Interview with Dr. Roneet Lev

 

Dr. Roneet Lev is an emergency physician, the chief of the emergency department at Scripps Mercy Hospital in San Diego the and chair of the Prescription Drug Abuse Medical Taskforce in San Diego and Imperial Counties. This interview took place on September 26th, 2018.

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Just to start off, it might be helpful for the audience if you gave us a brief overview of your background and current role.

I am an emergency physician, the chief of the emergency department at Scripps Mercy Hospital in San Diego, and chair of the Prescription Drug Abuse Medical Taskforce in San Diego and Imperial Counties. The task force was established in 2011. We bring together the various parts of the medical community in order to combat this epidemic. Our task force has dentists, emergency physicians, general practitioners, pain specialists, MAT treatment programs, law-enforcement, and hospital associations all coming together and figuring out what we can do in San Diego County to deal with the epidemic.

How long have you been part of that coalition?

Since 2011; I established it.

Is the Coalition a series of regular meetings and discussions or...how exactly does it work?

To clarify, the County of San Diego started a task force in 2008, bringing together law enforcement, education, policy, and public health. I am a member of the Executive Committee. I chair the medical task force, which is a different but complementary task force. We have a pharmacy committee, a data committee, all different sections working together and collaboratively on this issue.

What was the most memorable experience you had with the coalition, whether it was something you observed or something you heard someone say that stuck with you?

The most memorable experience I've had is the data that we collected and research that we did that stems from putting professionals together. Many physicians said, “you know, if patients took medication as they’re told, they wouldn’t die from their prescriptions.” So then we worked with the medical examiners to find out if that’s really true. We have data that we published that’s called “The Death Diaries”. That was really striking, to work with a medical examiner, because I am an emergency physician. My job is to keep people alive. Anytime someone dies, it’s a failure. Working with the medical examiner's office, we saw data after data, person after person, prescription after prescription, of people who died. Looking at that was very eye-opening.

What does the opioid crisis currently look like in San Diego? Is it getting better or do you see some further challenges on the road ahead?

We’re not there yet. We’re making improvements, but for us to say that the epidemic is over, we need to go back to the number of deaths from 1999-2000. That’s the goal. Unfortunately, we’re not there. We have more work to do. We’re making improvements in the number of the prescriptions — there’s been a decrease in prescriptions and a great awareness of the problem and issue, but we’re not where we need to be in terms of deaths.

From your perspective as an ER physician, what makes the opioid crisis different from other drug epidemics?

We have always had drugs and addiction in our society: alcohol, cocaine, marijuana, amphetamines. What’s different now and the reason that I got involved is that there is a medical contribution to this epidemic. There are prescriptions that I and my colleagues have written that have resulted in an addiction to opioids and various other prescriptions – not just opioids, because most people who die from an overdose die from a cocktail of medications, not just one.

What are your thoughts about efforts in the 1990s for pain to be seen as a vital sign?

At that time, I was in my residency training as an emergency physician. At the same time, the O2 stat monitor was discovered or was starting to be used. The O2 stat, if you’ve been to the doctor, is the little thing that fits on your finger and measures how much oxygen you’re getting. That should have been the fifth vital sign and is the fifth vital sign. Pain kind of got tacked on; I always thought it kind of jumped ahead of breathing. Breathing is more important than pain — not that pain is not important, but I thought, “if anything, it should be the 6th vital sign, not the fifth.” Measuring pain can be helpful. If you’re having a heart attack, and we’re seeing how the medicines are working for you, knowing that you’re going from a nine to a six is helpful. But it’s a subjective number. I have patients who will have a 20 out of 10 pain rating while they’re texting and eating chips. That’s subjective.

That makes sense. I know with the effort to reduce the prescribing of opioid-based medication, there are concerns that these measures could adversely affect patients who genuinely suffer from debilitating pain. What do you think is the best way to strike a balance between the two?

In terms of managing the epidemic, I would divide people into two groups. I think we can end the epidemic by preventing a new generation of Americans from becoming addicted in the first place. That’s how we could end the epidemic. For the people who are already on chronic pain medication, I think we need to manage them, not take away their pain medication. That’s the wrong approach. We need to make sure their prescriptions are managed safely as much as possible.

Was there anything that you came across in the course of your work that changed your perspective on the opioid crisis?

A lot of things have changed my perspective. Every time I speak at a conference or meet people, that changes my perspective. It really opens my eyes to how I prescribe. I have an understanding of who is at risk of dying, so when I see people now and look at their medication, I say, “wow I’m really worried about you. you’re taking medications that have drug interaction. let’s talk about that; what can we do to make that better?” I have learned a lot about co-prescribing naloxone to people who are taking high doses, about how to make connections with patients who are entering treatment program at the emergency department, about the problems with opioids and benzodiazepines. And now we’re learning about the problems with marijuana, because my work with opioids led me to problems with marijuana. Every day, being involved with this and thinking about the problem, I think about how ways we can do things better and what we can learn and improve.

What role or responsibility do you think pharmaceutical companies like Purdue should have in the effort to alleviate the crisis?

I don’t know the answer to that one. I don’t know what their efforts are. I think that we need to be careful about how it serves their interest. We are in a capitalistic society, businesses have a right to make a profit, and there’s the issue of supply and demand. I don’t know what their role is except for being honest with their product.

There was a New York Times article about an emergency room physician in an Oakland hospital who has started to administer buprenorphine to some of the patients who come in who are in withdrawal. He also schedules follow-up clinic visits and things like that. What are your thoughts about that kind of an approach?

Andrew Herring has, within Alameda County and his hospital, created an MAT system within the emergency department. I think what he’s doing within his hospital and with his patients is wonderful. I don’t think the same approach is applicable to every emergency department in the United States. For example, in San Diego County, we already have MAT programs around the county and our job as an emergency physician is not to become an MAT program, but to have a handoff of our patients to a program that can handle them. What he has created within the hospital are MAT clinics. That works well for his community and his hospital, but it’s not necessarily the same thing in other communities.

If somebody gave you a magic wand that allowed you to change any policy at the state or the federal level in order to more effectively alleviate the crisis, which policy would you change?

 

Twofold: we have to understand what got us into this epidemic in the first place. We passed a lot of laws and policies in 1999 and 2000 that created this epidemic in the first place. Every state agency needs to go and look at the policies and think about undoing those. Second, if I had a magic wand, I would go to CMS and review all medications that are involved in this epidemic, which is not just opioids. The issues are opioids, benzodiazepines, and sleeping pills — that is a combination people are dying from. And we need to make sure we don’t pay for those medications that aren’t prescribed as they are intended. That’s how we can end the epidemic. We should not be paying for opioids and benzodiazepines together; we should not be paying for going up and up and up on opioid prescription. What I mean is that yes, we have to treat patients as individuals and there are exceptions, but those should be exception and not the rule. Basically, I’m saying we’re actually funding this epidemic; we still are funding this epidemic by paying for these prescriptions that have a terrible cost of deaths. If I had a magic wand, my number one goal is to make sure that any medications that health plans, health insurance, and the government helps pay for follow the CDC guidelines, which are the gold standard now for prescribing.

You mentioned looking at the data to see what’s been happening. Are there any other findings that were striking when you were looking at the data?

The number of pills that we dispense was very interesting. For certain specialties, like orthopedic surgeons, their average number of pills per prescription was 189 pills. That was striking. It was striking that psychiatrists were the number two prescribers (after primary care physicians) to people who died, and that indicated that they [the people who died] had reached out to psychiatrists to prescribe pills as well. Again, it’s not just opioid prescriptions – it’s the benzodiazepines and sleep aids that people die from. It also struck me that we can predict death and intervene — we could see over time how patients went to more and more doctors before they died. We can probably make an intervention by predicting who those people are and making sure they only get prescriptions from one doctor and one pharmacy and not allow them to go to different doctors, different pharmacies, different health plans. I thought it was interesting that methadone is the number one drug that patient die from alone. Most patients die from a cocktail, but there were 46 deaths from methadone alone. That’s an opportunity to work with an MAT program. We should be working collaboratively, the medical community and MAT programs. I could go on and on. I saw that most patients that died were chronic users, which means that they were on the same exact medicine for three months or more – the people at highest risk of dying. Doctor-shoppers were not a majority of the people who died, but they consumed the majority of the prescriptions. We have several publications on that.

I know in some parts of the country, fentanyl has increasingly become an issue, and in some cases, has been mixed in with other drugs without the user knowing about that beforehand. What does that situation look like in San Diego County?

I think it was just last week that we had three deaths of people who used cocaine that was mixed in with fentanyl. There is messaging out there to the public to be careful of what you’re using, because it could be laced and you don’t know it. Number two, that means we need to get naloxone out even to cocaine users, which is something we didn’t think about before because we think of giving naloxone to people who use heroin or opioids. But now, if this continues to be a trend, then people who use cocaine need naloxone as well. For the medical communities, the messaging also is to give out naloxone and encourage our labs to test for fentanyl, because a lot of them are not able to do that.

 

Some regions of the country have been trying out harm-reduction policies such as supervised injection sites and needle exchanges. What are your thoughts about those approaches?

Well, those are two different things. Needle exchanges are much different from supervised injection sites. Needle exchanges have been shown to decrease the incidence of hepatitis C and HIV, and they are able to provide treatment and naloxone — so those have been proven to be effective. For the other harm-reduction practice of supervised injection sites, I don’t see the same kind of benefits. I can’t say that I support that.

What do you think is the single biggest barrier or bottleneck that prevents individuals with opioid use disorder from having access to professional help and treatment?

It depends on what region of the country you’re in. There are definitely parts of the United States and California that don’t have access to treatment for opioid disorders.

A lot of times, news articles about the opioid crisis will have statistics about overdose deaths or the economic cost of the crisis. Given your experience as an emergency room physician, how do you think we can present a less abstract portrayal of the crisis — something a bit more personal that the general public can relate to?

I think the public can relate to that. I think anybody in America just has to look within their own family, neighbors, or coworkers because they will have someone who has died from this epidemic or currently struggling with an addiction. I think this is a modern-day plague. In the Middle Ages, we may have had black plague or cholera, but right now in the United States, we have this epidemic.

I think that’s all the questions I had. Did you have any additional thoughts you wanted to share?

I think it’s helpful if we distinguish the deaths from prescriptions from those from illicit heroin and fentanyl use because I think we can show that we’re making some improvement with decreased prescription deaths. We should get the credit for making the improvements where we are.