Opinion editor’s note: This article was submitted by the voting members of the DHS Opioid Prescribing Work Group. They are listed below.

We, the members of the Minnesota Department of Human Services’ Opioid Prescribing Work Group (OPWG), are writing this letter to express our collective astonishment and dismay at the recent decision by DHS Commissioner Tony Lourey to eliminate the position of medical director for Minnesota’s Medicaid program and thus remove Dr. Jeff Schiff from his duties at DHS. We strongly disagree with this decision and believe that it undermines the effectiveness of our group and puts patients’ lives at risk.

While Schiff’s work at DHS entailed far more than spearheading the state’s response to the opioid crisis, the loss of his leadership from the OPWG has the greatest potential to cause harm to both physicians and patients alike. It should be remembered that the Opioid Prescribing Work Group exists only because of the legislation Schiff helped author — the Opioid Prescribing Improvement Program — which was passed by the Legislature and signed into law by Gov. Mark Dayton in 2015. This program is unique among the 50 states in its recognition of the critical role of overprescribing in causing and sustaining this crisis and of the need to bring in rigorous science to find appropriate targets for intervention. This group has come a long way toward achieving this goal, but its work is far from finished.

It bears remembering that while Illicitly Made Fentanyl (IMF) now grabs the headlines, this crisis began with prescriptions. The dramatic rise of heroin and fentanyl as drugs of abuse in the last five to seven years did not occur randomly but only after more than a decade of prescription opioid exposure at levels never seen before. This created a vast new market for these substances as more and more patients found themselves dependent and discovered it was easier or cheaper to obtain relief from opioids bought from vendors on the street rather than the clinician’s office or pharmacy. Indeed, more than 75% of users of heroin and fentanyl began their relationship with opioids via prescriptions.

The rise of illicit fentanyl as the immediate cause of death for so many has also caused a false narrative to arise that threatens to blunt our response to this crisis. That narrative holds that the prescription crisis is “over” and that the real problem is the illegal drugs for which the answer is more aggressive law enforcement, not action by the medical community. This is a dangerous fiction. While illicit fentanyl does account for the majority of deaths in the U.S., more than 17,000 patients lost their lives in 2017 to accidental prescription overdose as well. That is more than the supposed “peak” of the prescription crisis in the years 2009 to 2012. No one was suggesting the prescription crisis was over then. And in Minnesota specifically, the number of overdose deaths from prescriptions in 2017 was 195, greater than the 184 lost to fentanyl. There aren’t two separate opioid epidemics in this country — one legal and the other illegal. There is one epidemic but with two faces, both of which need an effective public health response more than increased arrests.

Data like that above underscore the fact that this crisis is far from over. Such data also underscore the importance of the work the OPWG is doing and why the loss of one of its key leaders represents a decision that is potentially very damaging. There are more than a million Medicaid recipients in the state of Minnesota, and hundreds of thousands of opioid prescriptions will be written in the next year and the year after that. There is still a great deal at stake here, and it is imperative that we get the job done right.

Err too much on the side of opioid restriction, and some patients may suffer harm, particularly those who have been accustomed to opioids after months or years of treatment. Err too much on the side of industry self-regulation, and overprescribing will continue with predictable increased rates of dependence, addiction and overdose death. And all of this must be done while preserving relationships with physicians, dentists and other providers who are trying to make sure patients get proper treatment while balancing the imperatives of a busy clinical practice.

Navigating these treacherous waters is a complicated but necessary task and demands the attention of professionals with years of experience in the industry. It demands a physician leader who can communicate with credibility to practitioners and patients alike. To eliminate the position of medical director for Medicaid services removes that physician leader so necessary for the achievement of these goals.

In conclusion, we again express our profound disagreement with this decision and call for reconsideration on behalf of the patients and physicians involved in the Medicaid program. To proceed without the dedicated leadership of a medical director like Dr. Schiff is to take unnecessary risks with the outcome of our response to this deadly crisis. It is a disservice to providers and a danger to patients.

 

This article was submitted by these voting members of the DHS Opioid Prescribing Work Group: Dr. Chris Johnson, chair; Dr. Brad Johnson; Dr. Charlie Reznikoff; Detective Charlie Strack; state Sen. Chris Eaton; Dr. Igwe Ifeyinwa; Dr. Lindsey Thomas; Dr. Matthew Lewis; Peter Marshall, PharmD; Rebekah Forrest, RN, CNP; Richard Nadeau, DDS.