The opioid crisis in the United States boasts some horrifying numbers. According to the U.S. Department of Health and Human Services (HHS), more than 42,000 people died from overdosing on opioids in 2016, with an estimated 11.5 million people misusing their prescription opioids.
Tackling the problem requires a comprehensive and interconnected effort between healthcare and addiction recovery professionals, as well as diligent support from the general public. In the Inland Northwest, the fight is occurring on a number of fronts.
Kelley Griffith, the executive director of pharmacy, respiratory therapy and emergency services at Kootenai Health, said the broadest strategy focuses on significantly reducing the number of individual pills in the community.
“Many people are obtaining opioids for free from a loved one or family member,” Griffith said.
One approach is for hospitals to take a more conservative approach with discharge prescriptions following a patient visit or procedure.
“Maybe you used to get 30 pills if you sprained your ankle, whereas now you may get 10 or five, and you may need to call in and request a refill,” Griffith said. “Just decreasing the number of pills in the environment is going to go a long way in reducing new users.”
When HHS declared the opioid crisis a public health emergency in 2017, it also kickstarted a number of support mechanisms for this effort, Griffith said, specifically a prescription monitoring program that began this year. She said opioid abuse findings from the Centers for Disease Control and Prevention (CDC) have also helped to unify the medical community’s approach to pain management.
“Historically most of the physicians in practice today grew up being taught that pain is the fifth vital sign - it is subjective and it can be different for everyone, so prescribing habits, depending on when you trained, could be very loose,” Griffith said.
Dr. Bryan McLelland, an oral and maxillofacial surgeon with the Post Falls and Spokane-based Liberty Oral & Facial Surgery, said prescription guidelines in the past contributed to the possibility of excess prescription drugs in the community.
“Historically for wisdom teeth surgery that would typically involve 16 tablets of hydrocodone with a refill,” McLelland said. “The government then prevented us from prescribing refills, so in response to this the refill was added into the original prescription for a total of 30 hydrocodone.”
Once the opioid epidemic became more apparent, McLelland said many practitioners looked for a way to balance a reduction of opioids against the patient’s need for pre-and-postoperative pain.
“The dilemma is that after surgery there is pain that must be controlled, and simply giving less narcotics without consideration makes the practitioner feel good but may be shorting our patients’ legitimate needs,” he said.
Dr. McLelland now employs a specific regimen of fewer opioids combined with over-the-counter anti-inflammatories like Ibuprofen, as well as the surgical use of a longer-lasting local anesthetic called Exparel to reduce some of the initial post-operative pain.
“We now prescribe five tablets of narcotics rather than the 16 tablets for a standard, third molar surgery, and we have less requests for refills than previously,” McLelland said.
He said doctors and medical professionals can make an impact on the crisis with their own individual research and choices.
“Each doctor needs to take a critical look at what they prescribe and make changes when appropriate,” McLelland said. “We must be cautious not to overreact and make those with legitimate pain and make appropriate use of pain medicine go without and suffer.”
Educating the public on the potential dangers of long-term opioid use is also a major component in reducing new cases of abuse.
“When you take an opiate there is a euphoric aspect that triggers your brain and triggers your reward response,” Griffith said. “It really is working with that part of your brain that says, ‘Yes, do more of that,’ but it isn’t always the best choice in alleviating long-term pain.”
McLelland said all patients of opioids have a responsibility to limit them beyond the intended use.
“Each patient needs to do their best to not leave left over pain medicine in areas where teenagers and others can gain access to the unused medicine - taking those medicines back to the pharmacy for disposal is a great option,” he said.
The need for opioids remains, however, as proper use can still provide significant pain reduction in cases of short-term injuries, surgery recovery and some chronic pain situations. In those cases, Griffith said the goal is to establish relationships between doctors and patients where opioid use is specifically and carefully managed.
“The emergency room will no longer be a path to narcotics,” Griffith said. “If you are a pain patient who has real pain, you need to establish a relationship with a provider. We want people to get the care they need, and we are trying to get that started at a primary physician level.”
She admits there are challenges ahead on that front, as some primary physicians won’t take new chronic pain patients, and other specialists come with insurance and accessibility challenges. She said Kootenai Health can help discharged patients establish those pain contract relationships with providers, as well as avenues to alternative pain management.
‘A Way Forward’
Addiction support and pain management alternatives
To someone who doesn’t need opioids to treat chronic pain, the response to the epidemic seems logical and manageable. However, the road to recovery for those already addicted to these drugs can seem like an insurmountable challenge.
“Even if you slow the rate of new abusers, you still have a huge population that is chronically addicted, and that is not easily resolved,” Griffith said. “For some patients it is a matter of trying to taper off those medications, but they still have a tolerance and a psychological need, so that has to be done carefully. Then there are patients who are never going to get off opiates because there is no resolution to their pain.”
Ron Weaver understands the devastating balance between addiction and pain relief better than most. He started traditional medical treatment for a chronic pain condition in his back 30 years ago. It led to a dependence on some of the most powerful - and dangerous - drugs available by prescription.
“I am really the prime example of the struggle we’re dealing with in the opioid crisis,” Weaver said. “They thought I was a drug addict, but they were wrong. What I was was someone seeking pain relief, and nobody wanted to talk about that because that was something they didn’t know how to treat.”
“I was contemplating suicide,” Weaver continued. “Nobody had any answers for my pain, so I started reading everything I could on the subject.”
A breakthrough for him was reading “The Mindfulness Solution to Pain” by Dr. Jackie Gardner-Nix, a book about how moods, thoughts and emotions can influence the perception of pain in the body.
“That was the first thing that told me what I could do about my pain other than showing up at a doctor’s office asking for a prescription,” Weaver said.
Through this research, Weaver was able to find other methods to cope with and minimize his chronic pain. This included working to identify specific pain triggers - activities, foods, even weather patterns that influenced his inflammation. It also meant accepting that some pain was always going to be a part of his life.
“You can’t make it your enemy,” Weaver said. “A chronic pain person has to learn that pain is your companion… Almost all patients have higher pain days and lower pain days. My number one trigger is weather, specifically barometric pressure. I can’t change the weather, but I can change my activity schedule. I can have an impact on my pain.”
With his own success, Weaver was asked to speak to a few struggling pain patients. He was asked more and more, and eventually he was encouraged to develop a program that provided specific modules of the things that helped him.
It became A Way Forward, an eight-session intensive program that works closely with a number of regional outlets, including Heritage Health and Northwest Specialty Hospital, to provide a comprehensive education on adjusting thoughts about pain, dealing with pain, raising tolerance levels and wellness practices designed to increase the body’s ability to manage pain. Through those local provider partnerships, patients entering pain management programs with those outlets are enrolled in the program.
Weaver established a partnership with Dr. Marian Wilson from Washington State University to study the impact of the peer program on its participants. It found significant improvements for patients on a number of pain tolerance and pain management measures. An overview of the study can be found on the A Way Forward website, www.AWayForwardNow.com.
Weaver, a retired meat cutter, said he didn’t necessarily intend to create a second career, only to help the other Ron Weavers out there suffering from previously unmanageable pain.
“I’m nobody special, these principles are universal, just nobody had organized it previously - I travel the country with this message and I haven’t seen anything like it out there,” he said. “I’ve done everything I can to make it available to anybody else.”
One of the key components is removing the stigma of pain management in the first place and avoiding the focus on prescription abuse.
“Pain doesn’t show up tidy on x-rays and MRIs,” Weaver said. “These prescriptions are connected to human beings, and when you tell them you are going to take away their meds and offer nothing in return, you have a problem.”
A Way Forward is meant for all chronic pain sufferers, regardless of how they managed the pain in the past.
“It’s not about whether they need intervention, or whether those medications you are using are working great or not,” Weaver said. “If you are part of (one of the local) pain management clinics, you will go through the program, and that could be people who are not taking anything except maybe Ibuprofen for their pain. Nobody is being sent because they are on too high a dose. This can be beneficial for people who have even mild aches and pains.”
Weaver said the program begins with his own story, which often means establishing his point of view to those who may be adversarial at first about the need to go through a “program.”
“I don’t mind the angry people because they make the best converts - they are here of their own volition, but I also know they are tired of seeing doctors who don’t believe them about their pain,” Weaver said. “I’m not a doctor, and I’m not here to lecture them.”
The next phase is developing a different perspective on chronic pain. That’s a tough one, Weaver said, because people are biologically trained to equate pain with something being wrong.
“But I can’t look at my pain and say it’s bad because it’s going to be with me my entire life,” he said.
Then the program moves into cognitive behavior therapies, charting triggers and real life tactics to modify pain. Dietary components are discussed, including complementary treatments like ginger tea and anti-inflammatory foods and the need to stay as active as possible.
And another component relates to self-worth. Many chronic pain sufferers measure themselves by what they can and can’t do, as well as the labels applied to them personally and by others.
“In this society we place so much on what we do, and how that is closely related to my paycheck, but I don’t have control over what I do, my pain does, so it’s about learning to switch those values,” Weaver said. “To define who I am, and not what I do.”
Weaver said progress on the underlying causes for the opioid epidemic will only happen once more learn to accept there aren’t easy, straightforward solutions.
“People ask me how I personally manage my pain, but it isn’t one thing. It’s 20 or 25 things all put together,” Weaver said.