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‘We were just throwing around opioids’

Minnesota native Dr. Holly Geyer (MD ’08) is a hospitalist at Mayo Clinic in Phoenix, Ariz., with additional specialty licensure in addiction medicine.

Fresh off the publication of her first book Ending the Crisis: Mayo Clinic’s Guide to Opioid Addiction and Safe Opioid Use (Mayo Clinic Press, 2023), Geyer sat down with North Dakota Medicine to discuss the economics of prescription medications, opioids on television, and how the crisis has already changed medical education.

Dr. Geyer, you’re out with a new book based on the Mayo Clinic’s Opioid Stewardship Program. How would you summarize the book’s emphasis and recommendations?

To put it into perspective, we are 30 plus years into the opioid crisis, and the book represents the collective knowledge of our Opioid Stewardship Program at Mayo Clinic – from all of our campuses – on how to use opioids safely. What is pain? Why do we experience it? How do you use opioids appropriately in certain types of pain? What are alternatives? What’s going on in the brain with opioids? What do we do at the end of the day to get our loved ones into a treatment program and navigate the treatment industry and, from there, the insurance industry? All of these concepts are things that we, as providers, oftentimes neglect to empower patients with. That’s what this book is about – offering those tools directly to the consumer, especially if their provider doesn’t thoroughly offer them.

When was it apparent to you that the opioid crisis was real?

When the CDC [Centers for Disease Control and Prevention] guidelines for prescribing opioids in chronic pain came out in 2016, Mayo Clinic called me in as a physician expert to help initiate an institutional opioid stewardship program. As we explored the national epidemic and all the facets of our practice that would need to be addressed to support safe prescribing and management of opioid addiction, it was obvious I had my work cut out for me. Fulfilling this role has been my life for the past couple of years: addressing how we prescribe opioids safely to the right person for the right reason and the right indication at the right dose for the right length of time, and steering patients to the right treatments when addiction is identified. It’s amazing how much we’ve learned in a decade – there’s so much we can do within the healthcare sector to prevent and manage opioid-related complications! Yet only 23% of U.S. healthcare systems endorse running an opioid stewardship program. There’s certainly opportunity for improvement.

Your book is for patients and families dealing with opioid use disorder, but to what degree is this bigger than individuals: advertising and the pharmaceutical industry, poverty and declining life expectancy in the U.S., and jobs in economically depressed regions?

It would be wonderful if only one discipline or industry was responsible for the opioid epidemic. But problems this big usually involve multiple players, and that’s certainly the case here. To start with, we’ve got pharmaceutical companies that grossly undersold the risks of opioid addiction and heavily marketed their products through what were found to be illegal marketing campaigns. At the same time, we had reputable medical organizations campaigning pain as “the fifth vital sign,” which drove up consumption based on subjective scoring tools. Then we had the federal government tying healthcare reimbursement to patient satisfaction with their pain management plans and the providers who willingly adapted poor quality medical evidence to guide practice. I’m sure many of your readers are familiar with the now notorious five-line letter in the New England Journal of Medicine publicly reporting that prescribed opioids were low risk for addiction – a statement utilized by multiple industries to increase profits. Add to this the millions of Americans who failed to store their opioids safely or saved them instead of disposing of them for the next home do-it-yourself project. This list doesn’t even begin to address issues like poor insurance coverage for non-opioid alternatives or inadequate coverage of addiction treatment services. You’re right that simultaneously compounding these issues were other societal problems like homelessness, financial insecurity, rising rates of mental health disorders, and the growth of the illicit market. When you put this all together, it becomes apparent why there’s no singular solution to ending the crisis.

To that point, are we seeing different levels of opioid use disorder in different parts of the country?

Absolutely. We’ve seen a lot of blue-collar states being disproportionately affected. African American and Latino communities too. Plus, death rates in minority communities are typically much higher than that of Caucasians, and their access to validated treatments is lower as well. Overall, opioid overdose deaths nationally continue to climb. We saw a 30% increase in opioid overdose deaths in 2020, and another 15% in 2021. But the past two years have seen perhaps some stabilization of this increase which gives us hope that perhaps we’re reaching our peak.

I imagine you’ve seen some of the recent television series about opioids, like “Dopesick,” or maybe read the Sam Quinones book Dreamland. What does the fact that all these stories are emerging in popular media tell you about where we’re at as a country with this crisis?

Right now, opioids are the number one cause of accidental death in adults under age 45 in the U.S. But what you’re seeing on every one of those shows is the problem, not the solution. What we need out there is media coverage on patient empowerment to use their opioids safely and the importance of addressing opioid addiction with proven treatments like buprenorphine. We also need the media to help spread understanding on the biological roots that drive addiction.

Has this crisis affected the way we train medical students about opioids and other prescriptions?

I feel privileged to have attended UND where education on pain was robust. Many medical schools weren’t integrating that education until recently. I will say that much of what we know about the biological roots of addiction have grown out of the opioid epidemic, so we’re all learning together now. Most medical schools in the United States now include training on pain and opioids as part of their curriculum. It’s amazing how many of them are enthusiastic about entering fields that address the epidemic – particularly the addiction medicine subspecialty.

To that point – changing both medical education and physician practice – where do you see the next five or ten years with regard to opioids?

We’ve got a long road ahead of us, but we’re making progress. It’s exciting to see how many novel therapeutics are being experimented with to improve pain without causing euphoria or dependency. Similarly, I expect many clinical trials to show that use of non-opioid therapies like scheduled acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs), are as efficacious as opioids for pain management. I certainly hope that more healthcare programs across the United States establish opioid stewardship programs and become increasingly engaged in managing opioid addiction as a part of standard practice.

What’s next for you on all this?

I’m looking forward to more opportunities to speak publicly on the themes covered in the book. I’ve had the chance to get this material to several members of U.S. Congress and hope to be increasingly influential in policy that promotes opioid stewardship at a national level. I’ll also be partnering with the National Football League Alumni Association to help use influencers to spread the word on safe opioid use starting this spring. So overall, I’m optimistic that the messaging will be amplified to a broad range of audiences.

Interview conducted and edited for space by Brian James Schill