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Local doctors are backing off opioid prescriptions as crisis continues to grow

South Bend Tribune - 4/8/2018

April 08--SOUTH BEND -- Dr. Todd Graham's murder was a sobering event in the opioid epidemic. The doctor at South Bend Orthopaedics was shot and killed last summer by a patient's husband for not prescribing opioid pain medication.

A week after Graham's death, local doctors came together at a news conference with a promise to act. A promise to reverse the mistakes they made in helping create a reservoir of available opioid prescription pills.

"When Todd was killed, that galvanized everybody," said Dr. Stephen Anderson, chief medical officer for Saint Joseph Health System. "I hate to say it, but it really took something like that to look at ourselves, our behaviors as prescribers and how that has contributed to the excess of narcotics in the community."

Now it's a struggle to balance the needs of patients who legitimately need the medication while changing prescribing practices to avoid creating a new generation of addicts. The epidemic, meanwhile, continues to grow.

Earlier this month, the Centers for Disease Control and Prevention released a report showing overdose cases had climbed by 30 percent at emergency rooms from July 2016 to September 2017. Indiana was at about 35 percent; the Midwest was the hardest-hit region, seeing a 70 percent increase in emergency room visits.

Locally, South Bend EMS used 494 doses of naloxone, the opioid-overdose antidote, in 2017, up from 338 doses the previous year. Overdose deaths in St. Joseph County did drop from 60 to 57 in 2017, but the total is still higher than the number of people killed in homicides and motor vehicle accidents combined.

But doctors appear to be changing their practices. The number of prescriptions in St. Joseph County has steadily decreased in recent years, totaling about 81 prescriptions per 100 people in 2016, according to the most recent data from CDC; that's a drop from a 2012 high of 100 prescriptions per 100 people.

Many doctors admit they didn't have the best prescribing practices. But they argue that they were also misled by opioid manufacturers and distributors about how addictive opioids were and whether they were the best option for treating chronic pain.

Those claims have led to federal lawsuits against manufacturers by cities and counties looking for financial reimbursement for the costs of battling the health crisis. South Bend and Marshall and LaPorte counties have all filed suits, and St. Joseph County has approved plans to also file.

'A big impact'

Last year, local doctors set out with a goal of "no new addicts," and Anderson says he sees progress.

"The recognition and education has already made a big impact in our community," he said.

About four months ago, the St. Joseph Health System worked with its emergency departments to limit the amount of opioids being prescribed, especially for an acute injury. Now, emergency room doctors will only prescribe up to 12 pills of Tylenol 3, Anderson said, which has a lower risk of addiction compared to other opioid pain medications.

Before, it wasn't uncommon for doctors to write prescriptions for 20 to 60 pills.

"We need to educate doctors that they don't need to write large prescription for narcotics at all," Anderson said. "You don't want to give 60 pills. You may not want to give any. Look for other methods."

Beacon Health System has made similar changes in its emergency room's prescribing practices, said Dr. Brandon Zabukovic, who specializes in both family and addiction medicine. The ERs are instructed to only prescribe a few days' worth of pain medication, giving the patient enough relief until they can meet with their doctor.

Beyond the emergency room, other doctors within Saint Joseph Health are encouraged to discuss their opioid prescribing practices, Anderson said. Trinity Health, Saint Joseph Health's parent company, also expects prescribing doctors to complete at least two hours of continuing education on opioid management by 2019.

Beacon will focus on its surgical department, Zabukovic said. Doctors will travel to Virginia this month to work with the Mayo Clinic on prescribing practices for patients recovering from general surgery.

It's not only doctors making changes. Indiana legislators and the Indiana State Medical Association are also influencing prescribing practices.

Last month, ISMA was awarded $230,000 to launch a program later this year that will offer opioid-prescribing courses for Indiana doctors. The courses will be based on best practices and customized for different specialties.

Legislators also passed two laws, one requiring doctors to receive at least two hours of training on opioid prescribing every two years. The other requires doctors prescribing any medications to check INSPECT, a statewide database that tracks a patient's prescriptions. Doctors will know if another physician recently prescribed opioids to the patient.

An over-correction?

While doctors are making changes, some patients are getting worried about their pain treatment.

Steven Martin from Elkhart fears doctors are over-correcting. He says he relies on his monthly opioid prescription to get through the day. Martin typically takes three to four pain pills a day for his chronic back pain, but he says he sticks to his prescription and doesn't misuse them.

Other treatments, such as physical therapy, only made his pain worse, he said. And while he wishes he wasn't on opioids, he sees the pain killers as his only option for now. He doesn't want doctors to become too fearful of prescribing the pills.

"I can't move around," Martin said about being off his medication. "The pain is too much. It's just agony."

Doctors may be pulling back on the amount of opioids they are prescribing, but there still is a place for the narcotic prescriptions, Zabukovic said.

He believes a relatively small number of people clearly need the medication. Still, he said, "we have to be really cautious about swinging the pendulum too far away for people that might benefit. Trying to find the right person and the right amount is very difficult, but we don't want people to go untreated."

What patients and doctors need to do is change the way they view pain, said Dr. Stacie Wenk, president-elect of the Indiana State Medical Association. The guidance doctors were getting over several years was to guide patients to a pain-free state, she said.

Wenk believes doctors need to work with their patients to manage the pain and be able to function throughout a day -- not necessarily reach a level of zero pain.

"We have to do a lot of education of people that painlessness is not a reasonable expectation," Zabukovic said.

And there are alternatives to opioids for pain treatment, doctors say. But those treatments pose a whole other problem -- insurance coverage.

Treatments such as physical therapy, massage therapy, chiropractic work and acupuncture aren't always covered by insurance. Even if an insurance policy offers some coverage, the out-of-pocket expenses can still be steep if a patient needs months of treatment.

"A lot of these things are not well covered," Anderson said. "It's a lot easier for a doctor to write a prescription and say 'see you in a month.'"

The state medical association went to state legislators this year with a resolution to broaden insurance coverage, but it didn't get far because of the complexity of the issue.

"It's not an easy topic to cover," Wenk said.

Wenk doesn't see insurance companies as necessarily opposed to covering other treatments. Studies still need to be conducted on the effectiveness of alternative treatments. In the end, she says, it's a matter of education, not resistance.

"I think we have gone down the traditional path so long that these concepts are new," she said. "I think they are willing to have conversations about this."

Martin, the patient from Elkhart, would welcome new forms of therapy for his pain. He understands the addictive threat of opioids. He has gone through withdrawal before and knows he'll need help if he finds a permanent solution to his pain and no longer needs his pills.

Until that happens, he's worried that with more pressure on doctors because of the opioids crisis, his monthly allotment will start to decrease or completely stop.

"I wish people would stop abusing them," Martin said. "It's people like me that are the ones suffering."

lwright@SBTinfo.com

574-235-6324

@LWrightSBT

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