North Sonoma County doctors aim to cut prescriptions for powerful painkillers

A key medical services provider in north Sonoma County is aggressively trying to reduce the high rate at which its doctors prescribe a powerful, addictive class of painkillers.

On the heels of a recent federal report that identified Cloverdale as a hotspot for a class of prescription drugs that includes oxycodone, methadone and morphine, Alexander Valley Healthcare’s head physician said he and other local health care professionals are trying to change what was standard practice in the management of chronic pain.

“For the longest time we were encouraged to give medication to treat pain,” said Gary Pace, chief medical director of the clinic, which serves about 4,700 patients a year.

Pace said that about five years ago the medical profession began questioning whether a class of drugs known as opioids were being overprescribed for pain management. New clinical evidence showed that prescribing opioid medications was not only ineffective beyond certain dosages but also rendered the patient more susceptible to pain in the long run.

The new medical knowledge surfaced as the rates of opioid addiction, overdoses and overdose-related deaths all continued to climb, local health officials said.

“The rates of opiate use and abuse and all of the morbidity and mortality that goes with that has been going up in the United States, in California and Sonoma County,” said Dr. Karen Holbrook, county deputy health officer.

Earlier this month, the Centers for Medicare & Medicaid Services released a new online tool that allowed users to see opioid prescription rates in regions down to the ZIP code-level across the country. The data were based on prescription drug claims submitted to Medicare.

Cloverdale’s 95425 ZIP code had a rate of 16 percent. That is, 16 percent of all Medicare prescription drug claims - a rate more than triple the state and national averages of about 5 percent - were for opioid drugs. Seven providers wrote prescriptions for 1,201 opioid claims of the ZIP code’s 7,557 total drug claims.

Other hot spots included the 95415 zip code, which includes Boonville, with a 16.8 percent rate, and 95458, which includes Lucerne, at 16.51 percent.

But Pace and other local health care providers said this week that the data used in the online tool are based on 2013 Medicare claims. As such, it does not account for recent progress in curbing the rates of opioid prescriptions.

A key player in the campaign to reduce opioid prescription rates in Sonoma County is Partnership HealthPlan of California, a nonprofit managed health care organization that administers the state’s Medi-Cal benefits in the county.

In January 2014, Partnership HealthPlan launched an initiative called Managing Pain Safely aimed at getting physicians to reduce the over-prescribing of opioids. The plan examined data derived from its own membership.

“A lot of rural areas, northern areas, are suffering from high opioid use,” said Robb Layne, a Partnership HealthPlan spokesman. “We found out from our data that more people are dying from opioid use than car crashes.”

The target threshold for the initiative is to avoid exceeding the U.S. Food and Drug Administration’s maximum daily dosage of 120 milligrams of morphine equivalent. The program measures total opioid prescriptions per member per month; opioid prescription escalations for chronic users; initial opioid prescriptions; and unsafe dose, currently tracked on a per prescription basis.

The initiative was given a “soft launch” in the fall of 2013, with the release of guidelines for primary care providers, community pharmacies, emergency rooms and dentists.

Layne said the initiative is already paying dividends. He said across the plan’s network, total opioid prescriptions from January 2014 to July 2015 have been reduced by 43 percent; initial prescriptions between February 2014 and July 2015 have decreased 33 percent; unsafe doses greater than 120 milligrams of morphine equivalent have decreased by 43 percent; and prescription escalations have declined by 15 percent from January 2014 to July 2015.

The data are based on prescription claims for all Partnership HealthPlan members who are age 18 and older, enrolled in Medi-Cal with at least one opioid prescription.

Layne said that often physicians don’t understand that there’s a “point of diminishing return” on the effects of opioids. Beyond a certain dosage, the opioid drug does not give any more pain relief.

“There’s a sweet spot for pain management and not having a harmful effect on the body,” he said.

Pace, the chief medical officer of Alexander Valley Healthcare, said overuse of opioid drugs can actually make the body more susceptible to pain because of adverse side-effects.

“They think their disease is getting worse, but it’s the medicine that’s making them worse,” he said. “Before, we thought more medicine was better in trying to control the pain.”

Pace and Layne said new trends in pain management are aimed at weaning patients down to recommended levels of pain medications, as well as offering opioid alternatives such as acupuncture, chiropractic services, physical therapy and non-narcotic treatments.

“It’s the right thing to do,” Pace said. “For patients, it’s very hard for them because it’s uncomfortable for them to go down in dosage.”

Payne said the health plan has begun paying for some of these alternative treatments. He said that reducing opioid overuse and abuse will require a communitywide approach. Holbrook, the county deputy health officer, said such an approach will soon be launched.

The county is convening a work group comprised of county health officials and local health care providers that will examine the opioid issue and come up with standard practices, she said.

The group will “dive deeper to find out if there are discrepancies across the county,” she said.

Holbrook said local health care experts are taking a comprehensive approach to addressing the problem surrounding opioid use through education and systems and policy changes. She said the goals are to educate the public about the misuse and abuse of opioids, to provide physicians with training they need for safe prescribing and to adopt uniform guidelines for health care providers prescribing opioids.

You can reach Staff Writer Martin Espinoza at 707-521-5213 or martin.espinoza@pressdemocrat.com. On Twitter @renofish.