Opiate crisis hits everywhere including small towns

Dealing with chronic pain is an issue for many Americans. The problem is, over the years, the medical community has relied on opiates to help people manage their pain. Over time, this practice has evolved into a full fledged addiction epidemic.

People were dying because of it. Something had to be done.

"There is an opioid epidemic in this country. The majority of opioids used in the world for pain are used in the United States. We've created an epidemic for prescribing opioids for non-cancer related pain," said Dr. Jay Jerome, of Cascade Medical in Leavenworth. "That being said, more people die from intentional and unintentional overdose in the United States than they do in car crashes. It's clear that this is not just a minor thing. This is a real and major epidemic in our country."

In terms of how this is handled at Cascade, Jerome said he needs to talk about whether they prescribe opiates for acute or chronic pain. There are various ways to manage that, Jerome said.

"We want to help people with their pain, but be cognizant that people get the appropriate pain control and not just unlimited use of opiates, so we can curb the opiate crisis," Jerome said.

There is a set of opiate prescribing guidelines issued by the Washington State Department of Health that Cascade Medical follows in regards to management of opiate therapy for chronic, non-malignant pain.

There are different things in terms of pain management, he said.

"It is very deep and layered. We treat everybody individually. If they come in with a problem, the provider follows their own clinical judgement when it comes to treating acute pain," Jerome said.

Sometimes it includes opiates and sometimes it doesn't, he said.

In the Seattle area, many chronic pain patients come through the ER. Jerome said they do not see much of that in Leavenworth.

"We are very clear up front that we will not treat chronic pain with opiate based therapy through the emergency department. This is very clear. We may make people worse. We may misguide their pain. We will not prescribe opiates through the ER for chronic pain," Jerome said.

About 3,000-3,500 people visit the CM Emergency Room every year. Many patients who go to the ER do so because they are in some form of pain, whether that's from a bone fracture, migraine, chronic pain or other form of illness or injury.

"Occasionally, people will come to the ER asking for opioid prescriptions by name, which is always a red flag," said Amy Webb, Cascade Medical Chief Operation officer. "We look for evidence-based, non-opioid solutions whenever possible. When we do prescribe opioids, we are careful to do our due diligence and use every tool the state has made available to us, including the Prescription Monitoring Program."

When it comes to acute pain, like from a broken arm, Jerome said they will treat people.

"If you have chronic back pain and you've taken a lot of pain medicine for this and you're run out of your pain meds and you need to see a doctor, then you need to see a doctor at the clinic not the emergency department," he said.

Jerome said he sees a lot of people with chronic pain. His patients with chronic, non-malignant pain, sign a "pain contract" outlining their treatment program. They must agree to submit to random drug screens whenever he sees fit.

The patient must follow the guidelines set forth with their pain management, meaning if they're supposed to take a certain amount per month, they're not allowed to have anymore. They are required to see Dr. Jerome every three months for re-checks.

He also monitors the prescribing activity on the Prescription Monitoring Database. The goal for people with chronic pain is to keep them functional and productive members of society.

"I am not able to cure chronic pain. Chronic pain is very difficult to treat. It is the body's perception of pain and we can help that with opiates, some with non-opiates," Jerome said. "My goal is never to get somebody pain free, it is to learn and give them the tools to manage their pain effectively. I want to help people, but I will tell them many times opiates make pain worse."

There is a clear syndrome where people get hyperalgesia as they take their opiate dose, he said.

"They feel like they need more. They become tolerant to the pain medication. The pain gets worse and they are no more functional than they were on high dose opiates. They are actually less functional," Jerome said. "Then, they are more at risk for unintentional overdose and death."

Frequently, Dr. Jerome said he will give his patients treatment options. He has not accelerated the use of opiates. In fact, he said he is finding alternative methods to help people with their pain and decrease their opiate use, because it is not effective.

This does not apply to cancer related pain.

"If you have metastatic cancer and you're in intractable pain, that is a different ball game," he said.

There is no clear answer when it comes to getting people off opiates over time. In his clinical judgement, opiates are not useful in the long run for chronic pain.

"There has been use by prior generations of treating physicians and we are in a state where people use opiates," Jerome said. "I rarely start people on significant amounts of opiates for chronic pain anymore. I will do it, but it has to be documented why we are doing it and closely followed."

There are state guidelines regarding prescribing opiates. If a certain amount of opiates are prescribed, Dr. Jerome said they are required to have consultations. There are certain levels of medication interactions which are particularly dangerous for patients.

He said they are trying to avoid those interactions as much as possible.

"The epidemic started when we noticed people were dying from opiates combined with benzodiazepines. For example, morphine or methadone combined with clonazepam or valium.

People would take the medicine and not wake up," he said. "People that are abusing it are the people that develop tolerance."

The problem was people unfortunately combined substances, sometimes alcohol, sleep apnea and things like that, which do not mix well with pain medications.

"It's one of the toughest challenges we face here," Jerome said.

Ian Dunn can be reached at 548-5286 or editor@leavenworthecho.com.