This is the third part in a series on opioid abuse and addiction. — Eds.
Opioids are addictive. And as opioid overdoses continue to rise around the country, the medical community is rethinking the drugs’ place in pain management after decades of thinking they were less dangerous.
“I remember in the ’90s, OxyContin was touted as a wonder drug for pain,” said Trudy Funk, the executive director of addiction treatment nonprofit Curran-Seeley Foundation. “It was very commonly prescribed, and no one was really looking at the probable side effects. Doctors didn’t know the power of addiction as they know now. It’s become very obvious, and awareness in the medical field has increased 110 percent, thank goodness.”
Findings by U.S. Sen. Claire McCaskill, D-Missouri, illustrate how the pharmaceutical industry promoted opioids to those vulnerable to addiction, giving millions of dollars to pain-treatment advocacy groups marketing drugs like OxyContin, Fentanyl and Vicodin.
Although the manufacturer of OxyContin, Purdue Pharma, said it will stop promoting the drug to U.S. doctors, it will keep selling it, but overdose rates continue to rise.
A new report from the Centers for Disease Control and Prevention released March 6 found that in one year emergency department visits for overdoses from opioids jumped by about 30 percent. The largest regional increase occurred in the Midwest, which saw a 69.7 percent increase in opioid overdoses. Overdoses increased by 40.3 percent here in the West.
And the worst part? An article published March 6 in the Journal of the American Medical Association found that in a randomized clinical trial of 240 patients with back, hip or knee pain, the use of opioids versus non-opioid medication did not result in significantly better pain treatment.
“Given that the risk of opioid medicines are overdose and death, it would need to have a substantial benefit in order to justify that,” Dr. Jim Little Jr. said. “Opioids still have a role, but I think they have a limited role and we really need to be cautious about that. All medicines have side effects and opiates have significant side effects, so we have to be really cautious.”
It’s no secret that Jackson is an active, often injury-prone community.
“We definitely have a lot of injuries on a percentage basis,” said Dr. Brent Blue, Teton County Coroner and physician. “But most doctors are very, very careful about prescribing.”
Little called opioid addiction a “major health crisis.”
“I think our profession, as physicians and providers, we really need to own our role in solving this problem,” he said. “It’s not an easy solution, but that doesn’t mean it’s not a worthwhile solution. We do need to make sure we are treating addiction in general and opioid addiction in specific with every resource we have at our ability.”
There’s a database called the Prescription Drug Monitoring Program that allows doctors and pharmacists check any narcotics prescriptions their patients may have within the state — an attempt to keep patients from “doctor shopping” for opioids.
“You need to be very, very careful to make sure patients are taking prescriptions as prescribed and not abusing them,” Little said.
Physicians like Little hope that database will eventually expand for more seamless integration with other states.
Ken Jarman, the St. John’s Medical Center’s director of pharmacy, said the database is great to query patients who have filled prescriptions and see how frequently and where those prescriptions were given. But data that crosses state lines is critical and an “unfortunate limitation” of the database.
Still, Jarman said, it helps to see if there are doctors who prescribe large quantities of opiates without a clear reason.
“If there seems to be an outlier, we should be raising those concerns with the prescriber and contacting the board of pharmacy or the board of medicine or the board of dentistry,” he said. “It’s such a multifactorial problem that we need to all work together within the medical community, pharmacies and prescribers and practitioners working together.”
Another problem is when opiates are being prescribed for symptoms that may not need a medication that strong.
“Cancer-related pain is different than other forms of noncancer pain,” Jarman said. “Some of those long-acting opiates can raise eyebrows if the intended use just doesn’t make a lot of sense. In the era of big data and big analytics, we have an opportunity to leverage that technology.”
Pain is subjective
Little said doctors are in a tough position when it comes to pain management.
“There are still providers in Jackson and elsewhere that prescribe too many narcotics,” Little said. “I don’t think it’s intended. The provider wants to do the right thing and make sure their patient isn’t in pain after a surgery, and unfortunately that’s misused sometimes … I think, in general, providers are very empathetic and want to do everything they can to treat patients’ pain.”
Pain management has evolved in the American healthcare system. Little said that a couple of decades ago there was a national move in the medical community to call a “pain score” the fifth vital sign.
“That was hugely detrimental to the narcotic opiate abuse problem in this country,” he said said.
A pain score is subjective, but doctors felt obligated to do something about it.
State medical boards used to discipline doctors for under-treating pain. Some hospitals even passed rules that if a patient reported a pain score above 5 on a 1-10 scale, doctors had to do something about it immediately.
“Childbirth could be a 2 for one patient and a 12 for another,” Little said. “Everybody’s pain level is subjective, and there’s no universal standard for that.”
Jarman spoke to that difficulty, too, and stressed the importance of taking excess medications to drop boxes at the Teton County Sheriff’s Office and Teton County Public Health.
“It’s tough to anticipate,” he said, speaking to the quantity of medication prescribed per patient. “Everyone is going to react to surgeries or acute pain differently. Sometimes you need all the opiates, and sometimes you don’t to get through the bout of acute pain.”
After losing his son to a heroin overdose, Dave Wade said opioids make him sick — literally and figuratively. After hip surgery he defied doctors’ suggestions to medicate and stay relatively immobile, choosing to walk without crutches and not mask the pain.
“I know in my body and in my mind that pain is there for a reason,” Wade said. “There are a lot of pitfalls with trying to be 100 percent pain free.”
Jarman suggested that patients could reconsider the role of pain, like Wade did.
“I think too frequently people go into a procedure or they go into some situation and they think pain is bad and no one wants to feel pain,” Jarman said. “I understand that, but expectation setting a little bit of pain in certain things is normal and that’s the body healing. Trying to say ‘We’re going to get you zero pain’ isn’t appropriate or in the best interest of the patient. … I think too many folks don’t go in with the appropriate mindset that, ‘I’m going to have pain and that’s going to be OK.’”
A paradigm shift, Little suggested, might also be necessary in how doctors view pain.
“I think as providers, we need to acknowledge that we can’t cure all pain,” he said. “We can’t eliminate all pain. So we have to be able to help patients cope with their pain rather than seeing the pain as something we have to eliminate.”
And opiates really don’t solve anything, Little added. They alter the perception of pain and don’t treat it.
“Opiates are almost never a solution to a problem,” he said. “They don’t fix anything. All they’re doing is masking the pain temporarily so you can either do something else to fix the pain or hopefully the pain is resolved. You always have to be thinking about what we are going to do to address the underlying pain so we don’t need to use opiates long-term.”
If not opiates, then what?
The best way to help recovering addicts, Blue said, can be the drug Buprenorphine, which can help addicts battle cravings when paired with counseling.
“The most important thing is to keep them from buying things on the street or shooting up drugs because that’s where your toll gets really high,” Blue said.
But treatment, Little said, isn’t easy to assess. Buprenorphine is expensive and a limited resource because providers have to be specially registered to administer it.
“Getting them into treatment is a huge barrier,” Little said, describing insurance policies’ limit on coverage and cultural barriers surrounding the social stigma of being an addict. “A lot of patients end up going to Alcoholics Anonymous or Narcotics Anonymous, but that in and of itself is not a solution to the lack of health insurance.”
Since introduction to opioids doesn’t always lead to addiction, doctors must explore their proper use in pain management.
It’s important to note that all of the caution when prescribing opiates doesn’t mean that opiates don’t have their place in pain management. They do, especially with cancer-associated pain and end-of-life care. It’s just important for doctors to recognize if their patients are susceptible to addiction and have tendencies towards addictive behavior — and then prescribe for only the intended purpose, not prolonged use.
It’s nuanced and complicated, Jarman said.
“We should prescribe what is minimally necessary to treat them,” he said.
That’s why Little thinks that, when appropriate, there are other effective treatment options to explore.
A case study in success is the emergency department at St. Joseph’s University Medical Center in New Jersey, where staff managed to reduce their opioid use by more than half using methods like dry needling pain trigger points and administering laughing gas. Another success story can be found in Colorado, where 10 hospital emergency departments completed an opioid-reduction test program and decreased opioid use by 36 percent in a six-month period.
There are other medications, like Ibuprofen and other anti-inflammatory drugs, that could be substituted for opiates. There are also non-narcotic pain relievers, like Tylenol.
“We can also use other modalities, like physical therapy, massage therapy, even in some cases acupuncture can be very helpful and certainly doesn’t have the risk of dependence that opiates do,” Little said.
The Associated Press reported that Ohio’s Medicaid program recently expanded its coverage for acupuncture as a treatment for chronic pain after a task force ordered state officials to explore alternative pain therapies. The validity of acupuncture is still questioned by some medical experts, but some, like the military and Veterans Affairs medical system, have offered acupuncture as a pain treatment for years.
Jarman detailed what he called “multimodal pain management strategies” that can “work synergistically with opiates to decrease the amount of opiates that are necessary for acute pain.”
“Through a lot of our post-operative protocols and the education we’ve provided to our surgical teams, we’ve really stressed that,” Jarman said. “That’s something we stress at the hospital, and it’s a topic stressed nationally. That educational piece that I’m trying to change and the protocols we establish at the hospital is one piece.”
Task force is possible
There were more bills introduced in the 2018 Wyoming Legislature’s budget session about marijuana than about opioids. The only bill addressing opioids was introduced by Senate President Eli Bebout, R-Riverton, to create an opioid addiction task force. It’s since passed out of the Senate and into the House with a few minor changes to wording.
“We all recognize it’s out there and the damage and the seriousness of it,” Bebout told the News&Guide. “This ought to be a priority of our state.”
The task force would look at prescription drug monitoring programs and electronic prescribing systems, patient prescription history verification requirements, grants relating to substance abuse education, prevention and treatment, the availability and use of Naloxone and other prescription drugs to counteract opioid overdoses and the quality of treatment for opioid addiction and overdoses in Wyoming. Also important are strategies to reduce the administration of opioids, including promotion of alternative treatments, methodologies and possible limits on the quantity of opioids a health care provider is authorized to prescribe, authorized uses of opioids and any needed legal exceptions and strategies for community engagement.
A report would be created for various legislative committees and the governor by October 2018.
After talking with other Senate presidents from around the country, Bebout said he wanted to “move it up on our agenda items” and start looking at what the state is doing to combat opioid abuse.
“We’ve been pretty active, Wyoming has,” he said. “If you look around the country, even what data is out there — and it’s kind of iffy — but we’re doing really well. But that’s not acceptable to me. We really need to take this on full force, head on, and see what we can do.”
The task force would consist of 14 and come with little money, $25,000 for legislative members’ expenses and $40,000 for nonlegislative members’ expenses.
Whether or not a task force makes it out of the budget session, which needs a two-thirds majority to pass on the floor, Bebout said he will continue to advocate for the issue.
“It may not make progress, but I hope it gets some real good attention and debate,” Bebout said, alluding to the difficulty of passing a bill in a budget and not a general session. “There are people out there working hard on this. We need their input. We need to hear from them and what they think. And that’s the whole purpose of putting this together, to see what is the best plan for Wyoming.
“It is a high priority and we’re going to move forward,” he said. “We’re going to try to be as proactive as we can and do it the Wyoming way.”
The News&Guide is publishing a series on opioid abuse in Wyoming. Look for more stories in the weeks to come.