State Changes How Doctors Can Prescribe Pain Medications

New state guidelines went into effect this month around how doctors can prescribe pain medications are now in place to combat abuse and heroin addiction.

The changes come on the heels of Gov. Scott Walker issueing a public health advisory in the fall to combat what has been deemed as an “escalating opioid epidemic,” has hit Racine County hard.

The new guidelines, set in place by the Wisconsin Medical Examining Board, challenges medical practitioners to make more informed decisions about acute and chronic pain treatment. However, the guidelines don’t apply to people in active cancer treatment, palliative care, or end-of-life care.  Opioids are a class of drug doctors use to sometimes manage pain. The drug class also includes the illegal drug, heroin.

Developed with the Center for Disease Control, the state guidelines outline several best practices for responsible prescribing.

“There is no high-quality evidence to support opioid therapy longer than six months in duration,” according to the guidelines published by the Wisconsin Medical Examiner’s Board. “Despite this fact, it is considered acceptable although not preferable to continue patients on treatment who have been on chronic opioid therapy prior to this guidelines release and who have shown no evidence of aberrant behavior.”

Why the rule change?

According to the Department of Health Services, the rate of opioid prescription deaths in Racine County has increased to 15.3 per 1,000 residents in 2015 from 7.2, a 113 percent increase compared to the number in 2006. Hospital stays for patients encountering opioid issues in Racine County have also increased to 50.7 per 1,000 residents from 29.7, a 71 percent increase.

“Prescription opioids have been the main driver of drug overdose deaths and poisonings,” according to a Wisconsin Department of Health Services report titled: Overview of Opioids Morbidity and Mortality in Wisconsin. “In 2015, the majority of opioid-related deaths (63 percent) in Wisconsin involved prescription drugs. Prescription opioid use is often the gateway to heroin use. Three out of four people who use heroin first use prescription opioids (CDC, 2016).”

Lt. Larry DeRosier, of the South Shore Fire Department, said heroin and opioid abuse is a constant issue.

To compound the problem, drug dealers are cutting Carfentanil, an elephant tranquilizer, into the heroin. The mix is so potentent that when someone overdoses, the typical dosage of Narcan, a drug they use to counteract the drug, won’t touch it.

“We used to only carry four milligrams on our ambulances, now our fleet has 12 milligrams,” DeRosier said. “That’s because of Carfentanil. When people have that and they heroin, they won’t breathe. And we didn’t even have enough Narcan to get them to breathe — that’s the crazy thing people don’t understand.

How did this epidemic begin

The problem with prescription opioid pain medication dates back to 2001 when the Joint Commission on Health Care made pain the fifth vital sign. Up until that time patients were only prescribed opioids after having surgery, suffering from acute trauma, and in acute cancer situations.

In order to reduce suffering the Joint Commission said that doctors should be prescribing opioids to everyone who was in chronic pain, said Nileshkumar Patel, MD, MBA.

He spoke about a month ago to primary care physicians at the Great Lakes Cardiology Symposium held in Pleasant Prairie where he outlined the changes in the guidelines.

“There were good intentions to reduce suffering among chronic pain patients, but little did they realize that this was going to create a massive opioid addiction and overdosing death problem in our communities,” Patel said.

Guidelines Target Prescription Pain Medications Protocols

The goal of the new guidelines: cut the number of people addicted to prescription pain medication. This in turn will help reduce the number of people dying from prescription pain medication overdoses, heroin addiction and deaths, hospital inpatient stays and emergency room visits, and the number of babies being born with opioid drug withdrawal symptoms.

“So the government said that you should be writing and now the government is saying, ‘No, here are different ways,’” Patel said.

Changes include:

• Patients not willing to accept alternatives to pain medication should not be considered for opioid therapy.
• If opioids are used, doctors need to combine them with other forms of therapy to address the root cause of the pain.
• The lowest dose and fewest number of pills needed should be prescribed.
• Discouraging the use of oxycodone.

Under the old guidelines, doctors were encouraged to review a patient’s prescription history in the Wisconsin Prescription Drug Monitoring Program. In April, the law now requires doctors to do patient reviews before prescribing any controlled substances if they are writing a prescription for more than a three-day supply of opioids.

“Every physician has a potential to impact a patient who is addicted to opioids — to make a difference in our communities,” he said.

Some Raise Concerns On Guideline Implementation

Guida Brown, executive director for the Hope Council in Kenosha County, said the guideline changes are a step in the right direction.

But she sees potential issues of whether doctors will actually carry out the guidelines since doctors are judged based on the quality of care they give to patients. If patients are inconvenienced by having to go back to the pharmacy for two prescriptions or still have pain and don’t get the types of medication they want, they can give the doctor bad reviews.

“This is a great step if doctors use it, but doctors have an insurmountable problem. They are evaluated by some patients who expect all of their pain to go away,” Guida said.

This is a cultural shift on how people use pain medications, that people have an unrealistic expectation to be pain-free their whole lives, she said.

“There is a legitimate use for opioids, it should only be used for emergent pain because of accident, injury or surgery… but no more than three days,” she said.

DeRosier says the changes are needed because many of those he’s seeing are people that ultimately become too dependent on drugs to work and they wind up on entitlement programs.

“That’s exactly what the state wants to stop: people going on welfare and we end up taking care of them,” he said.

DeRosier doesn’t think doctors will have an issue with complying with the guidelines. But he does think illegal oxycontin use will be in our future as opioids become harder to get.

“You’ll see more prescription medication abuse and crime because people will need to spend more money to get it,” he said.

Editor’s note: If you or someone you care about has an addiction issue, here’s a list of resources in Racine County: resourcebrochure2016.doc.