April 2018—The National Institute on Drug Abuse estimates that 100 million Americans suffer from chronic pain. The majority of drug overdose deaths involve an opioid, and nearly half of drug overdoses caused by opioids involve prescription drugs.
The American Medical Association has formed a task force to combat the opioid crisis and has supported state-based prescription drug monitoring programs through which registered physicians can access information about their patients’ current medications before prescribing a new one. The AMA also supports increased access to naloxone to reduce deaths from overdose and encourages physicians to become certified in providing medication-assisted treatment for substance use disorders with buprenorphine.
The CAP Council on Scientific Affairs has formed a project team that is developing a position statement on the opioid crisis that will soon be complete. Barbarajean Magnani, PhD, MD, who chairs the CAP Toxicology Resource Committee, is a member of that team.
R. Bruce Williams, MD
Dr. Magnani reports that opioid abuse in her region increasingly involves very potent, dangerous designer drugs. Clinicians at Tufts University School of Medicine, where she chairs the Department of Anatomic and Clinical Pathology, are encouraged to call her laboratory’s consultation service about any concerns regarding possible drug use, especially when a patient’s toxicology screen picks up drugs other than those prescribed.
R. Ross Reichard, MD, medical director, Office of Decedent Affairs at Mayo Clinic in Rochester, Minn., and chair of the CAP Forensic Pathology Committee, attests to the need for good communication among clinical toxicology laboratories, health care providers, poison control centers, medical examiners and coroners, and forensic pathologists. Maintain a low threshold to call colleagues, he says, and encourage them to do the same. Combining intersecting points of view educates and saves time.
The overarching questions relate to how we monitor, prescribe, and treat chronic pain and substance use disorders. This takes in how best to collaborate with clinicians and other experts to develop drug-testing methodologies that align with the clinical question, reflect the limitations of testing, and provide interpretive results to guide management.
Opioids are only one of the classes of drugs that are abused and misused, and a substantial portion of opioid deaths can be tied to the combined effects of their use in conjunction with other drugs that depress the central nervous system. Clinical colleagues will, appropriately, look to us for screening to detect better-known opioids along with new synthetics that continue to emerge. We will continue to pursue proficiency testing programs to help us detect new opioid agents and to advocate for more training programs in forensic pathology to ease the burden on medical examiners and coroners.
Pathologists educate clinicians about framing test orders to detect and monitor the ways these drugs are used for pain and how to manage medications prescribed to treat opioid substance abuse disorder. That guidance should cover the rationale that drives appropriate reflex testing for downstream effects of opioid misuse such as HIV; hepatitis C; organ damage affecting the liver, heart, kidneys, and lungs; and bleeding problems that can complicate coagulation and/or transfusion.
While we now hear more about opioid abuse, methamphetamine and its derivatives are equally prominent concerns in some regions, especially west of the Mississippi. James L. Caruso, MD, who is chief medical examiner/coroner for the city of Denver, encounters at least as many drug deaths due to methamphetamine as to heroin. Combined intoxications, he says, are also seen frequently. Dr. Caruso, a former chair of our Toxicology Resource Committee and a longtime CAP delegate to the AMA, attends meetings of the AMA opioid task force as well as the AMA House of Delegates’ public health reference committee to provide a forensic pathologist’s perspective.
Mary Ann Sens, MD, PhD, executive vice president of the National Association of Medical Examiners and professor and chair of pathology at the University of North Dakota School of Medicine and Health Sciences, sees in her practice patterns like those Dr. Caruso reports. Dr. Sens, who is also chief medical examiner/coroner for several counties in North Dakota and Minnesota, reminded me that pathologists who specialize in autopsy and forensic medicine often function as public health officers. They were the first to “ring the bell,” she says, about opiates, hantavirus, SIDS, and Alzheimer’s disease. And now this.
Forensic pathologists acting as medical examiners are responsible for determining the cause of death, taking into account the medical history, autopsy findings, and toxicological analysis. The official cause of death provided to the CDC is entered into the National Vital Statistics System, whose many purposes include setting levels of government funding and monitoring its adequacy. In many medical examiner facilities, teams are hard-pressed to handle the increasing number of deaths due to opioids taken alone or with other drugs. Forensic examiners, whose work is critical to our nation’s response to the opioid crisis, are in immediate need of more staff, more support, and more funding.
Not long ago, friends entertained us with a glowing account of their grandchild’s breathless chapter-and-verse description of a local firefighter’s visit to her classroom, all suited up in his giant coat, big boots, and huge helmet. “Firefighters have to be ready,” she had sternly told her parents. The moment the bell rings, they have to pull on their boots, grab their helmets, and jump on the truck.
We cannot know what the next substance of abuse will be or how many lives it will take. But we do know that pathologists have a critical role in this crisis. Sound, clear interpretive laboratory results are essential to effective treatment. So we can be as engaged in what we are learning and as determined to share it as a second-grader who has just met her first firefighter. We can carefully elucidate for our clinicians how to select drug-testing methodologies that align with the clinical question, reflect an understanding of testing limitations, and address downstream effects of drug abuse and misuse. And finally, we can advocate for appropriate resources to meet these urgent public health needs. Pathologists are medicine’s first responders. We’re on that truck, too.
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Dr. Williams welcomes communication from CAP members. Write to him at president@cap.org.