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Multnomah County's limits on opioid prescriptions just got super-sized by the federal government



TRIBUNE PHOTO: JAIME VALDEZ - Students in a Kaiser Permanente pain management class participate in a movement exercise to aid their chronic pain. “Shocking.”

“Debilitating.”

“Frustrating.”

“Complicated.”

These are some of the words patients used to describe their chronic pain during a pain management class last week at Kaiser Permanente’s Interstate campus in North Portland. The conditions that brought patients there varied, but all wanted the same thing: to regain some control over the all-encompassing pain.

“Life hurts,” said one woman.

For decades, doctors — particularly those in the Portland region — reached for the prescription pad to address chronic pain. Now all of that is changing.

U.S. Surgeon General Vivek Murthy announced last Thursday that he is taking the unprecedented step of sending 2.3 million letters to drug prescribers urging them to change how they think about pain and addiction. Murthy made the move to address an epidemic of opioid misuse and overdose. Overprescription of drugs like Vicodin and OxyContin has been “devastasting,” he said.


See related story:Patients using pot to manage chronic pain


The Centers for Disease Control and Prevention issued new guidelines in March that set a low limit on the amount of opiates medical personnel should be prescribing to patients with non-terminal chronic conditions.

Multnomah County — where opiate addiction, abuse and overdose has been historically high — has already taken similar steps to limit prescriptions of the drugs in local medical systems. But the new national guidance is even lower than limits set by the county.

“It’s been changing quite rapidly, in fact,” says Kaiser’s Dr. Mark Harvey, a family medicine physician at the Mount Scott Medical Clinic. “We didn’t used to fully understand about how much was too much to take.”

But patients who have relied on opioids to get through the day for years or even decades are having a hard time adjusting. “I think it’s very difficult for them, and I can totally understand why,” Harvey says.

The change highlights new research saying drug companies may have over-promised benefits and under-reported side effects of opioids, as well as new attitudes toward the efficacy of alternative treatments.

It also addresses a newly discovered racial element. Research reported in November 2015 shows that drug and alcohol abuse, as well as growing numbers of suicides, are contributing to a wave of higher death rates for middle-aged white Americans. According to the New York Times, researchers hypothesized that a “pronounced racial difference” in the prescription of opioids and an increase in middle-aged white Americans living with chronic pain could be to blame.

This is at a time when death rates for middle-aged people of other ethnicities are decreasing.

Multnomah County has a head start

Dr. Judith Becher has already been through the dark valley of restricting opioids to chronic pain patients.

Becher is a physician at Northeast Health Center in the Multnomah County Health Department, which in 2012 started an aggressive program to limit opioid prescriptions to curb the epidemic of addictions and overdoses.

Becher says now her patients are happier and healthier on lower doses, but it wasn’t easy getting to this point.

“We were challenging the medical paradigm that they knew and that we knew,” she says. Several patients dropped her, and maintaining relationships with the ones who stayed was difficult. “People really wondered whether we had their best interests in mind. Who was this invisible body that was telling them that they couldn’t have these medications that they had been taking for so long?”

But the simple fact was that opioids weren’t always that effective for chronic pain.

Becher says now when she sees a patient with chronic pain, her first task is to figure out the root cause and, next, to see how far they can get to solving the problem with nonpharmaceutical treatments: physical therapy, chiropractic care, acupuncture or muscle conditioning.

TRIBUNE PHOTOS: JAIME VALDEZ - Instructors Teresa Keane and Melissa Hockett demonstrate a breathing exercise. Alternative treatments gain mainstream recognition

At Kaiser’s pain management class, those sorts of treatments receive top billing.

Nurse practitioner Teresa Keane leads the class in a small pelvic rotation that can help to relieve back pain, or deep-belly breathing that gets more oxygen moving. She even explains the benefits and science behind the use of meditation in calming the brain’s pain-alarm system.

“Notice where you are holding tension,” Keane tells the class. She encourages them to be aware of how they hold their body through daily tasks such as washing the dishes or getting into a car, and how that might aggravate their system. “People don’t realize that just changing the way you breathe is a really effective way to manage pain.”

Keane says the class is her favorite part of her job, in contrast to what she normally does. “When I’m not here, the other thing I do in my job is prescribe meds,” she says.

Dr. Paul Lewis, health officer of Multnomah County and the tri-county area, says these alternative routes require more work and ingenuity on the part of patients, providers and insurers.

“A prescription is pretty easy to do,” Lewis says. “Other things are a little more effort and there’s a lot of barriers to making those available as alternatives.”

Many doctors are talking about the need for a more holistic approach to addressing chronic pain. While acute pain — a broken leg, a surgery site — is still treated effectively with opioids, chronic pain can take over the brain. The neurology of a person in chronic pain is much more involved in the disorder, which is why depression and other complicating secondary factors can start to play a significant role.

So, Lewis says, going to a yoga class might be good to get moving, but it also can be good because the patient is chatting with new friends.

“Sometimes it’s easy to ignore that, but it’s really important,” Lewis says. “That social support component turns out to be critical.”

TRIBUNE PHOTO: JAIME VALDEZ - As opioids are revealed to be largely problematic against chronic pain, providers are coming up with new ideas.

No more simple answers

A statewide task force will meet Sept. 23 to continue discussions on how to implement the CDC’s new recommendations in Oregon.

Dr. Katrina Hedberg, the state epidemiologist and state health officer, says one in five people report living in chronic pain — a number that hasn’t changed during the decades opioids have been freely prescribed.

“There isn’t a simple answer,” Hedberg says. “Opioids and prescriptions sound like a simple answer, but now we have all these unintended consequences.”

She says the task now is to educate providers on the new thinking but also the patients who will no longer have access to instant relief.

“It’s not easy,” Hedberg says. “We have a lot of sympathy for people living in pain. It’s just that opioids aren’t the answer either.”


Shasta Kearns Moore
Reporter
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