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MN Health Care Roundtable
Sharon Brigner, MS, RN, PhRMA
Ms. Brigner is deputy vice president in state government affairs for the Pharmaceutical Research and Manufacturers of America (PhRMA), a trade association in Washington, DC. She provides clinical expertise and policy support for issues related to appropriate use of medicines, including prescription drug abuse/misuse efforts.
Karina A. Forrest-Perkins, MHR, LADC, Wayside Recovery Center
Ms. Forrest-Perkins is CEO at Wayside Recovery Center (The Wayside House), a women’s chemical dependency and co-occurring treatment center in the Twin Cities. She is a national speaker on the adaptive impact of overwhelming stress and its intersection with substance use and abuse.
Ashwin George, MD, MBA, Valley Pain Relief and Wellness Center
Dr. George is addiction medicine director at Valley Pain Relief and Wellness Center, where he provides treatment for opioid dependency and heroin addiction, alcohol and chemical dependency, and addiction counseling services. He is certified in Suboxone treatment for narcotic addiction.
Todd Ginkel, DC, PDR Clinics
Dr. Ginkel is founder and CEO of Physicians’ Diagnostics & Rehabilitation Clinics (PDR) and a member of the American Back Society. He recently participated on the task force to review and revise the treatment guidelines for acute and subacute low back pain for the Institute for Clinical Systems Improvement (ICSI).
Beth Gomez, RN, BSN, JD, Coverys
Ms. Gomez is a manager overseeing the Midwest risk management operations for Coverys. She previously served as a senior risk consultant for the University of Michigan. She graduated with a BSN from the University of Michigan, where she held a certification in critical care nursing during her tenure as an intensive care unit RN.
Larry Lee, FACP, MBA, UCare
Dr. Lee is senior vice president and chief medical officer at UCare, where he has overall responsibility for clinical and quality practices, including medical policy, pharmacy, clinical services, and quality management. A board-certified general internist, he previoulsy served as a staff physician with the Veterans Health Administration in Minneapolis.
Laura Palombi, PharmD, MPH, MAT,
University of Minnesota College of Pharmacy
Ms. Palombi is an assistant professor at the University of Minnesota College of Pharmacy in Duluth. She has been involved in a variety of projects and collaborations, including Operation Community Connect, the Carlton County Drug Court, and the Carlton County Drug Abuse Task Force.
Jeff Schiff, MD, MBA, DHS
Dr. Schiff is medical director for Minnesota Medicaid at DHS. His work focuses on evidence-based benefit policy, improved care delivery models, and improvement of clinical quality. His interests include the role of social and family risk factors in health outcomes, integrated delivery systems, and quality measurement.
the opioid epidemic:
Complex Problems, Complex Solutions
Minnesota Physician Publishing’s 49th Minnesota Health Care Roundtable focused on the topic of The Opioid Epidemic: Complex Problems, Complex Solutions. Eight panelists and our moderator, Minnesota Physician Publisher Mike Starnes, met on April 26, 2018, to discuss this topic.
Engaging doctors is key to fighting the opioid epidemic, but there are many other remedies we must pursue. A single silver bullet remedy does not exist. This is a complex problem with complex solutions. Let’s put some of the societal challenges into perspective. What should we know about the opioid epidemic?
Dr. Schiff: This is an epidemic where overdose results in death. We have known for many years that the death rate from opioids well exceeds the death rate from motor vehicle accidents. We have about 10,000 people in this state who are in treatment for opioid addiction every year. On the prescribing side, we have over 5,000 people a year in Minnesota health care programs who become at risk because they have at least a 45-day supply, and they become new chronic users. We have a big population with the potential to move through that pipeline.
Dr. Lee: The populations we serve [at UCare] are a pretty representative cross-section of Minnesota. Like other health plans, we have observed that, as the crisis has been recognized over the last couple of years and multiple stakeholders have taken action, the numbers are leveling off. We can only see, though, the opioids that are prescribed through the legitimate prescription mechanism. We also see the services that are utilized to treat the consequences of opioid use disorder and its related medical conditions, which everyone in this room would recognize: comorbidities, associated mental illness, accidents, and other kinds of medical events.
Ms. Forrest-Perkins: Our residential programs [at Wayside Recovery Center] have waiting lists of 70 or more each week. We not only provide care to the individuals in our residential centers, but we also care-coordinate to get people who are on the waiting list into some other type of treatment option to deal with their complexity while they’re on the list. If they are on waiting lists too long, we miss a window of opportunity to work with them, and we could lose them to overdose.
Ms. Brigner: As a former ER nurse, I’ve seen, in Minnesota, an 83 percent increase in ER admissions due to opioids, and the hospitalization rate is going up dramatically. At PhRMA, we are committed to work with you and with other stakeholders, because this is not going away.
Ms. Gomez: It’s not just opioid deaths, but an issue with polysubstance abuse. A patient who might be on an opioid is also on Ativan, they’re getting fentanyl from somewhere, or they’re getting benzo from another entity. That increases the rise in deaths, and you cannot always identify which patients might be at higher risk. We help deliver office risk assessments to help identify those at higher risk for polysubstance abuse or opioid abuse.
Dr. George: Prescription numbers have decreased, especially in Minnesota, since 2010. The dense data shows that very clearly, but, on the other hand, overdose deaths from heroin have also increased. In the last six months, most of my patients who said they used heroin actually had fentanyl in their urine. We prescribe them naloxone to ensure that they can survive those overdose episodes. In the last six months, there have been significant overdoses that have happened predominately because of fentanyl, in patients who do not have heroin in their urine.
Let’s look at how this epidemic started. Multiple factors led us to where we are today. Let’s start with FDA drug classifications and CDC guidelines around opioids.
Ms. Gomez: The CDC guidelines are very good, and people should be following them. I don’t know of many that are actually using them, but you also have to put it in the proper perspective for patients who do need more. It is perfectly okay to go against the standard of care as long as you document the rationale behind it, so that somebody else picking up what you have done will be able to read what you wrote and say, “That makes perfect sense. I know why you’re doing that.” That may be outside of the standard of care, given the present situation, but it still follows a good standard, and it is appropriate.
Ms. Brigner: Part of the build of the opioid crisis has been a real lack of clinical evidence and guidelines. There is a public perception that using medicines is actually safe—70 percent of the medicines obtained that are misused and abused come from the family’s own medicine cabinet. A big piece of our messaging and education centers on how to use medicines exactly as prescribed, to not share them, to store them safely, and then to dispose of unused medicines in a proper way, such as your household trash, so they can disintegrate in landfills. We’ve seen a lot of the contributing factors for the opioid crisis being the lack of evidence-based guidelines, the perception of safety, that a doctor is prescribing it versus a shady person in an alley.
Dr. Lee: During my medical training in the early to mid-1990s, clinical practice guidelines were coming on the scene. The Agency for Healthcare Policy and Research was the federal government’s effort to publish what were supposed to be regarded as national, definitive clinical practice guidelines. There was at least one guideline around pain management, with a pain management ladder that called out opioids. The emphasis at that time was on controlling pain, and part of that effort was to emphasize measuring pain. It became a metric of quality. Pain scales were to be administered. Implied with that was that pain is bad. If the patient still has pain, then you’re under-treating. That was the prevailing philosophy. My point is that government policies—the products and programs that come out of our government agencies—often reflect the long-term priorities from that time. Government often reacts slowly, which has allowed the crisis to evolve and not be brought to attention.
In 2001, the Joint Commission issued a report about pain being a fifth vital sign. We didn’t really need to live with pain, since there are ways around it. If we had a realistic perception of pain, it might have put the brakes on this rush to overprescribe opioids.
Dr. Ginkel: I’ve treated spine pain for almost 30 years. My position is that pain is really a part of life and part of the healing process. To medicate away all forms of pain or all inflammation hinders the healing process, as well as the psychology of the person who goes through this process. When you have an injury, you experience discomfort, you work through that, the body recovers itself, there is an inflammatory process, and you heal. Take away one of those steps, and maybe now all of a sudden you become a chronic pain patient. The medicated way, trying to remove all forms of the healing process, really does turn the person into more of a chronic pain patient.
Dr. Lee: Doctors have always recognized that opioids had the potential for addiction. It was always in their minds, but was it at the forefront or in the background, and what was the level of risk? I’ll keep referring back to the time when I was in training. The message that my classmates and I heard was that the new generation of opioid pain medication is a safe and effective way to treat pain. Doctors should feel confident in prescribing them because, while they are opioids, the label states that these medications have habit-forming addictive potential, so you don’t need to worry too much about it. It was promoted at the time that patients with chronic pain don’t become addicts.
Dr. Schiff: When we started the Opioid Prescribing Improvement Program, we made a strong statement that we did not find sufficient evidence that opioids were helpful for treating chronic pain. Dr. [Erin] Krebs at the Minneapolis VA Medical Center just came out with a landmark study that compared opioids to NSAIDs for chronic pain. People did not know that NSAIDs were equivalent and much less harmful. We look at three distinct areas, beginning with less opioid going out the door for the first prescription. You have to look at that period of time—up to 45 days—because that’s when people go from being prescribed opioids for pain to being dependent. If you continue to prescribe during that interval, you need to make sure that you’re not treating other kinds of patient suffering, such as mental health, anxiety, posttraumatic stress disorder, and other factors. After 45 days, how do we make sure that folks who are on medicines for chronic pain are either weaned or are very safely prescribed?
To a certain extent, the opioid epidemic was created by the health care delivery system itself. How do we retool our idea of what an epidemic is to address the problems that opioids present?
Dr. Ginkel: First of all, we have to get the prescriptions under control—how many prescriptions we have, and what we’re prescribing them for. It is one thing to help somebody with their pain immediately. That’s great, but if it’s an ongoing pain problem or an ongoing medication, that’s when the risk of addiction starts.
Ms. Gomez: Just because patients are given opioids, that does not make them dependent or necessarily at risk for being dependent. Social isolation and stigma contribute to dependency as well. You can stop prescribing opioids, bring the hammer down, and legislate against physicians who overprescribe, but what are we doing to address social isolation and stigma? Instead of incarcerating them, let’s put them in a treatment center. Also, we shouldn’t separate mothers from their children just because the mother has an issue. We need to keep them together and try to facilitate their movement into a more functional society. We need to keep the kids engaged in believing that they have self-worth, and we need to teach people better parenting skills. We need to keep them active in school, after-school programs, and churches. We have to look at more than just the prescribing.
Ms. Palombi: I do a lot of community education, community forums throughout northeastern Minnesota, focus groups, naloxone trainings. We usually try to gather data on what the community believes to be the problem. Stigma is one thing that always comes up, which is not surprising. Only 11 percent of people with substance use disorder ever end up in treatment. Stigma is one of the reasons that happens, especially in our rural areas, where people are afraid to admit that they have a problem. They’re in a community that isn’t very supportive of them. A lot of our communities are convinced that addiction is a moral failure rather than a disease state. If I could work on one thing that would make a huge impact, it would be reducing stigma in our communities.
Dr. Ginkel: Stigma is huge. From the physician’s point of view, at least the ones that I work with, I don’t think we’re blaming. I think it’s a situation that exists that we need to deal with. I don’t think our physicians enjoy seeing somebody come in with a simple musculoligamentous strain/sprain and is on opioids, but we’ve got to deal with it.
Ms. Gomez: Stigma runs both ways. There are many people out there who have cancer, and I’ve known a few who wouldn’t take opioids because they didn’t want to become addicted, even though they were terminal patients. It’s sad for these cancer patients, who do need relief from pain, and it wouldn’t matter if they became dependent during their short remaining lives. At least they would die comfortably and with dignity.
Dr. Schiff: We also have to address cultural trauma. We have five times the rate of opioid death in our Native American population, and twice the amount in our American-born African American population. Those are communities that talk about posttraumatic slave disorder, that talk about the Dakota Indian wars, that talk about trauma that still exists in their culture, and we have science around the epigenetics of how that affects multiple generations. We have to recognize the role of social determinants, but we also have to get to the culture.
Ms. Brigner: Addiction should be viewed as a disease, just like diabetes or mental illness, and not as a moral failing. We need to look at multiple facets, including funding for addiction, mental health, and the comorbidities of patients who suffer from opioid addiction and other preexisting conditions. We would be remiss if we didn’t talk about patients with legitimate chronic pain. There are patients out there who will need to exceed dosage limitations as laid out in a guideline. A bureaucrat should not be the one making that decision, it should be a health care provider who knows that patient’s health history, knows their background, knows if they have an addictive personality, and knows that there are other options that the pharmaceutical industry might bring forth, such as abuse deterrent formulations that make it very difficult to abuse, snort, melt, or inject.
Dr. Ginkel: Funding for organizations is important, but I don’t know how you do it. We work in multiple platforms with different payer groups. Access to care is pretty good, although the duration of treatment may not be long enough. Interestingly, on the work comp side, a lot of payers now send patients out of state to get them away from the environment that they live in during their 30- or 90-day treatment.
Ms. Forrest-Perkins: We could take away all opioid medications and stop prescribing, change how systems operate, and change how medical professionals are educated. But we still would not be addressing the underlying issue of a highly traumatized society that is seeking ways to mitigate emotional pain. If we took opioids away, patients would still find a way to help themselves feel better. If we do not address that as part of our overarching strategy, we will not be the causal factor that will leverage change in the way that we need to leverage change.
Dr. George: We’re talking about the opioid epidemic, but we’re not using the word addiction. Addiction is a disease that is inherent in our genetics. Throughout history, environmental factors have turned certain diseases into epidemics. For plague and cholera, we addressed environmental factors through public health measures. HIV was once an epidemic, but we addressed it though primary prevention, and it is now a chronic disease. How do we address the underlying emotional issues and social isolation that led to the opioid epidemic? How do we release patients from emotional trauma? We need intense education—not education at the doctor’s office, but at every person’s home, through intense media. This is not an infectious disease epidemic. This is the expression of modern disease. In the future, epidemics are not going to be infectious diseases, they are going to be some other form. Public health measures could go a long way. We’re trying to block small holes in the dam, but we need to focus on reducing the flood.
What are the barriers to people seeking help for opioid use disorders?
Dr. Schiff: We have a choice to look at this as a moral deficiency—which I believe is still pretty apparent in many parts of our society—or as a use disorder. We have to get away from stigmatizing folks who have, unfortunately, gone down that path. It doesn’t mean that we don’t have to do urine drug test for folks who come in for treatment and make sure that we help people with tighter control of their drugs if they come in. It means that we have to be compassionate and see this as a disease, and we have to do that in all sectors—from the people who diagnose use disorders, to our legislators, to the people who treat, to law enforcement, and to incarceration folks.
Ms. Forrest-Perkins: The insurance payment structure—what they are willing to pay for, what they are not willing to pay for, when money is cut off, and the complexity around what is currently in place—makes it difficult to look at what is needed to heal from a chronic disease condition like addiction that affects brain function. It takes five to eight months, at least, for the patient to build new neuropathways that wrap and myelinate. Treatment stays now are approved at between three and seven days for the most acute crises, and most addiction treatment programs are limited to 28 days. Even at 90 days or 108 days, patients have not even begun to build new neuropathways that can compete with the old neuropathways that have formed routinized ways of behavior. The neuroscientific evidence has not yet influenced the insurance industry or the payment mechanisms. This isn’t like a broken ankle, which you can treat in a primary care setting with very short and intense touchpoints.
Dr. Lee: We finance health care in the United States through what I’ll call the health service benefits administration chassis, a set of mechanisms meant to contract for, pay for, and—I’ll use the “R” word—ration medical services, recognizing that there is a finite amount of funding that has to provide for a long list of health service benefits that are articulated, either in contract or in regulation. When administering a finite resource, the only way to do it is with mechanisms that require services to be administered, covered, and metered out according to an objective mechanism. When it comes to intensity of different settings of care for substance abuse disorder or, even more generally, for behavioral health services, the industry administers those services according to criteria that drive what level of intensity and what setting of care is considered appropriate. During the transition from inpatient care to outpatient care, the industry applies criteria that have been developed with scientific evidence and consensus from the medical professional community. It’s not done arbitrarily. It is developed carefully and administered carefully.
What role can the pharmacist play to help solve some of these challenges?
Ms. Palombi: Community pharmacists have an opportunity to engage with patients who might be at risk of opioid use disorder or of overdose. At both the College of Pharmacy and the School of Medicine, students talk about substance use disorder and opioids. A survey of all pharmacists practicing in Minnesota included questions on their attitudes toward substance use disorder and pharmacist utilization of the tools available to them, such as naloxone protocols, authorized take-back legislation, and syringe access. The vast majority agreed that there is a role for pharmacy in the opioid crisis. We also need to get our providers and our pharmacists used to having conversations about opioid usage in a professional manner. We give them practice while they’re in school, so that we’re not hearing, later on, that it’s an awkward conversation. It shouldn’t be an awkward conversation if the pharmacist calls the provider, or vice versa, to express their concern for the patient.
What are the biggest misperceptions around the opioid epidemic?
Ms. Forrest-Perkins: From the treatment lens, it’s the misperception that the chronicity and acuity that we see is just from using opioids. The reality is that it is polysubstance problem. It’s a very complex issue with a polysubstance component that may contribute to death when overdose takes place.
Ms. Brigner: Some people believe that there is some one-size-fits-all solution or a magic bullet that we just haven’t found yet. That couldn’t be further from the truth. If there was one solution, we would have figured it out by now. One thing that is certain, we’re past the time for just talk. We need to come together with a unified, concerted effort by all stakeholders, plans, pharmacists, government, law enforcement officers, health care providers, and the biopharmaceutical industry. Everybody needs to be at the table. Finger-pointing can only take us so far. We need to start talking about serious solutions.
Dr. Ginkel: Patients come in and say, “I need pain medication.” The more they want it, the more they need it. That’s probably more likely to be the person that you wouldn’t want to prescribe opioids to. They have anxiety around their pain, and are probably more likely to be dependent. When patients who are probably dependent or addicted come in, there is a brain chemistry change and a personality change. Their motivations are different. Their consistency in therapy is different. Their motivation to try to recover is different. I’ve had patients sit across from me with spine pain. They go through treatment, and I’ll ask them, “How’s your back? What do you have for spine pain?” “Nothing.” “What about the opioids?” “Don’t touch them.” At that point, they are still taking opioids, but not for pain. They get upset, maybe violent if you want to try to change that. There are also those that become very pain focused, so whether they have pain or not, they can imagine they have pain somewhere. You can create that in your brain. These inappropriate belief systems are alive and well in them.
Dr. George: Our chronic pain and opioid addiction program attempts to identify and help chronic patients who have an addiction issue. At the same time, we try to contain this problem. For patients who may have addiction issues, we need to understand that their neurobiological changes are either persistent or permanent, and focus on a different pathway. I go back to the primary prevention perspective, where the public needs to be educated that pain pills are not the solution to pain. Pain has to be expected to certain levels, and there may be other ways to relieve it. I’m an addiction specialist, but I have multiple friends who work in primary care, and the underlying theme for them is, “I have five or 10 minutes, and I have a patient who is focusing on pain.” The physician, in the 10 minutes available, has no option other than to write a prescription and say, “Okay, I’m going to help you with your pain.” On the other hand, a different patient might walk into the primary care office already aware of the problems and perils of going on opioids and aware of other treatment modalities. If public education can help patients, the pressure on the primary care provider will be far less.
Dr. Ginkel: What are we treating, physiological pain or psychological pain? Maybe that is what we have to be able to distinguish in the treatment room, and find out the right pathway for them.
How can the media become more proactive in supporting efforts to bring the opioid epidemic under control?
Dr. George: I think the media should focus on more positive stories to create an environment where, as we’ve been saying, we could function in a more collaborative way, rather than in a blame culture. Highlighting positive stories would help patients to come forward and seek help, knowing that there is something out there that can make their lives better. Fairview recently had a story about how opioid-addicted patients and pregnant women were treated, and it was more focused on a couple of patients who had good outcomes and how the babies were delivered without any problems. Stories like that show patients that there is hope out there, versus all the stories that highlight death from opioids.
Ms. Brigner: Another way is for the media to highlight the tremendous research and development advances of the pharmaceutical industry. We have 40 medicines in the pipeline to treat addiction, and 40 medicines to help with medication-assisted therapy [MAT]. A few years ago, there were no medications to assist patients who are trying to wean off opioids and to get off their addicted patterns. Our industry spends, on average, $2.6 billion to bring a drug to market, and only 12 percent of them ever do make it to market. Accountability is important, but we also need to ensure that organizations and industries are able to do what they do best. For my industry, it’s research and development to develop non-opioid alternatives and to make sure that we have other options, including medication-assisted therapies. For physicians, it’s focusing on the patient and making sure that they start low, go slow. Educate patients before they medicate.
Ms. Gomez: The media is a little too simplistic in their understanding of how it all works. If you find somebody with a long history of polysubstance abuse and you hit them up with Narcan, that’s great, but then what do you do after Narcan? Twenty minutes later, if you haven’t called EMS or if you haven’t gotten help, the patient goes back into a stupor again and could still die. We do need Narcan out there, just as we need EpiPens for allergic reactions, but there’s got to be a followup. This happens in hospitals. You give them Narcan, you ship them back off to the floor, and after a while the nurse says, “He’s fine, he’s snoring.” He’s not snoring, he’s somnolent. Let’s face it, it’s kind of sexy for the media to talk about something like opioid deaths. They could do so much more by talking about projects that work well, if they did a little more research and told readers about a place to find grants if you need money to start a community organization for kids. Media could be part of the solution, instead of being part of the sensationalism.
Ms. Forrest-Perkins: The media could dispel some of the mythology around addiction by comparing it with other chronic health conditions, where you are in a relationship with your primary care partner for the rest of your life. People often believe that when you go to treatment for addiction, you never need to go back, as if treatment should be a one-and-done thing. I went to treatment 30 years ago, and no one with diabetes would say that. People with diabetes go to the doctor on a regular basis and have their blood checked on a regular basis.
Ms. Palombi: I don’t believe this is just the media’s responsibility. One thing we can all work on is the language that we use when we talk about substance use disorder, even on the drug court teams that I’m a part of. We’ve been working with folks in recovery for a long time, and we still use words that are stigmatizing and moralizing: clean versus dirty, junky and addict, urine drug screens that come back positive or negative. The words we use are important, and each of us should be aware of how we’re actually talking about the issue and whether we frame it as a medical issue or as a moral failure.
Ms. Gomez: The media will only run with articles that they believe will bring in readers. You don’t hear about the housewife who overdoses. You hear about the young males, maybe those that have been in some kind of altercation or something, or about athletes. You don’t hear about how it affects a multitude of other people. You’ve got your big, important, sexy kind of articles, but you don’t have real life. They’re not really sharing what real life is all about, so I think it has become skewed.
Dr. Schiff: It really depends on your media outlet. Calling the media a monolith is a little like calling doctors a monolith. There has been some coverage about the decrease in life expectancy in middle-aged folks who are Caucasian, based on opioids and suicides. That does get covered in different ways and in different places. I would like it if the media, as some of my colleagues have said, would cover the compassionate care more than the conflict. It would make a big difference.
Dr. Lee: I’m going to go out on a limb. Should certain kinds of behavior that are dangerous and irresponsible—such hoarding pills and leaving them unsecured in your home—be stigmatized in the media? Maybe that should be called out through public service announcements or other coverage as being just as reckless as leaving a firearm unattended in your house. Why not? Lying to your physician is, perhaps, a behavior that should be stigmatized and regarded as irresponsible. I believe that, in American society, we are too timid to convey messages, strong messages, about individual behavior and individual responsibility.
Dr. Schiff: There is a science behind public health messaging that says you can get the attention of some people by these negative messages, and they are sometimes effective. You have to be careful, though, because there is also the opportunity to go too far with that messaging and then turn people off.
Dr. Lee: A quick example of a public health message being used right now that uses a negative message: texting while driving, distracted driving. That’s being done right now, and it is using a very stark, even scary message about what could reasonably be interpreted as a public health issue—distracted driving. There are as many fatalities from that in Minnesota as from drunk driving.
What are the most important things a physician should consider before writing a prescription for an opioid-based pain medication?
Dr. George: The first and most important thing would be to risk-stratify opioid assessment tools. If the patient has a history of addiction to some other substance or has severe mental illness, the provider should not prescribe opioids. If my risk assessment tool says that an opioid is not the appropriate medication for my patient, then I will stand my ground and say, “Sorry, I cannot give you opioid pain medications, but I can definitely help you with other modalities for pain relief.” My patient has the right to accept my recommendation or to refuse my recommendation. Patients who do not agree with my recommendation can find another doctor, but at least they have been forewarned and understand the risks. This has happened multiple times, and six months, one year, two years later, I have the same patient coming back, now understanding that they have an addiction problem. I cannot stop patients from getting medications from somebody else, but at least I can educate them during my one encounter.
Dr. Schiff: The further along you get into prescribing, the more screening that should be done. Pain catastrophizing, anxiety, depression, and posttraumatic stress disorder are all things we should evaluate. We should find the folks who are at risk and then identify different mechanisms, rather than going down the line 45 days or 60 days or 90 days or a year later. We hope that the guidelines help our providers in Minnesota have some of these tough conversations. We also tell our providers how they compare to their peers.
Dr. Ginkel: I had surgery about a year ago, and I left the hospital with 100 Percocet pills. I took three. The amount is really sensitive. After five days of use, your probability of being a one-year user is 6 percent. After 30 days, you’re at about 30 percent. When you look at prescribing to somebody, it’s important that you look at risk tools. In our office, we use a Keele [University] tool that assesses for catastrophizing, anxiety, depression, and fear avoidance. We can look at those traits or characteristics, and help work with the patient’s inappropriate belief systems, versus treating with medications. If somebody is really high on anxiety, opioids are probably not the recommended therapy. My patients may demand opioids if they’re anxious, but I don’t believe it’s the right medication for them, nor do I believe that clinicians are obligated to prescribe opioids.
Dr. Lee: I’d like to mention something coming down the pike, I believe in 2019, in the health plan pharmacy PBM [pharmacy benefits manager] space regarding the 100-pill scenario after surgery. Seven days is going to become the new CMS standard. The rules haven’t been finalized yet, but the Medicare program is going to allow for a restricted recipient kind of program. Here in Minnesota, we’re familiar with in-state public programs for opioid overuse and other kinds of utilization by the individual beneficiaries. A beneficiary can be placed on a restricted status, where they can receive their prescriptions from only one prescriber, use only one pharmacy, and go to only one hospital. To date, the Medicare program has not allowed for any kind of restriction to be placed on Medicare beneficiaries. That will change.
What information should physicians tell patients before they prescribe opiods?
Dr. Schiff: There is the risk equation that doctors or other prescribers need to talk about, but the biggest thing is to say, “If I’m going to give this to you, it will be for a very short period of time.” I hope that all providers give that message across the board, because that’s the most important thing. We should stop thinking this is a chronic therapy, and start thinking of it as something that can be useful for a short-term level of acute pain.
Ms. Brigner: Seven days of pain medication may be great, but there have to be exceptions. Not everybody responds the same way to pain medicines, just as not everybody responds the same to the same surgery. I had a rare genetic cancer gene and had to have my stomach removed and have a double mastectomy. I thought, “Oh, my God, I’m frightened. How am I going to handle pain and get back to work?” My identical twin had the same genetic cancer gene and had the same surgery. I had a higher pain tolerance than she did. You asked what physicians should say to patients. For me, I need to hear that there is a treatment plan. I don’t want to hear, “Okay, Sharon, seven days of pills,” or, “In about two weeks, we’re switching you to Advil.” At that time, all I can handle is getting my drain changed or my dressing changed. I don’t want to think about going without pain medicine in two weeks. Patients who are going through legitimate pain need to have an action plan and a plan to wean. They need to hear, “This is going to be tough, but we’re going to get through it, and we’re going to do this, this, and this.” Remember that not everybody responds the same to pain medicines, and allow exceptions in prescribing.
Dr. Lee: We’ve all been patients at some point. The worst part is the fear. It’s the professional responsibility of every clinician to address that as effectively as possible. Prescribers and providers also need to be aware that there are a lot of eyes watching their prescribing patterns, scrutinizing every prescription they write. In the Medicare program, all Medicare Advantage Plans and all Part D Medicare prescription drug benefit plans run the analytics by a company called Acumen, a contractor to CMS. Every Part D plan gets the reports back, and all part D plans are required to follow up on any questionable high dose or risky combinations involving opioids. One of my responsibilities at UCare is to do the outreach to prescribers based on those Acumen reports. It is sometimes hard to get prescribers on the phone. What tends to work is to tell the truth: “Your prescription was flagged by Medicare and that’s why I’m calling you.” I’ve never had anyone hang up on me when I say that.
Ms. Forrest-Perkins: Practicing physicians have long worked separately from behavioral health professionals. Integrated care models, with co-located providers in your wings of service, is really the optimum model. If not that, make sure that the physician has lists of resources in hand. Physicians may do a referral and worry that it will go into a black hole. They may not see the patient again to get an update, or wonder whether they have referred to a quality behavioral health provider. Behavioral health partners need to help physicians make sure they have the questions and point them to a fast-tracker system. Minnesota has this for mental health and addiction treatment now, allowing physicians to find resources in their county. On the behavioral health side, we could also put together and vet packets of information. Some primary care clinics and hospital systems already have expert screens and brief screens internally for the individuals seeking care, but we could go much further to give advice about symptoms that may come up in the future, and that may manifest differently for different individuals.
Dr. George: Verbal or written pain contracts establishing patient expectations have also helped immensely. In pain management, the verbal contract has turned into a written contract. You tell the patients when you will start them on pain medications and specify the risks of addiction and the risks of mixing other medications such as benzos with their pain medications. You can provide that information in a five-minute visit, and also give it in writing so they can read through it when they are back at home. Pain contracts help, but there are also some negatives. What do you do when somebody violates the contract? Do you just kick them out of the practice and leave them on their own, or do you find other ways to help them?
Ms. Gomez: Prescribing only seven pills after a procedure is the best way to go, but the caveat then becomes when the government or the law says, “Okay, physicians, you can only prescribe ‘X’ amount.” What does that do in a medical malpractice case, when you’ve prescribed, or not prescribed, “X” amount? Who renders the standard of care in medicine? It should be physicians, not the state. I understand that we should be giving seven and not 100. It should be a reasonable number, and we have to determine what’s reasonable and what’s not. You should say, “Come back to me in seven days. If you still have pain, maybe there’s a secondary issue.” But I tell you, you’re going to be left in a quandary if you don’t follow the state law versus the standard of what your organization or your profession tells you is acceptable or unacceptable. You will be held to both standards, and you better be able to document and justify why you chose one route and not the other.
Dr. Schiff: I’d like to talk about the state versus the doctors, since I am a doctor at the state. We follow the medical community and work with the medical community, so I believe that there are not two separate standards. In Minnesota, at least for the quality improvement portion of this, we’ve tried to create some leeway. We know that there are going to be some patients who need more than seven days, and we know that there are going to be some people who are going to be over 700 morphine milligram equivalents. What we’ve tried to say is that if you’re over that amount way more than your peer physicians, then we’re going to tap you on the shoulder and ask you to do something. Not that we expect you to always perform within a perfect standard, but when we see the gigantic amount of variation we have, we’re really trying to bring down the extremes of that variation first. If we can bring down the extremes, we still leave room for some judgments.
How can issues of social disparities be best addressed when developing solutions to the opioid epidemic?
Ms. Palombi: We need to listen to what those populations have to say and understand that different populations have different ways of doing things. For example, in our work in northeastern Minnesota with some of our tribal nations, we put the power in the hands of the tribal nations. We ask them what they need, what they want to see. We work on the strengths in that community and the strengths of that culture. This has gone a long way in the healing process. We need to take the time to listen and to see why those disparities are occurring, and dig deep into that.
Dr. Lee: We are working on a project to accelerate the transition of getting patients who present to the emergency department into a scenario where an opioid use disorder is recognized, accelerating their initiation of definitive treatment that includes MAT, and also getting the patient rapidly established with a community-based substance abuse treatment provider. Our model of embedding drug abuse counselors and being able to start MAT in the emergency department was piloted at Yale and written up in JAMA. The approach that Hennepin Healthcare is going to employ is built upon the Yale model, with some modifications to fit the way things are configured in our community. UCare is providing grant support, and also will be supporting the data collection and analytics for the project.
Dr. Schiff: The programs I’m most jazzed about, in terms of supporting communities, have been done for the tribal nations in Ontario. These are programs where community resources have surrounded MAT and the classic treatment providers so that they have cultural and community support and can wrap around other supports, including those involving dads and moms. These Ontario community programs have had great success, and we’re mirroring those in the moms program in Minnesota’s White Earth Nation. We have grants out to do similar work and to replicate that model with the other four northern tribes.
Dr. George: I would like to add co-occurrence of mental illness. In communities where there is higher risk of addiction, they also have higher rates of co-occurring mental illness. Addressing mental health, either through counseling, medication, or improved access to mental health in those communities, where the rates of addiction are high, can make a difference.
One final question: what are the most important things we need to do to bring the opioid epidemic under control?
Ms. Brigner: Our energies are best served if we focus on prevention, education, and treatment. Those are the three areas where we have solid evidence. If we talk about the dangers of misuse and abuse of certain medications to patients, or even to teens, when that behavior starts early, they are 50 percent less likely to abuse medicines. Treatment is key. Despite stigmatization, and despite people who believe patients are just going to go back out and do it, we have to provide those rescue medicines and those medication-assisted therapies. It is our ethical responsibility and the right thing to do. Also, in my industry, to work on innovation. We cannot give up. We need to look at the regulatory pathways to expedite approval of generics, to expedite approval pathways for non-opioid alternatives. Even if you take away all of the opioids, you’re left with the behavior, you’re left with a real issue of what to do if patients just find something else to abuse.
Dr. Lee: I would emphasize two themes. First, that each stakeholder has a part in this effort, and each stakeholder has accountabilities. Second, demand data and evidence so that we can objectively measure the effect of interventions to determine what works and what doesn’t, and also help to reinforce responsibility and accountability. Every sector, both in the health care space and beyond, has a role to play, and should want to hold itself accountable and responsible for its piece.
Ms. Palombi: We must also look at the root causes. We have a lot of people who have suffered a lot of trauma. Opioid use disorder has been called a disease of despair. Just as we’re not going to point fingers and say that this is any one group’s problem, we also need to know that we all need to be a part of the solution. It’s not just health care, it’s not just law enforcement, it’s not just public health, and it’s not just the community. It requires a multimodal and multipronged approach.
Dr. Schiff: In addition to the health care sector, we need to involve law enforcement, child welfare, schools, and other sectors that want to play a part. We need to bring everybody together, and we’re working on getting funding to do that. I have two themes. One is around alignment across all the sectors. The second is that we all want compassionate care when we see our health care providers for any reason, and that’s even more important for folks who have opioid use disorder. At the state level and at the local levels, we need to make sure that all care is given compassionately. It’s more than just providing care without stigma, it’s also about caring. Caring is part of the cure here. There’s a tagline we started to use at DHS, which is, “This is about all of us.” We have to remember that.
Ms. Forrest-Perkins: If we’ve ever been avoidant of change in the past, we need to deal with that tension now and put it to bed. The ethics of finding a solution to this demand that we all do our work differently, collaborate differently, and think differently about solutions. People are coming to us with a life and death situation, and they deserve that priority.
Dr. Ginkel: I’d like to see more nonpharmacological approaches to treat pain. Physical therapy, chiropractic, acupuncture, massage, and yoga are all tools that don’t have the side effects that opioids do, and they should all be the first line of approach. If you do need drug therapy, there’s also non-opioid therapy. We also need more screening. There is an opioid risk tool and other tools that should be used before prescribing opioids. The American Pain Society also has guidelines on pharmacologic and nonpharmacologic ways to address pain. Those are things that we should access, as well as ICSI [Institute For Clinical Systems Improvement] guidelines.
Ms. Gomez: The University of Michigan just started a program called OPEN, which stands for Opioid Prescribing Engagement Network. They get everybody in the community together, including the police, and they look for the opioid-naïve, high-risk patients. Then they start developing programs in certain areas to try to engage. We also need to have candor. It is what it is, and we should talk about it without any bias, embracing it and discussing it in a loving manner. When patients have an issue, they have an issue. I don’t think an opioid addiction should be any more embarrassing for a person than, let’s say, a male who has impotence. Everything is what it is. Embrace it and talk about it in a nonjudgmental fashion.
Dr. George: If we want to turn the tide in this disease as an epidemic, we need public health education that focuses on how to manage pain, as well as other modalities, including nonpharmacological modalities. We need to reach people before they have pain. Once you’re in the doctor’s office and you have pain or you’ve had surgery, no matter what the provider says, you’re not listening, because you have other stresses going on. Public education must focus on risk factors of opioids and on risky behaviors. This could be as simple as taking the Percocet from the cabinet that your husband or your wife was prescribed a couple of years back. I channel this based on how HIV was managed, and how we have successfully controlled the HIV epidemic based on public health measures. That involved similar approaches: general education and addressing risk factors. We changed the HIV epidemic into a disease, not just through improved treatment, but through public health approaches. We can do the same with the opioid epidemic.
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