By now most people are fully aware of the role that opioid over-prescribing played in the development of the opioid crisis in the US. The 2016 CDC guidelines on opioid prescribing for chronic pain and Maine’s law limiting prescribing of high dose opioids (with exceptions, including for palliative and end-of-life care) were crucial to reversing that trend in our state and in creating a shift to safer, more evidence based treatments for chronic pain. But this has also resulted in very challenging experiences for some people who have been on chronic daily opioids, most especially for those who have been on very high doses for long periods of time. The work of “de-prescribing” or tapering of opioids is complex, requires time and patience, must include education for our patients and our care teams, and is best accomplished in partnership with our patients. The US Department of Health and Human Services has published an important resource in support of this approach, and it can be found here: https://www.hhs.gov/about/news/2019/10/10/hhs-announces-guide-appropriate-tapering-or-discontinuation-long-term-opioid-use.html
Unfortunately there are some prescribers who have simply stopped prescribing altogether, pulling the rug out from under their patients and inducing unnecessary withdrawal symptoms. Others have tapered patients too rapidly, or have dismissed patients when they react with anger and fear about such a change in treatment. And when a provider departs or retires, leaving a panel of patients on long term opioids, the covering providers are left in a no-win situation wherein they may be asked to prescribe in a manner that they consider unsafe, or to have a very difficult ongoing conversation with a patient with whom they have no relationship. It is also true that up to 1/3 of people taking opioids on a daily basis for a long time meet the criteria for Opioid Use Disorder (addiction to opioids). This is a difficult concept for patients and providers to embrace, because our common concepts of addiction (loss of job, housing and relationships and criminal activity) is often not the case in these circumstances. But as a medical diagnosis it is real and if we are unwilling to consider the diagnosis of Opioid Use Disorder and to treat it appropriately (typically with buprenorphine/naloxone, or “Suboxone”) we are doing a disservice to our patients and to our community.
Two recently published articles raise the possibility of another subset of people who have been on long term opioids, which they label as Complex Persistent Dependence (CPD). These are people who will find tapering much more difficult, with marked worsening of pain, the development of withdrawal symptoms despite careful tapering, and emotional deregulation (loss of self-control) and depression as the taper is being undertaken. People on higher doses for longer periods of time, those with mental illness diagnoses (including depression) and those who have a history of significant emotional trauma or PTSD may be more prone to CPD. And it is possible that this group of people could have both their experience of chronic pain and the emotional disruptions of dose tapering significantly improved if they were treated with buprenorphine. Because it is only a partial opioid agonist (that is, it fills the opioid receptors but does not induce the level of sedation or euphoria that opioids cause) and because it is long acting, buprenorphine can help control pain, reduce the risk of sedation and of accidental overdose, and once stabilized, tapering of the dose can be much better tolerated. And the use of buprenorphine in this circumstance does not require special training (“X Waiver”).
The challenges of this work are evident, and it is difficult to manage in isolation. I’m pleased that the Schmidt Institute, in partnership PCHC and with the support of the State of Maine can now offer, free of charge, the expertise of our interdisciplinary Controlled Substance Stewardship team to any provider or practice in the state, to assist them in this vital and sensitive work. The model that has worked well within PCHC for over 6 years has the potential to improve outcomes and create a more satisfactory process for patients and for providers, as we move to a new era of chronic pain management.
2019 has been a difficult year for rural Maine hospitals. Calais Regional Hospital recently filed for bankruptcy and just a few months ago Penobscot Valley Hospital did the same. And more hospitals in our state and across the country are imperiled. Over 100 rural hospitals in the US have closed since 2010 and it is estimated that 430 more are at risk of closing, the two mentioned here and others in Maine among them. This is nothing new. I recall meetings in Lincoln in the early 1990s aimed at addressing the real risk of closure of that small hospital, and strategizing to address its viability. Underpayment by public payers, providing care for the uninsured, predatory negotiating by private payers, inefficiencies of small scale operations, declining populations, and recruiting challenges all underlie the destabilization of these vital community resources. Maine’s delay in expanding MaineCare exacerbated the problem – between 2008 and 2016 states that did not expand Medicaid saw more hospital closures than those who did not and uninsured rates dropped 36% to 16% in expansion states but only 38% to 32% in non-expansion states.
Hospital leadership teams, community healthcare partners and public policy leaders have failed to collaborate, innovate and address these longstanding threats, and far too often have accelerated their competition for diminishing resources. All of this comes at an alarming cost and it is not just about convenience. When rural hospitals close the consequences are dire. Ambulances have to travel greater distances to get to critically ill or injured people, and then transport them long distances for care. Critical and basic skill sets, like obstetrical care, are lost. Following a hospital closure there is typically a rapid exodus of doctors and other healthcare professionals and jobs in the community are lost. Most alarmingly a new study has shown that when a rural hospital closes the mortality rate in the areas served by that hospital rises by nearly 6%.
Our country does not have a strategy to address the health care needs of people who live in rural areas and there is not even a meaningful discussion of a comprehensive approach to this challenge. In that vacuum there is some local innovation occurring. In rural NY state there is a proposal for a full collaboration between all health care entities and the people they serve to build a “Total Cost of Care” model in which the insurers, Medicare and Medicaid agree to a lump sum payment to cover the cost of care of everyone in the region and the healthcare and social service organizations work together and in partnership with the people they serve to determine the best use of that money. New models for the roles of paramedics and community health workers also hold promise, and pharmacists can be very important members of a primary care team. Federally Qualified Health Centers are natural partners in this work and if FQHCs and community hospitals can break through the barriers of their historical competition and recognize the highly complementary nature of their roles in rural areas there is much that can be accomplished. It will require a new perspective from the leaders of our hospitals, medical practices and community leaders and that is a big undertaking. But therein lies our hope.
Last month, I wrote about a study which linked the availability of primary care with life expectancy and which also showed that the availability of primary care providers has a much more powerful impact on life expectancy than the availability of specialists. Primary care settings are the most cost effective place to offer preventive care, treatment of acute illnesses and minor injuries and management of chronic diseases. And other studies have shown that spending in primary care results in better outcomes and lower costs. So it would make sense for society to invest in primary care, right? Unfortunately a recent Rand study revealed some discouraging information.
- Only 2% of Medicare spending is on primary care (compared to 7.7% for commercial insurances). Some of this is due to the fact that an aging population requires more expensive specialty and hospital care, but this is still an alarmingly low number.
- The low was 1.6% in Hawaii and the high was 3.2% in North Dakota.
- The variations in spending are not related to the availability of primary care and may have more to do with cultural preferences for where a population of people seeks to get their care. Some will have a specialist for each organ system rather than a primary care providers, others appear to be getting basic primary care services in specialist offices.
- Medicare spending on primary care was especially low for Black Americans (1.7%) and Native Americans (1.5%).
Some states, like Oregon and Rhode Island, have mandated that commercial insurance companies increase their spending in primary care and when that was done it resulted in an overall cost savings of $300 per enrollee per year. Prior to making those changes costs had been increasing at a rate of $88 per enrollee per year. The path seems obvious but at this point Medicare has no plans to increase spending in primary care. Even modest increases would allow primary care practices to expand resources and to compete with hospital systems and specialty practices for recruiting physicians. And as medical students graduate (often with massive debt), they take note of the fact that primary care specialties are perennially among the lowest paid in our profession. Additional financial support for this vital service would help to make it a more attractive option for people choosing their career path. Hopefully Medicare will see the light, and policy makers will work to increase investment in primary care. It will improve the health of our communities and save money for the healthcare system.
Everyone knows this old saw and the implication is that keeping away from a doctor implies that you are healthy. I like the message that healthy eating and living translates to better health, and in fact one of my favorite cartoons depicts a man sitting on his doorstep happily eating an apple with three men in white coats lurking off in the distance with the caption “An apple every 8 hours keeps three doctors away”. It slays me every time. But as you might intuit, not seeing a doctor (or other health care provider) may not be so good for your health.
Just last month JAMA Internal Medicine published a study by Basu et al, which looked at the impact of having doctors available to see patients and the results were eye opening. They studied outcomes in 3124 counties across the US from 2005 to 20015 and without getting into the details of their methodology, here is what they found:
- In those 10 years the number of physicians in those counties increased from 196,014 to 204,419, but the population at large grew faster.
Primary care physicians (e.g. family doctors, internists and pediatricians) decreased from 46.6/100,000 people to 41.4, with greater losses in more rural areas.
- For every 10 additional primary care physicians/100,000 people life expectancy in that population increased by 51.5 days, but only by 19.2 days for every specialist 10 specialists/100,000 people.
- Increasing the number of primary care physicians had the most positive impact on mortality (death) from cardiovascular disease, cancer and lung diseases.
It makes sense that cardiovascular disease, cancer, and respiratory illness are most sensitive to the presence or absence of primary care. Those illnesses are especially responsive to careful management with nimble responses to flare ups, and cancers can be impacted by reliable, evidence based screening, all of which is most impactfully provided through primary care.
This kind of data should compel our policy makers to work to enhance primary care and its availability in our rural states like Maine, which has experienced an overall drop in life expectancy in the last 15 years. CMS has comprehensive primary care initiative aimed at this, robust loan repayment programs and financial and tax incentives to attract health professionals to rural areas would help, states could invest much more in supporting primary care and our health care delivery system must change to value primary care at a level commensurate with its importance. A recent issue of the Journal of Ambulatory Care Management includes an important article on sustaining access to healthcare in rural areas, and PCHC’s CEO, Lori Dwyer and I have a companion opinion piece. I’ll be discussing both in a future Noah’s Notes.
Since the advent of the Affordable Care Act in 2009 over 20 million previously uninsured people have gained health insurance coverage. This has had a number of positive impacts on access to care and health outcomes which I’ve covered in previous blogs. But as we all know, there have also been challenges. The Supreme Court ruling, which made expansion of Medicaid optional for states, the compromises on benefits coverage that were required to get the plan passed in the first place, and the elimination of a public option (e.g. Medicare buy in for people 55 and older) by the US Senate diminished the impact of the law. Congress’ removal of the individual mandate last year and the current administration’s dramatic reductions in outreach funding and time access to enrollment have further undermined the ACA.
And now a Commonwealth Fund survey reveals some disturbing trends. While the uninsured rate has declined from 20% in 2010 to 12% for the past 3 years (and it is unfortunate we could not make more progress on that) the rate of underinsured has risen from 16% to 23% during the same time period). And more surprisingly, the most rapid rate of increase in the underinsured is among those with employer based insurance, not those who purchase their insurance as individuals. This is a reflection of ever increasing deductibles and co-pays as health care cost increases outpace wages, driven largely by pharmaceutical costs and the ongoing waste in healthcare spending ($1 trillion of the $3 trillion spent on healthcare each year).
Most of us have experienced this phenomenon on a very personal level as year after year our personal costs for health insurance coverage increase while there is simultaneous pressure on benefit design to try to create cost reductions. The authors of the survey suggest several strategies to reverse this trend and they include:
• Improve the basic required coverage under the ACA to require coverage of more of the costs of care and of medications.
• Increase Medicaid expansion.
• Support growth of reinsurance markets.
• Restore outreach and enrollment funding.
• Reinstate funding to reduce cost sharing (which ahs been cancelled by the Trump administration).
• Eliminate “junk plans”, the short term plans with very limited benefits that were expanded by congress last year.
• Make health insurance premiums tax deductible.
There are other strategies that ought to be considered as well. Medicare buy in for people aged 55 and over was seriously considered in 2009 and ought to be re-evaluated. States may also undertake innovations like allowing buy in to Medicaid. We ought to be able to do better and we can if we put people first in public policy.
While the scope the opioid crisis has become apparent to most people in this country, most of our broad understanding of the challenges we face are a result of its impact on adults. Relatively little is known about how children are affected and what we have known is often based either on extrapolation from data related to adults or indirect measurement. Childhood opioid poisonings are one such example.
Up until this point we knew how many children each year presented to hospital emergency departments with opioid poisoning and how many of those children died. However, for the first time researchers carefully examined trends in pediatric deaths from opioid poisonings and published their findings in JAMA Open Network last month. What they revealed is startling and should serve as a call to action.
- Between 1999 and 2016 just under 9000 children died from opioid poisonings and 38% of those deaths occurred at home.
- During that time period the mortality rate for children from opioid poisonings increased by 300%, poisonings by prescription opioids increased by 95% and heroin overdoses in adolescents increased by 400%.
- 73% of those who died were males.
- 73% of those poisonings were from prescription opioids.
- 7% of the deaths were children under the age of 5.
- 25% of the deaths in children under the age of 5 were actually homicides.
- Adolescents make up 80% of the deaths and heroin was the primary cause of death in 1900 of the deaths in children between the ages of 15 and 19.
We all must work to identify effective prevention strategies, including education, safer packaging and storage of prescription opioids and of the medications we use to treat opioid use disorder (methadone and buprenorphine), and promotion of responsible prescribing practices. Naloxone, the antidote for opioid overdose, should be in every home in which there is a prescription for opioid medications, and should be easily accessed by people who use drugs and by those who care for them. We must develop reliable screening for substance use among pre-adolescents and adolescents so that early interventions can be offered. We must strengthen community and public health support for struggling families. And we must be be certain that appropriate treatment is available if they have developed a substance use disorder.
What could be more important?
Many of us who are committed to universal access to healthcare have celebrated some of the successes of the Affordable Care Act, like 20 million more Americans having health insurance, but a recent UPI report reminds us that our healthcare system is far from perfect. In a December 17 article they reported the results of a Gallup survey which showed the following:
- 29% of adults in the US postponed treatment due to costs.
- More than half of them reported a serious or somewhat serious medical condition (representing 19% of all US adults).
- The extent to which people delay treatment depends on the nature of their health insurance coverage – those with no insurance are the most likely to forego treatment, those with Medicare and Medicaid are the least likely to delay, and those with insurance but higher deductibles and/or co-pays are somewhere in between.
It is likely that no one would find this data surprising, but it should be alarming to everyone. Delayed treatment leads to escalated costs and unnecessary suffering and death, and this is compounded when public policy results in increased costs to individuals. No matter where you stand on the ACA, the decisions last year to reduce support for the insurance exchanges and to remove the penalty for the individual who chooses not to get health insurance means that fewer people have insurance than otherwise would be the case, and that the pool of insured people have a higher disease burden and therefore higher costs, which unarguably leads to higher costs for all manifested in their deductibles, co-pays and premiums.
In addition, 30% to 50% of all health care costs are unnecessary and wasteful, the administrative burden on the system is unsustainable, and industries like Big PhRMA are profiteering from a broken model. In the US we spend $3.5 trillion a year on healthcare – 19% of GDP. There is a great deal of interest in congress in addressing this and the bills that result will represent either the interests of insurers and pharmaceutical companies or the interests of people living in our communities. It compels all of us to learn and to engage on this issue and to work toward an outcome which moves us toward broader access to more affordable care.
During the debates about healthcare in the last 2 years one argument that was made by Senator Ron Johnson of Wisconsin against Medicaid expansion was that more people with access to health care resulted in more opioid prescriptions and made the crisis of addiction worse.
Most people working in healthcare argued that the origins of the opioid crisis were far earlier than Medicaid expansion (which only began in 2010), but with expansion of MaineCare now imminent it would be helpful to have information which would help us to anticipate its impact.
In August of this year Saloner et. al. published an article in the Journal of the American Medical Association Open Network outlining the results of a study they conducted on prescribing patterns in 3 Medicaid expansion states (California, Maryland and Washington) and two non-expansion states (Florida and Georgia). This study included 11.9 million people who filled 2 or more prescriptions for opioids over the course of a year and analyzed on a county by county basis. Here is what they found:
- Prior to expansion nearly 70 people per 100,000 filled prescriptions for Suboxone across all counties, meaning that they were being treated for opioid addiction, or Opioid Use Disorder (the medical term).
- After expansion, the counties where Medicaid was expanded showed and increase in Suboxone prescribing by nearly 13% compared to non-expansion counties.
- Conversely, the rate of prescribing for opioid pain relievers did not increase after expansion, relative to non-expansion counties. In fact across all sectors, opioid pain reliever prescribing decreased steadily.
These data suggest that when Medicaid is expanded access to treatment for Opioid Use Disorder improved and expansion did not increase the prescribing rates of opioid pain relievers, in fact there is a trend of steadily decreasing rates of those prescriptions. Given that we know from very strong clinical evidence that treatment of people with Opioid Use Disorder with medication like Suboxone decreases deaths from overdose, decreases transmission of diseases like Hepatitis C and improves retention in treatment programs this is good news for Maine as we move toward MaineCare expansion and allowing more people to access healthcare.
The term ‘burnout’ has become prevalent in both discussion of the healthcare delivery environment and in medical literature.
It is vitally important and threatens the stability of our healthcare system, and most importantly our primary care practices across the country. Burnout most generally refers to providers (especially physicians, nurse practitioners and physician assistants) but can impact anyone, and is described as a loss of empathy as a consequence of an environment in which resources are not matched to the tasks expected of providers, new tasks are added on a regular basis, there is a shifting role for providers and there is little control over the amount and pace of work we face on a day to day basis. The loss of empathy then results in cynicism, fatigue and a failure of engagement with each patient and with the full embrace of the management of a panel of patients, and the consequences for quality of care can be profound. Most alarmingly, burnout rates for family doctors are estimated to be over 50%. As you might imagine, healthcare organizations must attend to this challenge and that attention should be urgent. Here at PCHC we have had a Joy in Medicine workgroup tackling this for the past 18 months and our scribe pilots, the standard primary care schedules, and efforts at increased staffing and reducing desktop documents have resulted from that endeavor (which is ongoing).
But a recent article raises the possibility that the situation may be more nuanced than burnout alone. The authors, Dr. Simon Talbot and Dr. Wendy Dean, writing in STAT magazine argue that there is an unrecognized threat to provider wellbeing and they label it as “Moral Injury”. They assert that moral injury is mistaken for burnout and that risks misapplied and ineffective solutions. They go on to make these points:
- The complexity of the work that we undertake and the myriad of interests (patient, employer, payers, self, etc.) involved create highly conflicted allegiances on the part of providers and it is this conflict that robs us of our resilience.
- The ongoing moral injury in healthcare is being unable to provide high quality care and healing in a consistently reliable fashion due to financial concerns, limited or no insurance coverage, and the overwhelming impact of electronic health records.
- Most providers feel called to their work, and have sacrificed a great deal of time, energy and money in order to train to do that work. Leaving training and entering a work environment that is as rapidly changing and challenging as healthcare creates an ongoing tension that is difficult to manage and “Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting”. I would argue this is most dramatic in primary care.
So in addition to providing support and resources, leaders of healthcare organizations must consider these “competing allegiances”, strive to mitigate their impact, and advocate for public policy and organizational innovations aimed at creating an environment in which the best interests of the patient are paramount. I’m all in.
That was one of my Dad’s favorite aphorisms, and a recent article brought that particular quote to mind. “Adverse events associated with opioid-containing cough and cold medication in children” was published in April’s online version of Clinical Toxicology.
Opioid containing cough syrups (Robitussin AC, Tussionex and others) have been around for a long time and are widely used, despite the fact that other studies show that they are ineffective in reducing cough. The risks of these drugs are elevated in children but their use has persisted. In this current study they looked at US cases of adverse events in children related to these cough medications between 2008 and 2015. The results were:
- 114 of 7035 cases reviewed involved an opioid containing product.
- In 98 cases the adverse event could reasonably be linked to the opioid.
- There were 3 deaths and all involved a cough medicine combination of an antihistamine and hydrocodone (the opioid in Tussionex).
- Other adverse events included somnolence, lethargy, lethargy (all also more common with hydrocodone than with codeine).
In January of this year the FDA required warning labels on these cough medicines to attempt to limit their use in children under the age of 18 and included their highest level of warning (“black box warning”) about the risks of misuse, abuse, addiction, overdose and death, and slowed or difficult breathing that can result from exposure to codeine or hydrocodone.
Another article published in Pediatrics in June of 2017 looked at the risks of over the counter cold and cough remedies for children and found that between 2009 and 2014 there were 3251 reports of adverse events, 60% of which were in children under the age of 4, and which included racing heart, somnolence, hallucinations, gait disturbances and agitation. There were 20 cases of death, most in children under the age of 2 and involving an unsupervised ingestion of diphenhydramine or dextromethorphan.
One of the authors of the first study stated, “Health care providers should never prescribe opioid-containing cough and cold products to children. Ever”. Given the fact that none of these medicines, with or without opioids, works to reduce cough or other cold symptoms I would expand that to say don’t prescribe or recommend them at all, to anyone, ever. Another of my favorites of Dad’s sayings, which he always used when people asked what they should use for a cold: “a handkerchief”.
(2018) Adverse events associated with opioid-containing cough and cold medications in children, Clinical Toxicology, DOI: 10.1080/15563650.2018.1459665