Tribe's Wellness Center responding to nationwide opioid crisis

By Danielle Frost

Beginning Tuesday, Jan. 2, many in Grand Ronde who use opioid medications to relieve pain will no longer be able to access them due to mandates from federal and state governments, as well as rising concerns over a nationwide “opioid epidemic.”

Earlier this year, the Oregon Health Plan, which many Tribal members use as their primary insurance provider, announced that it will no longer cover opioids for chronic back and spine conditions as of New Year’s Day.

“Prescribers must establish a tapering plan for patients currently prescribed opioids for these conditions,” the memo states.

The Grand Ronde Health & Wellness Center is working to align its practices as state and federal regulations are continually changing.

For example, the U.S. Drug Enforcement Administration published a notice in the Federal Register during the first week in November, stating that it would reduce the supply of many commonly prescribed schedule II opioid painkillers. These include oxycodone, hydrocodone, oxymorphone, hydromorphone, morphine, codeine and fentanyl, citing decreased demand for the medication.

“This reduction will result in changes of availability and cause shifting of brands to try and accommodate fills for patients,” Grand Ronde Pharmacy Director Leatha Lynch says. “I also see things like this causing increasing demands of other medications to help cover pain, which then causes those to go into a shortage as well.”

Given recent statistics from the Centers for Disease Control and Prevention, the crackdown on opioid use is no surprise. Since 1999, there have been more than 165,000 deaths from overdoses related to prescription opioids, which breaks down to 40 people per day.

Additionally, a national survey from 2014 indicated that 4.3 million Americans used prescription opioids recreationally in the last month.

However, although the amount of opioids prescribed and sold in the United States quadrupled since 1999, the overall amount of pain reported by Americans hasn’t changed.

The question on the minds of local doctors, clinic managers, pharmacists, addiction counselors and others is: Will cutting off the legal supply help curb the opioid crisis or will users turn to street drugs, such as heroin and synthetic opioids, to avoid painful medication withdrawals?

Just how far the pendulum has swung since OxyContin was first approved in late 1995 to how it has now become a focal point for opioid abuse issues was illustrated by Grand Ronde Medical Director Lance Loberg.

“A lot of problems originated due to treatments such as massage, physical therapy and acupuncture not being covered by the Oregon Health Plan,” he says. “Providers were pressured to prescribe opioids. Now, OHP is realizing it and approving other modalities. But now we have patients here who depend on these medications for back pain. Taking those away will be a big desatisfier … but there is a lot of research that shows the risks of opioids outweigh the benefits.”

The other issue that arises is that, over time, people build up a tolerance to opioids and larger doses must be taken to achieve the same effect.

“People end up being in more pain, and they think they need more medication,” Loberg says. “A lot of this was driven by big pharma.”

According to an Oct. 30, 2017, article in The New Yorker, after national studies showed inadequate treatment of chronic non-cancer pain by physicians, demands were made to address the issue. Seeing the trend for doctors to take pain more seriously, drug companies pitched products such as OxyContin, which was marketed as less addicting because its formulation allowed for dosing every 12 hours instead of four to six hours.

Tribal physician Dr. Marion Hull said that in the 1990s, the Oregon Medical Board required all Oregon physicians to take a class on pain management. At the time, there were some physicians who were sanctioned for not prescribing adequate amounts of narcotics.

“Notably, this coincided closely with the Oregon euthanasia legislation,” she says.

Now, the pendulum has swung in the opposite direction of very limited opioid prescriptions.

 “This is hard for us because our goal in life is to help people,” Hull says. “It is difficult when people come in and have an agenda about what they want to take when we know it may not be the best thing for them. It puts us in an adversarial position with our patients and we don’t like it.”

The Tribal Health & Wellness Center is working toward implementing new procedures, using treatments such as physical therapy, chiropractic, acupuncture and opioid alternatives like anti-inflammatories and nerve pain medications.

Health Services Executive Director Kelly Rowe says that the clinic’s policy changes are being driven by nationwide substance abuse issues, as well as recommendations from the CDC and Indian Health Service. Also, having a pharmacy director in place after the position was vacant for a few years has helped in the effort to streamline policies.

“We want to keep our patients safe and provide a healthy lifestyle,” Rowe says. “It’s just one of those things, as the rules get stricter and stricter, we need to help patients manage the best we can.”

After being hired as pharmacy director last year, Lynch joined the Tribe’s Controlled Substance Management Committee.

“Since the pharmacy is the one dispensing, I wanted to bring us into the conversation,” she says.

Lynch says that although the pharmacy had a pain agreement, it wasn’t used consistently with patients.

“That leaves a lot open for interpretation,” Lynch says. “As pain clinics are being closed down, people are scrambling trying to manage their pain. We decided to have something more streamlined. It is still in process.”

The group, which includes Health & Wellness Center employees, spent time during the past year comparing guidelines, policies and procedures at local, state and federal levels.

“With the changes to the Oregon Health Plan, it will impact how we process coordination of benefits,” Rowe says. “It’s a huge shift and there are other guidelines for CDC. We are constantly shifting and adjusting where they need to be. For our patients (on pain medication), their worst fears are that the pain is going to come back and get worse.”

The new rules put doctors in a tough spot, too.

“They are under scrutiny as well from the Oregon Health Board,” Lynch says.  

Loberg agrees. “I think sorting things out with OHP is going to be the big challenge,” he says. “Ultimately, it would be nice to offer acupuncture and physical therapy at the clinic, and other alternatives beyond just saying, ‘No.’ ”

Currently, massage and chiropractic services are offered onsite.

When opioids must be used, the CDC is recommending starting with the lowest possible dose, prescribing immediate release vs. extended release tablets and limiting acute pain prescriptions to three days or less since long-term opioid use often begins with short-term prescriptions.

“It is definitely going to be more difficult to get them for acute use,” Lynch says.

Rowe says that the restrictions may unwittingly make it more difficult for doctors to treat patients.

“With smaller amounts (of medication), prior authorization and having to show that you aren’t abusing it, everything slows down,” Rowe says. “It puts up roadblocks for people who don’t abuse their medication and the providers … but it is the climate we are in. We are still committed to helping people manage pain.”

Lynch says that the ultimate goal is to still provide pain relief, but without risking lives in the process.

“We have to go along with the regulatory bodies,” she says.

A ‘profit-driven, public health crisis’

At the time of OxyContin approval in 1995, the Food and Drug Administration believed the controlled-release formula would result in less abuse potential since the drug would be absorbed slowly.

However, the FDA’s labeling of the product unwittingly resulted in widespread abuse. It noted that crushing the controlled release capsule and using it could result in abuse and that injecting it could be lethal because the controlled release properties would no longer be effective, giving users a “high” all at once.

Purdue Pharma, manufacturer of OxyContin, was issued a warning letter from the FDA in January 2003 for misleading advertisements, among them ads that omitted and minimized the safety risks associated with the drug and promoted it for uses beyond severe pain.

In 2007, Purdue Pharma ultimately plead guilty in federal court of misbranding its product and agreed to pay $600 million in fines, one of the largest amounts ever paid at the time by a drug company. According to an Oct. 30, 2017, article in The New Yorker, the marketing was intentionally misleading, often presenting these drugs as safer and more effective than other painkillers.

Legal battles over OxyContin continue to this day. For example, earlier this year the Cherokee Nation filed a lawsuit against distributors and pharmacies in Tribal Court over the opioid epidemic. In January, the city of Everett, Wash., filed a lawsuit against Purdue Pharma, alleging that the company knew its product was being sold on the black market.

On Aug. 3, Multnomah County filed a $250 million lawsuit against several major U.S. pharmaceutical companies, including Purdue Pharma. The county alleges that drug companies spent vast sums of money “marketing, advertising, generating articles, holding continuing medical education courses, making sales visits to individual doctors, and supporting a network of professional societies and advocacy groups intended to create a new, yet false, consensus supporting the long-term use of opioids.”

Such efforts were “wildly successful,’’ the county asserts, making billions in profits, but also creating a “profit-driven public health crisis.’’

‘It took everything from me’

Tribal member Barry Larsen is a recovering addict and alcoholic. He takes tramadol to manage pain, but says it doesn’t cause problems for him.

“I take it as prescribed and don’t abuse it,” he says. “Alcohol is my drug of choice and has been a problem for the past 25 years, but not opioids.”

At one point, he was hooked on methamphetamine, but quit using it two years ago.

“It took everything from me,” Larsen says. “As long as there was dope around, everything was good. But when we were sitting there at Christmas with no tree, no presents and our power about to be shut off, that was enough.”

Today, he co-leads classes for recovering addicts in Grand Ronde, a far cry from where he was a few years ago. Although Larsen doesn’t struggle with opioid use, he knows of others who have, with devastating consequences. Opioids contain heroin, which is known as being one of the most difficult drugs to quit using due to extremely painful withdrawal symptoms.

“I believe what really started this whole thing was OxyContin,” Larsen says. “People were crushing it, snorting it and smoking it. The pills were like $30 each. When you get per capita, you can do that but eventually it becomes a problem. A heroin dealer comes rolling along, and gives them more for much cheaper, and pretty soon they’re addicted.”

Behavioral Health Alcohol/Drug Counselor Joe Martineau knows all too well about the devastating effects of substance abuse.

“Today, it seems as if we treat every problem with a drug,” he says. “This is a problem nationally and on this Reservation. It’s at a point today where a higher percentage than ever are using prescription medications. It is important to educate the Tribe about what prescription drug abuse is and what the symptoms are.”

Some of those symptoms include constipation, nausea, feeling high, drowsiness, confusion, poor coordination and increased pain with higher doses.

“We need to come together as a community to help our people be in less danger,” Martineau says. “If you’re in a situation where you are dependent on medications, and your doctor is prescribing less, then you may go to illegal sources and get the synthetic version.”

Synthetic opiates, often made in clandestine labs, have been responsible for an increasing number of overdoses because the drugs are often “cut” with other unknown and potentially fatal substances.

According to overdose records from 24 major cities reviewed by The Washington Post, synthetic fentanyl, a drug 100 times more powerful than morphine, rose from 582 fatal overdoses in 2014 to 3,946 last year. Officials estimate a much higher number of fatal overdoses this year, especially as the noose tightens around prescription drug availability.

The overdose stories hit Martineau close to home.

“My younger brother became super addicted to opiates,” he says. “This summer, he tried fentanyl for the first time and he died. I’ve lost three nieces, three nephews and three brothers to drugs. My connection is family … People are dying.”