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March 8, 2016

Bret Bielawski: Combating an Epidemic

March 9, 2016

Bret Bielawski is an assistant professor in the Department of Osteopathic Medical Specialties at MSU's College of Osteopathic Medicine Macomb Center.

There is an epidemic raging through our communities.

It has wiped out more of our citizens than all the U.S. wars combined since the Korean War. It spares no state, county or city. It quietly gains entry into our homes through seemingly innocuous and well‐intentioned means. It resides in our medicine cabinets and can remain dormant for a decade until it is ingested. Upon entry, it floods the brain with a massive release of the neurotransmitter dopamine, a rush that the body has never felt before. The brain’s reward circuitry is now ignited and craves more and more, creating an addiction to the substance that often results in overdose and death.

Are you thinking the culprit is heroin? You are partially correct because the body converts heroin to morphine after it is injected or snorted. Morphine and other prescription opioids such as OxyContin and hydrocodone (Vicodin, Norco) have the exact same mechanism of action in the brain as heroin and are all too commonly prescribed for pain.

In 2014, hydrocodone/acetaminophen was the most common generic drug prescribed in the U.S. (123 million prescriptions). In 2010, the U.S. represented only 5 percent of the world’s population, yet consumed 80 percent of the world’s’ opioid supply and 99 percent of the hydrocodone supply. Prescription opioids cause 44 overdose deaths a day in the U.S.

Michigan has not been spared by this epidemic. In fact Michigan ranked 10th in the U.S. in per capita prescribing rates of opioid pain relievers in 2012, and 18th highest in the U.S. of all overdose deaths. In 2014, 660,000 hydrocodone tablets were dispersed throughout East Lansing with only a census of 47,000 (2012). Often, these medications are simply placed next to an old bottle of Motrin in the medicine cabinet thereby providing extra pills for friends and relatives. Seventy percent of people who abuse prescription painkillers obtain them from friends or relatives, whether given, sold or stolen.

So why are there so many prescriptions? This epidemic was spawned in the 1980s by numerous factors. In 2001, the Joint Commission, [JCAHO, a hospital accreditation body] published a new guideline sponsored by Purdue Pharma, (the makers of Oxycontin mandating that hospitals routinely ask patients if they have pain and document subjective pain levels as the “5th Vital Sign”. The guideline also stated that “there is no evidence that addiction is significant issue when persons are given opioids for pain control.” There was also a lack of rigorous medical literature on this topic at that time and physicians did not receive sufficient medical school training on pain management in that era. Over time many physicians became lax in their prescribing habits.

Battling this epidemic is a dire public health concern. I have seen firsthand how quickly prescription opioids wear out within weeks, cause physical dependence as they go through withdrawal, eventually causing full blown addiction. I have seen my prescriptions become diverted, evidenced by negative urine drug screens as well as patients obtaining multiple prescriptions from other providers.

It is because of this that I have resigned to prescribing opiates for over two years now. It is not a crime for physicians to deny a request for Vicodin “to just have on hand, when my back flares up”. There are plenty of safer and more efficacious therapies than these prescription opiates that are no different than heroin.

This is why I believe that it is absolutely critical that we address this issue with our future physicians. MSU’s College of Osteopathic Medicine, in line with osteopathic medicine’s philosophy of holistic patient care, has always been at the forefront of training students how to communicate with their patients, taking time to understand their concerns and express empathy.

Addressing a patient’s pain starts by developing rapport in the doctor-patient relationship, a crucial skill taught from the first semester of medical school. As faculty critique the videos of students interviewing patients for the first time, they squirm in their seats. With repeated practice, students improve quickly, emerging confidently with excellent interview skills, which is a tremendous asset for any physician’s career. Students are also taught to obtain a thorough history encompassing the whole patient with a particular focus on identifying any maladaptive behaviors that impair the mind/body/spirit balance. How many times have you heard of patients switching doctors because of poor bedside manner? Patients want to be heard, understood and treated with empathy.

MSU‐COM also is preparing medical students to offer an alternative to medicine. The College teaches the requisite skill of Osteopathic Manipulative Medicine. This is a wonderful complement and often preferred method to treat pain of various musculoskeletal disorders. It is safe, effective and non‐addictive. OMM is a hands‐on approach with methods designed to reduce pain by restoring the body’s natural structure. I could not imagine practicing Internal Medicine without OMM. I employ these techniques in my office daily and doing so prevents the need for having to prescribe various pain medications, let alone highly addictive narcotics.

Michigan’s opiate epidemic has likely touched all of us in one way or another. Rest assured, as we continue to prepare more highly trained osteopathic physicians, these skilled practitioners will be at the forefront helping to combat this public health crisis.