In the 19½ years America waged the Vietnam War, more than 58,000 Americans died. Last year alone, according to the Center for Disease Control, nearly 48,000 Americans died from opioid overdoses.
About 130 Americans will die from opioid overdoses every day and the opioid death rate is six times higher than it was in 1999.
History of the epidemic
The increase in opioid overdoses has complex sources. In 1996, Purdue Pharma released OxyContin, which was aggressively marketed as being less addictive than other opioids. Some users, to bypass the time release element in swallowing OxyContin, crush and snort it or crush and mix it with water to inject it. A confidential Justice Department report showed that Purdue Pharma was aware of the “significant abuse” of OxyContin, but concealed that information.
Snorting and injecting increases the euphoria and also significantly increases the likelihood of overdosing. Additionally, many pharmacies were robbed and OxyContin and MS Contin, another opioid, were sold on the streets, to be snorted or injected. As doctors prescribed OxyContin less, many users turned to heroin, which was evermore available, cheaper than OxyContin and MS Contin, and increasingly purer. Synthetic opioid deaths nearly doubled between 2013 and 2014, possibly due in part to the addition of Fentanyl, a synthetic opioid that is manufactured in illicit laboratories. Heroin is sometimes spiked with Fentanyl, and Fentanyl is sometimes sold as heroin. Fentanyl’s potency is so great that a dose no larger than a few grains of salt can be lethal.
Local clinics fight back
Healthcare providers were looped into a system that kept putting more opioids on the street. Doctors working weekends on call were deluged with people saying that their drugs had been stolen, seeking a new opioid prescription or an early refill. Most of those people were drug seekers, known by both the medical community and the police.
So, Marshfield Clinic Health System (MCHS) developed an internal training program in 2017 titled, “A Paradigm Shift in Opioid Prescribing.” It was presented live and online, attended by over 800 physicians and thousands of other providers. The intent was to reduce the misuse of prescription opioids.
Michael Larson, Ph.D., Pain/Health Psychology, Director of Controlled Medication Policy, Marshfield Clinic said, “MCHS has been monitoring opioid prescribing by our prescribers since 2009. In 2015, we changed our monitoring significantly to include morphine milligrams equivalence for dosing. In 2016, we began monitoring methadone and oxycodone separately, with direct intervention with prescribers of these medications to ensure understanding of the unique problems and requirements for these medications.”
Educating prescribers has also been crucial in curtailing opioid addictions.
“Our prescribers clearly respond well when provided with specific information about a specific patient-related concern. This is helped by our unique system that allows us to drill down into very specific prescriber-patient data to identify areas of concern, but also highlight changes or successes.”
MCHS’s doctors are also collaborating with each other to lessen the likelihood of opioid addiction.
“We have developed a peer review process specifically for opioid prescribing when a prescriber has been identified as not meeting specific requirements that are identified in our prescribing guidelines.”
Monitoring and peer review are working.
“This monitoring and intervention with prescribers has been an ongoing process in various forms since 2009. From 2012 through all of 2017, MCHS has seen a 49.5 percent reduction in total Morphine Milligrams Equivalent prescribing throughout our entire system. We have also seen dramatic reduction in patients on methadone and high dose oxycodone for chronic non-cancer pain conditions,” he said.
It isn’t just MCHS’s staff that are partnering to proactively reduce opioid addiction: MCHS is partnering with other community entities.
“We’ve partnered with community resources to impact change in how opioids are prescribed, managed, and to develop treatment resources,” he said. “This was most notable in the Minocqua area as part of the Lakeland Area Prescription Drug Abuse Taskforce that was developed in 2011 to bring together community leaders to make changes.”
It’s an expansive partnership.
“This collaboration included area law enforcement, pharmacist, Emergency Department providers, medical providers from several different health systems, and tribal leaders,” he said.
Hard realities had to be acknowledged and addressed.
“We first focused on acknowledging that we were all invested in reducing patient reliance on these medications, reducing overdoses, and reducing prescribed amounts. This was a major first step because law enforcement were really looking at medical providers as legal drug pushers and that was a hurdle we had to overcome.”
In 2011, the status quo was that a police report had to be filed if opioid medication was declared lost or stolen.
“Law enforcement was very clear that they often have little time to do any meaningful investigation and it was essentially a waste of time and resources for this type of report to be done,” Larson said.
Now, emergency departments and Urgent Care will not provide refills for lost or stolen medication. Morphine had its own set of rules.
“If the total morphine dose was 60 mg or less, there’d be no refill. It if was more than 60 mg, half the dose would be provided to the patient,” he said.
The effect was profound and wide-reaching.
“The number of reported lost and stolen medication dramatically dropped. Law enforcement was happy because they did not have meaningless traffic and they noted less prescription medication on the streets from local providers. Emergency rooms and urgent cares were very happy because people knew that they would not prescribe for these issues, so that traffic was also reduced.”
The collaborative effort extended to the Native American population.
“Our area tribal healthcare providers indicated that they would not provide a referral for outside pain management services when the patient had failed their internal opioid agreement. This became another norm for the other providers in the area. They could be referred for non-opioid treatments, but not for opioids. That made a major difference in our area.”
The difference can be quantified. For example, the Minocqua Center Pain Management Program was able to reduce opioid prescribing for chronic non-cancer pain by 95 percent from 2011 to 2017 (in total morphine milligrams equivalent).”
MCHS will continue to expand and refine its approaches to reducing opioid addiction, using a multi-pronged approach.
“We will continue to develop our treatment services thru our Family Health Center programs,” Larson said. “The Center for Community Health Advancement will continue to work thru the various coalitions to help with prevention. MCHS will continue to work on reducing reliance on opioids for chronic non-cancer pain with clear understanding of the need to ensure the safety of our patients. And we continue to work on developing our provider and patient toolkits to offer non-opioid options for pain control.”
Another powerful partnership
While MCHS partners with various entities, HSHS Western Wisconsin Division (HSHS Sacred Heart and St. Joseph’s hospitals) has partnered with Prevea Health. Toni Simonson, Ph.D., Executive Director of Behavioral Health for HSHS Sacred Heart and St. Joseph’s Hospitals and Prevea Health, works for both HSHS hospitals in Western Wisconsin and Prevea Health. She ensures that all services provided between the organizations are complementary and collaborative. Together, HSHS Western Wisconsin Division and Prevea are working to address the opioid epidemic.
Like MCHS did with its staff, HSHS Western Division and Prevea Health started by upgrading the expertise of its direct care staff.
“HSHS Western Wisconsin Division and Prevea Health have sent counselors and physicians to Hazelden Betty Ford for education/training in best practices for Opioid Use Disorders,” she said. “Then an all-staff training occurred at L.E. Phillips Libertas Treatment Center, facilitated by those trained at Hazelden Betty Ford, regarding opioid abuse/addiction and Medication Assisted Treatment.”
L.E. Phillips Libertas Treatment Center has enhanced services provided to include the induction of evidence-based medications for opioid use disorders. Additionally, L.E. Phillips Libertas Treatment Center and the Prevea Health Medication Assisted Treatment program work closely together to ensure continuity of care for patients.
Medication assisted treatment is the difference maker, Simonson said.
“Medication assisted treatment, which includes counseling services in conjunction with medications that are proven effective for the treatment of opioid use disorders, has been most effective,” she said.
Its application has expanded because of its effectiveness.
“In September 2018, Prevea Health opened a Medication Assisted Treatment program for opioid abuse in Chippewa Falls. Nurses, counselors, physicians and advanced practice providers are all involved in this program.”
The efficacy of medication assisted treatment is why expansion continues.
“There will be an ongoing expansion,” Simonson said. “We are looking into the possibility of adding this service to our Prevea Behavioral Care clinic in Eau Claire.”
HSHS Western Division and Prevea Health are also partnering with a statewide project.
“Several of our staff members, including physicians, are involved in the Wisconsin Opioid Project ECHO (Extension for Community Healthcare Outcomes),” she said. “They can present real-life patient cases (with all patient-identifying information removed) to a panel of experts, who can then discuss and provide recommendations for treatment. Everyone attending these presentations can learn a great deal from these discussions.”
Wisconsin Opioid Project ECHO also offers educational presentations on a variety of opioid-related topics, with the opportunity for attendees to ask questions. A recent presentation was held on “Drug Testing in Clinical Practice: The Science and Art of Drug Monitoring.”
And if HSHS doctors want immediate backup, expert advice is a phone call away.
“Our physicians have access to the new Addictions Consultation Hotline to obtain guidance from addiction treatment experts on complex cases related to medications in substance use disorders,” she said.
Mayo Clinic’s response
Mayo Clinic is the top-ranked hospital in the United States and also has the most top rankings in specialties, too, giving it unmatched internal resources.
Paul Horvath, M.D., chair of Urgent Care said, “We work with experts throughout the Mayo Clinic enterprise.”
However, one way you become number one is tapping every possible source.
“We have worked with the Wisconsin Medical Society to encourage education of prescribers. We will continue to collaborate with the state of Wisconsin to develop evidence-based practice guidelines to help prescribers treat pain effectively,” Horvath said.
Mayo also collaborates with area academia.
Donn Dexter, M.D., chair of education, said, “Jose Ortiz, Jr., M.D., an orthopedic hand surgeon, is participating in a research trial investigating treating patients without opioids after certain soft tissue hand surgeries. There are multiple studies that have demonstrated the value of prescribing fewer opioids after some surgeries. His team is working in conjunction with faculty from University of Wisconsin-Eau Claire to demonstrate that for some specific soft tissue procedures there is no need for opioids at all. Other local studies are planned.”
Mayo also taps the Wisconsin Prescription Drug Monitoring Program’s data. Gathered data is disseminated to Mayo staff.
Terrence Witt, M.D., Family Medicine physician, Mayo Clinic Opioid Stewardship Program Oversight Group member, said, “We support the state of Wisconsin requirement for each physician to take two hours of approved continuing education on responsible opioid prescribing and have educated our physicians about this obligation.”
Mayo Clinic has also developed a number of educational products regarding opioid prescribing and all Mayo clinicians complete an internal training program, including safe opioid prescribing practices. Mayo also presents an annual two-day conference titled “Mayo Clinic Opioid Conference: Evidence, Clinical Considerations and Best Practice.”
The Opioid Stewardship Program continues to upgrade the providers’ understanding of the dynamics of the crisis. In addition to the training programs, Mayo implemented a number of practice changes to help staff prescribe opioids safely.
Witt said: “First, we have placed a link to the Wisconsin Prescription Drug Monitoring Program within our electronic medical record, so that prescribers have easy access to data regarding their patients’ controlled substance prescriptions.”
Mayo also strives to have all staff on the same page.
“We have made efforts to create standardized, evidence-based pain management order sets that include both opioids and non-opiate pain treatments,” Witt said. “Also, a number of specialty practices have begun to develop guidelines regarding opioid use in specific medical and surgical problems.”
And Mayo is always considering non-opioid options.
“Practices have developed procedures regarding outpatient prescriptions, in particular refills, that support treating their patients’ pain while minimizing opioids,” he said. “Finally, prescribers have access to other Mayo experts when they have questions about prescribing opioids.”
Horvath added: “There are many challenges here. We are working to change entrenched attitudes and culture of both patients and prescribers regarding pain management. As physicians, we strive to relieve suffering. We have been taught that pain should be eliminated when possible and that liberally prescribed opioids were a safe and effective tool.”
Now doctors have to adapt to the new data.
“As we’ve learned more about the risks and relative lack of efficacy, particularly in chronic pain, of opioids, we’ve all had to unlearn a lot of what we’ve been taught and learn to use other effective tools, all while supporting our patients through their own struggles,” he said.
It’s a challenge for all involved.
“It takes open, honest and supportive communication. We as prescribers have begun to learn the problems with our previous prescribing patterns and started to use other tools to alleviate patient suffering. Through that process, physicians have had countless conversations with their patients sharing what we’ve learned, what we have yet to learn, while empathizing with their struggles and supporting their goals. Through these conversations, we have built trust between physicians and patients that ultimately is leading to improved outcomes.”