Efforts to combat the nation’s opioid crisis has impacted Wabash Valley doctors and medical providers, who increasingly look for alternatives to treat their patients’ pain as they face new rules and laws limiting the use of opioids.
“I think there’s been a change in physician attitude and practice with the opioid crisis,” said Dr. James Turner, medical director of the Lugar Center for Rural Health at Union Hospital and a family physician.
John McGoff, president of the Indiana State Medical Association, previously served on the state medical licensing board and helped draft new rules related to opioid prescribing.
Physicians realize they have played a role in the opioid epidemic and “it is incumbent on us to help stem the crisis,” not only through rules and regulations, but also through self-regulation based on best practices and new guidelines, McGoff said.
“What we thought was best practice by giving pain medications, in fact, may have been harmful, and we’re now being more judicious in how they are used,” he said. The state medical association also offers free, monthly education on best practices for prescribing opioids, McGoff said.
Improved education is key, Turner said.
One positive change in the medical field is that medical students and residents are now starting to receive training on the appropriate use of pain medication, something that hasn’t happened in the past. “There was really no formal training or education,” Turner said.
In the past, medical students and residents learned informally, with knowledge passed down by attending physicians and others. Also, physicians and medical providers are looking increasingly to alternatives such as acupuncture, massage therapy and TENSunits, a back pain treatment that uses low voltage electric current to relieve pain. But one of the challenges is that health insurance may not cover those alternatives, Turner said.
Overall, “We don’t have a lot of tools to treat pain,” he said. Many people are on blood thinners and can’t use anti-inflammatory medicines such as ibuprofen. Some people with kidney or liver issues may face restrictions in some of the over-the-counter medications they can take.
“Even as people discuss alternative ways to manage pain, often there is no funding source behind it,” Turner said. Another challenge in managing pain is that “it’s subjective.”
With the efforts to stem the opioid crisis, he does see changes in physician practices, including more use of alternative treatments as well as fewer opioid prescriptions.
Under new Indiana rules adopted in recent years, patients who are on opioids long-term must be seen every few months and during those visits, “We look for any opportunities for dose reduction,” Turner said. Initially, and at least annually, doctors must review records on INSPECT, Indiana’s prescription drug monitoring program, “to make sure we are the only provider providing their pain medicine.”
INSPECT collects and tracks controlled substance dispensation data, which is made available to medical practitioners and law enforcement under certain conditions.
Turner also talked about the growth of pain management centers. “That marketplace has exploded nationwide … people are beginning to specialize in pain management, and there are resources for physicians to refer to,” he said. Union Health now has a pain management center, which serves patients suffering from chronic pain. It offers a range of services, including both physical and psychological care from a staff of interventional specialists, nurse practitioners and psychologist. Patients are generally referred to the clinic by their primary care providers; it is located in the Bone and Joint Center.
Indiana ahead of the curve
Dr. Randy Stevens, a Terre Haute physician who treats patients with addictions, says Indiana was “ahead of the game” a few years back with state legislation and rules established through the Indiana Medical Licensing Board; the rules affect physicians who prescribe long-term opioid therapy (more than 90 days), once certain dosage limits are met. When those limits are met, physicians must take a number of measures, including a psychological assessment, a history and physical. The patient and doctor must sign a “treatment agreement” that includes prescribing policies, consent to drug screening, permission to conduct random pill counts and requirements to take the medications only as prescribed. The rules require an annual review of the patient’s INspect report and office visits at least every four months, and every two months if there are dosage changes.
Another Indiana law that went into effect last July prohibits doctors from prescribing more than a seven-day supply to patients under 18 or to adults for whom that is their first prescription from that provider. Hospital emergency departments also have limits in opioid prescriptions. In January, the Indiana Department of Health, Indiana Hospital Association and Indiana State Medical Association issued new guidelines to follow when prescribing opioids to treat acute pain, which is shorter term and relates to damaged tissue.
For acute pain, doctors should first consider such treatments as ice, heat, acupuncture, physical therapy or massage therapy, the guidelines state. If necessary, those measures can be used in combination with non-opioid medications. The guidelines reserve opioids for acute pain from severe injuries or surgical procedures, and prescribing the lowest effective dose.
“I think the rules in Indiana are pretty good,” Stevens said. “There has been good cooperation between the Legislature and Medical Licensing Board.”
Times have changed, Stevens said. Years ago, across the nation, physicians were encouraged to use opioid pain medications, and doctors might face sanctions for inadequate treatment of pain if they didn’t prescribe them. “Around the country, people had licenses suspended for inadequate treatment of pain,” Stevens said.
‘No pain’ not a realistic option
Nathan Vooys, Terre Haute Regional Hospital chief executive officer, says the opioid epidemic “has brought medication and appropriate use of medication to the absolute forefront … I think most physicians right now are trying to find other ways to deal with patients’ pain, whether it’s things like physical therapy” or non-opioid medications.
“I also know the expectation of pain control is a hot topic. Over the years, I think we all sort of got to a point where we were trying to make our patients pain, zero,” or pain-free, Vooys said. “For a lot of things we do in a hospital, especially post surgical treatment, you can’t get to zero.”
Vooys believes it’s a matter of talking to patients early on and explaining, “You’ll have a level of pain and we’ll manage it the best we can. There might be a few different things we can do to minimize it … but you won’t be pain-free.”
He also noted strict controls over the hospital pharmacy, with a team that meets at least monthly to review reports that might “flag unusual behaviors … We want to make sure controls are in place to prevent, or identify trends, so we don’t have a situation where someone is diverting drugs from the hospital” to themselves, family or others.
Mental health must be addressed
Turner noted that most patients with an addiction also have a mood disorder, and a major challenge exists in providing them with the mental health services they may need. “We have not funded mental health in this country very well. We’ve funded it very poorly,” he said. Many physicians believe that if the mood disorder is not addressed, “You will never solve the addiction issue,” he said.
Recently, officials announced that a “soft opening” in April is planned for a new opioid treatment program in Vigo County. Western Indiana Recovery Services is expected to be in full operation by June.
Hamilton Center has been working with the state to open the clinic, and it has been partnering with Sagamore Medical Recovery Services, LLC. Sagamore will provide the medical services and Hamilton Center will provide the behavioral health services in the clinic. It will be located at 88 Wabash Court behind the Vigo County Courthouse.