When Dr. Julio Menocal was completing his residency in the late ’80s, most aspiring physicians were instructed on one way to manage pain: aggressively.
“For the longest time, we were taught that you needed to treat pain aggressively to increase function, for sprains and stuff like that,” said Menocal, a family medicine doctor with a practice in Frederick. “And I don’t think anyone did it out of malice, it’s just — you want to make sure the patients feel better.”
Today, in the midst of a state and nationwide opioid epidemic, that line of thinking has changed. Just more than 20 years after OxyContin hit the market in 1996, Maryland — and Frederick County — is experiencing an all-time high in the number of opioid-related deaths.
Statewide, the number of prescription-opioid related fatalities increased from 302 in 2007 to 418 to 2016, according to the latest data from the Maryland Department of Health. In Frederick County, the number grew from 6 to 18.
The number of deaths from heroin and fentanyl overdoses increased even more substantially. Heroin-related deaths in Frederick County increased from 8 in 2007 to 46 in 2016. Fentanyl-related deaths shot from 0 to 49. And for local doctors, the link between prescription narcotics and street drugs is often inextricable, with patients hooked to opioid painkillers frequently turning to cheaper and more accessible substances.
“In 2011, we started seeing the biggest chunk of the fatalities — the biggest percent — were coming from the prescription drugs,” said Dr. Jay Gonchigar, the founder and director of the Newbridge Pain and Spine Center in Frederick. “But as the regulations started tightening up, what happened was these patients started going back to the street drugs. It’s made worse because of the Fentanyl that’s come to the market since then, and in Maryland this year there continues to be a double digit increase in fatalities.”
Conventional medical teaching used to consider opioid painkillers a “birthright” for patients, Gonchigar added, as essential and low-risk as Tylenol. But in 2009, as drug overdoses supplanted car accidents as the leading cause of death for Americans, the medical establishment began to rethink a group of medications once considered — and marketed by many pharmaceutical companies — as a one-step cure-all for pain.
As efforts to control the opioid crisis continue, doctors in Frederick County are doing their part to reduce the rates of narcotic prescriptions and explore new approaches to pain management that don’t depend on opioids, both for patients with acute injuries — including sprains, strains and broken bones — and chronic pain.
Some approaches involve weaning patients off high doses of opioids or using less harmful medications as a first-line defense against pain. But many doctors are also becoming more open to alternative forms of medicine — chiropractic therapy, acupuncture or movement therapies such as yoga, just to name a few.
“I’m definitely seeing a shift,” said Dr. Lisa Sullivan, an anesthesiologist at Frederick Memorial Hospital who also runs Real Health Studios, a holistic treatment center in Frederick. “I think traditionally, a lot of classic Western physicians pooh-poohed alternative forms of medicine. They were kind of like, ‘That’s way out there.’ But I think they’re realizing, ‘Wow there’s something to this. Maybe we don’t need to have a controlled randomized trial if something just works for somebody.’”
From prescription to addiction
Recent data from the Centers for Disease Control and Prevention show that opioid prescription rates have decreased in Frederick County, from around 945 milligrams per capita in 2010 to around 742 in 2015. The move away from opioid painkillers has largely been due to the addictive property of the drugs, which hurt some patients more than they helped.
For Kim Wilson, a Frederick resident and former Montgomery County police officer, opioids led to a years-long struggle with dependence after an on-the-job injury. In 2004, shortly after completing field training, Wilson was injured on a call when another car struck the driver’s side of her police cruiser.
The blow, she said, wrenched her seatbelt against her body and forced her vest, badge and gun into her side and back, leaving lasting muscle damage and chronic pain. Neither specialists nor her primary care physician could provide a definitive diagnosis for the pain, but they did prescribe opioid painkillers, which gradually gained a stranglehold on her day-to-day life.
“It was the first thing I thought about in the morning and the last thing I did before bed,” Wilson said. “There were times when I had a pharmacy’s worth of pills at home. I couldn’t work out without meds, I couldn’t get out of bed without meds. It got to the point where it was affecting the relationships in my life.”
Over the next few years, Wilson’s pain level became so high that she often couldn’t bear the weight of protective equipment, forcing her to retire from the Montgomery County Police Department. Frequent flare-ups landed her at Urgent Care facilities or back in front of pain specialists, who continued to prescribe opioids to manage the pain. At first, Wilson said, she was on low doses of several different kinds of medication. But as time went on, she became dependent on larger amounts of oxycodone.
Though Wilson never doctor-shopped — when patients visit several different doctors to receive several different prescriptions at the same time — she did assiduously ensure that she never ran out of medication. That required a monthly cycle of counting pills, visiting her doctor and driving to refill her prescription, all to avoid undiagnosed pain and withdrawal symptoms. Without the drugs, Wilson said, she became agitated and foggy, and her pain level became even more unbearable.
“It really consumes you,” she added. “There were a couple of times when I would run out and be digging through old prescriptions, just to have something to bring in.”
Though the risk of addiction to opioid painkillers is now well-established, there was a time when medical studies asserted the opposite. In 1980, a brief letter was published in the New England Journal of Medicine — a prestigious industry publication — stating that addiction was rare in patients treated with narcotics in hospitals.
The short and limited note — which only referenced patients treated with opioids in monitored hospital settings — helped launch a spiral of studies promoting the prescription of opioids for patients to use at home. Purdue Pharma, the maker of OxyContin, used the same data to claim that less than one percent of patients who are prescribed opioids become addicted. Over just a few short years, the prevailing medical attitude on opioids changed from one of caution to what some practitioners described as excessive tolerance.
“The other problem is that OxyContin and Opana came on the market and changed the dialogue,” Menocal said. “Those two drugs, the chemical composition was such that when it released into the system, it gave people a very quick high. Which, 9 times out of 10, is not a big deal. But you have something called the MOP receptors, and when they’re activated, people can get addicted to that. So, with those two drugs, things were just out of control.”
Like a number of other patients, Wilson gradually realized that her use of opioids to control pain had become an addiction. Beyond her dependence on the pills, she said, the drugs caused several nasty side effects, including gastrointestinal distress that left her with several food sensitivities. Sometimes called “opioid-induced bowel dysfunction,” symptoms include nausea, bloating and acid reflux, according to an article in the journal Contemporary Oncology.
Around two years ago, Wilson said, she confessed her issues with addiction to her primary care physician, who helped wean her off the drugs. She also began taking classes at The Institute for Integrative Nutrition, an online health coach training program, and learned different ways to manage her pain. Today, Wilson said, she largely controls her symptoms through an anti-inflammatory diet, moderate exercise such as yoga, and weekly acupuncture sessions.
“I don’t even take aspirin or Tylenol,” Wilson added. “I am so against pills right now. What I’ve been doing — that’s been a huge game-changer.”
According to Sullivan, there are few studies on the effectiveness of alternative pain management strategies such as acupuncture. But in many cases, individual results have been so positive that local doctors have begun recommending the therapies to a broader pool of patients.
At Menocal’s practice, he and nurse practitioner Chris Haas often refer patients to a local chiropractor, a practice they say has reduced narcotic use by 70 percent among patients with acute injuries. Dr. Rishi Gupta, an orthopedic surgeon with the Mid-Maryland Musculoskeletal Institute in Frederick, encourages massage and yoga for some patients both before and after surgery. And the recently opened Stockman Cancer Institute — part of the Frederick Regional Health System — includes an integrative medicine suite with space for alternative therapies.
At Real Health Studios, Sullivan also offers a suite of holistic treatments, including Feldenkrais — an exercise therapy that focuses on bodily awareness and slow, small movements. As with most alternative therapies, though, the services come with a substantial price tag. An introduction to Feldenkrais package costs $225, while a six-month health coaching package costs $575.
As a relatively new business, Sullivan said, she can’t currently accept health insurance, and it’s unlikely the treatments would be covered even if she could. In February, new guidelines were published by the American College of Physicians that recommended non-pharmacological means to treat back pain and urged insurance companies to cover treatments such as acupuncture and chiropractic therapy. But despite the recommendations, most providers still don’t reimburse for alternative medicine.
“I do offer receipts to patients, like, ‘Go forth and see if they’ll cover it if you submit it,” Sullivan said. “But the fact is, most of them won’t, and I don’t think there will be a big shift towards these therapies until insurance does cover them. The cost is a very legitimate point.”
Another factor, Gonchigar added, is often time. The majority of pain patients aren’t able to take time off work to recover, or maintain schedules that accommodate multiple chiropractic or physical therapy appointments. Opioids, on the other hand, provide a quick and efficient way for patients to regain some level of functionality.
“No one can take three days off in a week for six weeks, and then again six months from now,” he added. “If they do, they’ll probably end up losing their jobs.”
As a result, physicians are also focusing on more traditional ways to curb opioid prescription. For the last two years, Menocal and Haas have given no more than a five-day supply of opioids for acute injuries and prefer to prescribe a combination of Ibuprofen and Tylenol as a first-line defense. Pain management specialists have even more leeway to target their approaches, said Dr. Anish Patel, the medical director of the Frederick office of the National Spine and Pain Centers.
The industry has seen a variety of medical advances in the last several years, including spinal cord stimulation — a way of treating spine pain with mild electrical currents — and intrathecal pumps, a way of delivering small doses of medication directly into the spinal canal. The treatments, which are more common with providers across the country, offer a more targeted approach to pain management.
“I mean, we’re talking sometimes up to one one-hundredth of a dose into the spine compared to what you’re taking by mouth,” Patel said. “That’s a massive reduction in opioids. Plus pills, obviously, are much more easy to divert. It’s much easier for me to take some pills out and sell them as opposed to a liquid that is implanted into my body inside a steel pump.”
Even the emergency room at Frederick Memorial Hospital has adopted strategies to quell the misuse of opioids. Physicians now use Ibuprofen, Tylenol or intravenous (IV) fluids as an initial treatment for most injuries, and prescribe no more than three days worth of narcotics if they’re absolutely necessary for a patient, said Dr. Vipul Kella, the medical director of the emergency department. If opioids are delivered via IV, the drugs are now delivered more slowly — sometimes over the course of 30 minutes — to avoid a quick high.
Providers in the ED have also reduced both the minimum and the maximum doses for opioids, and offer naloxone to patients who come in for overdoses, Kella added.
“We’re seeing more and more people coming in with acute overdoses and addiction — it’s one of the fastest growing populations in the ED,” he said. “We have an important obligation in the emergency room to make sure we’re not making the problem worse.”
One of the most important methods of preventing abuse arrived at the state level through the Prescription Drug Monitoring Program, a subset of Maryland’s health information exchange. The program, first initiated in 2011, allows prescribers to look up patients in an online database and check every prescription they’ve had filled within the state.
Starting July 1, 2018, prescribers will be mandated to register with the program and run a search before dispensing certain drugs, said Kathleen Rebbert-Franklin, the director of Health Promotion and Prevention at the Maryland Department of Health. For local providers, it’s an important tool to prevent doctor-shopping and ensure that opioid medications aren’t abused.
“We all know that prescription abuse can lead to the use of other drugs,” Rebbert-Franklin said. “So, we’re trying to stop it on its own and stop the progression into other sorts of opioids.”
A Band-Aid solution
Despite the county-wide push to reduce opioid prescriptions, local physicians are keen to acknowledge their importance in many types of treatment. The drugs are crucial, Menocal said, for cancer and end-of-life pain management, or patients with conditions that drastically reduce their quality of life.
“Terminal cancer patients, people with sickle cell. Older people with bedsores in nursing homes,” Menocal said. “It is your duty to treat some patients as aggressively as they want to be treated. And if you don’t treat their pain adequately, you may be subjected to reporting.”
Some doctors have even been frustrated with recent efforts to restrict the use of opioids, which they say occasionally go too far. In March, Gov. Larry Hogan attempted to pass legislation that would have banned doctors from prescribing more than seven days worth of opioids to most patients. Every physician interviewed for this piece disagreed with the proposed restriction, saying it went too far in restricting care.
Gupta has also experienced some resistance from insurance companies to cover long-term narcotics. One of his more recent patients, he said, had developed a tolerance to opioids before his surgery and was struggling with pain after the operation. When Gupta prescribed another painkiller, the insurance company rejected the claim, he said, finally approving a short-term prescription after a lengthy pre-approval process.
“It was the first time I’ve had to deal with this sort of thing, where his insurance is saying they won’t cover his pain medication,” Gupta said. “On the one hand, to be brutally honest, I was a little bit irritated because I was like, ‘My patient is in pain and you’re denying me pain management.’ And they’re like, ‘We’re sorry, this is kind of what we need to do now.’”
The problem, Sullivan said, is that using opioids to treat pain is often a Band-Aid approach. The sensation of pain might disappear, but the underlying cause is never addressed. The pills also prevent patients from learning to cope with pain symptoms and regain function and movement.
Opioids also have other side effects that can actually exacerbate pain, Gonchigar added. The pills can cause central sleep apnea, which can lead to fragmented sleep and a greater sense of fatigue and discomfort. Most patients also develop a tolerance to opioid medications, which makes them less effective in the long-term.
“There’s always a struggle because people have this impression that if they take more medications, it should help,” Gonchigar said. “And then we have to educate them that that’s not the fact. Whether you take one, 10 or 50, it is not not linearly correlated in the sense that the more you take, the more you get better. You do not necessarily get better, and in fact, the problem can get worse.”