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September 08, 2016

Surgeon General Sends Out Letter on Opioids


The United States Surgeon General, Vivek H. Murthy, M.D., M.B.A., penned a letter in August 2016 that he sent to doctors throughout the country. The letter starts out, “asking for your help to solve an urgent health crisis facing America: the opioid epidemic.”

In the letter, Murthy notes that “it is important to recognize that we arrived at this place on a path paved with good intentions” and that nearly twenty years ago, “we were encouraged to be more aggressive about treating pain, often without enough training and support to do so safely.” Murthy believes that that aggression, combined with heavy marketing of opioids to physicians, is what brought us to this stage.

He mentions that, since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly, while the amount of pain reported by Americans has not changed. Murthy understands that the problem is not easily solved, and that it is hard to balance reducing patients’ pain with increasing patients’ risk of opioid addiction. He believes that, however, because of that balancing act, physicians are in a unique position to be able to end the opioid epidemic.

He closes the letter by asking the receiving physician to pledge their commitment to “turn the tide on the opioid crisis” and take a pledge at He believes the tide can be turned through educational methods, teaching physicians how to treat pain “safely and effectively,” and by starting to screen patients for opioid use disorder and provide or connect them with evidence-based treatment. Lastly, he believes that physicians can work to shape the way the rest of the country views addiction by actually speaking about it and treating it as a chronic illness, not as a moral failing.

Included in the envelope with the letter was a small card, an “opioid prescribing guide,” meant to provide easy tips to physicians when it comes to prescribing opioids. The card tells physicians that they should try other pain relief avenues, such as physical therapy or nonaddictive medications, with most patients before prescribing opioids. When they do prescribe opioids, the card instructs them to “start low and go slow,” meaning to prescribe the lowest dose for the shortest duration of time. The card also encourages physicians to continue assessing the patient’s reaction to the initial prescription, tailor prescription amounts based on patient and objective reports, and eventually taper off the use.

This letter is reminiscent of when former Surgeon General C. Everett Koop sent a letter to 107 million households regarding the AIDS epidemic.

Murthy has said that he was inspired to write the letter to all doctors in the country following a country-wide tour, while on which he learned that, despite, widespread media attention to the opioid overdose epidemic, many doctors still did not have a full understanding of how dangerous the drugs could be. During a shared anecdote at the Aspen Ideas Festival, Murthy was discussing a dinner he was having with a friend of his, a cardiologist in Florida, when he commented on his disbelief that they were taught that opioid medications weren’t addictive in their training. His friend responded, “Wait, you mean they are addictive?”

Dr. Gary Franklin, an addiction specialist at the University of Washington, noted that while he welcomes the letter, more needs to be done to change physicians’ prescribing habits. He believes more states need to follow in the footsteps of Massachusetts, which passed regulations for prescription painkillers in March, including a seven-day limit on first-time adult opioid prescriptions and a seven-day limit on every opiate prescription for minors, with certain exceptions.

This letter and card build upon other efforts by Congress, the National Pain Strategy, and the U.S. Department of Health and Human Services (HHS) Opioid Initiative.

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