The Rise of an Epidemic
To see how America – and our region – fell prey to opioid misuse and abuse, we have to rewind the tape 40 years.
In the 1980s, several influential medical journals published articles saying that, based on the research at the time, short-term opioid use wasn't addictive.
Opioids include illegal drugs like heroin and legal drugs like morphine and fentanyl.
Then, in the 1990s, in response to patient and physician concerns about pain management, The Joint Commission (an organization that accredits and certifies health care organizations) established pain as a fifth vital sign. They started grading – and funding – hospitals and medical centers on how well they treated patients' pain.
So when drug companies responded by making more opioid-based drugs available, they became most physicians' drug of choice for pain treatment. Over the next two decades, this led to widespread misuse of the drugs. And as the misuse and abuse spread, the medical community began to realize that those early articles were misguided, and that opioids are highly addictive – even in the short term.
Standardizing Pain Management in the Midst of a Crisis
That leads us to today, with a national crisis on our hands. Even though there are some national standards for opioids, there is no unified national standard for health care organizations. That leaves states, regions and medical providers to create their own procedures. This approach has some benefits. It allows medical organizations to target their standards to their own patient population. It gives them new, customized tools to fight pain. And it helps patients by treating their pain while reducing the chance that they might misuse or become addicted to opioids.
Chief Medical Officer, Jerry Epps, MD; Chief Nursing Officer, Janell Cecil, MSN; and Nursing Manager, Jessica Flanary, BSN (left to right) were instrumental in creating a plan to standardize medical care for IV drug users. Hospitals and medical centers around the state, including Vanderbilt, are now creating programs modeled after the one used by The University of Tennessee Medical Center.
The University of Tennessee Medical Center created a multi-level approach to fighting the crisis. This approach:
Changes the way pain is measured. Rather than relying on patients to rate pain on a 1-10 scale, the new standard identifies the pain’s cause, allowing physicians to more accurately diagnose and treat the pain.
Expands the pain-management pathway. This objective approach, or pathway, is followed by all medical center physicians and caregivers when treating pain. It ensures patients get consistent, objective treatment, and it creates clear lines of communication between patients and their caregivers.
Helps caregivers objectively evaluate their patients’ pain. If regular pain management therapies aren’t working, there may be an underlying complication that is causing the pain. This “three strikes” approach allows nurses to try prescribed drug therapy three times before letting the physician know that the patient isn’t responding as expected. Then treatment can be altered, if needed.
Limits the amount of opioids that can be prescribed. Opioids come in a variety of forms, from hydrocodone to morphine, which has made it difficult for physicians to accurately track patient dosages. Now, an apples-to-apples measurement allows dosages to be tracked via a state database. Physicians and pharmacists now know if a patient goes over the recommended daily limit of opioid drugs. In addition, the new TN Together Opioid Bill, one of the strictest in the nation, reasonably limits how much of this medication physicians can prescribe.
Standardizes management of IV drug users. People who use IV drugs are often hospitalized for infections related to their drug use. This medical center program, established in 2017, maximizes safety for opioid-addicted patients who are undergoing treatment for infections due to their drug use. Since its inception, other medical centers and hospitals in the region, including Vanderbilt, have established similar programs.
Gets unused medications off the street. According to Epps, more than half of opioid addictions start because a friend or family member shares unused prescription drugs. One way to limit this is to properly dispose of unused drugs. The medical center provides a public drop-off for unused medications of all types (including supplements) at University Pharmacy, located in the main lobby across from the Garden View Eatery.
Gives physicians alternatives to opioids. Combating the opioid crisis means giving physicians other ways to treat pain. Two physicians at the medical center are leading the charge. Stephanie Vanterpool, MD, MBA, is the Director of Comprehensive Pain Services and an Assistant Professor in the Department of Anesthesiology, at the University of Tennessee Graduate School of Medicine (UTGSM). Vanterpool works alongside Jason Buehler, MD, Assistant Professor in the Department of Anesthesiology and Division of Pain Medicine. Together they help provide options like ketamine or nitrous oxide for patients who suffer from both acute and chronic pain.
Stephanie Vanterpool, MD, MBA, and Jason Buehler, MD, discuss opioid alternatives being used by the medical center.
TN Together Opioid Bill
In July 2018, Tennessee enacted one of the strictest opioid laws in the nation, the TN Together Opioid Bill. TN Together is a multi-faceted plan, made up of legislation, more than $30 million in funds, and other executive actions aimed at attacking the state’s opioid epidemic. It does this through prevention, treatment and law enforcement.
Stephanie Vanterpool, MD, MBA, attended the announcement of the TN Together Opioid Bill alongside legislators and her fellow members on the Tennessee Commission on Pain and Addiction Medicine Education.
In conjunction with the bill, Tennessee Governor Bill Haslam established the Tennessee Commission on Pain and Addiction Medicine Education. The commission is comprised of 19 members, which represent the state’s public and private medical educational institutions, the Tennessee Department of Health, a broad group of professional associations and licensed health care practitioners.
Medical center physician Stephanie Vanterpool, MD, MBA, was appointed to the commission, which has been charged with developing core knowledge and skills to be adopted by all higher learning health care institutions in the state. These guidelines are to assist in greater understanding, assessment, diagnosis and treatment of pain and addiction.
Better Treatment Options for Drug-Addicted Moms and Babies
One population that’s particularly affected by opioid abuse is pregnant moms. In Tennessee, about 1,000 babies are born with Neonatal Abstinence Syndrome (NAS) every year. And last year, about 18 percent of babies born at the medical center had NAS.
The nationwide cost for treating one NAS newborn is approximately $60,000, which means Tennessee pays about $60 million per year in treatment for them. Helping moms detox during pregnancy could drop the number of NAS babies by 50 percent. That would save the state $30 million per year in funding.
That’s according to Craig Towers, MD, UTGSM professor and maternal-fetal medicine specialist with High Risk Obstetrical Consultants. Since 2013, Towers has led an observational research study at the medical center to evaluate whether detoxifying the mother during pregnancy would lower the incidence of NAS without putting the fetus at risk.
Craig Towers, MD, UTGSM professor and maternal-fetal medicine specialist with High Risk Obstetrical Consultants
The study, which combined drug detox with an intense behavioral therapy program, found that, not only can mothers detox safely during pregnancy, their babies are born without NAS.
“Most physicians have been taught that detoxing while pregnant hurts the baby,” said Towers. And while that information was based on a single, limited study done decades ago, drug substitution therapy has been the standard treatment for pregnant moms ever since.
But Towers' groundbreaking study is changing that. In 2017, the American Congress of Obstetricians and Gynecologists updated its recommended therapy for pregnant women with an opioid-use disorder.
The new guidelines include the treatment options and screening recommendations pioneered by Towers. “This approach is very successful when connected with behavioral health and results in babies born who do not suffer NAS," he said.
The University of Tennessee Medical Center’s multifaceted approach, in conjunction with the TN Together bill, seeks to reverse opioids’ grip on our East Tennessee communities.
Read more about the TN Together Opioid Bill
Read more on Tower’s study at the American Journal of Obstetrics & Gynecology: Detoxification from opiate drugs during pregnancy