Strung Out

Dr. Reb Close, left, and Dr. Casey Grover, right, have spent countless hours of volunteer time to launch Prescribe Safe, and have published scholarly articles about the initiative

Inside the ER, a woman hunches over in pain, rubbing her sweaty forehead as she sways back and forth. She’s sitting with a doctor as she suffers through opiate withdrawal. She describes her symptoms: nausea, vomiting, diarrhea. She’s in the ER partly to address those symptoms, but also because persistent migraines – the problem that got her onto prescription pain meds to begin with – haven’t gone away. The migraines themselves are often triggered by opiate withdrawal.

Now she hopes to wean herself off prescription drugs and the cycle of addiction, dependence and withdrawal, a cycle no one informed her about when she got her first prescription for hydrocodone in 2011. The ER physician tonight, Casey Grover, gives the patient multiple intravenous non-opiate medications, including the anti-inflammatory Toradol and anti-nausea drug Metoclopramide. Grover also gives the patient information on a new Monterey County program called Prescribe Safe, aimed at ending addiction to prescription medications – and stopping addiction before it starts.

Before Prescribe Safe was implemented in 2014, this woman’s situation would’ve been treated as an isolated circumstance. Now, doctors look up her medical history in a statewide system, the California Prescription Drug Monitoring Program called CURES, that will be shared with other healthcare institutions, and she’ll be treated according to new guidelines. Prescribe Safe has gotten local providers on board to use CURES, and to change the way they prescribe medications. From hospitals to police to prosecutors, local officials are working together to address prescription drug abuse at multiple levels.

Prescribe Safe launched officially in 2014, but was in the making for about a decade. Ten years ago, CHOMP began a “recurrent visitor” program after years of seeing repeat patients coming into the ER. Before Prescribe Safe, emergency rooms handing out meds without much scrutiny, making it easy for addicts to visit a rotating range of hospitals and stock up on pills. There was no system in place keeping track of visits, only a slew of doctors who wanted to help the best way they knew how: by prescribing strong drugs.

CURES was first introduced in six California hospitals this spring, and the need became clear right away: It quickly uncovered a severe case of an addict, a 57-year-old woman who had been to different emergency rooms 900 times over the last three years. That equates to almost a visit a day.

“This came up with one of our worst offenders,” Grover says. “She takes a bed, and when your mom’s having a heart attack or a stroke, that bed is being used [by her]. She’s there because she wants Norco, and our heart attack patient is waiting in the waiting room. If we can identify this particular patient as someone who needs substance abuse treatment and save that ER bed, everybody wins.”

•••

After marijuana, prescription medications are the most widely used drugs in the U.S. and maybe the most dangerous – no one has ever documented a pot overdose. Overdose-related deaths from prescription meds outnumber cocaine and heroin deaths, combined. In Monterey County, you are more likely to die from prescription drug overdose than from a car accident, a statistic that holds true in around 30 states.

In the two years since Prescribe Safe launched, the numbers have been turning around. In the year before Prescribe Safe, 2,856 recurrent emergency room visits were documented in Monterey County, meaning the same patient returned to be treated for the same condition within a 12-month period (ranging anywhere from a few to a few hundred times). The year after implementation, that number dropped to 1,185, more than a 50-percent decrease, estimated to have saved county hospitals close to $1 million, according to CHOMP.

The amount of narcotic pills prescribed during that year also dropped, according to Doctors on Duty, from 60,740 in the year prior to 27,948 – a 54-percent decrease. And between 2013 and 2015, Monterey County’s deadly prescription overdose rate decreased by 28 percent, to 34 deaths in 2015.

Prescribe Safe was developed by two local doctors – Reb Close, an ER physician at CHOMP, and Anthony Chavis, chief medical officer of Montage Health, the parent company of CHOMP – and the program has become the blueprint for addiction intervention programs across California.

Close became a point of contact for medication abuse issues that surfaced in her department. When San Diego released their own version of Prescribe Safe, she looked closely at what they were doing. “We were addressing it patient by patient,” Close says. “They were addressing the system.”

Prescribe Safe means fewer opioid prescriptions are getting written to begin with, those that are written are better tracked, and there is clearer communication between doctor and patient.

It’s given ER doctors a new framework to minimize the pain med prescriptions they write, which is important because it can be challenging for physicians to identify which patients are most at risk. “Drug abuse crosses the socioeconomic sphere,” Chavis says, “from the high-functioning pillars of our community to the homeless; people of color and white; the grandmother, the father working on a construction site and the A-student in high school.

“We have seen teens die at pill parties and toddlers die at home when medications are not safely stored. We see 80-year-olds with addiction who struggle to care for themselves, frequently requiring treatment for falls that happen while under the influence.”

Many states and counties have different names for their own similar programs, but each has the same goal: to reduce drug addiction by reducing prescriptions. It’s their own version of cops arresting dealers rather than users – but in this case, the dealers are doctors.

As Close puts it, “We aren’t changing the drug problem. We’re fixing one of the suppliers.”

•••

The official Prescribe Safe taskforce consists of 17 organizations, including law enforcement agencies and fire departments, the Monterey County Health Department, emergency medical technicians, pharmacies, insurance companies, Doctors on Duty and all four Monterey County hospitals (CHOMP, Salinas Valley Memorial, Natividad Medical Center and Mee Memorial).

Every six months, representatives of all of these groups come together for a two-hour meeting. There’s coffee, fruit and a lot of discussion about what everyone is doing.

One key player from the outset has been Amy Patterson, the deputy district attorney in charge of Monterey County’s health care fraud unit – a relatively new unit that was created with a state grant around the same time that Prescribe Safe began. Before that, health care fraud charges were filed under “general,” but now all relevant cases go through Patterson. While she can’t point to a specific number, Patterson sees a clear before-and-after since Prescribe Safe launched: “It used to be that when someone would go to a pharmacy with a forged prescription, the pharmacist might recognize some red flags and contact the doctor who would say, ‘Wait a second, I didn’t write that script, don’t fill it,’ and that would be the end of it.

“Now, someone contacts law enforcement. There’s been an increase in reporting by the health care providers because of the relationships that we’ve built. They feel comfortable calling me up.”

Another piece of the program is new guidelines for how physicians talk to patients. Things that call for a closer look and more questions about the patient’s history include: “requesting specific controlled substances, repeatedly running out of medication early, loss or theft of controlled prescription medications and unwillingness to try non-opioid treatments.”

If a physician spots a warning sign for prescription drug abuse, they can look up any patient in the new secure database to see whether they’ve been moving around at different locations. This forms a foundation for Prescribe Safe’s mission, and is also part of a separate statewide effort known as the Emergency Department Information Exchange.

“With [the exchange],” Grover says, “I get an email literally the minute somebody checks in that’s on our radar and I can just give the provider a heads up.”

Prescribe Safe also offers doctors new guidelines for how to treat patients. For patients with acute pain, it’s now recommended to only prescribe short-acting opioids in the smallest amount possible, 10-15 pills at most, with a maximum dose of four times daily. As for chronic pain, it should only be treated by a primary care physician or pain specialist in an outpatient setting – not a hospital – and chronic pain patients should have only one provider and one pharmacy.

Close says that since the new guideline posters went up on the walls of CHOMP’s ER, the prescription drugs that patients ask for have changed dramatically. “I’m not writing for medications that I have no business as an ER doc writing because I have the guidelines to back me up,” she says. “The fights have stopped, the arguments have stopped. I don’t deal with it anymore.”

When narcotics are necessary, patients no longer just get a prescription to walk away with and fill at a pharmacy.

“If somebody’s sobbing at 2am in excruciating pain, I’ll give them four or five tablets – that’s why we have them,” Grover says. “They also get a handout on the side effects of those medications. I tell them they can be addictive, and I plead with them to not use them unless they absolutely need them.”

In the past, Grover says, there was less talking and information exchanged: “It was just a prescription and not a lot of discussion, and people ended up in places they wouldn’t have dreamed.”

Many cases begin innocently, with commonplace injuries and people who lead healthy lives. “You’re talking about something that’s prescribed from a doctor, a trusted source,” Patterson says. “Since these substances are so highly addictive, at some point it shifts from being a medical need to something so much more dangerous. You don’t think you’re ever going to be a drug addict – you’re an athlete, it’s not in your family history – but if the doctor is reckless in his or her prescribing, the results could be deadly.”

It’s not only injuries that bring on drug prescriptions; it’s everything from multiple sclerosis to cancer. There are some diseases for which many patients “have an altered perception of pain,” Grover says, using fibromyalgia as an example. “What’s crazy is we can think of at least two or three cases of when fibromyalgia was fatal. It’s not because fibromyalgia is dangerous – it’s because these patients get put on opiates, their dose increases as their body gets used to it, and then they overdose.”

Prescribe Safe has changed the approach, with doctors first looking for alternative pain interventions:“Five, six, seven years ago it was ‘Fibromyalgia? Here have opiates,’” Grover says. “Now it’s ‘No, let’s do everything else. Let’s do cognitive behavioral therapy, psychotherapy, physical therapy, acupuncture, yoga, meditation, stretching, antidepressants, neuropathic pain medicine… everything but opiates.’”


POWER OVER PAIN

Learn more about how to dispose of unwanted pain meds, and spot warning signs of addiction.

  • • If you or someone you know is seeking help with an addiction to prescription medication, call 211 for confidential referral and treatment.
  • • Safely dispose of prescription substances at various local venues including Walgreens in Seaside, Carmel Police Department, Central Avenue Pharmacy in Pacific Grove, AllCare Pharmacy in Salinas, Carmel Drug Store, CSUMB Campus Health Center and Pebble Beach Community Services District.
  • • For more about Prescribe Safe, including information on pain management options and a list of local pain management physicians, visit www.chomp.org/prescribe-safe.

Up until the 19th century, painkillers didn’t really exist. For thousands of years, pain was treated by opiates, but it wasn’t until a bloody Civil War that the use of morphine skyrocketed.

It wasn’t long until the Bayer Company turned heroin into a commercial drug, and at the turn of the century the use of painkillers surged – among everyone, not just veterans.

By the 1920s doctors had learned how addictive these drugs were, so they were largely outlawed and barely utilized until there were casualties from World War II. In cases where surgery was avoidable, veterans in the ’50s and ’60s were treated with painkillers, which led to another drug explosion – but this time a much larger one. Again, amid narcotic mayhem, doctors grew aware of prescription drug abuse and became much stricter about doling out pills.

Then, in the mid-’70s, Percocet and Vicodin arrived on the market. Twenty years later came OxyContin.

“Certain medications were big money-makers for pharmaceutical companies,” Grover says, “and as the medical community was more interested in treating pain, these companies put out studies suggesting that some of these medications weren’t addictive. It was really weak evidence. Now we know they’re very addictive, and we’re trying to catch up with the mistakes we’ve made. I have a presentation slide that basically says ‘I need to apologize on behalf of the medical community. Like, we goofed.’”

Close sums it up more succinctly: “We were wrong.”

Nowadays, every patient who goes into the CHOMP ER leaves with a Prescribe Safe handout. “Everybody,” Close stresses, “I don’t care what you’re there for. We’re not saying, ‘You have a problem,’ we’re saying, ‘This is a problem.’”

All groups in the Prescribe Safe taskforce agree that education about prescription drugs and addiction is the best place to begin. “We did all the data collection and then we started thinking, ‘We need to educate,’” Patterson says.

“The whole idea of Prescribe Safe is novel,” she says. “We’re one of the top mentor counties doing this in California. I go out and speak to local law enforcement agencies and other counties’ district attorney’s offices and explain Prescribe Safe, and it’s amazing how excited they are about starting something in their own county and following our lead.”

That means lots of local outreach. Last month, Grover presented at a Rotary Club meeting and town hall meeting in Salinas and connected with Sun Street Center, a drug rehabilitation organization.

And the model for Monterey County’s Prescribe Safe Initiative is going big. Close is mentoring new coalitions elsewhere in California to organize their own versions of Prescribe Safe, including East Bay Safe Rx in Alameda and Contra County counties and Safe Rx Santa Cruz County. She’s in talks with Marin and San Diego county officials, and is also working with the California Health Care Foundation to launch similar groups in other parts of the state. Close and Grover have been co-authors on five academic articles about Prescribe Safe in The Western Journal of Emergency Medicine since 2009.

Part of Prescribe Safe is partnering with existing efforts. The U.S. Drug Enforcement Agency holds occasional prescription drug take-back days, accepting medications with no questions asked. The idea is to give people a safe, environmentally conscious way to dispose of extra pain pills instead of leaving them unused in a medicine cabinet, waiting to be found by an addict.

Last May, a record volume of drugs – 893,498 pounds – was turned in nationwide. (For information about drug take-back opportunities locally, and resources for people who might be suffering from addiction, see sidebar, p. 24.)

Although prescription drug abuse is still among the leading causes of preventable deaths in the U.S., the fact that Prescribe Safe exists gives healthcare providers – and patients – newfound hope.

“Progress we’ve made is patient and provider awareness,” Grover says. “No one ever sits in third grade thinking, ‘I hope I can be addicted to Percocet when I grow up.’ People are starting to realize that as a community, it’s our problem.”

Editor's note: This story has been updated to reflect the following correction. Dr. Anthony Chavis is chief medical officer of Montage Health, not CEO as previously stated.

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