An uphill battle

Last week, the term “opioid crisis” received national attention when President Trump declared the proliferation, abuse and deadliness of narcotic painkillers a public health emergency. He cited 64,000 deaths last year from overdoses—175 Americans a day—and directed federal agencies to combat the problem (though the funding available was just $57,000).

California has been addressing the epidemic for several years through a multi-pronged approach called the Prescription Drug Overdose Prevention Initiative, in which Butte County has played a notable role (see infobox). Dr. Mark Lundberg left his job as county public health officer last fall to provide medically assisted treatment for drug addiction through Butte County Behavioral Health; his successor, Dr. Andy Miller, has championed community prescribing guidelines: a set of recommendations for dispensing opiates, established by local clinicians.

As Miller tells the community groups whose endorsement he’s seeking—including the Chico City Council at the Oct. 17 meeting—Butte County has nearly three times more prescription opioids in circulation than the national average. This statistic comes from the U.S. Centers for Disease Control and Prevention, which maps every county nationwide.

Rural counties across Northern California are similarly afflicted. In fact, the CDC’s opioid map shows the same pattern nationwide, with the highest averages in rural areas versus metropolitan.

The CDC and other health professionals measure opioids in a unit known as MME, morphine milligram equivalent, allowing comparison of different-strength narcotics.

Butte County’s average is 1,880 MME prescribed per resident annually; the national average is 640. To put the numbers in perspective, Miller said a 200mg dose would be lethal. Since not every person in the county takes an opioid—such as Vicodin, Percocet and Fentanyl—“obviously with an average like that, there are some who are prescribed significantly more.”

The community prescribing guidelines comprise a general framework plus specific protocols for primary care physicians and emergency room doctors. (Pain management specialists, who participated in the development process, could not reach consensus for their own subset.)

Their overarching aim: get Butte County’s MME prescriptions down to the national average. Miller said there is no preset time frame for reaching that mark but that it’s important to “draw a line in the sand and say, ‘This is where we’d like to get.’…

“The goal is pretty aggressive, but you’re talking about getting down to our national average—we already have a national crisis. So, even if we get to our goal, it does not mean that our problem has gone away.”

Lundberg told the CN&R that he supports the effort. So, too, did Dr. Brandan Stark, a family practice physician in Chico who’s also an addiction medicine specialist. What Lundberg offers to publicly insured patients at Behavioral Health, Stark provides to privately insured patients at Argyll Medical Group.

“We’ve got a huge problem with these medications and we have to do something,” Stark said. “Starting with some basic guidelines is a great idea.”

Miller stresses that the prescribing guidelines represent a collective effort, incorporating the input of three dozen clinicians; however, he’s marked this project as a personal priority for himself as public health officer.

He’s seen prescribing guidelines in action at Northern Valley Indian Health, where he worked as medical director before taking the county job. He’s also heard frustration at state-level health conferences where colleagues would tout opioid-treatment approaches, such as the work done by Lundberg, but have little more than laments to offer when it comes to addressing excessive prescribing.

“I think that they’ve kind of developed a learned helplessness there,” he said. “I was in clinical medicine recently enough that I haven’t yet given up on that.”

Miller initially met with 20 clinicians in primary care, emergency medicine and pain management from the county’s four hospitals. He refined the guidelines in subsequent meetings with a handful of clinicians from each group. He’s hoping the medical staff of each hospital will give its seal of approval to the guidelines, though he knows such policy decisions require consideration—thus, time.

Meanwhile, Miller has spoken to a dozen community organizations and government entities. Chico Sunrise Rotary already has endorsed the proposal, he said; the City Clerk’s Office said the City Council will decide whether to give an endorsement at a future meeting, date undetermined.

Why have people with no medical training weigh in on a medical matter?

“Doctors, without really good guidelines and without guidance from other parts of our society, have been in part responsible for getting us where we are,” Miller said. “Physicians are like anyone else: Even doing their best, they can find themselves in a difficult place.

“They need permission from the community, and from their community of professionals, to do the right thing and change their behavior.”

Lundberg agreed, calling Miller’s wide outreach “a brilliant idea.” He cited another consequence: changing patients’ expectations. He compared opioid guidelines to a recent emphasis on reducing the use of antibiotics in the face of drug-resistant strains.

“The community can help create the expectation that you got good care even though you didn’t get a Norco … or a Percocet … or a[nother] narcotic,” Lundberg continued. “You got good care because that doctor tried to give you newer and better treatments.”

In rural areas, though, the range of treatments tends to be more limited than in cities. That is one possible explanation for the higher rate of opioid prescriptions.

“When you’re out in the wilds, people can’t go get expert care … so family doctors or whoever’s out there do the best they can to try and help their patients,” Stark said. “We’ve been trained to decrease pain, so we give pain medicine if that’s all we have.”

Miller emphasized that opioids are not inherently bad medicine; they have a place in health care as a short-term pain reliever. The problem—supported by the CDC and other research—is long-term use. Opioids are not proven to offer significant benefit with extended use, he said, while producing negative effects such as addiction.

Because the drugs are addicting, Lundberg and Stark hope patients currently taking opioids prescribed by their physician won’t be left in the lurch. Treatment facilities and pro-fessionals already face high demand.

“That is the dark side of these guidelines,” Stark said. “I’m all for decreasing narcotic prescribing, but there’s already a whole population of people out there either addicted or dependent.

“You kick all these people off their medicines, what are they going to do? They’re going to score on the streets. They’re not going to get sick; they’re not going to go without.”