Eas­ing an epi­demic one doc­tor at a time

The Telegram (St. John’s) - - FRONT PAGE - BY CARLA K. JOHN­SON

Melissa Jones is on a mis­sion to break doc­tors of their habit, and in the process try to turn the tide of the painkiller epi­demic that has en­gulfed two mil­lion Amer­i­cans. It was in doc­tors’ of­fices where the epi­demic be­gan, and it’s in doc­tors’ of­fices where it must be fought.

Even doc­tors can be ad­dicted to opi­oids, in a way: It’s hard to stop pre­scrib­ing them.

Melissa Jones is on a mis­sion to break doc­tors of their habit, and in the process try to turn the tide of the painkiller epi­demic that has en­gulfed two mil­lion Amer­i­cans.

It was in doc­tors’ of­fices where the epi­demic be­gan, and it’s in doc­tors’ of­fices where it must be fought. So Jones is us­ing some of the same tac­tics phar­ma­ceu­ti­cal sales forces used to push their po­tent pills into com­mu­ni­ties — this time, to get them out.

She drives 100 miles a day to visit doc­tors across western Penn­syl­va­nia’s Al­legheny and West­more­land coun­ties, where pre­scrip­tion painkillers and their il­licit cousin, heroin, killed more than 600 peo­ple last year. Bear­ing a smile, ed­u­ca­tional pam­phlets and some­times sand­wiches, she is work­ing to help doc­tors stick to new na­tional pre­scrib­ing guide­lines, give them tips on how to han­dle pa­tients de­mand­ing pills and re­mind them that opi­oids aren’t very good for chronic pain any­way.

“Most peo­ple trust their doc­tors,” said Jones’ boss, Ch­eryl Bartlett. “But we haven’t trained doc­tors about ad­dic­tion, how to rec­og­nize it early and treat it in their prac­tices. Why not help doc­tors bet­ter un­der­stand how to care for their pa­tients?”

The rate of opi­oid pre­scrib­ing has started to edge down in re­cent years, but it re­mains 56 per cent higher than it was 20 years ago, enough to pro­vide nearly ev­ery adult in Amer­ica with a bot­tle of pills. The num­ber of over­dose deaths is still climb­ing, from pills that have been pre­scribed and from the surge of even more pow­er­ful opi­oids like fen­tanyl on the black mar­ket, where many turn for cheaper drugs af­ter be­com­ing ad­dicted.

While nar­cotics can bring short-term pain re­lief and help pa­tients with cancer and in endof-life care, they’re of­ten mis­pre­scribed.

In­creas­ingly, the fight to save lives has put doc­tors in the crosshairs: They of­ten feel they have no good choices to treat pain, and not enough time with pa­tients who are al­ready de­pen­dent on opi­oids.

Penn­syl­va­nia is among about a dozen states where peo­ple like Jones try to flip the script on drug mar­ket­ing and push doc­tors to­ward change. De­spite mount­ing ev­i­dence about the dan­gers of opi­oids — and their limited ben­e­fits for chronic pain — far less is known about what works to change doc­tors’ be­hav­iour.

Tough to re­verse

“What’s tak­ing so long to re­verse this thing?” asked an ex­as­per­ated Dr. Gary Franklin, a Univer­sity of Wash­ing­ton re­searcher who, more than a decade ago, pub­lished a pa­per sound­ing the alarm about fa­tal over­doses in pa­tients pre­scribed opi­oids.

Across the U.S., law­mak­ers are re­strict­ing how doc­tors han­dle mil­lions of quick en­coun­ters with pa­tients in pain.

In Penn­syl­va­nia, where the opi­oid death rate is above the na­tional av­er­age and ris­ing, doc­tors now face sanc­tions if they fail to check a state-run data­base to flag those get­ting nar­cotics from mul­ti­ple doc­tors. Mas­sachusetts bars doc­tors from pre­scrib­ing more than a seven-day sup­ply to first-time opi­oid pa­tients. Wash­ing­ton state won’t let doc­tors pre­scribe high doses with­out con­sult­ing a pain spe­cial­ist. And an Illi­nois con­gress­man wants all U.S. opi­oid pre­scribers to take classes ev­ery three years.

Jones uses a gen­tler ap­proach. Her vis­its, funded by state lot­tery dol­lars, are vol­un­tary and part of a pro­gram for low-in­come se­niors run by the Bos­ton-based non-profit or­ga­ni­za­tion Alosa Health. Jones and her col­leagues visit 2,600 Penn­syl­va­nia doc­tors a year to talk about opi­oids and other is­sues.


It used to be dif­fi­cult for Dr. Dorothy Wil­helm, a geri­atrics doc­tor in Monroeville out­side of Pitts­burgh, to get pa­tients to agree to a urine screen to test for pre­scrip­tion med­i­ca­tions and il­licit drugs. Now, with new guide­lines and pocket cards from Jones that help her ex­plain the screens, pa­tients don’t fight her any­more.

Ev­i­dence from New York City’s pub­lic health depart­ment and the Vet­er­ans Health Ad­min­is­tra­tion sug­gests Jones and oth­ers like her can re­duce opi­oid pre­scrib­ing, adapt­ing a tried-and-true tac­tic from the phar­ma­ceu­ti­cal in­dus­try called de­tail­ing.

Drug com­pa­nies send charis­matic sales reps to visit doc­tors with free pens, lunches and pill sam­ples, along with some­times-skewed in­for­ma­tion.

In 2007, Pur­due Pharma agreed to pay more than $600 mil­lion in fines for falsely in­form­ing its sales force that its opi­oid pill Oxycon­tin had less po­ten­tial for ad­dic­tion and abuse than other painkillers. The mar­ket­ing helped feed a 20-year trend of sky­rock­et­ing pre­scrib­ing.

Jones, who has a nurs­ing back­ground, is fight­ing back with a charm of­fen­sive of sci­ence-backed facts.

“When I see her com­ing, I know I’m go­ing to learn some­thing and it’s fair,” said Dr. Rudy An­ton­cic, an in­ternist in Mc­k­eesport.

Time hard to come by

An­ton­cic said he doesn’t have time to mon­i­tor pa­tients for ad­dic­tion, dis­cuss over­dose re­ver­sal drugs or fol­low other steps in new opi­oid-pre­scrib­ing guide­lines — so he refers pa­tients to pain spe­cial­ists in­stead.

“I’m forced to say, ‘Go to the pain clinic. Let those guys fig­ure it out,”’ he said.

Pain medicine emerged in the 1970s as a spe­cialty. Many pain spe­cial­ists pre­scribe re­spon­si­bly, but oth­ers are no­to­ri­ous over-pre­scribers, hand­ing out medicine to known ad­dicts. Jones would rather see her doc­tors keep their pa­tients and fol­low the guide­lines.

Over sand­wiches at a large med­i­cal prac­tice in Monroeville re­cently, Jones quizzed two doc­tors about what’s slow­ing down change. Their an­swers boiled down to choices, time and money.

“The prob­lem with treat­ing pain is there are not a lot of op­tions,” said Dr. Richard Rosen­thal. “Tylenol can af­fect the liver. Anti-in­flam­ma­to­ries can af­fect the heart, the liver, the kid­neys. You’re not sup­posed to use mus­cle re­lax­ants” with el­derly pa­tients.

Dr. Chaitali Sarkar said pa­tients want pills for “in­stant grat­i­fi­ca­tion” and re­sist safer al­ter­na­tives.

“We need more than 20 min­utes to talk to pa­tients,” Sarkar told Jones. “Every­body’s stretched thin.”

Jones re­minds doc­tors that opi­oids’ side-ef­fects — be­sides ad­dic­tion and death — in­clude con­sti­pa­tion and, in men, low testos­terone.

Min­i­miz­ing harm by get­ting off opi­oids can seem a dis­mal prospect to pa­tients, un­less a doc­tor of­fers other ways to cope with pain.

What about tai chi, mas­sage or acupunc­ture? Jones asked, point­ing to re­search in the ed­u­ca­tional ma­te­ri­als she gave the doc­tors. Those usu­ally aren’t cov­ered by in­sur­ance so can be ex­pen­sive for pa­tients, Rosen­thal said. Phys­i­cal ther­apy might be cov­ered, but co-pays add up.

Many chronic pain pa­tients with valid opi­oid pre­scrip­tions be­come ad­dicted — the best guess is about 1 in 10, ac­cord­ing to an anal­y­sis of 38 stud­ies.

For pa­tients de­pen­dent on opi­oids, Jones makes sure doc­tors know how to ta­per them grad­u­ally to a lower dose. A pocket card she gives them sug­gests start­ing off by cut­ting the dose by a quar­ter or a half each week, which prompts scoffs from most doc­tors.

Cut­ting a dose in half “would not be well-re­ceived” by pa­tients, Rosen­thal said.

Start off slower, Jones nudged, re­mind­ing that us­ing an­ti­his­tamines or an­tidiar­rheal drugs can help man­age with­drawal symp­toms.

An­other big worry for doc­tors try­ing to limit opi­oids for pa­tients: Some pa­tients may seek pills from deal­ers on the street.

It’s been more than a year since the Cen­ters for Dis­ease Con­trol and Pre­ven­tion pub­lished the first na­tional pre­scrib­ing guide­lines for opi­oids. The ac­tion was fol­lowed quickly by most state gov­er­nors sign­ing an un­prece­dented Com­pact to Fight Opi­oid Ad­dic­tion.

The ul­ti­mate goal is fewer deaths, but it may take years.

Re­search sug­gests “it takes some­where be­tween 13 to 17 years for a new guide­line to get fully im­ple­mented,” said Univer­sity of Colorado re­searcher Robert Valuck, who co-or­di­nates his state’s re­sponse to the opi­oid cri­sis.

Among laws aimed at doc­tors, one of the more promis­ing re­quires them to check a pre­scrip­tion drug-mon­i­tor­ing data­base to weed out pa­tients with mul­ti­ple doc­tors, phar­ma­cies and pre­scrip­tions.

Most states now have th­ese data­bases. Penn­syl­va­nia is among the few re­quir­ing doc­tors to check it ev­ery time they pre­scribe an opi­oid.

One study found states re­quir­ing such checks, com­bined with re­stric­tions on pain clin­ics, re­duced opi­oid pre­scrib­ing by eight per cent and pre­scrip­tion opi­oid over­dose death rates by 12 per cent, with­out in­creas­ing heroin over­dose deaths.

Doc­tors tell Jones they love the new re­quire­ment be­cause it keeps them from be­ing fooled into feed­ing ad­dic­tion. Some pa­tients even say they don’t want to be tracked, so will stop tak­ing opi­oids.

If doc­tors can change their be­hav­iour and pa­tients can change their ex­pec­ta­tions, there may be hope.

“We can’t wait 17 years,” Valuck said. “The cost to so­ci­ety is too great. We have to ad­dress this prob­lem as ag­gres­sively as we can.”


In this May 4 photo, Melissa Jones, right, a nurse ed­u­ca­tor with Alosa Health, speaks with Dr. Dorothy Wil­helm in an exam room at a med­i­cal of­fice in Monroeville, Pa. Jones vis­its med­i­cal of­fices in western Penn­syl­va­nia to ed­u­cate doc­tors about new opi­oid pre­scrib­ing guide­lines.


Nurse ed­u­ca­tor Melissa Jones, cen­tre speaks with so­cial worker Jean Easter (left) and physi­cian’s as­sis­tant Emily Braunegg in the lunch room of a med­i­cal of­fice in Monroeville, Pa.


Melissa Jones ex­plains ed­u­ca­tional ma­te­ri­als on opi­oids and man­ag­ing pain at a doc­tor’s of­fice in Elizabeth, Pa., in May.


In this May 4 photo, Melissa Jones, a nurse ed­u­ca­tor with Alosa Health, speaks with (from left) Dr. Richard Rosen­thal, physi­cian’s as­sis­tant Emily Braunegg and so­cial worker Jean Easter in the lunch­room of a med­i­cal of­fice in Monroeville, Pa.

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