Published in Health Care
Dr. Lynda Hulst works with medical assistant Patrick Meinnes at the Mary Free Bed clinic in Holland Township. To get into the clinic’s chronic pain management program, patients typically have to wait two months, double the wait time from 18 months ago. The longer waits come as doctors look to avoid prescribing opioids and shift to alternative treatments. Dr. Lynda Hulst works with medical assistant Patrick Meinnes at the Mary Free Bed clinic in Holland Township. To get into the clinic’s chronic pain management program, patients typically have to wait two months, double the wait time from 18 months ago. The longer waits come as doctors look to avoid prescribing opioids and shift to alternative treatments. Photo: Katy Batdorff

Health care providers retool prescription practices in shift away from opioids

BY Sunday, November 10, 2019 01:23pm

When Dr. Lynda Hulst went to work at Mary Free Bed Rehabilitation Hospital 18 months ago, patients typically waited a month to get into its chronic pain management program.

Today, that wait takes two months, as physicians refer more patients to an alternative treatment, particularly as they face higher scrutiny when prescribing opioids.

The doubling of the wait time illustrates how care providers increasingly are looking for alternatives to opioids to treat patients living with chronic pain, she said.

Hulst, a primary care physician who works as part of the multidisciplinary team that treats chronic pain, recalls the words of a Zeeland physician who referred a patient using opioids to Mary Free Bed’s Holland Township clinic: “‘The state’s watching me. I can’t keep writing all of these.’” 

“They’re just being more conscious about ‘why am I prescribing this?’” Hulst said of other physicians. “They are paying way more attention to every script they write.”

Mary Free Bed currently offers the pain rehab program in Holland, Grand Rapids, Kalamazoo and Traverse City and has plans to expand it to Troy.

The program’s growth is just one example of how care providers have adjusted to a drug epidemic by seeking alternatives for pain management and limiting the use of highly addictive opioids.

Opioid prescriptions across the U.S. declined 33 percent from 2013 to 2018, from 251.8 million to 168.8 million, according to the American Medical Association. In 2018 alone, opioid prescriptions fell nationwide by 20 million, or 12.4 percent.

Another example of the reduced dispensing rate comes from this year’s annual report from the Michigan Health & Hospital Association’s Keystone Center, which focuses on quality and patient safety. The annual report highlighted how a consortium of 24 Midwest hospitals, including 17 in Michigan, reduced opioid administration 11.6 percent in the first six months of this year. During the same time, their use of alternatives to manage pain increased by 13 percent.

The Midwest Alternatives to Opioids (ALTO) program is modeled after an initiative that led to a 36-percent reduction in opioid use in Colorado over a six-month period.

Hospitals participating in ALTO achieved the reduction through better care coordination in emergency departments and the adoption of new policies and procedures for non-opioid options, according to the Keystone Center report. A second cohort of hospitals launched the Midwest Alternatives to Opioids program in September.

Using alternative pain drugs produced “no noticeable difference in patient satisfaction and length of time people spent in the emergency department, or costs associated with those treatments,” said Brittany Bogan, executive director of the Keystone Center.

The reduced use of opioids came about as hospitals focused more on “appropriate pain management” for patients in the ER, rather than defaulting to writing opioid prescriptions, Bogan said. Alternatives include using nerve blocks and nitrous oxide, followed by non-opioid painkillers after patients leave the ER.

“The goal would be to send patients home with a non-opioid alternative, if at all possible, and work with the patient to ensure it’s just as effective in managing their pain without the risks that are associated with an opioid,” Bogan said, citing high-dose Tylenol or ibuprofen as possible alternatives.

For longer-term pain management, care providers can use alternatives such as acupuncture and massage to ease pain, Bogan said.

Driving discussions

Because different people may experience pain differently and have varying pain thresholds, doctors need to have deeper conversations with patients about treatments. When a patient is living with ongoing chronic pain, those conversations are “absolutely critical, and it continues over time as the situation changes,” Bogan said.

“There are a lot of different things that can be offered to patients at different stages in life,” Bogan said. “What’s necessary for that acute pain episode may be different than what’s needed over time. It’s very much a patient and provider having an ongoing conversation.”

However, doctors will still prescribe an opioid for a patient when needed, she said.

“There can be a concern in patients with chronic pain that have been on opioids for a long time that they will no longer be available to them. That’s another conversation of ‘how can we assure we are still treating your pain.’ We’re not going to leave a patient high and dry in pain and just not prescribe their opioids over time,” Bogan said. “We need to work with them to safely taper them off the opioid, if that’s an option for that patient, and assure that we’re still providing pain management for everybody.”

Working with patient advisory panels, the MHA also created a patient guide for managing pain when in the hospital for a surgical procedure, including what to ask a surgeon prior to surgery about managing their pain while in the hospital and after discharge, Bogan said. When an opioid is necessary, surgeons will use a “minimum amount” and then continuously look to switch to alternative, non-narcotic options, she said.

At Mary Free Bed, the pain management program for people living with chronic pain stemming from an injury or illness includes physical and occupational therapy, counseling, lessons on reducing stress and anxiety, ensuring they’re getting enough sleep, and analyzing diet and nutrition. As well, the program also works to identify what movement and physical activity patients can do within their pain tolerance.

Doctors refer some patients to the 10-week program to avoid opioids or to get them off the drugs, Hulst said. In some instances, patients need to learn to accept and live with a certain amount of pain.

“The focus is largely changing from ‘here’s your script’ to teaching folks how you get through your day,” Hulst said. “Let’s take a look at where you are right now and teach you other ways to manage your pain.”

Empowering patients

In another example of the health care industry’s response to the crisis, Grand Rapids-based health insurance plan Priority Health reports that in its first year, an initiative launched in November 2017 generated a 50-percent reduction in the use of opioids by members enrolled in commercial health policies. Opioid use by Medicaid policy enrollees declined 44 percent, and 24 percent for Medicare enrollees, said Dr. James Forshee, Priority Health’s chief medical officer.

Priority Health hopes data for the second year will show even further reduction in the opioid dispensing rate, Forshee said.

The health plan drove the opioid dispensing rate lower by encouraging the use of alternative painkillers while allowing doctors “to make decisions as they saw fit,” and by limiting the length and lowering the daily dose of prescriptions to reduce the risk of addiction. Short-acting opioids for acute pain were limited to 15 days, and to 30 days for long-acting opioids for chronic pain.

As of July 2018, a state law enacted in response to the crisis limited opioid prescription to seven days for acute pain.

The health plan also sought to make sure that members could access medically-assisted treatment if they became addicted, as well as behavioral health services and pain management specialists, Forshee said.

Forshee credits the reduced dispensing to greater awareness of the crisis among physicians and patients and a greater understanding of the risks. 

“There is certainly a new awareness now and the awareness is now fortunately coming out in front of the patient,” he said. “Patients feel a little more empowered now to ask their physicians about alternatives.”

Read 1583 times
SUBSCRIBE TO MIBIZ TODAY FOR WEST MICHIGAN’S FINEST BUSINESS NEWS REPORTING >