Healthcare Providers Helped Bring About the Opioid Epidemic; Now It’s Time to Help End It

Some programs already in place, many more needed

By Toby Cosgrove., M.D.

Cleveland Clinic president and CEO

Too many of the stories we hear about opioid-related deaths start the same way – with a patient prescribed a pain medication for an injury or medical procedure.

The stories then progress to street drugs like heroin or fentanyl, leading all too often to death. In 2016, about 60,000 Americans died of opioid abuse, an American death toll greater than the whole of the Vietnam War.

This has to stop and healthcare providers have a key role in turning the tide. One of the most sobering statistics, from a physician’s point of view, is that over 75 percent of opioid and heroin deaths begin with a prescription pain killer. The healthcare industry bears some responsibility.

That’s not to say that patients aren’t in legitimate pain. They are, maybe as many as 100 million by some estimates. But we as healthcare providers have to approach pain differently, smarter.

Declaring the opioid crisis a National Public Health Emergency is a good first step. But we in healthcare can’t wait for Washington. We have approaches at our disposal that can effect very real change.

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Better policies have shown to make a difference quickly. In just the past few months, we’ve:

  • Reduced the number of opioid prescriptions exceeding 3 days by 50 percent in our emergency departments, simply through education and communication.
  • Reduced the number of patients receiving opioids by one-third in a group of colorectal surgery patients.
  • Hired a full-time Doctor of Pharmacy, who as a pain-management specialist can improve prescribing practices and clinical care.
  • Designated every hospital unit with “pain champions,” who are conversant with alternative pain strategies.

What it boils down to is this: healthcare providers have to make this a priority and we have to give physicians the tools they need to effect change.

Essentially, we can attack the opioid epidemic in four ways: giving healthcare providers the prescribing tools and resources they need; insisting on team engagement among hospital departments; tracking prescribing data and demanding accountability; and sharing information with other hospitals in the region.

Our electronic medical records system has been an indispensable tool. It has allowed us to connect directly to the Ohio Automated Rx Reporting System (OARRS); now, a physician can see a patient’s history of controlled substances within seconds while formulating a treatment plan. Also, our patient-provider agreements and consents are stored electronically so anyone who cares for that patient can see it, review it and update it as appropriate.

At the same time, we can use the electronic medical record to gather data so that we truly understand current practice – What type of patients are being prescribed narcotics? Which departments prescribe opioids most often? – then use that data to standardize care across the system.

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Here are a few more approaches we’re using at Cleveland Clinic:

A Twist on “Just Say No”: Saying “no” to patients who are seeking narcotics for pain relief is difficult. That’s why we’ve instituted training courses for physicians on how to decline opioid requests from patients, with an emphasis on being compassionate. These are difficult conversations and the stakes are high. We must help our physicians navigate this by giving them the skills, strategy and practice to show empathy while managing emotion, setting boundaries and employing de-escalation tactics when needed.

Getting Back on TREK: Back pain strikes about 31 million Americans at some point during their lives. All too often, the first-line treatment is surgery or pain killers. At Cleveland Clinic, we are offering a different approach. Back on TREK (Transform Restore Empower Knowledge) is a pilot program treating patients with chronic low back pain (with or without leg pain), with the goal of restoring function through non-surgical treatment approaches and providing patients with tools to manage their pain without narcotics. The program utilizes a combined treatment approach of psychologically informed physical therapy; pain neuroscience education and behavioral medicine sessions utilizing cognitive behavioral therapy and psychological education techniques. More than 60 percent of patients showed significant improvement in pain and disability; over half demonstrated significant reduction in fatigue, pain interference, and overall physical health.

Painless mastectomy: An experimental drug, Exparel, is a local, time-released anesthetic used after a mastectomy to help patients with the worst of the pain — the first four days — so patients can avoid opioids.

Narcotic-free colorectal surgery: A program at Cleveland Clinic Akron General replaces narcotics with pre-surgical pain management, peripheral nerve blocks during procedure, and encouragement for the patient to get out of bed and move around within 4 to 6 hours of getting to the recovery floor. Of 80 patients in the program, one-third avoided narcotics. As a result, readmission rates and surgical costs dropped, hospital stays were shortened by 50 percent, risk of complications were reduced, and recovery improved with less pain.

New “ERAS” of recovery: Several medical centers, including Cleveland Clinic, have been developing the concept of “fast-track” or “enhanced” recovery after surgery. Recently, comprehensive research has indicated that an ERAS (“Enhanced Recovery After Surgery”) methodology that permits patients to eat before surgery, limits opioids by prescribing alternate medications, and encourages regular walking reduces complication rates and accelerates recovery after surgery. ERAS can reduce blood clots, nausea, infection, muscle atrophy, hospital stay and more. Patients are also given a post-operative nutrition plan to accelerate recovery, and physicians are using multi-modal analgesia, limiting the use of narcotics.

The good news is that the fight against the opioid epidemic is moving in the right direction. Everyone – hospitals, physicians, lawmakers, law enforcement and the general public – see this as the national emergency that it is.

By leveraging the tools at our disposal – or by creating new tools – we can save lives.

Link to original article here:  Healthcare Providers Helped Bring About the Opioid Epidemic; Now It’s Time to Help End It

Major Science Report Lays Out a Plan to Tamp Down Opioid Crisis

The National Academies report includes recommendations for federal agencies, states and medical personnel.

When the U.S. Food and Drug Administration screens new opioid drugs it should better anticipate how people might abuse them in the real world, the National Academies of Sciences, Engineering and Medicine warns in a major report issued Thursday on the country’s opioid crisis, which kills 91 people a day—often via overdoses on prescription drugs. The FDA needs to move beyond its traditional focus on clinical studies about drug effectiveness and side effects, and to seek public health data on potential abuse, the Academies advises in its 400-page proposal for targeting the deadly issue.

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The FDA had asked for the report, and its release comes as several states are suing pharmaceutical companies over allegations that they downplayed the addictive nature of certain prescription painkillers and helped fuel the current crisis. “The focus of the request from the FDA was for advice on what they could do to evaluate [opioids] more completely before approving them for use,” says Stanford University anesthesiology professor David Clark, a member of the Academies committee that drafted the report. A key recommendation, Clark says, is for “the FDA to move beyond its standard matrix of considerations for drug safety and—at least for opioids—move into a more public health–centered matrix of considerations which could help us predict what might happen for people beyond the intended recipient of the drug.”

The 18-member committee, which worked on the report for more than a year, identified specific steps that states, federal agencies and medical providers should take to stem the tide of abuse of substances including heroin, fentanyl and prescription drugs—even as they ensure pain patients have access to legal relief. Any policy that aims to restrict lawful access to prescription opioids would drive some people toward the illegal market, the report warns. Instead it urges states, regulators and public health agencies to work toward universal access to evidence-based interventions for substance abuse, including treatment programs and full coverage of medications approved to fight addiction. The report calls for expanding access to the overdose antidote naloxone to laypeople, and also says jurisdictions should explicitly authorize syringe exchange as well as their sale or distribution. “Reducing the scope of the epidemic of opioid addiction is my highest immediate priority as commissioner,” the FDA’s Scott Gottlieb said in an e-mailed statement. “I was encouraged to see that many of [the Academies’] recommendations for the FDA are in areas where we’ve made new commitments.”

The Academies’ report also recommends increasing the FDA’s formal reevaluations of opioid approval decisions, in order to ensure that the drugs’ benefits still outweigh the risks. It advises the FDA and other federal health agencies to improve their data tracking on pain and opioid use, and to invest more money in research for a clearer picture of the opioid epidemic—and for potential ways to combat it, such as programs that track prescribing and dispensing information.

Officials battling the crisis on the ground applauded some of the Academies’ findings. “The report is in line with the work we are already doing in Baltimore City,” says Leana Wen, the city’s public health commissioner. “We have had needle exchange programs for over 20 years, and we also have a very aggressive naloxone program.” The report focuses on improving research and regulatory actions before a prescription drug hits the market, Wen notes. “All these are important, but I continue to emphasize what I see on the frontlines—a need for increased access to treatment that is evidence-based and well established.” With naloxone’s price rising and a shortage of substance abuse treatment beds, these are crucial needs, she says.

The report also says states should take specific actions, such as creating more year-round programs in which pharmacies or other establishments take back unused prescription painkillers—so they do not sit around patients’ houses, where they might be abused or stolen. (According to the National Institute on Drug Abuse, nearly half of young people who inject heroin abused prescription opioids first.) “The concerns on this point are more impetus rather than obstacle,” Clark says. “It is not uncommon to have drug take-back programs through churches, pharmacies, universities, and public interest groups and community organizations. But none of those organizations are set up to do that kind of thing on an ongoing basis.” Some pharmacies have already moved in this direction by setting up drop boxes to dispose of old drugs when someone comes in to fill a new prescription, he adds.

The President’s Commission on Combating Drug Addiction and the Opioid Crisis, chaired by New Jersey Gov. Chris Christie, also aims to come up with concrete recommendations. It was scheduled to release an interim report last month but has not done so, and now expects to put the report out at the end of this month, around its next meeting. “The Commission is continuing to look at how the administration can best address this unprecedented crisis and will be releasing its [final] report in October,” Richard Baum, acting director of the Office of National Drug Control Policy, told Scientific American in an e-mailed statement. “The Trump administration is committed to addressing the opioid epidemic,” Baum wrote, and in just six months it has “sent nearly $500 million to the states to address the epidemic locally, begun work on the president’s first National Drug Control Strategy and established the President’s Commission on Combating Drug Addiction and the Opioid Crisis.” (The latest version of the Senate health care bill, released Thursday, also would include $45 billion to help support substance abuse treatment.)

Addressing the opioid epidemic requires action in the medical and patient community as well, the Academies’ committee says. It advises states to create better pain education materials for medical schools, medical licensing boards and the public. States and the federal government should also work in concert to help boost access to medication for addiction—and to make sure patients can afford it, the report says. Managing the opioid crisis is a balancing act requiring trade-offs when it comes to restricting the lawful opioid supply, influencing prescriber practices, cutting demand and reducing harm, the committee members wrote. Yet they add that their proposal should, “leave adequate space for responsible prescribing and reasonable access for patients and physicians who believe an opioid is medically necessary.”

Article by: Dina Fine Maron on July 13, 2017

Link to article here: Major Science Report Lays Out a Plan to Tamp Down Opioid Crisis

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Lives Lost: One story of opioid recovery

Lisa is alive today because of new tactics in the fight against opioid addiction.

CANTON, OH Every morning, Lisa dissolves a pill under her tongue. She doesn’t mind the flavor: chalky, like children’s aspirin, with a hint of orange.

The pill is Suboxone, a medication that helps Lisa control her cravings for opioids. After years of abusing prescription pills and heroin, and surviving more than a dozen overdoses, she has been sober four months and counting.

Her bills are paid. There is food in the refrigerator. She spends time with her children.

“I’m happy, actually,” Lisa said. “This is the best things have been in a long, long time.”

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But her story is about more than a pill. Lisa is alive and in recovery because Stark County embraced new techniques to fight an opioid epidemic that has killed hundreds locally and thousands across the state.

Medication-assisted treatment, outreach by police officers, the wide-spread use of overdose-reversing naloxone and peer support all played a role in Lisa’s story.

Lisa is 51 years old and lives in Canton. She agreed to speak with The Canton Repository on the condition her last name not be used because of concerns regarding her past associates.

Lisa almost didn’t make it to this point. By her own count, she overdosed at least nine times that landed her in a hospital. That number doesn’t include the dozen or so times her teenage son waited anxiously at her side to blast overdose-reversing naloxone up her nose.

“He saved my life more times than I know,” she said.

Lisa started smoking marijuana when she was 13 years old. In her 20s, she started using methamphetamine, cocaine and prescription pills. Vicodin was the first opioid she tried. Her mother gave her the pill to ease a headache.

“That was the miracle cure for hangovers after that,” Lisa said.

Sometime later, a pain management doctor prescribed Lisa opioids such as Percocet, Vicodin and OxyContin for migraines and pain related to scar tissue. The doctor didn’t ask about her past drug use, she said.

Lisa had a medicine cabinet full of opioids, but she would blow through a month’s worth of pills in a few weeks. The first pain management doctor ultimately dropped Lisa after she got an opioid prescription from a dentist. She found another clinic, but authorities shut it down.

Drugs such as heroin, cocaine or opioid painkillers flood the brain with dopamine, causing a feeling of pleasure. Food, sex and exercise also release dopamine, but can’t compete with surge from the drugs.

Over time, drug use depletes the amount of dopamine in the brain. Addiction takes hold and the brain’s structure changes.

“They have to seek substances to fill that gap,” said Dr. Jamesetta Lewis, of Mercy Medical Center’s Pain Management Center. “That’s when an addiction develops. They have to get more and more substances to bridge that dopamine gap the brain can’t fill itself.”

Unable to get pills, Lisa used heroin. That was about eight years ago. Heroin was cheaper than pills and stronger. She used every day. When she heard about someone overdosing, she’d try to buy the same stuff.

“I never cared if I died,” Lisa said. “I never cared. I just didn’t care. And if I was going to die, that was the way to do it because it was completely painless. You just go to sleep.”

Addiction consumed her life and hurt those closest to her. Her adult daughter started using opioids. Lisa’s teenage son worried every time he left the house or went to school that he’d return to find her dead or in jail. At night he skipped sleep to make sure she didn’t die.

“Growing up seeing your family do that, it does something to you,” he said.

Ready for help

Two Canton Police narcotics officers knocked on Lisa’s door one day this winter.

Detective Mike Rastetter and a supervisor were checking complaints about drug activity at Lisa’s home. They knew Lisa from all the times she had overdosed.

“She looked skin and bones,” Rastetter said. “She looked really bad.”

Lisa was sick from withdrawal and desperate when they knocked. What she didn’t know at the time was that the department had told officers to look for ways to help people addicted to drugs get treatment.

Lisa told the detectives she was going to die if she didn’t get help. They started making calls. About four hours later, Lisa was in a detox bed at the Crisis Intervention & Recovery Center.

“We were fortunate enough that day that it was available,” Rastetter said.

Medication-assisted treatment

Addiction treatment can take different forms. After a week of detox, Lisa went to CommQuest Services’ Regional Center For Opiate Recovery in Massillon, which opened in 2015 specifically to treat opioid addiction. Since then, it has received 2,500 unduplicated referrals from more than 20 counties.

“We talk about recovery being a process of learning to enjoy life and repairing the damage you did while you were using and improving the overall quality of your life,” said CommQuest President and CEO Keith Hochadel.

Lisa’s treatment plan combined counseling and 12-step meetings with daily doses of Suboxone, a combination of naloxone and buprenorphine, an opioid. Suboxone reduces the euphoria and cravings associated with opioids so a patient can focus on recovery.

The thought of getting high is always in her mind, Lisa said, but she counts to 20 and thinks about something else and the craving passes.

“I can function every day,” Lisa said. “I function.”

Starting this month, Stark Mental Health and Addiction Recovery will use two-thirds of a $741,000 federal and local funding package to expand treatment with Suboxone and Vivitrol, a medication that blocks an opioid from making the user high.

But the local treatment community has realized that treating addiction involves more than medication and counseling sessions. Men and women in recovery need help to rebuild their lives and the best guide can be a person who has walked the same road.

Rebuilding lives

When Lisa started at ReCOR, she had to go to Massillon every day to get her dose of Suboxone. She couldn’t drive and everyone she knew who had a car was using drugs. She was able to get a ride with a peer supporter from Stark County TASC.

Peer supporters are individuals in recovery who are trained to help others addicted to drugs or alcohol.

“You actually know what they’re talking about,” said Nicole Osborne, who oversees TASC’s peer supporters. “You actually know where they’re coming from. You didn’t just read it in a book in school.”

Three times a week peer supporters from TASC visit individuals detoxing at the Crisis Center. Rides to treatment appointments are just some of the help they offer.

People addicted to alcohol or drugs put everything else in their lives on hold, Osborne said.

When she meets a new client, she asks the woman about her “life to-do list,” the things she’s avoided or ignored for months or years. That can be getting a driver’s license, finding a home, clearing up arrest warrants or getting a job.

“You need the basics of life,” Osborne said. “You need to know where you’re going to sleep that night. It’s hard to even think about being sober or not using drugs if you don’t have a place to live or no food.”

Peer supporters also link clients to others who can help them stay sober.

Lisa said teaming with a peer supporter removed any excuses she might have had for not going to treatment.

“You don’t have a reason to say, ‘I can’t do it,’” she said.

Police outreach

Lisa is drug-tested regularly in the ReCOR program and said she goes to 12-step meetings almost daily.

Rastetter stops and checks on Lisa and her family about once a month. Right now he’s trying to find her a job.

The 11-year Canton police veteran said he never thought his job would include navigating the maze of addiction services, insurance and housing assistance. Finding local resources on the fly is a challenge, he said, but it’s getting better.

“It’s worth a chance,” Rastetter said. “If we save two or three people’s lives and they get off heroin, then it’s worth it. It really is.”

Lisa is one of about five people the police have helped get into detox, and the department is trying to assist more.

Taking a cue from communities such as Mansfield, Akron and Green, Canton police started a Recovery Response Team in late June. The team includes police, a caseworker from TASC and a Crisis Center nurse. Every week, the team visits individuals who recently overdosed.

“The jails are not equipped to deal with addiction recovery, and I think that looking at this from a health care standpoint and as a health care crisis is very important,” said Lt. John Gabbard, who oversees the initiative.

The police will still pursue drug dealers, but Gabbard asked for patience from residents who might not understand the new approach toward individuals using drugs.

“Give us a chance to convince you that taking the long-term approach of getting them help will be more beneficial to the neighborhood than trying to evict them into someone else’s neighborhood and not dealing with that problem,” Gabbard said.

Looking forward

Now that Lisa’s life isn’t ruled by a daily hustle for drugs, she has a lot of things she wants to do.

She wants to get a job and more furniture for her home. She wants to drive again. She wants to spend time with her family, including her daughter who is now in recovery.

Her plan is to “do things and make memories,” Lisa said. “Ones that I can remember and ones where everybody’s happy.

Relapse is always a risk, and with opioids, the consequence of one slip can be fatal.

Her kids were proud of her recovery.

“Not everyone is as lucky as her to where you can OD as many times as she did and be alive to this day,” her son said.

Article written by: Shane Hoover, Cantonrep.com staff writer

Link to original article here: Lives Lost: One story of opioid recovery