The opioid crisis continues, here and nationwide
By Marcia Frellick, WSMA Reports contributor
A 30-year-old patient named Troy had lifelong
pain from a congenital hip malformation, only
partially relieved by a hip replacement.
Like a growing number of chronic-pain patients, he
had been self-medicating with heroin, then landed in
a Washington hospital with a septic embolus to the
prosthetic hip. There, a hospitalist provided partial
relief with buprenorphine, prescribed for his opioid use
disorder. Troy also received addiction counseling and
help developing an employment plan.
However, he failed to follow up in clinic, reverted to using
heroin and eventually ended up in prison.
Stories like Troy’s don’t have to end that way, says Lucina
Grande, MD. Dr. Grande is a primary care physician at
Pioneer Family Practice in Lacey, Washington, and about a
third of her patients come to the clinic for help with chronic
pain or addictions. She often prescribes buprenorphine.
Best known by the brand name Suboxone, buprenorphine
is a powerful pain medicine and a safe version among
opioids. It blocks neural receptors that lead to respiratory depression and overdose death. It also blocks euphoria
and craving for opioids, so it effectively treats addiction.
“Buprenorphine frequently transforms lives and sometimes
saves them,” she says. “It is thrilling for me to
watch people go through this transformation and provide
support as they rebuild their lives.”
Dr. Grande offers an alternative to the scenario above:
The hospitalist offers Troy a six-month buprenorphine
implant, approved in May by the U.S. Food and Drug
Administration, prior to discharge. The steady drug level
keeps him comfortable and helps him hold a job. “His
heroin use, though not eliminated, is markedly reduced, along with his risk of incarceration, hospital readmission
and overdose death,” Dr. Grande says.
This is just one of the stories that could have been different
if physicians in all specialties knew more about pain management
options and listened more intently and with
more compassion to signs that a patient may be struggling
with an opioid addiction, she said.
Fatal overdoses have quadrupled
The numbers struggling with addiction nationally are
multiplying. In March of this year, amid growing concerns
about a nationwide epidemic of painkiller addiction, the
Centers for Disease Control and Prevention issued new guidelines for physicians on use of drugs like OxyContin
Fatal overdoses from prescription opioids nationwide have
quadrupled since 1999, according to the CDC. In the latest
year available, 2013-14, rates of poisoning deaths increased
14 percent, from 7.9 per 100,000 to 9 per 100,000.
Washington state has been a leader in fighting opioid addiction,
and new data from the state Department of Health
show a significant drop in deaths from prescription narcotics,
from 512 deaths in 2008 to 319 in 2014.
The WSMA has been partnering with others who are committed
to attacking the problem—the governor’s office,
members of the legislature, the Department of Health,
many major health systems, the Washington State Hospital
Association, the poison control center and others—and together,
the efforts continue to make Washington a national
example of what is working.
The WSMA continues to support the ER is for Emergencies
program, which it launched in 2012, a program
through which patients struggling with addiction or pain
management problems may be identified.
The WSMA also strongly supports the state’s prescription
drug monitoring program and encourages health care providers
to use the program’s database to check a patient’s
medical history for signs of potential opioid abuse.
Tools to treat addiction
The buprenorphine implant (called Probuphine)
that Dr. Grande mentioned is one of the newest tools in
treating opioid addiction. “Very few people know it exists,” she says. “Even for people who treat addiction, it’s been
under the radar.”
She acknowledges it is costly. It was approved by the FDA
for people already stable on the sublingual form of buprenorphine.
However, it is expensive relative to the sublingual
form ($5,000 for six months) and only makes sense
for patients who would like protection from opioid craving
but are at risk of inconsistent use or diversion if they were
prescribed buprenorphine in individual doses, she says.
“The best candidates, I think, are people in a controlled
situation—such as those hospitalized, incarcerated or in
inpatient addiction treatment programs. They can initiate
treatment on the sublingual formulation and then be offered
the implant prior to discharge or release.”
Another change with great potential impact is for obstetricians
to start prescribing buprenorphine for their patients
with addictions, she says. They have a longitudinal relationship
with patients, which is ideal for managing addiction,
but currently, most physicians are referring their patients
to outside sources and the patients aren’t following up.
Among the reasons physicians say they don’t want to
prescribe buprenorphine is that it requires a waiver from
the Drug Enforcement Agency, which entails a minimum
eight hours of training (application for the waiver is available from the SAMHSA website). So far, only about 3 percent of
primary care physicians have applied for the waiver. Some
physicians who don’t want to treat opioid addictions have
also said they don’t want to add patients they consider
To the first, she says, the minimum eight hours of training
can be accomplished on one weekend day. To the second,
she says, “These people are already your patients. It’s just
taking care of the ones you have with this problem.”
Pain centers close; demand surges
The problem in Washington is exacerbated by the closing
of eight Seattle Pain Centers, which served about 25,000
patients. In July, Seattle physician Frank D. Li, medical
director of the centers, was barred from practicing medicine
and billing Medicaid after the state Medical Quality
Assurance Commission charged that he failed to properly
monitor prescription use of opiates.
Jeb Shepard, associate director of health policy and regulatory
affairs at the WSMA said, “Eight thousand of those
patients were actively being treated for chronic pain or
other pain with opioids. They had the rug pulled out from
They began to show up in primary care clinics for prescriptions,
and primary care physicians were finding they didn’t
have the resources or education to treat such complex
patients, Shepard said.
The larger systems—University of Washington Medical
Center, Virginia Mason and Swedish—were so inundated that
they were turning people away. “These very large, very well resourced
systems still can’t handle the number of patients
coming from the fallout of the Seattle Pain Centers,” he said.
Shepard said in light of these developments and the worsening
crisis, WSMA’s legislative efforts in 2017 will have a
strong emphasis on addressing the opioid epidemic. Gov.
Jay Inslee worked with the WSMA and WSHA and issued
an executive order in October that outlined
strategies for fighting the problem.
“This is a chance to change the momentum from opioids
toward non-pharmacological treatments or other drugs such
as buprenorphine or non-opioid alternatives,” Shepard said.
Ray C. Hsiao, MD, WSMA immediate past president and
a child psychiatrist and addiction specialist at Seattle
Children’s, said in a statement: “The governor’s executive
order provides a path forward that brings together state
agencies, health provider organizations, law enforcement
and other partners in a coordinated and unprecedented
effort to combat the opioid crisis in this state.”