The ‘loaded revolver’ in the medicine cabinet

WASHINGTON -- Doctors are sharing ideas and data in the campaign against a health crisis which the Centers for Disease Control says now kills more people in the U.S. than car crashes: overdosing on opioids."Opioid" generally refers to painkilling...

WASHINGTON - Doctors are sharing ideas and data in the campaign against a health crisis which the Centers for Disease Control says now kills more people in the U.S. than car crashes: overdosing on opioids.
“Opioid” generally refers to painkilling prescription medications that have similar effects as opium, such as hydrocodone, codeine and morphine. Brand-name opioids include Vicodin, OxyContin and Percocet. President Obama’s proposed fiscal year 2017 budget calls for $1 billion in heroin and prescription medication addiction treatment, and $500 million in overdose prevention and treatment - a portion of which is specifically proposed for rural areas, as overdose and use rates there are “particularly” high.
Five different hospitals in the north-central region of Minnesota have rallied together to minimize the number of new patients they start on opioid treatment, educate patients who are getting opioid treatment about the risks, and tighten up the monitoring of prescriptions.
The hospitals also committed to following guidelines that help reduce the level of opioids being prescribed for chronic pain, and encourage treatments like applying heat and ice, physical therapy, and over-the-counter drugs instead.
A panel of chief medical officers from those hospitals together with law enforcement met Tuesday at Essentia Health St Joseph’s in Brainerd to talk about the new strategy and why they feel it’s necessary for the good of patients on opioid therapy and the good of the community as a whole.
Dr. Peter Henry, chief medical officer of Essentia Health Central Region, Dr. Robert Westin, CMO of the Cuyuna Regional Medical Center and Dr. Tom Bracken, CMO of Mille Lacs Health System, all sat down to talk. Dr. John Halfen, family medicine with Geriatrics, Lakewood Health System, in Staples, joined the meeting via phone.
Their patients have died unexpectedly, or died later of heroin overdoses. Addicts of prescription narcotics sometimes shift to heroin when pills become too expensive to get their hands on or not powerful enough of a fix.
“We see tragedy all around us,” Bracken said.
The doctors said they themselves experienced multiple instances where patients threatened them if they didn’t give them opioids.
“I think most health care providers, including our nurses and nurse practitioners, physician’s assistants, are being put in a very difficult situation where patients are demanding therapy with an opiate, and they do not have an appropriate (pain) indication or they are showing escalating use or inappropriate use - they become very threatening,” Henry said. “It’s almost a daily occurrence within our system.”
One of the flashpoints that helped spur the doctors to act locally was when Mille Lacs Health System stopped offering prenatal care at its Onamia facility three years ago, Bracken said. It coincided with the rise of the heroin epidemic in central Minnesota, and after a while the Mille Lacs hospital began hearing troubling news from the other regional hospitals their obstetrics patients had moved to, like Brainerd, Crosby, Little Falls and St. Cloud.
“We started getting calls: ‘Why are we seeing all these patients whose babies are going into narcotic withdrawal?’ ” Bracken remembered. “There was less standardization then than there (is) now. Some places were not checking pregnant mothers for narcotics, so the women either gravitated there for prenatal care, or they just didn’t have prenatal care. And that was the majority of them, the heroin addicts mostly didn’t have prenatal care.”
A shift in doctors’ understanding of chronic pain, and pain in general, means opioid drugs aren’t the catch-all solution to pain management anymore.
“We’ve all looked at pain as something you need to stomp out: ‘Pain is bad, let’s treat it until it goes away,’ ” Westin said. “That’s actually been the mantra of some ambulance services and ERs in the past - 10, 15 years - where they would treat pain until it was a zero. The problem with that is, you get a lot of exposure to narcotics if you treat your pain down to a zero, and sometimes, pain is helpful.”
Bracken remembered some 20 years ago when prescribing opioids was the norm.
“We went to state meetings, we went to conferences, where drug companies hired pharmacists to tell us, ‘There’s almost no risk of addiction,’ and ‘You can control these people’s pain’ and ‘The best medicine to use is a sustained-release narcotic,’ ” he said. “I had troubles with it then, but it moved it on to not only that, but ‘You have to make that (pain) number go away.’”
The federal Centers for Medicare and Medicaid Services require doctors to participate in publicly reported patient satisfaction surveys that specifically ask patients how well their pain is controlled, Henry said, so the amount of money hospitals are reimbursed by the government can hinge in part on how much they get rid of pain.
Doctors are also pushed to prescribe opioids in part because of their own desire to make the people under their care feel better -- and because pain is subjective.
“Physicians don’t prescribe these things for a profit, they prescribe these things because they think they’re helping people,” Halfen said. “The patients put on a good front a lot of times. Do they have pain? Don’t they have pain? It’s really hard to determine.”
An Essentia-wide program that began in October resulted in a 10 to 12 percent reduction in the amount of patients on opioids, Henry said.
Data prevents diversion
Westin said new coordination between hospitals helps prevent illicit opioid users from shifting from one hospital to another in order to get around an individual hospital’s prevention measures.
“To know that Essentia is doing a broader sweep on this allows us then to say ‘Are we in our system ready to accommodate that if those people start spinning off and trying to look for other avenues to potentially get meds?’” he said. “As you coordinate all the facilities together, you try and eliminate that.”
Regulating opioid prescriptions has seen an improvement in that electronic data tracking helps identify when patients are double dipping by getting more than one pain med prescription, Westin said. In years past, doctors would need to do old-fashioned detective work.
“You’d have to call personally to every pharmacy in the region to know if a patient was using it at a different place, getting it from a different doctor,” he said.
Now, the Minnesota Board of Pharmacy’s Web database offers doctors an easy way to check up on what narcotic prescriptions their patients might have in other places. The state’s Web page lets them see the records not only in Minnesota but in Wisconsin, North Dakota, South Dakota and Iowa. When a provider issues a prescription for certain kinds of drugs, it’s mandatory pharmacists and prescriber dispensaries put that record into the database within a week. Patients do not need to give authorization for their prescriptions to be entered into the database.
“It’s pretty hard to hide from it,” Henry said.
One patient at Cuyuna claimed not to have had any major recent health problems, but an electronic search of prescription records turned up 22 different prescriptions for narcotics from seven different providers in the last year, Westin said.

Danger from pills ever-present Sgt. Andy Galles, Crow Wing County Sheriff’s Office, Lakes Area Drug and Addiction Division, praised the collaboration between hospitals because it made the job of law enforcement easier.
“Your prescriptions cause our problems,” he told the doctors at the meeting Tuesday.
In addition to pain pills being diverted by patients, they’re also stolen from patients, such as family members nicking pills from the medicine cabinet. The sheriff’s office has dealt with a recurring pattern of medication being stolen from houses for sale, Galles said and medication being imported from out of state and from Mexico.
“It’ll eliminate some of the problem, but it’ll never eliminate all of the problem,” Galles said of the hospital coordination effort. “But, it is a good first step in at least combating the problem.”
Westin said patients’ own preventative measures to secure or dispose of medication could be the deciding factor to keep opioid abuse from spreading.
“You could liken this to a loaded revolver,” Galles said. “You don’t leave a loaded revolver or your deer hunting rifle laying in the living room or sitting in the bathroom next to the toilet just because deer season is over. You unload it, you put it in a safe, you take the bullets away, you make sure your kids don’t have access to it. That’s very similar to what we’re talking about here: these things kill people and get kids into big trouble.”

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