Opioid addiction has grown to epidemic proportions locally and nationwide. In 2015, more people in the United States died from drug overdoses than in car crashes. Vermonters have seen firsthand the negative impact that opioid addiction can have on families, friends and entire communities.
In response to the crisis, Vermont’s medical community is working to not only care for people seeking treatment but to help patients avoid addiction in the first place. Starting July 1st, all doctors and other clinicians who prescribe opioids to patients will be operating under a strict new set of rules. Here to help us understand those new rules, and what they mean for doctors and patients, is Dr. Patty Fisher, medical director for case management and medical staff affairs at the UVM Medical Center.
Listen to the interview at the link below, or read the transcript that follows.
Let’s start with the basics. What is an opioid?
Patty Fisher: Opioids are substances that act on the opioid receptors to produce a morphine-like effect. They’re used medically to treat pain. Opioids include opiates, an older term that refers to drugs derived from the opium poppy, like morphine. Other opioids are semi-synthetic or synthetic drugs such as hydrocodone, oxycodone and fentanyl.
Can you tell us a little more about what those do to the brain and why somebody might get addicted to them?
Patty Fisher: In the right person with the predisposition to have a substance-use disorder, opioids produce a euphoric effect. They create pleasure. Someone that takes these that might be predisposed to this might like the effect that the opioid gives them, and want more. We’ll talk a little bit later about the path to addiction and how quickly that can occur.
It can happen pretty quickly in folks that are, like I said, predisposed to it, and their body, even after a one-week course of an opioid, can become physically dependent on it and actually need the drug or they go through withdrawal.
What types of things might somebody be prescribed an opioid for?
Patty Fisher: Prescribing practices for opioids actually changed in the mid-’90s when OxyContin came on the market. Prior to that, opioids were really only used to treat cancer-related pain. Due to pretty heavy drug marketing by the pain industry and by Purdue Pharma, who made OxyContin, they, through the mid-’90s into the early 2000s convinced doctors to use opioids for all sorts of chronic pain conditions: Accidents, back pain, sports injuries, after surgery.
The medical community really shifted its thinking around opioids and did change its prescribing practices, much to the detriment of, I think, lots of folks who are now dependent on them or who have died due to overdose.
You’re saying an opioid addiction can start in the doctor’s office?
Patty Fisher: Absolutely. There was a JAMA article and a CDC article that came out this past April and March, respectively, that showed that … The JAMA article was looking at post-surgical prescribing and found that 6% of patients that received an opioid for any type of surgical procedure, minor or major procedures, would end up on opioids 90 days later, was their measure. Which, 6% may not sound like a lot, but if you times that by how many people in the United States have surgery, it’s 2 million new chronic opioid users a year.
The CDC article also found about similar statistics, that 6% of people that received an opiate for one week were dependent on it a year later, with one refill. If they took it for, say, eight days, that went up to 13.5% who were dependent on that a year later. It could happen really quickly, and to lots of people.
Can you help me understand the difference between being dependent on an opioid or being treated for chronic pain or full-blown opioid use disorder? Is there a …
Patty Fisher: That’s tricky.
Is that hard to do?
Patty Fisher: People that are prescribed opioids for chronic pain, so they are taking opioids every day, are probably also physically dependent on them, meaning that you can’t take it today and stop it tomorrow if you’ve been taking it all the way along, because you’re going to have withdrawal effects. You’re going to feel sick. You’re going to have sweats, runny nose, diarrhea, body aches. It can feel pretty miserable.
When we prescribe opioids to people chronically like that, we tell them, actually, not to stop it suddenly, because you’re going to feel pretty lousy. You actually have to taper off them pretty slowly. People that develop substance-use disorders start having, I guess, aberrant behavior. They need more and more and more of the drug to have the same effect, and then they start doing different things to try to obtain the drug, whether it’s going to different doctors or asking them for more or maybe buying it or taking it from a friend. That’s where the drug use clearly becomes a problem for someone.
Can you tell us about the new rules that go into effect on July 1st?
Patty Fisher: I can. The new rules were actually based on some data from some research that Dr. [Charles] MacLean did at UVM, calling patients back a week postoperatively and saying, “You were given 30 pills. How many do you have left?” It turns out that about 40% of people don’t take any opiates, and of the people that take opiates, they only take about 30% of what they were prescribed.
That was some of the data that was used to create the rules, because clearly we are prescribing more than we need to even for things like surgical procedures. The new rules have two different components to them. Actually, three, if you include the Vermont Prescription Monitoring System requirement, which is a separate rule, but we can still mention that.
That the rules are for acute pain prescribing. Someone with a new painful episode who needs pain meds, they’re seen today in the emergency department for an ankle fracture, they have surgery today, or they’re seen in a primary care physician’s office for some kind of injury, the new rule really tells you, based on your patient’s complaint or surgical procedure, how much opiate they should be prescribed and for how long.
The other piece of the rule is that you have to give patients informed consent, you have to give them information about an opiate, and you have to tell them the risks of opiates if they choose to take them as prescribed. There’s going to be quite a bit of paperwork involved and education given to patients about the medications.
The other piece of it is that you have to check the Vermont Prescription Monitoring System, which is a drug database that pharmacists enter information of filled prescriptions, and so we can look at prescriptions for controlled substances that are filled in Vermont, New York, and New Hampshire, and I think also Connecticut now, to make sure that patients aren’t getting prescriptions from other doctors in the area.
That’s for the acute pain piece of it. The other piece of it is for chronic pain medication prescribing. There are also rules about how often you have to see your patients and what kind of universal precautions should be put into place for patients on chronic pain medications, like contracts for treatment, drug monitoring, doing urine drug screens, random pill counts, closer oversight of the medication to try to make sure that they’re not being diverted to other people.
Then, checking the drug database is the third piece of this, the Vermont Prescription Monitoring System. You have to do that at least yearly on chronic prescriptions, at a minimum yearly and for any refills.
Let’s talk about this from the perspective of a patient. Say I already take an opioid painkiller with my doctor’s supervision for back pain. Will I no longer be able to get my prescription filled?
Patty Fisher: Great question, and that is one of the hardest things to try to figure out what to do about, is I guess what I’ll call legacy patients, so patients that have been prescribed these medications for a long time sometimes, people that are prescribed these medications on very high doses sometimes, people that are prescribed long-acting opiates which have also been shown to put people at high risk for overdose and death, and we also have lots of patients that are on them with Ativan, Klonopin, Valium, those types of medications.
It’s a super tough conversation. I think at a minimum people will see closer monitoring in their doctors’ offices. They should be signing a consent to treat that they have discussed, their doctor has discussed with them the risks of opiates, and that they are consenting to take the opiates despite the risks. They will also see closer monitoring in the form of urine drug testing and pill counts.
I don’t think doctors can tell who is misusing, diverting, not using their medications appropriately, so I do think these rules should be applied to everybody. Then it’s more fair that way. If you treat everybody this way, then you’re not singling people out or trying to think that you can pick out of a crowd who’s at higher risk for diversion.
I think doctors and patients should be having really hard conversations about if this is the best thing for them long-term, particularly as people age, as they develop other chronic health conditions, opiates really should not be used in people with heart failure, lung problems, sleep apnea and some liver and kidney problems. They put these people at really high risk for dying because of the opiates.
Is it the best way to manage chronic pain? Probably not anymore. It’s a really hard conversation to have with someone and say, “You know, there’s really no indication for these medications anymore for long-term chronic pain. Let’s talk about other ways to manage your pain. Let’s work together on decreasing your dose slowly.” If you do it slowly over the period of months to a year, people will not feel those withdrawal effects that I mentioned, if you do it slow.
Can you talk about how the new rules will impact doctors, nurses and other clinicians? Is this going to be a challenge for them?
Patty Fisher: It is a challenge, because a lot of the work has to be done by a doctor or the prescriber. Checking the Vermont Prescription Monitoring System can be done by their delegate, but the consent with the patient to take the medication, the patient education piece of the prescription, all has to be done by the prescriber, so by the physician or the advanced practice provider. It is quite a bit more work than it was, instead of just giving someone a prescription. It’s all good things to be talking to patients about, but it is going to take folks extra time.
Do you think this is going to have an impact on the opioid crisis overall?
Patty Fisher: I think a lot less opiates are going to be going out the door from doctors, for sure, and there’s already data showing over the last couple years that opiate prescribing has really decreased in the medical community, not only in Vermont but around the country. The problem is that there are still lots of people dependent on opiates, and people with substance-use disorders that are then switching to heroin because it’s a cheaper, easier to access, more potent alternative to opioids.
We can’t forget that that’s happening while we are prescribing less, but prescribing less is definitely one piece of the solution to a much bigger problem. We do, as a community, need to find other ways to treat people’s pain. That is not something that we have done a very good job at across the country. There need to be other modalities that are available to people and covered by insurance for pain management.