Tara Koch was first prescribed opioids at 21, and it started a decade-long dependence on medications that she didn’t know the risks of.
“I felt like I was kind of dying inside, slowly, when I was on opiates,” said Koch, 32, of Bellefonte.
Koch was “stable-ish” on opioids, but she said she wasn’t living. It was difficult to maintain a job and take care of her kids.
It’s an increasingly familiar story in recent years, and as awareness about the risks of opioid addiction and abuse has increased, local medical groups have taken steps to address the issue and change their approaches to pain management.
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That awareness has increased “substantially” and helped to take the burden off of physicians and caregivers, said Dr. Wayne Sebastianelli, medical director of Penn State Sports Medicine and associate dean for Clinical Affairs, University Park Regional Campus.
He said that about a decade and a half ago, there was a push to create pain as the fifth vital sign — the others being blood pressure, temperature, pulse and respiratory rate. That meant that part of taking care of patients was making sure their pain was well managed.
It led to the perception, Sebastianelli said — by not only institutions and patients but also providers — that in order to make sure patients were well cared for, the appropriate pain management was required, which led to over-utilization of opioid-type medications.
“With every well-meaning intention, there are unintended consequences,” he said.
Helping patients in the wake of the opioid epidemic
Throughout the entire Geisinger health system, the total number of monthly opioid prescriptions dropped, since 2014, from 60,000 to 28,000, said Dr. Amit Mehta, Geisinger Community Practice Department director.
“I think definitely ... over the last few decades, there was over-prescription. No denying,” he said.
Pain is also a difficult subject to approach: It’s multifactorial, and sometimes it’s psychological, Mehta said.
Mehta said the approach at Geisinger is making sure the right person is prescribed the right medication at the right time.
The aim, he said, is to prescribe opioids for the shortest amount of time possible and follow up with patients closely so they don’t become addicted or start abusing the medications.
“If you talk to the patient and if you explain to them certain facts and run down what medications, how they work and how they can impact you and the risk of addiction and abuse, I think most of the people really understand that,” Mehta said. “They don’t want to become addicted. ... And I think that’s where Geisinger is changing the whole approach.”
Something that’s been “very effective” for Geisinger is its pharmacy-led chronic pain program, Mehta said. Many of its outpatient clinics have a pain pharmacist embedded in primary care.
Those pharmacists can help make a plan for what medications a patient will take and for how long, and then the prescription ultimately goes back to the referring primary care physician so that he or she can sign it, he said. It’s a collaboration between the pharmacist and the primary care doctors.
Approaching pain management in different ways
In the past three to four years, Sebastianelli said, the level of education has “escalated significantly” — not only for new medical professionals but also for those renewing their licenses.
Sebastianelli said his license is being renewed in December, and as part of that process, he needed to take a six-hour opioid course and pass a test.
The approach to pain management has changed a lot, he said.
“I think we are approaching pain management in a multimodal way,” Sebastianelli said. “So we’re doing nerve blocks; we’re doing psychotropic medications ... . We’re doing anti-inflammatories; we’re doing non-narcotic medications, like Tylenol, and then ultimately if you need some of the morphine-equivalent stuff, you use that but in much smaller doses than we used to.”
At Mount Nittany Health Pain Management Center, chronic pain patients who are benefiting from opioids can possibly get that medication in a different form.
Dr. Upendra Thaker said the pain clinic has advanced techniques where patients can have a catheter put in their spine with a programmable pump that can be filled with either a month or 90 days’ worth of medication. It’s a “very small” amount of opioids — micrograms rather than milligrams.
There are multiple benefits to this approach, including that the tolerance happens at a much slower rate than with oral medications; patients don’t get the typical side effects associated with opioid use, like constipation; and patients can’t abuse or divert the opioids because the medication is not under their control, he said.
A tool that’s been helpful for local providers is the Pennsylvania Prescription Drug Monitoring Program, which, according to the Pa. Department of Health’s website, “collects information on all filled prescriptions for controlled substances.”
“All of that has been very, very significant in its effect on identifying individuals who are over-utilizing prescribed narcotics,” Sebastianelli said.
The program can be used to ensure that patients aren’t receiving prescriptions for controlled substances from multiple providers that aren’t in communication with each other, he said.
The unintended consequence of this system, though, Sebastianelli said, is that people are going through withdrawal and there aren’t enough services to help them or they’re turning to illicit substances, like heroin, which on any given day could have a different concentration of morphine equivalents, and can lead to overdoses.
“It’s good that we control it, but I think we should have anticipated the need for detoxification and for appropriate sort of weaning of people off of medications so they didn’t have to turn to the street to find what they need,” he said.
Thaker said what they don’t want to happen is for the pendulum to swing the other way so that patients who do need opioids — like cancer patients or patients who are functional on opioids and have no other alternative — can’t get them.
Could medical marijuana help?
Another avenue of pain management that Mount Nittany Health is looking into is medical marijuana, with some providers having gone through the process of being certified physicians. Geisinger is not prescribing medical marijuana, but is looking into more evidence and having focused discussions.
Medical marijuana was legalized in Pennsylvania in 2016. The law allows people with “serious medical conditions,” such as cancer, chronic pain and opioid use disorder, to apply for a medical marijuana card.
For Tara Koch, “that has been a godsend.”
She was diagnosed with degenerative disc disease and spinal stenosis more than a decade ago, and in April, Koch said she received her medical marijuana patient card.
Koch, now an advocate for medical marijuana in addition to working full-time as a supervisor at a local retail store, said she’s happier and able to actually run around and play with her kids. She’s in the process of weaning off of methadone, and said every week that she steps down, she feels better and her mind is clearer.
“I’m still a work in progress,” she said. “My ultimate goal is to be totally opiate free.”