Southern Illinois doctor talks about the opioid crisis
(This is the first of an occasional series on the problem with opioid addiction in Illinois.)
The opioid epidemic is no secret.
Opioids, powerful, morphine-like painkillers, contributed to nearly 1,200 overdose deaths in Illinois in 2016, according to provisional data from the Illinois Department of Public Health. Heroin played a role in the deaths of another 1,000 people, most of whom likely started with prescription drugs, according to a 2014 survey by Washington University in St. Louis.
Drugs such as hydrocodone and oxycodone have been abused at record levels in recent years, according to the Substance Abuse and Mental Health Services Administration.
Studies have shown that the dangers of opioids stem from the strength and length of prescriptions. In Illinois, these and other prescribing trends have grown worse in the past decade for Schedule II opioids, the most addictive type legally available.
These trends can be found in data collected by the Illinois Prescription Monitoring Program, which records many types of prescriptions so doctors and pharmacists can see what their patients are taking and help catch people seeking fraudulent prescriptions, a practice known as doctor-shopping.
Counted for each time they filled a prescription, there were about 3 million Schedule II opioid patients in Illinois each year from 2008 through 2016. They lived in every part of the state, though prescribing trends varied in certain areas.
In the metro-east, for example, Madison County averaged 97,000 patients a year, 12,000 more than St. Clair County, and filled 30 percent more opioid prescriptions, even though the counties have almost the same population.
But perhaps no area in the state has been more afflicted as a region than the 16 southernmost counties: Hardin, Pope, Saline, Gallatin, Franklin, Massac, Union, Williamson, Alexander, Jackson, Johnson, Perry, Pulaski, White, Randolph and Hamilton. Opioid prescription rates there are stronger in several categories than other parts of the state.
The BND analyzed data from the PMP for Schedule II opioid patients from 2008 through 2016 and found:
▪ The number of prescriptions statewide increased 18 percent, growing almost every year, from 1.77 to 2.09 per patient. In the southern 16 counties, though, there were more prescriptions, and they grew faster than the rest of the state. Prescriptions there grew 30 percent, from 2.16 to 2.75.
▪ The length of pain treatment statewide grew nearly 50 percent, increasing almost every year. In the southern 16 counties, however, the length of pain treatment was consistently three weeks longer than the rest of the state. The average length of pain treatment in deep Southern Illinois grew from 46 days to 69, but in the rest of the state, the time grew from 27 days to 39.
Due to changes in PMP reporting forms, some data are reliable from only 2012 through 2016:
▪ Patients’ daily dose of opioids remained consistent, at about seven pills of 7.5-mg hydrocodone a day. In the lower 16 counties, however, daily doses were actually between eight and 10 mg less per day.
▪ Despite a smaller daily dose, over the course of a year, the average opioid patient in the lower 16 counties filled 38 percent more milligrams of “morphine-equivalent” opioids than in the remaining 86 counties. (Morphine equivalency is a standard that compares opioids to morphine.) In the southern region, patients filled an average of 2,600 milligrams per year — about four 10-mg hydrocodone pills a day for 65 days — compared with patients in the rest of Illinois who filled 1,900 milligrams a year — about four 10-mg hydrocodone pills a day for 48 days.
▪ For some of the most popular opioids, the number of weaker doses decreased while the number of stronger doses remained the same. For example, the number of 2.5-, 5- and 7.5-mg hydrocodone tablets, prescribed fell 42 percent while the 10-mg tablets shrank just 2 percent. For oxycodone tablets, the number of 2.5-, 5 and 7.5-mg pills decreased by 7 percent while 10-, 15-, 20- and 30-mg tablets grew by 37 percent.
▪ For hydrocodone tablets, the most popular type by far, the majority were prescribed to a much smaller number of patients. Of the nearly 10 million patients who filled prescriptions for hydrocodone tablets, 20 percent of them filled prescriptions for 60 percent of the drugs by morphine equivalency.
The reasons for such variations in opioid prescribing data are unknown.
Some have speculated that the 16 southernmost counties in Illinois filled prescriptions for more opioids because of a larger elderly population, but the data don’t contain patient age.
The Illinois Department of Human Services, which runs the PMP, said it does not study those trends.
“Further research is necessary,” a department spokeswoman said in an email.
Recovery in deep Southern Illinois
Dr. Aaron Newcomb first became aware of the growing opioid epidemic during his medical residency nearly a decade ago. There was no “a-ha” moment for him; it just became more obvious over time.
“It was just really painful for staff and everyone involved,” he said. “The situation sticks out like a sore thumb.”
After graduating from the family medicine program at Southern Illinois University in Carbondale in 2008, he opened his own practice in nearby Murphysboro. There, he noticed some providers weren’t as cautious with prescribing opioids as he was.
“I just kind of went with what the patients wanted (at first),” he said.
A year later, he moved back to Carbondale, where his medical partner wouldn’t prescribe opioids at all. Patients in pain would see her, but when she wouldn’t prescribe anything for them, they would turn to Newcomb.
“I wanted to try to do the best I could to prescribe and relieve suffering, and, at the same time, I wanted to be prudent about it,” he said.
As the opioid crisis worsened, Newcomb’s interest in best prescribing practices spurred him to learn more about addiction medicine, which gives people in opioid recovery a normal functioning life. He took a 50-hour course, passed a 400-question test, and became certified in the subspecialty in 2010.
Taking the next step, he and Shawnee Health Service, his hospital group, developed an opioid-treatment program, trained nurses and support staff, and wrote up rules and procedures for treating addiction. To help with the new effort and make sure there were no coverage gaps, Newcomb recruited another medical provider into the fold.
Dr. Jeff Ripperda, who practices in Murphysboro, took a shorter, eight-hour course on addiction treatment, but a lot of what he and Newcomb learned came from looking at their own prescribing habits.
Newcomb, for example, thought people were still on drugs when they had to take medication to stay opioid-free.
I wanted to try to do the best I could to prescribe and relieve suffering, and, at the same time, I wanted to be prudent about it.
Dr. Aaron Newcomb, Carbondale
“I felt like people weren’t really sober when they were taking it,” he said. One patient he spoke with had been stable for more than a decade with methadone, which is often used to treat for heroin addiction. It didn’t make sense to Newcomb that the patient’s success was due to taking one drug to break an addiction to another.
Ripperda was challenged to rethink his entire approach to painkillers.
“It took me objectively examining my own habits against the data, admitting that I was actually doing my patients a disservice with my previous practices, telling this to the patients when I announced a change in approach, and dealing with some backlash because of the change,” he said.
In 2005, prescribing 180 mg of morphine-equivalent opioids a day was not uncommon, Ripperda said. In fact, he, too, wrote a prescription for that amount for a woman who had arthritis and some surgeries, but she still felt awful. Previous doctors kept raising her dosage, expecting her pain to go down, but she became constipated and drowsy. She had been on such strong painkillers for so long that she suffered from opioid-induced hyperalgesia, a condition that ironically ratcheted up the pain she felt.
Looking back, Ripperda said he felt “embarrassed” by how much he’d prescribed, and he never gave anyone 180 mg of morphine-equivalent opioids again. The woman he treated has since moved away, and he sometimes wonders about how she’s doing and his responsibility for her health.
Other factors, they concluded, were more systemic.
The doctors’ medical school training presented them with a large obstacle. Both were in medical school as the reins were loosened on opioid prescribing.
“I remember distinctly being taught that chronic pain served no purpose and we should do whatever it takes to get patients out of pain,” Newcomb said. “I don’t recall ever having a lecture on (the) basic science of addiction, either in med(ical) school or residency.”
In the early 2000s, when he was doing coursework, doctors weren’t trained well to recognize addiction, Newcomb said, and even when it was obvious, addicted people were looked down on by the medical community as morally incompetent.
Ripperda said he felt “betrayed” by his education. Throughout medical school and his three-year residency, which he finished in 2007, doctors were taught to treat pain as a “fifth vital sign,” he said. Even though pain is subjective and can’t be observed, it was equal to body temperature, pulse rate, breathing rate and blood pressure.
“Boy, did we make a big mess with those ideas,” he said.
Meeting the community’s needs
Newcomb and Ripperda started treating for opioid addiction in 2011, but as soon as they started, federal regulations limited the number of patients they could treat.
Although the doctors got the mandatory training to treat for opioid addiction, the Drug Addiction Treatment Act, passed by Congress in 2000, had capped the number of patients they could see at 30, in part to limit the risk that patients would sell their medications.
As the opioid epidemic worsened, the Department of Health and Human Services reconsidered the cap, raising it from 30 to 100, and in August 2016, raised it again to 275. Doctors must wait a year before applying for the next level.
The cap is a conundrum of the opioid epidemic: Doctors must be trained to treat addiction, and their patient limits are capped, but there’s no special training outside of medical school or residency about the drugs that cause addiction, and doctors can treat as many patients as they want with the pills.
Lacking reliable data on how many people are addicted to opioids, Newcomb estimated there could be anywhere from 5,000 to 10,000 people who need medication-assisted treatment in the 16 southernmost counties.
Newcomb, who thinks the anti-opioid addiction medication buprenorphine should be more common, would like to see that change.
“We understand addiction like depression now … and buprenorphine is for opiate addiction like Prozac is to depression,” he said. “Until it is recognized that way, we will continue to have a paucity of use for the most effective treatment and the epidemic will continue to rage on.”
But, given the number of doctors who treat with buprenorphine, that seems unlikely to change.
As of late March, there were 22 doctors treating opioid addiction in the lower 16 counties, according to the federal Substance Abuse and Mental Health Services Administration, or SAMHSA, which implements the public health goals of the Department of Health and Human Services. However, those doctors have applied to treat only 1,990 patients, or about 90 per doctor.
By Newcomb’s assessment of people in need, that’s only 20 to 40 percent of the total demand, but the real number is even lower. Because at least one doctor retired, and others, including Newcomb and Ripperda, limit their practices so they aren’t overwhelmed, there are, at most, only 1,650 treatment spots.
“Not all prescribers will choose to treat the maximum 275 patients with opioid use disorders due to a number of practice-related factors,” SAMHSA said in an email.
It took me objectively examining my own habits against the data, admitting that I was actually doing my patients a disservice with my previous practices, telling this to the patients when I announced a change in approach, and dealing with some backlash because of the change.
Dr. Jeff Ripperda, Murphysboro
Newcomb estimated that about 50 to 60 percent of his patients “do fantastic” on buprenorphine products, including Suboxone and Subutex. About another 20 to 30 percent of people who take it are opioid-free, but they sometimes use other drugs. The remaining 10 percent of his patients are still “disintegrated with addiction” and are sometimes discontinued from treatment.
According to SAMHSA, buprenorphine can be taken indefinitely, and one study showed that more than 90 percent of patients treated for only six to 12 months relapse. For these reasons, Newcomb keeps patients on the drug unless they request to stop. About half of his patients are taking it long-term.
But the success of buprenorphine presents another conundrum in the opioid epidemic: As more people seek relief from addiction, they take up a limited number spots on doctors’ treatment lists, so fewer people may be able to receive treatment.
Opioid users can also find help at methadone clinics, which mainly treat for heroin use. Unlike doctors in private practice and at drug rehabilitation centers, methadone clinics are not subject to patient caps for buprenophine treatment. There are no methadone clinics in deep Southern Illinois, however. The closest ones are in Evansville, Indiana; Paducah, Kentucky; and Cape Girardeau, Missouri. None of these centers would say how many people from Illinois they treat.
There are two methadone clinics near St. Louis, Comprehensive Behavioral Health Center in East St. Louis and Centerstone in Alton, but they currently don't have any buprenorphine patients.
The Comprehensive Addiction and Recovery Act, signed into law in July 2016, now allows trained nurses and physician assistants to treat up to 30 people with buprenorphine.
Shawnee plans to expand its treatment capacity in Carbondale with two addiction-focused nurse practitioners, but that still may not be enough, according to Patsy Jensen, executive director of Shawnee Health Services where Newcomb and Ripperda work.
“Even with adding (mid-level practitioners), we still will not meet the community needs,” Jensen wrote in an email.
Hope on the horizon
Today, both doctors have a positive outlook on the future use of opioids.
Much of the medical community no longer recognizes pain as a fifth vital sign, and doctors’ old prescribing habits are starting to change, they said.
Lawsuits, too, are trying to reclaim how the medical community views the dangers of opioids by going after the pharmaceutical companies that some allege marketed these drugs too forcefully.
One such lawsuit, filed in April in St. Clair County on behalf of Illinoisans, alleges that drug companies, “through a sophisticated and highly deceptive and unfair marketing campaign that began in the late 1990s, deepened around 2006, and continues to the present, set out to, and did, reverse the popular and medical understanding of opioids.”
We now know for a fact that people are born with structural brains susceptible to developing addiction and that active disease literally changes the biochemistry and anatomy of the brain. It is a neurobiological disease, not just bad decision-making.
Dr. Aaron Newcomb
Despite their broad reactions to opioids, both Newcomb and Ripperda still consider them important tools in alleviating some types of pain. Both still prescribe them, but they limit themselves based on their research, some of which can be found in the CDC’s guidelines for prescribing opioids for chronic pain.
Ripperda has a strict 40 mg. morphine-equivalency dose limit per day, no matter the diagnosis. Newcomb tries to limit his patients to that, too, but some are on as much as 60 to 80 mg. And for end-of-life care, even higher doses of opioids is not controversial at all, he said.
Part of Ripperda’s change was assessing how his own actions compared to trends, something he thought not enough medical providers are doing.
“Physicians, nurse practitioners, and (physician assistants) are all generally not very good epidemiologists,” he said. “Advances in scientific data frequently require that we physicians admit that what we were doing before maybe wasn’t helpful or, worse, was possibly harmful. It’s hard to admit that.”
Still, Newcomb and Ripperda are hopeful about the future, and they think that the medical profession is more aware of pain-management education and addiction.
“We now know for a fact that people are born with structural brains susceptible to developing addiction and that active disease literally changes the biochemistry and anatomy of the brain,” Newcomb said. “It is a neurobiological disease, not just bad decision-making.”
Ripperda added: “I have the utmost faith that the next generation of physicians will be better at preventing, recognizing, and treating addiction than my generation is. Each generation of physicians has learned from the successes and failures of the generation before it. As long as medicine continues to attract bright, motivated people, this will always be the case.”
Prescriptions in the 16 southernmost counties
The southernmost 16 counties have had some of the highest levels of Schedule II opioid prescriptions in the state. In fact, 14 of the 16 counties ranked in the top 20 in terms of prescriptions per patient in 2016. Here are the numbers from that year:
Prescriptions per patient
Explaining the numbers
- The data this story used from the Illinois Prescription Monitoring Program is available for download.
- The BND’s findings treat hydrocodone as a Schedule II drug when it was reclassified from Schedule III only in late 2014.
- The Illinois PMP counts patients once for each type of prescription they fill, depending on a variety of information, including the drug, its strength, where the patient lives, and other things. For example, if someone filled one 5-mg. hydrocodone prescription and one 10-mg. hydrocodone prescription, that person would be counted as a patient twice. This means the number of total opioid patients may be lower overall, but that some average consumption trends per patient may be higher, including how many milligrams of morphine-equivalent opioids patients receive every year.
- Morphine equivalency, like other medical findings, is a debated subject. Although based on subjective responses to pain treatment, it is still an accepted way to measure relative drug strength. For example, morphine equivalency shows that 1 mg. of hydrocodone provides the same relief as 1 mg. of morphine, but 1 mg. of oxycodone, the second most popular opioid in Illinois, is akin to 1.5 mg. of morphine.
- People interact differently with opioids, depending on their body size, injury, opioid tolerance and other things. There is no average patient, and patients vary from year to year.
- Patients dropped to 2.3 million in 2016. Some suggest it’s due to heightened awareness of opioids among doctors, though DHS doesn’t know why.
- Another important consideration is whether patients are treated for acute pain or chronic pain. Some estimate there are far more acute-pain patients — those treated for shorter durations — than chronic-pain patients, but that chronic-pain patients consume the majority of the opioid supply. Illinois PMP data do not reflect these two groups, so it is impossible to say whether they were treated properly; however, there is no consensus on what defines them, or how they should be treated.