‘Prescribing Practices’

Opioid prescriptions subject of ‘Cost of Addiction’ forum

Above, Alicia Thatcher, a Marquette-area pharmacist, talks about how her profession handles the opioid epidemic Wednesday at UP Health System-Marquette. The presentation was part of the ongoing “Cost of Addiction” series. (Journal photo by Christie Bleck) Below, a stock photo of highly addictive opioids is shown. (Journal file photo)

MARQUETTE — Drug problems don’t always begin on a dark street corner in a shady area of town.

An estimated one out of five patients with non-cancer pain or pain-related diagnoses are prescribed opioids in office-based settings, according to the Centers for Disease Control.

That topic was the centerpiece of Wednesday’s presentation entitled “Prescribing Practices,” the third in a five-part series on “The Cost of Addiction.”

Dr. Kevin Piggott was one of the speakers at the event, which took place at UP Health System-Marquette.

He said there has been a 300 percent in the opioid prescription sales since 2009.

There’s a reason for this statistic.

“Eleven percent of Americans experience daily chronic pain, and opioids are commonly prescribed for pain,” Piggott said.

Approximately 52,000 people died in 2015 of a drug overdose, however, and of that number, about 33,000 involved an illicit or prescription-opioid medication, he said.

The battle against opioid abuse could be in question, at least in terms of funding.

Piggott said that before the end of his term, former President Barack Obama signed the 21st Century Cures Act, which would provide $1 billion to combat the opioid crisis.

“The question will be: Will those funds ever be appropriated?” Piggott asked. “Time will tell.”

Opioids, he said, include natural medications like codeine and morphine, semi-synthetics like oxycodone and heroin, and pure synthetics like methadone and Demerol.

The most common opioid agents responsible for overdoses are methadone, oxycodone and hydrocodone, he said.

Overdosing also is not merely a young adult’s affliction. The 45-54 age group, according to Piggott, has the highest rate: 10.6 per 100,000 deaths.

That said, stereotypes should be avoided, he said. However, people continue to be in pain, and it’s a physician’s duty to try to alleviate that pain.

Yet they’re trying balance what might be significant harm with potential benefits, said Piggott, who noted there’s no evidence there are benefits with the long-term use of opioids for pain — but there definitely is evidence of harm.

The CDC, he said, has three areas of concern: when to initiate treatment with opioids; opioid selection, dosage and follow-up; and risk assessment. For example, with chronic pain, opioids shouldn’t be considered the first line of defense.

“We really need to be looking at the alternatives,” Piggott said. “Is there an opportunity for physical therapy? Should we be getting people involved in cognitive behavioral therapy?”

For acute pain, providers also should give the lowest-possible effective dose.

“Three or fewer days will usually be sufficient,” Piggott said.

Dr. Michael Grossman began his segment of the presentation with what he called a dramatic conclusion.

“The science of chronic opioid abuse is clear: For the majority of patients — those with non-malignant pain, chronic pain — too often fatal risks far outweigh the unproven and transient benefits of this therapy,” Grossman said.

He said that to determine if someone is at risk, a patient is posed this question in his office: How many times in the past year have you used an illegal drug, or used a prescription medication, for a non-medical reason?

If the answer is yes, the patient usually is at high risk of addiction of not already addicted, he said.

One tool available to medical professionals is the Michigan Automated Prescription System that allows professionals to monitor patient drug use.

MAPS, Grossman said, is used to check new or current patients to see if they’re obtaining their drugs from somewhere else.

What if they suffered an unexpected injury?

“I probably would allow them to get additional drugs if they broke their arm, but sometimes they go to the ER for a headache, or just because their back pain is worse,” Grossman said. “They’re not allowed to do that.”

Also, most of his patients will undergo drug screening once a year, he said.

Pharmacist Alicia Thatcher talked about the epidemic from her standpoint.

Non-opioids are at the top of the list, she said, for treating pain.

“Opioids are last for a reason,” Thatcher said.

Topical medicines like Lidocaine patches work well for treating pain in a concentrated area, for example, plus they don’t have systemic drug interactions, she said.

Long-acting opioids have their place, but Thatcher cautioned against prescribing big quantities of short-acting opioids at the same time.

“This is where things get really scary and this is, unfortunately, where a handful of clinics — some of which are no longer practicing in this area, thank goodness — really harmed a lot of people,” Thatcher said.

She talked about the differences between tolerance, dependence and addiction.

“Tolerance is when a drug doesn’t work as well over time and repeated exposure,” Thatcher said. “It happens with long-term use of opioids, period. It leads to dose increases, even if the pain doesn’t worsen, even if the condition doesn’t worsen.”

Dependence means when a medicine is taken away or the dosage is decreased by a large amount, withdrawal symptoms occur, she said.

“We see fear and we see anxiety about these symptoms in people who are perfectly legitimate pain patients because they are afraid of spending their weekend throwing up,” Thatcher said. “They’re afraid of spending their weekend with everything hurting and feeling like their skin’s crawling, and anxious.”

Although that fear response is normal, it’s up to professionals to talk them through that fear and drop their doses in a responsible way, she said.

Patients acting in a manner that suggests addiction when they might be indicating uncontrolled pain is considered pseudo-addiction, she said.

Thatcher suggests opioid use be avoided for certain types of pain, and that patients be treated through one doctor and one pharmacy.

She too uses MAPS, plus she notices red flags. For instance, if someone went to an emergency room in Sault Ste. Marie, she questions why that person would fill a prescription in Marquette.

“The beauty of MAPS is that we see it up to date,” Thatcher said. “We can see their history of refill, how far apart they typically get things.”

A pharmacist has a special role in the fight against opioid addiction.

Thatcher said: “When we teach medications as pharmacists, part of that teaching is that we have to ask questions, and we have to listen to what’s actually coming out of that patient’s mouth, because so many times people will tell me things that they wouldn’t never tell their doctor.

“And it’s not always bad. Sometimes it’s just that they’re having a really nasty side effect or they’re struggling with some other issue, and I can communicate to the doctor and try to help better care happen.”

What can the community do?

Speaking up to a loved one, or his or her doctor, is one way to guard against opioid misuse, and that’s not necessarily being a tattletale.

“Doctors care,” Thatcher said. “They want their patients to do well. That kind of feedback is incredibly valuable.”

“The Cost of Addiction” series is sponsored by the Marquette-Alger Regional Education Service Agency, Campus Pharmacy, Marquette Alternative High School, the Marquette County Health Department, the Marquette County Substance Abuse Coalition, NorthCare Network, Pathways Community Mental Health, Susanne Wicklund and Great Lakes Recovery Centers Inc.

The next presentation, which deals with the state of Michigan’s response to the opioid epidemic, is set for April 12 at Northern Michigan University. The final event in the series, “Treatment Approaches,” is scheduled for May 17 at a site to be determined.