OFFICE OF THE MAYOR erry OF CHICAGO RAHM EMANUEL wavor October 27, 2017 American Medical Association American Dental Association ATIN: Dr. James L. Madara, CEO & Execuitve VP, Pathology ATTN: Dr. Joseph P. Crowley, President "AMA Plaza 211 East Chicago Avenue 330 North Wabash Avenue Chicago, Illinois 60611 Suite 39300 Chicago, Ilinois 60611 American Dental Association American Pharmacists Association ATIN: Dr. Kathleen T. O'Loughlin, Executive Director ATIN: Thomas E. Menighan, Executive VP & CEO 21 East Chicago Avenue 2215 Constitution Avenue, NW Chicago, Illinois 60611 Washington, DC 20037 Dear Medical Community Leaders: We are writing to call upon you to step up your work with us on an issue of utmost importance to our communities and your membership. It is not too strong to say that our nation is being ravaged by an epidemic. The devastation wrought by opioid addiction, both nationally and in the Chicagoland area, is intolerable. It is time for you and your members to take bold action to stop the rampant over-prescribing and abuse of pharmaceutical opioids. In Cook County, there were at least 1,091deaths due to opioid overdose in 2016, a 69%increase from the year before. The increase was driven by a nearly 446% increase in deaths due to illicit fentanyl. “This rise was felt across demographic categories, from race to gender to age group.! DuPage County, meanwhile, had over 200 opioid deaths in 2015, and then in 2016 saw a 100% increase in deaths from fentanyl alone and a 370% increase in deaths from fentanyl mixed with heroin.” Opioid deaths are now plaguing cities, suburbs and rural areas alike. And these grim statistics do not begin to capture the more widespread misery caused by opioid addiction— the unemployment and other economic hardships, the tearing of the family fabric and the increased stress on support agencies and other resources. * Rushovich T, Salisbury-Afshar E, Arunkumar P, Kiely M, Aks S, Arwady A, Prachand N. Increase in overdose deaths Involving opioids ~ Chicago, 2015-2016. CDPH Epidemiology data brief October 2017. Chicago Department of Public Health, * DuPage County Coroner's Office. Press Release (January 24, 2017).That this epidemic has been fueled in large part by the over-preseribing of pharmaceutical opioids is well established, The sale of prescription opioids in the United States rose four-fold between 1999 and 2010 even though Americans were not reporting more pain. Also since 1999, preseription opioid deaths have quadrupled as well—and heroin deaths have risen even more. In short, more opioid prescribing has been associated with more opioid deaths. And a 2014 study in the journal JAMA Psychiatry, for example, found that nationally, 75% of people who recently began using heroin actually initiated with opioid painkillers." Accordingly, prescribers have a strong role to play in ending the epidemic. As you know, in March of 2016 the Centers for Disease Control and Prevention (CDC), following research, information-gathering and public input, issued a Guideline for Prescribing Opioids for Chronic Pain (the “Opioid Guideline”). The Opioid Guideline can be found he: hitps://www.ede.gov/mmwr/volumes/65/rr/r6501el.htm. According to the CDC, following it would help “ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse ... or overdose from these drugs.”* Many medical groups have already been strongly promoting the Opioid Guideline, which contains 12 recommendations, each of which is followed by a rationale and considerations for implementation, Recommendation 6 of the Opioid Guideline, in particular, addresses the key issue of over-prescribing, and says: Long-term opioid use often begins with treatment of acute pain, When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed. {Emphasis added.] The Opioid Guideline also makes recommendations to ensure thorough assessments, consideration of non-opioid treatments, careful monitoring of risks and discontinuing opioid treatment safely. The City of Chicago, Cook County and DuPage County are pursuing all avenues to require our pharmaceutical benefits managers and other insurance and medical service providers 10 limit opioid prescribing to seven days for acute pain. But as city and county governments purchasing health care for our employees, we are a limited part of the overall supply chain. Your members are the doctors and dentisis who prescribe opioids and the pharmacists who fill those prescriptions throughout the country. Therefore, we need to know what else you and your members are going to do to address the nationwide scourge of over-preseribing pharmaceutical * See CDC website and citations: https://www.cde.gov/drugoverdose/epidemic/index.html. Retrieved October 2017, * Cicero T, Ellis M, Surrat H, et al. The Changing Face of Heroin Use in the United States. JAMA Psychiatry. 2014;71(7):821 826. doi:10.1001/jarapsychiatry.2014.366 . While not all painkillers were obtained from prescriptions, an excess supply of these drugs helped fuel the black market. 5 coc website: hutps://www.cde gov/drugoverdose/orescribing/guideline.html, Retrieved October 2017.opioids. We know that many of you are working vigorously with your membership to encourage use of the Opioid Guideline and associated best practices as well, whether through materials or educational forums or other means, but much more needs to be done. We now ask you take this work to the next level. We urge you to strengthen the protections embodied in recommendation 6 by calling upon all of your members to adopt a policy limiting opioid prescribing to no more than seven days for acute pain. We also urge you to make the Opioid Guideline a top priority across all sections of your association—from your policy makers to academic physicians to medical students—and in all of the education you offer, including in continuing medical education. Only with a vigorous effort that’s equal to the task before us will we create a unified front across the medical community. Such an effort is an essential step towards the eradication of this scourge on our communities. We will continue to do everything in our power to see this problem solved, but we cannot do it alone and we need your continued partnership to make a real difference in combating this, epidemic. We are confident that, working together, we can ensure quality health care while ridding our nation of opioid addiction. Sincerely, Ae) \ Q ‘ Rahm Emanuel Dan Cronin Mayor, City of Chicago DuPage County Board Chairman Toni Preckwinkle President, Cook County Board of Commissioners