BURLINGTON — Figures from the University of Vermont Medical Center show the doctors it employs are prescribing fewer opiates than they were a year ago.
A record number of Vermonters died from opiate overdoses last year, and experts say decreasing the number of prescription opiates in circulation could, over time, drive that number down.
That’s because research shows that as many as 4 out of 5 heroin users started out misusing prescription opiates.
People become addicted to their own prescriptions, by taking excess medication from others or buying diverted pills, experts say. Eventually it becomes too expensive or difficult to get the pills and addicts turn to heroin and other street drugs, which are becoming increasingly deadly.
“One piece of resolving (the opiate) crisis is making sure that less pills are available for people to use illicitly, and that less pills are given to people after they see their doctors that could lead them to become addicted,” said Dr. Stephen Leffler, chief population health and quality officer at the UVM Medical Center.
“That will absolutely have a downstream impact on the number of people who become addicted over the next decade,” he added.
The hospital is part of the Chittenden County Opioid Alliance, which holds regular stakeholder meetings to track the region’s response to opiates.
At a May meeting, Leffler gave a presentation showing the number of medical center patients prescribed an opiate dropped 9 percent from the fourth quarter of 2015 to the fourth quarter of 2016. The total number of prescriptions dropped 7 percent, and the average strength of those prescriptions dropped 4 percent during that same period.
Former Health Commissioner Dr. Harry Chen said it’s great that the medical center is tracking prescriptions, and the initial indicators are positive, but it’s not enough data to draw any conclusions.
The figures Leffler presented should serve as a baseline to measure the impact of new state regulations for opiate prescribing that take effect July 1. The original implementation date was delayed to give health care providers more time to prepare.
“If (the new rules) are embraced by the large hospital systems like UVM and the other players, and they’re integrated into their (medication) ordering protocols, I think it could make a huge difference,” Chen said in a phone interview Wednesday from Seattle, where he was speaking at a conference on opiate addiction.
Leffler said he agrees that the new rules will drive down opiate prescribing more, but added they will also require a major adjustment for doctors and patients.
“It’s always tough to have medical decisions be legislated because things change pretty quickly,” he said. “I’m hopeful that as we see how they (the rules) work, we have the ability to adjust them as necessary in either direction.”
The rules require patient education and informed consent before opiates are prescribed. They also set limits on the amount of opiates that can be prescribed based on a patient’s age and level of pain, among other requirements aimed at stemming overprescribing.
“It’s going to require significant conversations between patients and providers about what the patient should expect,” Leffler said.
People with ankle sprains or lower back pain who “in the past they may have gotten used to getting some opiates, it’s going to be much less likely that they will now,” Leffler said.
Some of the most difficult conversations may center around the prescribing of opiates for chronic pain — that lasting more than 90 days. The new rules require doctors to assess chronic pain patients for risk of addiction, re-evaluate their condition regularly and consider other treatment options such as anti-inflammatories, acupuncture, chiropractic or physical therapy.
There’s good reason for that, Chen said: “There is a clear nexus between prescribing opioids at higher doses for longer periods and people remaining on them and potentially abusing them.”
The stakes are even higher for young people, according to Chen, because research shows that just taking an opiate while the brain is still developing places the patient at greater risk for addiction later in life.
That’s why the new prescribing rules set lower limits for children and require the prescribing doctor to at least attempt to contact the child’s pediatrician.
That requirement came out of exhaustive meetings Chen and his team held with doctors across the state as the new rules were being developed, he said.
“It’s fascinating. The pediatrician says, ‘Why are all these doctors prescribing my patient opioids?’ That was their reaction. One of the guilty parties was emergency room doctors, and they say, ‘Well, we had to treat their pain,” Chen said.
Both Chen and Leffler are well acquainted with the difficulties of treating pain in emergency medicine, because both spent years as emergency room doctors. Leffler still spends a shift in the ER every Friday, according to a hospital spokesman.
Still, both were adamant that all doctors have a role to play in preventing addiction. For the last two years, Leffler has led an effort to make physicians more aware of how their prescribing practices compare with their colleagues’.
Chen said tracking individual doctors’ prescribing habits is an excellent practice, because once a health care network knows who prescribes the most, officials can drill down and see if there’s a good reason.
Leffler said in some cases they discover there is a good reason. Outliers may be oncologists or palliative care physicians whose patients have legitimate medical need for more opiates at higher doses. When that’s not the case, the data can serve as a wakeup call, he said.
“They want to do the right thing, so when they see that they’re an outlier, they typically bring their practice back into within the lines of what other people are doing,” Leffler said.
