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Sue Lani Madsen: Home-based care largely responsible for opioids crisis

Tell people you’re having orthopedic surgery, and everyone’s a comedian: “Make sure they give you the good drugs, man.”

That’s where today’s public health emergency has its roots: the physician’s prescription pad. Headlines on the dangers of high-powered opioids are all over the news this week, with scary stories of people who started with a legal prescription and ended seeking illegal heroin. But what changed in the last 30 years to create a crisis?

The nurse providing my discharge instructions from outpatient rotator cuff surgery emphasized the importance of the good drugs to avoid excruciating pain during recovery. Reluctantly, I accepted the opportunity for firsthand research into the use and hopefully not abuse of opioids.

Turns out opioid use also became the story of the week with President Donald Trump’s announcement of a public health emergency. Declaring an emergency without new spending energized the usual critics. While treatment programs to reverse addiction will eventually require additional or reprioritized funding, spending alone is always a poor metric for progress. Overprescribing pain pills is called lazy doctoring by one local physician, masking symptoms while giving an illusion of solution. Overprescribing money to fix policy problems is lazy legislating.

According to the Spokane Regional Health District, in Washington as a whole “fatalities from prescription drug overdoses are the leading cause of unintentional death, surpassing death by car crashes.” In the Inland Northwest, methamphetamines still lead heroin for accidental overdoses of illegal drugs, but opioid addiction definitely qualifies as a public health emergency.

The first American opioid epidemic arrived with the patent medicine explosion of the late 1800s. Popular pills and potions carried generous portions of opium, codeine, morphine or alcohol. Humans have always been intrigued with better living through chemicals, with a veneer of respectability for medicinal use. Even alcohol was available by prescription during Prohibition.

The problem of addictive prescription drugs never really went away. What changed to create the current state of emergency? Margaret Jones, a retired nurse formerly with the SRHD, recalled her own mother’s back surgery in 1938, followed by six months in a body cast. “She had to kick a drug habit before she could come home,” Jones said.

There’s the key. We brought the problem home. The biggest change in health care delivery over the last several decades is the move from hospital-based to home-based care. Instead of trained professionals monitoring pain levels and appropriate medications, we send people home with three prescriptions for powerful pain pills and a printed list of generic instructions. Instead of skilled nursing care, we expect informal networks of untrained family, friends and neighbors to pick up the load.

What could possibly go wrong with a system like that? Now we know.

We won’t be returning to the peak hospitalization rates of the 1970s and 1980s. Opiates and opioids still have an appropriate place in the treatment and management of short-term post-surgical pain as well as long-term chronic pain. Patients should not be discouraged from appropriate use by scary stories of addiction. And while treatment for addiction will be one part of addressing the latest public health emergency, an increasing need for treatment is an indication of failure in the system.

According to Kim Papich, spokesperson for the SRHD, “the focus of public health is to go upstream to look at prevention, it’s not just about treatment.” The health district will be educating providers on appropriate prescribing practices, and promoting the use of Washington’s Prescription Monitoring Program database to help providers identify problem patients and physicians. The Washington Health Care Authority has announced new rules to arbitrarily limit the number of pills per refill, regardless of how far it is to the pharmacy.

When the pharmacy is over 20 miles away, it just creates a hassle for caregivers. My primary caregiver for four days was a 16-year-old neighbor who administered medications, prepared meals and made sure I was tucked in with blankets to keep warm and with ice to reduce swelling. She was responsible for 14 tablets of morphine sulfate and 80 tablets of oxycodone. Her name appears nowhere in the system, yet her “unskilled” care was key to my recovery.


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