Alumni are fighting the opioid epidemic in many arenas, from prescribing standards to public policy to pain relief
The medical community is battling the U.S. opioid crisis on several fronts, from tighter prescribing standards and better tracking of opioid use to expanded pain treatment options. Alumni of the School of Medicine have been part of those efforts, which appear to be paying off.
The overall statistics remain grim, and U.S. drug deaths had their largest increase ever last year. But amid the heartbreaking stories of ravaged small towns and urban morgues overflowing with bodies of overdose victims, two trends offer hope: Deaths from prescription opioids, as opposed to illegal ones, have slowly declined after peaking in 2011. Similarly, the number of prescriptions written for opioid painkillers topped out in 2012 and headed downward, the first decline in two decades in prescriptions for this class of painkillers.
“I’m sure we’re writing fewer opioid prescriptions, and covering shorter time periods, than we were a year ago or five years ago,” said Matt Gratton, M.D., chairman of the Department of Emergency Medicine for UMKC and Truman Medical Center-Hospital Hill, where he was a resident from 1981 to 1983.
“New York City hospitals adopted prescribing guidelines for their emergency rooms four years ago, and they’ve spread quickly since then. We adopted virtually the same guidelines two and a half years ago on Hospital Hill and a year ago at Lakewood.”
In family medicine, the American Academy of Family Physicians has kept its 129,000 members supplied with the latest research, advice and policies on opioid abuse, along with helping hundreds of its members get training in treating opioid addiction.
Mike Munger, M.D. ’83, president of the academy, said, “As family physicians, we’re on the front lines of patient care, and we’ve put together a multi-prong approach in partnership with other medical associations and government agencies.”
How did this happen?
Opioids have a long history, from heroin to long-time prescription medicines including codeine or morphine, and then hybrids or synthetics such as hydrocodone and oxycodone. But from 1999 to 2013, opioid prescriptions by one measure quadrupled, and opioid addiction and deaths soared, too.
Pain relievers suited to short-term use for acute pain, such as after surgery, were sometimes prescribed in month-long quantities, encouraging overuse or diversion to illegal sales. Their use for chronic pain also increased, though research indicates their long-term effectiveness often is outweighed by the risk of dependence.
Sam Page, M.D. ’92, said one seed of the increase was planted back in 1980, when a letter to the editor of the New England Journal of Medicine cited hospital research indicating little risk of addiction to opioid analgesics.
“The letter was frequently cited to advocate for the widespread use of opioids in outpatient settings, and was widely used to create momentum for the establishment of pain as the fifth vital sign,” said Page, a St. Louis area anesthesiologist who also has served in the Missouri General Assembly.
That “vital sign” designation led to other things, said Ryan Jacobsen, M.D., whose emergency medicine residency was at Truman from 2006 to 2009. Prescribing large amounts of opioids, often for chronic pain, became more common. That set up more patients for addiction, or allowed them to sell or give their extra drugs to others if they didn’t need or want them.
“We tended to focus on completely eliminating pain for all conditions,” said Jacobsen, a clinical assistant professor in the School of Medicine and the medical director for emergency services in Johnson County, Kansas. “That set up patients for failure as they began to expect zero pain regardless of the problem, and prescriptions for strong opiate medication were given frequently for things that probably didn’t warrant it.”
“It’s a popular conception that anyone can walk into the ER and we’ll write a script for 100 Vicodin or oxycodone or whatever. Even in the bad old days that wasn’t true.” – Matt Gratton
Jacobsen said that also was reinforced when the medical field began evaluating physicians and hospitals through patient satisfaction surveys and linking them to reimbursements.
Others have pointed to pharmaceutical company marketing as part of the problem, underplaying the risks of addiction. Lawsuits have been filed against several of the companies, which say they complied with federal guidelines, and note that patients often did not use the drugs as prescribed.
And just as the trend toward fewer opioid prescriptions seems to be helping, a flood of more powerful, illegal opioids has washed in, mainly from China and Mexico. That has made relatively cheap but deadly alternatives available on the street as legal prescriptions have become harder to get. Chief among them is fentanyl, a synthetic opioid 100 times as potent as morphine.
Drug deaths involving fentanyl and its analogs more than doubled from 2015 to 2016. As a result, the 64,000 overdose deaths in 2016, the latest estimate from the National Center for Health Statistics, were up more than 22 percent from 2015.
As opioid overdose deaths increased, the Centers for Disease Control in 2016 and then the Centers for Medicare and Medicaid Services in 2017 revised their prescribing standards. As Gratton noted, many hospitals had already tightened up their emergency room guidelines before 2016.
“It’s a popular conception that anyone can walk into the ER and we’ll write a script for 100 Vicodin or oxycodone or whatever. Even in the bad old days that wasn’t true,” he said. “And even when I was a resident, in 1983, ER physicians worried about people abusing the ER to get a prescription.”
Still, Gratton said, the recent standardization of guidelines helps by encouraging emergency physicians to check with a patient’s primary physician whenever possible, and to check a prescription drug registry when one is available to make sure the patient isn’t trying to get multiple opioid prescriptions. The standards also can help reinforce physicians’ good instincts for balancing pain relief with not dispensing excess opioids.
“If you have someone come in with a broken wrist, you know what to do,” Gratton said. “And if you give him three or four days’ supply, he might have to come back if he can’t see his regular doctor that soon. It’s good to be aware of the trade-offs.”
Gratton said making ER patients connect with their primary care physician for follow-up might be one of the best things the guidelines encourage.
“We get to see patients only once,” he said. “We can’t build a therapeutic alliance in 10 minutes. And many specialists are not interested in prescribing narcotics. So it makes sense to have just one doctor, a family doctor, writing those prescriptions if anything is needed longer term.”
That’s music to Munger’s ears. The family physicians academy emphasizes its members’ role in managing overall patient care. Among the organization’s efforts to help combat the opioid crisis:
- A chronic pain management toolkit, including help in interviewing and assessing patients with chronic pain and devising a balanced
treatment plan with them.
- A position paper, “Chronic Pain Management and Opioid Misuse:
A Public Health Concern,” that spells out steps to prevent abuse
and addiction but also argues against over-regulation that
could keep needed pain relief
- Access to training on how to properly treat patients with opioid dependence or addiction.
“In 2015, with the Department of Health and Human Services and the White House, the AAFP committed to a two-year increase in the education of our members,” Munger said. “Since then, hundreds of family physicians have completed training to better treat opioid addiction, training that’s especially valuable in rural and underserved areas.”
The crisis defies any simple solution, Munger said, “but I’m optimistic going forward, given the increased awareness of the challenges and our efforts to educate and empower our physicians.”
Keeping better track
Another tool in the fight is a drug registry that tracks the prescriptions a person has. A physician can check it to make sure a prescription won’t conflict with something a patient already is taking. Such a check also can flag a patient who already has an opioid prescription and is trying to get extra pills, whether because of addiction or to put on the black market.
Every state except Missouri has such a prescription drug monitoring program. However, about half the people in Missouri are covered by a tracking system started by Page, the anesthesiologist who served in the state legislature.
Page could not get a statewide monitoring program through the legislature when he served from 2003 to 2009. But in 2014, he was elected to the St. Louis County Commission and got a registry set up for the county. Several other counties eventually joined with the St. Louis system. In the Kansas City area, Independence, Kansas City and Jackson County have joined the St. Louis County registry to provide a local registry for their metropolitan area.
In addition, Gov. Eric Greitens in July issued an order to assemble a database to help identify suspicious patterns of controlled-substance prescriptions. Page said the governor went as far as he could with an executive order, but it still would not allow a physician in real time to check a patient’s prescription history.
There is still debate on the merits of prescription drug management programs, at least in Missouri. Opponents say the registries raise privacy concerns, and they question their effectiveness, given the explosion of opioid deaths despite every other state having such a system. But a recent summary of research by the Leonard Davis Institute of Health Economics at the University of Pennsylvania concluded that the programs can help reduce the amount or strength of opioids prescribed and dispensed. The research summary also said the 25 states that made physicians join their registry generally saw better results than states with looser requirements.
Page said governments also could help combat the crisis by making sure antidotes to opioid overdoses are available to all ambulance crews and other first responders. Providing legal immunity for reporting an overdose also would help, he said.
“I know first hand the complex decisions that are made surrounding pain management and opioid prescribing,” he said.
Fostering other approaches
Treatment standards for chronic pain often encourage use of alternative therapies such as acupuncture and cognitive behavioral therapy before prescribing opioids. One alumnus versed in such therapies is Arif Kamal, M.D. ’05, MBA, MHS, director of quality and outcomes for the Duke Cancer Institute in Durham, North Carolina.
Kamal said the institute takes a “total pain approach” to treating its patients, developing and administering therapies for long-term relief that also can reduce opioid use and its risks and side effects.
“Anxiety and pain often go hand in hand,” said Kamal, who also is an associate professor of medicine at Duke. “Anxiety and depression affect how pain is felt and processed. Treating a patient’s underlying issues, with counseling or mind-body techniques or non-opioid medications, also can help manage pain.”
The approach “acknowledges the pain is real,” Kamal said, “but also makes use of the mind’s ability to process that pain. We know emotions play a big part in how pain is experienced.” So the total pain approach often includes training in coping skills and resilience to help patients manage and minimize the effects of chronic pain.
“If someone has had a setback or is facing a stressful time,” Kamal said, “we might add an extra weekly counseling session, instead of increasing the opioid dosage.”
Kamal said his situation was favorable for developing and proving non-drug therapies, given Duke’s commitment to research and the reimbursements often available for cancer care. He’s hopeful his center’s results will help persuade insurers to cover such treatments for non-cancer pain, too.
Kamal said some factors were beyond physicians’ control, from the nature of the drugs — effective against acute pain but addictive — to the profits to be made from illegal sales. But he sees progress in the guidelines for more thoughtful prescribing of opioids, and in the prescription drug registries as a way to identify addicted patients.
“There’s also the growing awareness that we need better treatment for addiction, and for chronic pain, ” Kamal said. “There’s no easy solution, and medicine has to be part of it.” •