Officer, Federation of State Medical Boards, Washington, DC
HARRY CHEN, MD, Commissioner, Vermont Department of Health, Burlington (former)
ROGER CHOU, MD, Professor of Medicine, Oregon Health and Science University, Portland
MELISSA L.D. CHRISTOPHER, PharmD, National Director, Academic Detailing, US Department of Veterans Affairs, Washington, DC
PATRICE A. HARRIS, MD, MA, Chair, Task Force to Reduce Rx Opioid Abuse, American Medical Association, Washington, DC
SAUL M. LEVIN, MD, MPA, Chief Executive Officer and Medical Director, American Psychiatric Association, Arlington, VA
SEAN MACKEY, MD, PhD, Chief, Division of Pain Medicine, and Redlich Professor of Pain Medicine, Stanford University, Palo Alto, CA
ELINORE MCCANCE-KATZ, MD, PhD, FAAAP, Chief Medical Officer, Rhode Island Department of Behavioral Healthcare, Providence (now Assistant Secretary for Mental Health and Substance Abuse, US Department of Health and Human Services, Washington, DC)
PAUL A. MOORE, DMD, PhD, MPH, Professor, School of Dental Medicine, University of Pittsburgh, PA
JAMES P. RATHMELL, MD, Chair, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital and Professor of Anesthesia, Harvard Medical School, Boston, MA
TRAVIS N. RIEDER, PhD, Assistant Director for Education Initiatives, Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
BOB TWILLMAN, PhD, Executive Director, Academy of Integrative Pain Management, Lenexa, KS
Development of this publication was facilitated by contributions of the following NAM staff, under the guidance of Michael McGinnis, MD, MPP, NAM Leonard D. Schaeffer Executive Officer and Executive Director of the Leadership Consortium for a Value & Science-Driven Health System:
MONICA WHITLEY, MPH, Program Officer
MICHELLE JOHNSTON-FLEECE, MPH, Senior Program Officer
EMMA FINE, Senior Program Assistant
KYRA E. CAPPELUCCI, Communications Specialist
LAURA DESTEFANO, Director of Communications
MOLLY DOYLE, Communications Specialist
BROOKE KEAN, Intern
This special publication was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with review procedures approved by the National Academy of Medicine. We wish to thank the following individuals for their review of this publication:
RICHARD BONNIE, LLB, Director, Institute of Law, Psychiatry, and Public Policy, University of Virginia, Charlottesville, VA
KATHRYN CATES-WESSEL, Chief Executive Officer, American Academy of Addiction Psychiatry, East Providence, RI
DEBORAH DOWELL, MD, MPH, Chief Medical Officer, Division of Unintentional Injury Prevention, Centers for Disease Control and Prevention, Atlanta, GA
CHRISTINE GLEASON, MD, ScB, Professor, University of Washington, Seattle
TAMARA HAEGERICH, PhD, Associate Director for Science, Division of Unintentional Injury, Centers for Disease Control and Prevention, Atlanta, GA
CHRISTOPHER M. JONES, PharmD, MPH, Acting Associate Deputy Assistant Secretary, Science and Data Policy, Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, Washington, DC
HAROLD PINCUS, MD, Professor, Columbia University, New York, NY
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the publication, nor did they see the final draft before public release. Review of this publication was overseen by Michael McGinnis, MD, MPP, Leonard D. Schaeffer Executive Officer, NAM. Responsibility for the final content of this publication rests entirely with the authors and the NAM.
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The nation is in the midst of a growing opioid-generated public health and medical crisis. The opioid epidemic now afflicts 2.5 million Americans, kills more than 90 every day, disrupts the lives of tens of millions more in the circles of victims’ concerned families and loved ones, and imposes overwhelming treatment, financial, and organizational burdens on our states, communities, health care organizations, and clinicians. The President’s Commission on Combating Drug Addiction and the Opioid Crisis has called for a national state of emergency, pointing out the scale of the epidemic as equivalent to a September 11 attack every 3 weeks, with a similarly tragic impact on the familial, social, and economic connections we all share.
Last year, 46 Governors signed the 2016 Governors Compact to Fight Opioid Addiction, pledging to redouble efforts, including the reduction of inappropriate prescribing and the provision of needed treatment services. It marked the first time in over a decade that the Governors have used a compact to drive collective action. A blueprint has been developed, and each state has set in motion renewed efforts to improve the effectiveness of community-level prevention and treatment activities, including shoring up the state-wide policy and enforcement capacities needed. Although we are seeing improved awareness, commitment, and initiative for change, the opioid crisis—the rapid rise of opioid use disorder—cannot be controlled without the partnership of key stakeholders.
Given its leadership role in science, policy, and practice, the National Academy of Medicine (NAM) is a committed stakeholder in this work. The National Academies’ 2017 report Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use called attention to the importance of achieving the right balance in medicine’s twin obligations to treat pain effectively and to prevent and treat opioid use disorder. It proposed a comprehensive strategy for doing so, including the use of effective nonopioid analgesics for chronic pain management, improved monitoring and assessment of the prescribing and use of opioids, incorporation of a public health perspective
in the FDA’s review of pharmaceuticals, and reduction of barriers to treatment of opioid use disorder.
To ensure the synergy and reach of our efforts to the front lines, the NAM, at the request of the National Governors Association, has brought together a group of experts representing the key leadership of the nation’s scientific, professional, and policy organizations to explore clinicians’ role to counter the opioid epidemic. We are pleased to present the result of that work in this NAM Special Publication, First Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic.
This call to action for the nation’s clinicians—physicians, physician assistants, nurses, nurse practitioners, dentists, social workers, behavioral health practitioners, pharmacists, and first responders—examines the potential that resides in their reach, expertise, and commitment, and highlights their roles in prevention, management, and leadership to address this crisis. Through this lens, it outlines action steps to quicken the pace of progress as we marshal their energies and effectiveness in implementing strategies that will benefit both the health and well-being of their patients and the health of their communities. Only through the sort of collaboration represented here can we anticipate countering the opioid crisis and its toll on our patients, communities, states, and the nation. We are pleased to join together in this work and grateful to the authors for their foundational contribution.
Scott Pattison, JD
CEO and Executive Director
National Academy of Medicine
Victor J. Dzau, MD
National Governors Association
Jay C. Butler, MD
Association of State and Territorial Health Officials
Michael McGinnis, MD, MPP
Leonard D. Schaeffer Executive Officer
National Academy of Medicine