BY ALEX ACQUISTO
Lexington Herald Leader | NOVEMBER 08, 2019 09:45 AM
On a recent Saturday night in the emergency room at St. Claire Hospital in Morehead, Dr. Philip Overall faced a familiar dilemma.
It was just after 10:30 p.m., and a woman in her 50s with a spate of chronic illnesses had just arrived with debilitating abdominal pain.
Overall pulled open the curtain to the patient’s temporary room to find her sitting hunched on her bed, clutching her left side through her hospital gown. The sharpness of her pain, which had throbbed for several hours, kept her from lying down or breathing normally, and she had started to sweat, she told Overall, “‘cuz I’m hurting so bad.”
The 36-year-old ER medical director asked her to lay back, and she winced and her limbs twitched as he gently pressed on her abdomen — the first of several routine tests and scans that would be conducted to determine the root of her pain. Other than a slightly elevated heart rate, her vitals were normal.
Her list of ailments is extensive, as is her daily list of prescriptions: epilepsy, Hepatitis C, high blood pressure, diabetes, heart attack survivor, and at least one medication to manage each. She tells Overall she’s undergone past surgeries to remove her appendix and gallbladder, and had multiple Caesarean sections for her children.
She also has a history of opioid abuse, though her last drug screening was clean, Overall sees a few minutes later as he’s combing through her medical records on his computer. Complicating matters, she said she’s allergic to Ibuprofen, Tylenol, and a handful of low-grade opioids, including morphine.
This means if Overall wants to treat her pain immediately, one of his only choices is Dilaudid — a highly addictive opioid typically reserved for cancer patients.
Giving her this drug would likely knock her pain out completely, but it also risks inflaming her addiction. Even if she hadn’t been in recovery, prescribing such a strong opioid always carries with it the risk of future abuse, Overall said.
But opting not to treat her pain with traditional promptness meant she would continue to sit in anguish at least until her labs returned and he could better understand why she was hurting, or until she was admitted to the hospital.
“She may be in pain, but am I going to throw Dilaudid at her for something that I don’t even know what it is, when she’s got a history of opioid abuse?” Overall wondered aloud. “Is this medicine really necessary? Right now, I don’t think it is,” he decided.
In other words, does providing relief with opioids outweigh the known risk of exposure? It’s a question doctors in hospitals across Kentucky are asking themselves, in some cases for the first time, as part of a new statewide initiative to combat the deadly addiction crisis by uniformly slashing opioid prescription rates.
A few years ago, Overall said he would’ve treated her pain “reflexively,” without a second thought. “Now, I withhold those narcotics unless I deem them immediately appropriate.”
This cautious stewarding of prescription opioids has been a common practice among several doctors at the Eastern Kentucky hospital since 2016, when the state’s fatal overdose rate was at its peak.
In Overall’s ER, where acute pain is the most common reason patients visit, the internal shift meant no longer using opioids as a “first line therapy for pain control,” he said, reading from his department policy.
Instead, staff are urged to “maximize” alternatives, like ice, heat, and over-the-counter painkillers such as acetaminophen, Ibuprofen, muscle relaxers, and other non-steroidal anti-inflammatory drugs (NSAIDs). “Strongly discourage” treating more comparably minor ailments with opioids, the policy directs, including headaches, simple sprains, contusions, fibromyalgia, osteoarthritis, and, in the case of Overall’s female patient, “non-specific abdominal pain.”
If opioids are necessary, “prescribe the lowest effective dose and quantity,” or a dose that lasts no longer than three days. In those cases, each patient must first be searched in the eKASPER system — a statewide controlled prescription monitoring database. It gives a provider details of a patient’s history, including the type and frequency of past prescriptions. Refills aren’t allowed.
In Overall’s ER, where about 30,000 patients visit each year, upwards of 14 percent of those discharged in 2016 left with opioids, according to hospital data. The national rate around that time was closer to 17 percent, according to a study from the American College of Emergency Physicians.
Statewide in 2017, Kentucky providers prescribed 87 opioids for every 100 people — the seventh highest rate in the country, according to the Centers for Disease Control and Prevention. That same year, the Kentucky General Assembly passed House Bill 333, which placed a three-day limit on opioid prescriptions for acute pain.
Overall’s policies went even further, making opioids a last resort in nearly all circumstances. In 2017, a year after changes were instituted, the rate of patients leaving his ER with an opioid dropped by more than two thirds, to under 4 percent, where it has hovered since. Of the 2,413 patients who visited the ER in July, only 82 — about 3 percent — left with a prescription.
Now, roughly a decade after Kentucky was first choked by a devastating opioid abuse epidemic that roiled the nation and stacked death tolls higher than the Vietnam War, positive results like St. Claire’s are motivating a small cohort of UK HealthCare doctors to achieve something historic: slash high-risk prescription opioid rates at virtually all of Kentucky’s 125 hospitals by at least half.