A Multipronged Approach to Curbing the Opioid and Heroin Epidemic in South Central Pennsylvania

By Thomas Crocker
Friday, March 24, 2017

WellSpan Health is working hard to address the opioid crisis in the communities it serves by prescribing alternative methods of managing chronic pain, instituting a controlled substance agreement between physicians and patients, and ensuring more individuals have access to the lifesaving overdose reversal drug naloxone.

The United States is in the grip of a public health crisis involving both prescription opioid medications intended to relieve chronic pain — such as hydrocodone, oxycodone and fentanyl — and illegal heroin.

The crisis has hit Pennsylvania particularly hard. In 2014, the state had the country’s eighth-highest drug overdose death rate. Data indicate opioids and heroin contribute to many overdose deaths. A report by the Drug Enforcement Administration Philadelphia Field Division found that heroin or at least one opioid was detected in approximately 81 percent of Pennsylvanians who died by overdose in 2015.

A Proactive Response

From 2000 to 2014, hospital admissions for pain medication overdoses increased 442 percent in South Central Pennsylvania; the region saw a 305 percent increase in heroin overdose admissions during the same period, according to the Pennsylvania Health Care Cost Containment Council. To respond to the crisis, WellSpan Health turned to its Chronic Pain Clinical Effectiveness Team. This multidisciplinary group of clinicians crafted a plan to address opioid and heroin abuse among patients, based on the CDC’s 2016 Guideline for Prescribing Opioids for Chronic Pain.

“The basis of the CDC’s recommendations is that opioids should rarely be a first-line treatment for chronic pain and that clinicians should assess whether opioids are appropriate for a patient, given the individual’s symptoms and his or her risk for addiction,” says Christopher Echterling, MD, Medical Director of Vulnerable Populations at WellSpan Health. “The guidelines also recommend clinicians consider alternative treatments for chronic pain.”

In recent years, the medical community has come to view opioids with a more skeptical eye, according to Dr. Echterling.

“Opioids aren’t as effective as physicians and advanced practice clinicians believed them to be for chronic, non-cancerous pain, and they are more dangerous than we thought,” Dr. Echterling says. “Non-opioid medications and non-pharmacologic treatments are often more effective than patients realize and involve fewer risks.”

A Judicious Approach

In some cases, opioids may be the most appropriate option. However, when a WellSpan Medical Group physician prescribes them for three months or longer, both patient and physician engage in a conversation about the risks and benefits, resulting in a signed controlled substance agreement stipulating certain conditions. The patient agrees to safety guidelines regarding medication usage, refill and storage, among other stipulations, and the prescriber agrees to help the patient use the medication responsibly and to use all available approaches to treat their pain. The patient also commits to undergo an annual urine test and pill count.

“We treat opioids the same as we do insulin or blood thinners — they are powerful medicines that can be highly effective, but they can also be dangerous and, therefore, require safety monitoring,” Dr. Echterling says.

Chris Echterling, MD, (left) speaks with Gov. Tom Wolf at the WellSpan Good Samaritan Hospital roundtable on opioid abuse.

Using the Entire Armamentarium

For patients who are unwilling or unable to adhere to the controlled substance agreement, WellSpan Medical Group clinicians discuss alternative pain management strategies, including non-opioid medications, physical therapy, exercise, cognitive behavioral therapy (CBT) and mindfulness. A variety of complementary therapies, such as acupuncture, are available at the WellSpan Center for Mind/Body Health.

“As a society, we often desire more passive treatment for pain, such as pills, rather than active treatments, such as CBT or exercise; changing perceptions and removing barriers is a work in progress,” Dr. Echterling says. “Alternative approaches, however, can be quite effective. More evidence exists showing CBT is a safe and efficacious treatment for chronic pain than exists for opioids.”

“If we’re concerned a patient is having postoperative pain inconsistent with what he or she should be having and the patient presents signs of developing addiction, we urge our surgeons to call the patient’s primary care provider [PCP]. Communication between PCPs and specialists within WellSpan Health, as well as between WellSpan clinicians and colleagues in private practice, is essential to combating opioid abuse and heroin use.”
— Christopher Echterling, MD, Medical Director of Vulnerable Populations at WellSpan

Countering Overdoses

WellSpan has also taken steps to address a devastating consequence of prescription opioid abuse and heroin use: overdose. The health system has been involved in prescribing naloxone, a drug that can counteract the effects of prescription painkiller or heroin overdose, and local law enforcement now is also armed with this antidote. Thanks to a 2014 Pennsylvania law, WellSpan clinicians are able to prescribe naloxone not only to patients at risk of overdose — based on their opioid dosing regimen, as indicated by electronic health record information — but also to individuals not under their care who might benefit from having the drug in the home, such as a substance abuse patient’s loved one. The greater availability of naloxone has led to a leveling off of overdose deaths in the communities WellSpan serves, according to Dr. Echterling.

Another development in the campaign against opioid abuse and heroin use occurred last November, when Pennsylvania Gov. Tom Wolf signed several measures — including one mandating clinicians consult Pennsylvania’s online prescription drug-monitoring program every time they prescribe an opioid — into law. WellSpan will continue to work with state and local partners to combat the problem of opioid abuse and heroin use.

“We are committed to understanding addiction as a chronic, life-threatening disease for which evidence-based treatments exist,” Dr. Echterling says. “We offer those treatments at WellSpan.”

WellSpan’s Substance Abuse Intensive Outpatient Program helps individuals dealing with drug or alcohol abuse. To refer a patient, call 717-851-1500.