Facing the crisis: Physicians exercise caution when prescribing opioid-based medications

Many prescribing doctors recognize the necessary role medications containing opioids play in pain management, despite growing concerns about opioid addiction and overdose. (Pioneer file photo)

By Taylor Fussman and Meghan Gunther-Haas, Pioneer Staff Writers

Editor’s note: This is the first in a two-part series on opioid abuse compared to the need for medications containing opioids in pain management locally and nationwide. The second installment will appear in Saturday’s paper.

MECOSTA, OSCEOLA COUNTIES — It may seem harmless to offer medication to a loved one in pain, but this simple act could lead to a friend or family member being hospitalized for opioid overdose.

As what has become known as the “opioid crisis” continues to sweep through the country, many people may believe this epidemic is only taking hold in major cities. This problem, however, has reached even the most rural parts of Mecosta and Osceola counties.

Despite concern from physicians and patients regarding the issue of opioid addiction and overdose, many prescribing doctors still recognize the necessary role medications containing opioids play in pain management.

“Our challenge is to balance between being compassionate doctors who want to help people in pain, but also making sure that we’re not contributing to the problem,” explained Dr. Joshua Vander Lugt, emergency department medical director at Spectrum Health Big Rapids Hospital.

Although physicians are making efforts to cut back on the number of prescriptions written for opioid medications, in 2016 there were still 90.2 retail opioid prescriptions dispensed per 100 people in Mecosta County and 81 dispensed per 100 people in Osceola County, according to the Center for Disease Control and Prevention (CDC).

These county rates are significantly higher than the U.S. average in 2016, which the CDC reported was 66.5 retail opioid prescriptions dispensed per 100 people. In total, there were 214.8 million prescriptions written that year.

According to Vander Lugt, emergency medical physicians account for less than 5 percent of total opioid prescriptions written nationally. The remaining percentage is written by primary care physicians, dentists or other non-emergency doctors.

Dr. Thomas Wright, division chief for Spectrum Health Medical Group, said the majority of opioid prescriptions come out of primary care.

“I think the management of chronic pain is something that nearly every primary care provider deals with because we are the first point of entry for folks who have conditions concerning chronic pain,” Wright said.

History behind opioid epidemic

While chronic, or persistent, pain is nothing new to patients and physicians, treatments have changed over time.

“Kind of in the early 1980s, opioids transformed from something that was really only used for end-of-life cancer patients, and it became something more widely used to treat all kinds of pain conditions,” Vander Lugt explained. “It’s a quick and easy fix, but it’s not a solution, sometimes, to be placed on these medications.”

In the 1990s, pain was identified as the fifth vital sign, along with blood pressure, pulse rate, respiratory rate and body temperature, Vander Lugt said.

“We did a pain scale from 1 being little pain to 10 being the worst pain. That was part of a standard evaluation of every patient,” he said. “While we’re checking patients’ vitals, we’re asking them, ‘Are you in any pain? Give it a number.’ It helps us track somebody who is in pain — helps us know what we’re treating.”

Pain is the chief complaint for an estimated 40 to 60 percent of the patients Vander Lugt and his peers see.

“It’s easy to see if someone has a broken arm, if it’s disformed, and know they must be in a lot of pain,” he said. “It’s harder to quantify that if someone maybe has abdominal pain, chest pain or back pain. Those things can be very dangerous complaints, potentially.

“So, getting a number on the pain, how intense is it, the duration, location, anything that might exacerbate or alleviate the pain, is an important part of a medical history. Rather than it just be part of the nursing and physician assessing, it was given a high priority and it became another vital sign.”

Vander Lugt said as emergency departments got busier and visitors were likely to see different doctors, prescriptions to deal with long-term pain could differ.

“Our focus is on finding who the sickest of the sick are, and making sure they’re safe, triaging them, getting them to the appropriate care — whether it’s transferring them to another hospital, admitting them to a surgeon or getting them to follow-up,” he said. “We do that in a limited time frame, and historically one of the quickest ways of getting a lot of different types of pain under control was opioids.”

As physicians weighed the necessity of dealing with people’s pain and prescribing something generally used for easing terminal patients, Vander Lugt said the technology of the medications available might not have kept up with medical ethics.

“I can make a stand as an emergency doctor, but I’m just one of hundreds and until there is a concerted effort among everybody, we really have a good way to stop the momentum that was taking us down a dangerous path,” he said.

State mandated changes

With few guidelines in prescribing opioids, people began taking medications, such as fentanyl, Codeine, Oxycontin, and became addicted, which proved to be fatal in some cases, Wright said.

“Suddenly, everyone is interested in turning back the clock, but to use a euphemism, ‘the cat’s out of the bag.’ This is not a medication you can easily cut back on,” he said.

As doctors work to reduce the number of opioids dispensed and the risk of their patients overdosing, they can look to various databases and tools, and can suggest different non-pharmacological options.

Vander Lugt said a person’s pain and the cause of their pain will determine the correct course of treatment, but prescribing non-pharmacological options, including ice, heat or physical therapy, or non-opioid medications, such as Tylenol, may reduce this risk of patients overdosing from opioids.

However, it may still be necessary for physicians to prescribe opioid medications. When this situation arises, doctors now have specific prescribing guidelines to adhere to.

According to the Department of Licensing and Regulatory Affairs and the Michigan Department of Health and Human Services, the Michigan Opioid Laws require prescribers to follow several steps before writing a prescription for a controlled substance containing an opioid. This state mandate was implemented in June.

These requirements include discussing the potential risk of addiction and overdose and how to properly dispose of an expired, unused or unwanted controlled substance with the patient and consulting the Michigan Automated Prescription System (MAPS) if writing a prescription for more than three days, among several others.

Vander Lugt explained MAPS is a database which gives doctors a way to monitor any controlled substances a patient may already be taking and assess the patient’s risk for addiction or overdose.

The MAPS system and other state mandated changes for prescribing opioids has had a significant impact on the way doctors across Michigan attempt to manage their patients’ pain.

For Paul Stern, DDS, with Caring Family Dentistry in Big Rapids, these updates to the Michigan Opioid Laws have required a change in procedure.

As part of the state mandated changes to Michigan Opioid Laws, prescribing physicians are required to discuss the potential risk of addiction and overdose with patients, and the patients are required to sign a form acknowledging these risks. (Pioneer file photo)

“Several years back, when there weren’t as many restrictions on opioids, it was routine for us to prescribe medications to patients after extractions,” he said. “But now, with the rules and regulations, which make sense, we don’t really prescribe opioids for extraction patients, unless necessary.”

Stern added if prescribing opioids for a difficult extraction does become necessary, he is required to follow the state mandates, involving checking the MAPS system and ensuring the patient is aware of the associated risks.

Although the new state laws and an increased awareness about the potential dangers of opioids among physicians and patients have helped shed light on the problem of opioid addiction and overdose, doctors say the country is still a long way from solving the “opioid crisis.”

“It’s a delicate situation because a lot of things happened together to create the crisis that we’re in, so it’s going to take a lot of people working together to get us out of it,” Vander Lugt said. “The people who are suffering from opioid dependence are very vulnerable people and we need to look at them and treat them with compassion and not judge them, because in the end it could be anybody. It could be your neighbor, your sister, anybody. It could be you.”

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