Calif. county implements new opioid prescription guidelines

Alternative pain management therapies are included that clinicians can utilize in place of opioids

By Christi Warren
The Press Democrat

SONOMA COUNTY, Calif. — After more than a year, Sonoma County health care providers finally have a set of standardized opioid prescription guidelines that experts hope will allow doctors to better manage patients’ pain, while curbing the spread of opioid addiction.

The guidelines were created by a coalition of county health care providers under the mantle of the Committee for Healthcare Improvement, which met about eight times during the past year to prepare and finalize the guidelines, said Karen Milman, the county’s health officer.

Sonoma County is “early” in its implementation of such guidelines, Milman said, the second on the North Coast to do so after Marin County in fall 2015.

Napa County is close to finalizing its guidelines and Lake and Mendocino counties have begun the process, she said.

The guidelines — one set for emergency departments and one for primary care providers — provide strategies for safe prescribing practices, including patient screenings, monitoring and reassessment throughout course of care, treatment agreements and tools for identifying patients with substance-use disorders.

The county also created a toolkit for the guidelines with helpful links, step-by-step guides for screenings and sample letters for patients that explain the new opioid guidelines.

The origins of the county’s guidelines began in the second half of 2015.

A November 2015 report titled “Unintentional Drug Poisoning in Sonoma County: A Focus on Prescription Opioids” was released by the planning and evaluation division of the county’s Department of Health Services.

It was followed by a January 2016 update that distilled the county’s problem in stark numbers.

The reports showed that in 2014, the most recent data available for the county, 25 percent of Sonoma County residents — 126,000 — had an opioid prescription.

Of those, a quarter had four or more opioid prescriptions, and 5 percent of those had prescriptions from four or more prescribers.

The report found 524 people in the county identified specifically as “doctor shoppers,” patients who obtained opioid prescriptions from four or more prescribers and four or more pharmacies.

The number of emergency room visits for accidental opioid overdose increased by 73 percent from 2009-2011 to 2012-2014, from 10 to 17.3 per 100,000 people — 61 percent higher than the statewide rate.

“The key point is that our healthcare providers were concerned enough about this issue that they all came together to address the standard of care, to address the problem from its start,” Milman said.

“What this is doing is really helping doctors in looking at when a patient comes to me and is new and in pain, (asking) how am I managing it, what are the best practices and when is it time to say this hasn’t worked and I want to switch to something else.”

Alternative pain management therapies — mindfulness, acupuncture, yoga and chiropractic care — are included that clinicians can utilize in place of opioids, noted Supervisor Shirlee Zane, who has long been involved in the effort to create such guidelines.

“Opioids shouldn’t be the only method (for addressing pain),” she said. “Let’s face it, doctors have overprescribed opioids because it’s cheaper to give someone a pill than three months of acupuncture.”

The overprescription of pain medications and physicians’ reliance on a “magic pill” for pain management stems from what was characterized as an undertreatment of pain in the 1990s, and a push for an increased focus on pain reduction.

In response to that, pharmaceutical companies started formulating and marketing prescription opioids that doctors immediately flocked to, including extended release forms of morphine, oxycodone and fentanyl, which are today among the most frequently abused prescription medications on the market.

“Physicians and clinicians were wanting to help their patients manage their pain, and they were also experiencing a lot of external pressure to make sure they were managing pain,” Milman said.

“One of the tools easily available, and promoted largely by the pharmaceutical companies, was opioid medication ... This is really a nationwide challenge.”

Copyright 2017 The Press Democrat
All Rights Reserved

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