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Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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First, Do No Harm

Marshaling Clinician Leadership to
Counter the Opioid Epidemic

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WASHINGTON, DC
NAM.EDU

Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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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.

Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”

—GOETHE

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Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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ABOUT THE NATIONAL ACADEMY OF MEDICINE

The National Academy of Medicine is one of three Academies constituting the National Academies of Sciences, Engineering, and Medicine (the National Academies). The National Academies provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote Jr., is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on issues of health, medical care, and biomedical science and technology. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

Learn more about the National Academy of Medicine at NAM.edu.

Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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AUTHORS

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

Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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NAM Staff

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

Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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REVIEWERS

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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Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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FOREWORD

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

Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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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

President

National Governors Association

Jay C. Butler, MD

President

Association of State and Territorial Health Officials

Michael McGinnis, MD, MPP

Leonard D. Schaeffer Executive Officer

National Academy of Medicine

Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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Suggested Citation:"Front Matter." National Academy of Medicine. 2017. First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/27116.
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There is no question that opioid use disorder has become the fastest growing, serious, and far-reaching public health crisis facing our nation today. The growing and unprecedented opioid epidemic is a critical issue for public health and medical care throughout the country. Provisional estimates suggest that nearly 65,000 Americans died from a drug overdose in 2016, a 21% increase from the previous year and at a level higher than occurred during the peak years for deaths from HIV infection and automobile fatalities.

Nearly half of opioid overdose deaths are related to medications obtained legally by prescription, sparking deep concern among leaders in the health care sector. The need is clear for clinicians, as the "gatekeepers" of opioid prescriptions, and as the front line in facilitating access to treatment for addiction, to work together with state and community leaders to reduce the impact of opioid misuse on American communities.

At the request of the National Governors Association, the National Academy of Medicine convened a group of experts and field leaders to explore clinicians' roles in addressing opioid misuse and addiction. The resulting Special Publication is informed by, and builds on, initiatives and guidelines that have been stewarded by various stakeholder organizations providing leadership in addressing these issues. In the midst of evolving understanding of and experience in pain management and substance abuse, the authors offer to clinicians a set of axioms applicable both to responsible, appropriate opioid prescribing practices, and to recognition and treatment of substance use disorder. Also underscored are actions that clinicians can take to improve their skills and effectiveness in the face of the growing need, including leadership engagement to ensure that communities have the resources and tools that clinicians require to fulfill their responsibilities.

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