Dr. Don Stader remembers the moment he knew something had to change about how physicians prescribe opioid pain pills.
He was working at a freestanding emergency room in Colorado a few years ago when a patient came in after a heroin overdose. She was young, 21 years old. She had been a promising college student once. She needed multiple zaps of the overdose-reversing drug naloxone to revive her.
Talking with her later, he traced her addiction backward. Before she used heroin, she had abused opioid painkillers. Eventually she bought them on the street, but the very first pills came with a doctor’s prescription. The ailment? A sprained ankle.
Stader remembers being shocked silent. Earlier that same day he had seen a patient with a severe ankle sprain. He had prescribed an opioid.
“We need to really think about and revolutionize how we control pain,” he remembers thinking. “It really was a call to me to change my practice.”
Now, Stader is part of a group of doctors and administrators who have come up with an ambitious plan for Colorado hospitals to dramatically reduce the amount of opioids they prescribe while still treating pain effectively. The program will roll out this year in a six-month pilot program at eight hospitals and three freestanding emergency rooms. Health officials hope to analyze data from the program at the three-month mark to figure out what is working best and what’s not, said Diane Rossi MacKay, with the Colorado Hospital Association.
The effort is part of a broad rethinking in the medical world about the place opioids, blamed for an epidemic of addiction and overdose, should hold in medicine. As Stader says, doctors for years treated opioids as a panacea.
“For far too long, pain has equaled an opioid,” said Stader, now a doctor in the emergency department at Swedish Medical Center. “And that’s what got us into this problem.”
But, now, state regulators across the country and the Centers for Disease Control and Prevention have issued guidelines calling on doctors to reduce their opioid prescribing. The Food and Drug Administration announced Thursday that it is seeking to remove one opioid, Opana ER, from the market because its addictive potential outweighs its medical benefit.
The new program that Stader helped put together — along with the Colorado Hospital Association and members of the Colorado chapter of the American College of Emergency Physicians — aims to go even further by combining a number of ideas into one bundle. Not only does the program encourage doctors to prescribe fewer opioids, it also provides them with condition-specific guidelines for treatments that can be used to control pain effectively without narcotics. In some cases, the guidelines might call for substituting doses of Tylenol and other medicines for opioids, Stader said. In others, there are “trigger point” procedures that could work.
The plan won’t eliminate opioids in the hospital altogether. But they aren’t the first resort in most instances.
In addition, the program calls for hospitals and emergency rooms to become front-line players in providing treatment to people with opioid addiction. Instead of telling patients to find a rehab clinic first, doctors potentially could start patients on medication-assisted therapy with a drug like buprenorphine or methadone right away. In a state survey this year, people who successfully quit heroin identified such treatment as the most effective way to do so.
“I don’t know of anywhere that has guidelines this comprehensive,” said Robert Valuck, who, as the director of the Colorado Consortium for Prescription Drug Abuse Prevention, helped unite the disparate ideas into a single plan. “It’s more of a leap than a step, and that is new.”
In addition to helping patients directly, Valuck said he hopes the program will also cut off a major pathway for addiction. While most people who become addicted to opioids start by using prescription pills, only a minority of those start with pills prescribed to them. Many others start by using loose pills left over from a prescription and stuffed away in a medicine cabinet.
Reducing the amount of unused opioids out in the world, Valuck said, is “the biggest piece of low-hanging fruit in this whole thing.”
And then there are the community benefits.
At Yampa Valley Medical Center, in Steamboat Springs, doctors see a patient a week who has either overdosed on opioids or heroin or is suffering from withdrawal. That’s in a community of only about 14,000 people.
“We’ve been shocked by the diversity,” said Wes Hunter, the hospital’s director of pharmacy and the president of the Colorado State Board of Pharmacy. “We’ve had grandmothers. We’ve had high schoolers. It runs the whole gamut of life. I don’t think anyone’s immune from it.”
YVMC is one of the hospitals participating in the pilot program. It’s meant a little more work for doctors and nurses, but Hunter said the results so far have been positive, with doctors finding the alternate treatments just as effective in most cases.
“We don’t want to be the place that fails on pain,” he said.
At Swedish, Stader said the hospital began implementing some elements of the program a year ago. In that time, the hospital has cut its opioid usage by 30 percent, he said.
“Opioids now aren’t just the only drugs we use,” he said. “They’re part of a large collection of drugs that we use to control pain better.”
