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.