Professor aims to change opioid prescribing practices
RICHMOND, Va. (AP) — A picture in VCU Health’s ambulatory center downtown looks, from a distance, like a tree.
“But if you get closer,” said Dr. A. Omar Abubaker, “you see it’s actually a collection of faces and images. To me, the opioid epidemic, both to clinicians and to the public, it’s from a distance. If I say, ‘Opioid epidemic,’ the first thing you think about are the graphs, the number of people that died, the statistics.
“For those of us that are affected, it’s about faces, memories, sons and daughters.”
Abubaker is the chairman of Virginia Commonwealth University’s School of Dentistry’s Department of Oral and Maxillofacial Surgery. He has been with the school for more than 25 years and, for most of his career, he was like every other doctor when it came to prescribing opioids: It was a habit.
But all that changed in September 2014, when his son died of an overdose of heroin, an illicit opioid drug.
There are still pieces of his son’s death that Abubaker cannot talk about. Pieces that, even when he tries to gather himself and face them when he is alone, haven’t gotten easier.
The experience radically shifted not just Abubaker’s personal life, but his professional one, too.
Suddenly, he wasn’t seeing the opioid epidemic in terms of charts and graphs and startlingly large annual death numbers, including 1,133 in Virginia last year. He was seeing his 21-year-old son.
And he knows — probably as well as anyone — how providers’ prescribing practices have fed the opioid epidemic. Though he isn’t certain what caused his son, Adam, to use heroin, he does know he was probably overprescribed opioid painkillers following surgeries when he was a teenager — the same drugs that Abubaker used to frequently prescribe.
“Both in medicine and dentistry, the Hippocratic Oath says, ‘Do no harm,’” Abubaker said. ’In fact, ‘Do no harm,’ comes even before, ‘Do good.’
“So the ‘Do no harm’ part comes down to how we stop prescribing medications as much as we have in the past. And the ‘Do good,’ is to see if our society — or any of us — can do something to make this better, to help the families affected.”
Providers have already started changing their prescribing practices, with federal data showing a dip in the most popular painkillers beginning around 2013 in Virginia. The state is also beginning to see fewer prescription painkiller deaths. In the first quarter of 2017, 113 people died from prescription opioids, down from 124 who had died at the same time last year.
But people cut off from the painkillers they grew addicted to have turned to illegal versions of the same basic drug in the form of heroin and fentanyl, offsetting any progress made on the prescription side. There were 127 heroin overdose fatalities so far this year, compared with 110 last year. The deadlier drug fentanyl is killing even more people — 190 so far this year, compared with 145 this time last year.
“This is the only disease created by doctors,” Abubaker said. “And it could be fixed by doctors.”
After the death of his son, Abubaker spent a year educating himself about addiction and received a graduate certificate in international addiction studies.
“I educated myself, because I didn’t want to be talking about it emotionally as a parent. As an educator, I have to talk intelligently and scientifically,” he said.
Dentists in the community still overprescribe opioids, he said. But he also has hope that, slowly but surely, more dentists are learning about the harm of such prescribing practices. He speaks regularly to community dentists about how they should change their prescribing practices.
When Abubaker was a dental student in the 1980s, opioids weren’t quite as popular. They really began taking off in the 1990s.
“That’s when teaching pain management changed, by pharmacy companies, by hospitals, by everybody that wanted to make sure you gave enough pain medications,” he said. “I vividly remember people telling me that people don’t get addicted if they have pain.
“I used to ask people: What do you do for pain? They’d say, ‘Percocet,’ and I’d say, ‘OK, no problem.’ Never, ‘Is that too strong for you?’ And that’s the pattern.”
Prescribing opioids became a habit for physicians. And it was the same for Abubaker before his son died. He was a typical doctor, he said, and that meant he would give out prescriptions for pain. He, like most other doctors, didn’t think there was anything wrong with it.
“Before, (it wasn’t) even a thought to give a prescription for a narcotic. It’s just a practice. It’s a habit,” he said. “Everybody that gets a tooth pulled — whether it’s one tooth or 10 teeth or all teeth — they get a prescription. And I don’t want to say I was careless, but I was like 95 percent of doctors and oral surgeons.
“So what I tell you about me before is reflective of the dental profession in general, and the practice of medicine.”
Though the opioid epidemic has been raging for years, Abubaker said dentists continue to overprescribe opioids.
For the majority of adolescents, dental procedures are the primary way through which they first take an opioid painkiller, he said. Common procedures like wisdom teeth removal often result in such a prescription.
“I have parents who send me letters telling me that their dentists still prescribe narcotics,” Abubaker said. “As much as I feel like many are informed, there are a lot of people out there who are not informed.”
One of the biggest ways to change how opioids are prescribed is simply to inform students of how dangerous they can be, and to train them according to new guidelines developed by the Centers for Disease Control and Prevention and the Virginia Board of Medicine.
Since the School of Dentistry changed the way it teaches about opioids, it has seen a difference in the number prescribed.
In 2015, 50 percent of the patients who had procedures like extraction or implants at VCU’s oral and maxillofacial program received narcotics — a class of drug that includes opioids — according to Abubaker. That is typically a higher number because those patients are more likely to have major surgery. In 2016, 44.37 percent of patients received narcotics.
For the School of Dentistry, 1.32 percent of patients who underwent procedures received a narcotic prescription in 2015. By 2016, that number reduced to 0.96 percent. Abubaker said he hopes to lower the rate of patients who receive opioid prescriptions after extractions to less than 10 percent.
Dr. Alan Dow, assistant vice president of health sciences for interprofessional education and collaborative care, said VCU’s medical school has started training its students to prescribe opioids according to the CDC’s safe opiate prescribing guidelines.
Those guidelines state that non-opioid painkillers are preferred, and providers should choose opioids only if the benefit outweighs the risk, the provider has developed a treatment plan with the patient, and they start with the lowest possible dose.
VCU also launched a continuing education program for practicing providers in April at www.safeopiateprescribing.org.
But changing the practices that many doctors have held for decades will not happen overnight. And the timing is a shadow that looms over the entire epidemic. Though the problem has been raging for years, many of the programs that are aimed at helping people have only recently been launched.
And the lingering question remains as the death toll has reached 6,967 in Virginia in the past decade: Is it too late?
When one of his children had a medical issue, Abubaker would typically refer them to one of his colleagues. But when he found out his son was battling addiction at the end of 2013, there was no one to turn to.
“I couldn’t say, ‘I have to get you an appointment with the addiction doctor at MCV,’ because they didn’t have one,” he said. “St. Mary’s didn’t have one, Johnston-Willis didn’t have one. Then my daughter said a friend of hers went to McShin. I said, ‘Where’s McShin?’ ‘It’s here in Richmond,’ ‘It’s in Lakeside? There’s an addiction center in Lakeside?’”
Abubaker enrolled Adam in McShin right away, and he did well there, staying for about 10 months before he was able to live in the community with sponsors from the program.
Abubaker isn’t entirely sure why his son began using heroin again. It is one of the most addictive drugs available, and some studies put the relapse rate at close to 90 percent. Adam was dealing with stress from school and stress from work and, on top of that, his mother died abruptly on Mother’s Day.
“He was calling his mom, somebody picked up the phone and he said, ‘I’ve been trying to get hold of my mom,’ and he said, ‘Well, your mom passed away,’” Abubaker said. “Poof. Like that. He had talked to her the day before. So it was traumatic, yes.”
Adam had virtually only one option when he was trying to get treatment in the Richmond area. And for many with addiction, access to treatment is still a problem, Abubaker said.
When providers cut off patients from opioid prescriptions if they suspect they are abusing it, those people must be redirected to treatment.
“Otherwise, what we’re saying is that we commit everyone who is on prescriptions to die because they’re going to heroin, and die on heroin, and then we’re going to have a new slate of people who don’t get addicted. Which is horrendous,” he said.
VCU’s Motivate Clinic — an office-based opioid treatment program — was started specifically for the purpose of expanding access to treatment. But, Dow said, even that program is overwhelmed. It was started in April and already has a waiting list.
Also just launched in April was Virginia’s Medicaid Addiction and Recovery Treatment Services program, which significantly expanded the number of people offered coverage for addiction treatment, and raised the rates for providers to give them an incentive to cover the Medicaid population.
Abubaker knows firsthand that teaching providers to prescribe fewer opioids is just one part of the battle.
Patients need to be treated, dealers need to be prosecuted — ending the opioid epidemic will have to come from virtually all parts of society, he said. Few areas are untouched by the opioid epidemic — from deaths to property crime to social services to unborn babies.
But even more importantly, regular people can contribute to reducing the stigma surrounding addiction, which is a disease that some people — like Adam — are predisposed to develop, Abubaker said. With treatment, they can live perfectly normal lives.
“We have to have compassion,” Abubaker said. ”(My son) didn’t come to me before because he was embarrassed. Clearly he knew and he told me after the recovery that nobody wants to be an addict and nobody wants to be called an addict.”
Compassion, Abubaker explained, could be the solution to the problem that changing hospital practices and broadening health care coverage cannot fix: the simple fact that too many are too afraid to ask for help.
“I think he was embarrassed because I’m a doctor, I’m a big deal. He was worried he’d disappoint me because he was addicted, because I never thought that would happen to me.”