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Controlling the Source

When it comes to stemming the tide of opioid addiction, tightening rules around prescribing these powerful painkillers is an important part of the solution. In this, Vermont is also breaking new ground, much like the hub and spoke system is leading the way in treatment.

UVM Associate Dean for Primary Care Charles MacLean, M.D., has been a key proponent of evidence-based prescribing rules that meet the needs of patients while ensuring the supply of opioids is tightly controlled.

His state-level public policy work has informed prescribing rules for chronic pain that were instituted in 2015, and rules for acute pain that took effect in July of 2017. Although 23 states have some type of prescribing rules on the books, MacLean says Vermont’s are among the most comprehensive. They are consistent with the Centers for Disease Control guidelines and emphasize using alternatives to opioids when possible, using the lowest effective dose possible, and monitoring carefully for side effects or problems. They provide specific scenarios for when to check the Vermont Prescription Monitoring System, and when to reevaluate patients using opioids for chronic pain. Guidelines for prescribing according to pain severity level and common surgical procedures are suggested, and increasingly these recommendations are being integrated into electronic health record systems, making it easier for physicians to access information on best practices.

In addition to MacLean’s and other faculty’s work, medical students and alums have played key roles in fine tuning and evaluating the rules.

For their public health project, seven medical students in the Class of 2020 surveyed over 400 Vermont prescribers to assess their attitudes regarding the 2017 rules. Working with UVM’s Area Health Education Centers, the students found that although 75 percent of providers thought the new rules were necessary, and 74 percent thought they would have a positive effect on prescribing, only 48 percent were in favor of them as they were rolled out. This feedback — and more specific comments individual physicians provided — could lead to improvements as Vermont policy makers adjust what’s on the books, says Dan Wigmore ‘20.

It may also inform how other states introduce prescribing rules, as Vermont is one of the first states to implement such rules, and their group was one of the first to evaluate their effectiveness, says Zara Bowden ‘20. The group has submitted their poster for presentation at the 2018 American Public Health Association annual conference.

Another study — published online in February of 2018 in the Journal of the American College of Physicians with Larner College of Medicine alum Mayo Fujii, M.D.’ 13 as first author — stands to inform post-operative prescribing best practices. The research team tracked patients who had undergone surgery across multiple specialties at UVM Medical Center and were prescribed opioids for post-operative pain, checking in by phone a week after surgery to ask how much of their prescribed opioid medication they ended up using. After about seven months of follow-up, they found that the median opioid use after surgery was just 27 percent of the total prescribed. The authors suggest using data from studies like theirs to standardize post-op prescribing practices. A follow-up study is underway to see how the prescribing has changed since the rules went into effect.

Of all the opioids prescribed in Vermont, most are being prescribed in primary care settings for chronically painful conditions.

“How to best manage chronic pain — that’s where we need to go next,” says MacLean. “Chronic pain is so complex, and people’s experiences are so different.” To this end, the Office of Primary Care is offering education and support to primary care offices in Vermont using a case-based approach that was developed at the University of New Mexico, called Project ECHO. This virtual mentoring and information sharing network brings a multi-disciplinary team of experts to a cohort of primary care physicians around the state to help solve specific patient problems.

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