As the United States' Department of Health and Human Services moves to release the National Pain Strategy later this month, Washington provides a rare example of reversing the overdose death rate from prescription opioids, which are widely used to manage chronic pain but can lead to abuse.
The overdose death rate in Washington decreased 27 percent 2008 and 2012, while national rates have remained essentially unchanged. According to a new study in the American Journal of Public Health, average opioid doses in Washington have also declined, likely accounting for many of the lives saved.
"Our State's ability to shift this epidemic into reverse has been the result of strong partnerships among state agencies, university pain specialists, legislators and health care providers," said study lead author Gary Franklin, Medical Director, Washington State Department of Labor and Industries, and a professor at the Univ. of Washington, Seattle.
New state laws on prescription opioid use, including one that mandated the adoption of new dosing guidelines; a statewide Prescription Drug Monitoring Program; and telemedicine and on-line programs for health care providers have all been key to the turnaround.
Providers on the front lines
"Health care providers are on the front lines of this transformation," said Dr. Mark Sullivan, Executive Director of COPE, (Collaborative Opioid Prescribing Education), based at the University of Washington School of Medicine. "Provider education is crucial because they write the prescriptions - 259 million nationally in 2012. They need to know how to respond to the suffering of their patients in ways that are safe and effective." COPE uses technology to reach providers across the state and the region, including in remote areas.
In the rural area of Coos Bay, Oregon, physician assistant Rachel Stappler at North Bend Medical Center (NBMC) has used COPE's educational resources to address a critical problem that emerged when the retirement of a respected physician left behind 2,000 patients taking dangerous combinations of medicines, including prescription opioids, "People would be due for refills, and their doctor was gone. They went to a different doctor every day demanding medicine. It became clear that there was a much larger problem on our hands than we had anticipated," Stappler explained.
She had been participating in UW TelePain, a COPE-supported free weekly program that connects health care providers with a panel of national pain experts via live video teleconference, webinar or phone. Over 1,000 providers have already participated in TelePain's educational seminars, which also offer the opportunity to present difficult cases for consultation. Stappler has presented 15 cases herself, and urges others to do the same.
She also registered for the on-line COPE-REMS program, and now keeps it open on a computer in her office, logging on during breaks between patients. It provides the latest guidelines on safer opioid prescribing: how to start, switch or discontinue opioid therapies; what dangerous drug-drug interactions to avoid; and how to safely handle dosing, among other topics. It uses video to model communications between doctors and patients dealing with often neglected pain-related topics: issues of depression, relationships, psychological trauma, and overall quality of life for the patient.
Stappler, who has a post residency in pain management, is using the telemedicine and on-line programs to help spearhead a system-wide transformation of pain management.
"Physicians have to stay new and trending," Stappler says. "We need to be comprehensive in our approach to treating patients with chronic pain."
Dr. Gregory Carter, Medical Director of St. Luke's Rehabilitation Institute in Spokane, Washington, has had a similar experience. St. Luke's is the Pacific Northwest's largest freestanding rehabilitation hospital, with patients who suffer from trauma, brain and spinal cord injuries, and chronic pain. Carter has participated in COPE's programs, and as medical director he encourages other physicians, nurse practitioners, residents, physician assistants and pharmacists to get trained as well.
"These are resources that didn't exist even five years ago," Carter said. "In Washington State, we have a problem that was recognized and solutions that were implemented, and it's working. "
The COPE approach is resonating with regional organizations such as Community Health Association of the Mountain/Plains States, covering Colorado, Montana, North Dakota, South Dakota, Utah and Wyoming; and the Northwest Regional Primary Care Association, which operates in Alaska, Idaho, Oregon and Washington. Both encourage providers in their more than 100 member health centers to get trained to help reduce opioid abuse and overdose and improve treatment of patients with chronic pain.
Given the continuing need for provider education, COPE received a second grant of $785,400 to expand its work in 2015, and is now offering free educational programs for providers nationwide. The grant is based on the Food and Drug Administration's Risk Evaluation and Mitigation Strategy (REMS) for extended-release and long-acting opioids (such as Vicodin and Oxycodone). The program requires manufacturers to fund independent educational programming for health care providers.
Statewide reforms are also ongoing. According to Franklin, dosing guidelines that were created in 2007 and updated in 2010 are receiving a major overhaul, with a comprehensive guideline due in June 2015. In addition, Sullivan notes that although opioid overdose deaths are down in Washington State, ongoing changes in physician practice and patient thinking about chronic pain are needed to decisively end the epidemic.