Like the rest of the country, Montana is struggling with an epidemic of abuse of opioid drugs, both prescription painkillers and illegal narcotics like heroin and fentanyl. At the end of this week, physicians and other health care providers and counselors are getting together in Missoula to learn about potential solutions.
The federally-funded Montana Pain Conference happens Thursday and Friday at the University of Montana. MTPR's Eric Whitney talks to a conference organizer, Dr. Mark Mentel, about the scope of Montana's opioid problem and how people in medicine here are trying to respond.
Mark Mentel: At the turn of the century our rate of prescription for opioid medications went up four fold. So currently we are prescribing four times the amount of opioids that we've prescribed in the early '90s. So the answer came for treating non-cancer pain with opioids, but we really need to back it off and find ways that we can treat patients who suffer from chronic non-cancer pain with other modalities and multi modalities.
Eric Whitney: Does Montana have a problem with over prescription of opioids?
MM: Just like anywhere else in the country. Our problem with the opioid crisis and the number of prescriptions we write is no different than anywhere else in the country.
EW: What are are the consequences of over prescription of opioids, specifically in Montana?
MM: What you've seen is basically a four fold increase in the number of deaths have been related to opioid overdoses, whether they were accidental or purposeful.
And there has been a large diversion of medicines as well, with people selling their medications to other individuals to abuse or misuse. So there's a big push to prescribe appropriately, try to manage chronic non cancer pain with alternative methods, trying to keep the doses as low as possible so we don't harm the public in which we've been entrusted to treat.
EW: The audience for the conference; is it a question of the medical leadership in the state saying we really need to get this information out, or is it health care professionals coming to leadership saying please help us with this problem?
MM: Both. There's a lot of us that are working in the state trying to get the information out and there's a lot of desire in the state. We've never been trained in how to deal with chronic non-cancer pain. I was never taught how to manage chronic non-cancer pain nor was I taught how to deal with the possibilities or the side effects of treating that, and that is opioid use disorder or substance use disorders related to opioids. And so I've actually had to go out and search for that training myself. And that's what this conference hopes to accomplish.
EW: The people who are going to be presenting at the conference, these are people who've figured out how to deal with chronic pain without over prescribing. And it's well-established that this is the way you deal with chronic pain if you're not going to use opioids to excess?
MM: These are leaders in their individual field, whether it be learning interviewing techniques, whether it's learning mindfulness techniques of learning to use your own body's powers to heal itself, to new medical interventions, to everything. We're trying to bring everyone up to speed as fast as possible right now with the most current information.
EW: What are some of those solutions, then? And what's the likelihood that they can be implemented here? Or do they rely on solutions and providers that are just not available in a rural state like Montana?
EW: These are all things that should be available to here in the state. Chronic non-cancer pain — it should be kind of thought of very similar to a chronic disease state much like diabetes. Yes there's a lot of good medicines out there, but really it comes down to the patient learning how to manage their own protocols, learning how to interact with their own disease and not let their disease interfere with their ability to live a full life.
It can be anything from physical therapy, to manipulation, to healthy diet healthy living, to exercise, to a lot of easy prescriptions we can do here in the state.
EW: It's going to be easy?
MM: Not easy, but these are simple solutions that people have access to. So I should say easy access to these things.
EW: If someone has an issue with opioid dependency are they going to be able to get access to alternate modalities to help them deal with that?
MM: There's not enough pain management specialists in the country to manage all the people who are in chronic pain. Really, this is something that primary care such as family doctors, nurse practitioners, physicians assistants, internal medicine specialist, those that are dealing in the front lines of medicine can manage most of this with some simple tools and some simple techniques and not have to refer as much off to chronic pain specialists. We are lacking, though, people that are able to deal with addiction medicine. There's not enough providers here in the state, so there might be some barriers to that. But, part of the conferences actually training people on how they could treat a substance use disorder.
EW: Is it a bigger challenge for physicians to change the way they practice or to get patients to try alternatives to the opioids that medicine has been giving us for decades now?
MM: It's going to be a slow move in both realms. There needs to be a push toward our prescribing patterns. But the same point in time there needs to be a push toward patient expectations. Again, there's no cure for chronic non-cancer pain. We have individuals that we tend to think of as those patients who have been on opioid medications for a long time. Our likelihood of moving them off opioids is probably not realistic. Getting them off opioids may actually cause more harm to them than good. Working toward a safer dosing and maybe working toward safer lifestyle choices such as making sure they have emergency medicines to counteract should they accidentally overdose would be readily available for them. We need to make sure those things are set up. There's also a mix of patient populations that also may have a combination of an opioid use disorder, have problems with addiction with it, but also suffer from chronic pain. And how do you manage that?
EW: What do you see as a bigger challenge for Montana: changing practices to have more reasonable rates of opioid prescription, or finding treatment for people with opioid use disorder?
MM: The thing that concerns me most and concerns a lot of us, if you look at some of the CDC data, we're actually making a move toward prescribing less, but as we decrease the number of opioids prescribed there's still a market demand for that out on the streets. And what we've seen taken that place is heroin and synthetic fentanyl, and those have actually increased the number of people who are dying from the opioid abuse epidemic here in the country. And so my thought is that really the big problem we have right now is moving people from a safer platform from what they are on right now to something — cutting them off might actually cause more harm because they still now have to go through withdrawal, they may still have problems with desiring this medicine, and so they might seek it out in the streets and move to heroin and other synthetics which may actually cause more harm than good. So we need to move people slowly. I'm thinking it needs to be a slow process. We just can't yank the rug out from underneath these patients.
EW: It sounds like there's evidence nationwide, and at least some evidence in Montana that the rate of opioid prescriptions is decreasing. So it sounds like we're making progress on over prescription of opioids. Is there evidence that Montana is making progress in increasing the number of people getting treatment for opiate addiction?
MM: That's hopefully part of the goal of some of this conference coming up. On the second day, the last half of the day is going to be spent on hopefully inspiring individuals out there, individual providers, how to take care or manage those people who have a substance use disorder with opioids learn more and understand a little bit more how that looks and how that feels in a practice, and so giving them the tools for that.
That is one area in the state that we're lacking, however we are making some moves and the numbers are increasing, and those people that can prescribe medication such as buprenorphine or combination medicine called Suboxone for opioid use order. And there's really good evidence that that medicine can actually help save lives and get people back to a normal lifestyle.
EW: Given the lack of specialists in Montana and particularly in behavioral health care and substance abuse treatment, is it plausible to think that primary care doctors in this state are going to be able to successfully treat people with opioid addictions or are they always going to need to refer those out to specialists or to treatment clinics?
MM: The goal for when this whole program — it's called the Data 2000 Waiver. It's a eight hour training course that came about in the year 2000 and it was set up so primary care could actually do this from an office based management. Primary care, those people in the front lines know their patients the best, and they're the ones that can give the best care that's pertinent to that individual as opposed to referring it out. And more people are comfortable seeing their own doctor, talking about this problem, than being referred to someone just for that lone individual problem that they're having. So it was designed for that.
EW: Dr. Mark Mentel, thanks for joining us on Montana Public Radio.
MM: Thank you. Appreciate it.
