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Rural Wisconsin doctor seeking ways to manage use of opioids

January 2, 2020 GMT
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In this Nov. 7, 2019 photo, Dr. Angela Gatzke-Plamann is seen at the Necedah Family Medical Center in Necedah, Wis., doing a check-in with Catina Stoflet, who has been on medication-assisted treatment for seven months. "There isn't another me just down the road. I'm the only one here," says Dr. Gatzke-Plamann. "So if I can fulfill that need, then I should do that. And I don't think that's something that urban or suburban physicians have to deal with." (Coburn Dukehart/Wisconsin Watch via AP)
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In this Nov. 7, 2019 photo, Dr. Angela Gatzke-Plamann is seen at the Necedah Family Medical Center in Necedah, Wis., doing a check-in with Catina Stoflet, who has been on medication-assisted treatment for seven months. "There isn't another me just down the road. I'm the only one here," says Dr. Gatzke-Plamann. "So if I can fulfill that need, then I should do that. And I don't think that's something that urban or suburban physicians have to deal with." (Coburn Dukehart/Wisconsin Watch via AP)

MILWAUKEE (AP) — Dr. Angela Gatzke-Plamann didn’t fully grasp her community’s opioid crisis until one desperate patient called on a Friday afternoon in 2016.

“He was in complete crisis because he was admitting to me that he had lost control of his use of opioids,” recalled Gatzke-Plamann, 40, the only full-time family physician in the central Wisconsin village of Necedah, population 916, nestled among bluffs and pines.

The patient had used opioids for several years for what Gatzke-Plamann called “a very painful condition.” But a urine screening one week earlier had revealed heroin and morphine in his system. He denied any misuse that day. Now he was not only admitting it but asking for help.

But Gatzke-Plamann had no resources to offer. She and the patient searched the internet while still on the phone, trying to find somewhere nearby that could help. No luck.

Here was a patient with a family and job who spiraled into addiction due to doctor-prescribed pain pills, yet the community’s barebones health system left him on his own to find treatment — which he later did, 65 miles away. If that situation was going to change in Necedah, it was up to Gatzke-Plamann.

“That weekend I went home and I said, ‘I’ve got to do something different,’” she recalled.

In many ways, rural communities like Necedah have become the face of the nation’s opioid epidemic. Drug overdose deaths are more common in rural areas than in urban ones. And rural doctors prescribe opioids more often by far, despite a nationwide decline in prescribing rates since 2012. Meanwhile, rural Americans have fewer alternatives to treat their very real pain, and they disproportionately lack access to effective addiction medication such as buprenorphine.

For rural physicians like Gatzke-Plamann, the burden of responding to the opioid epidemic falls on their already-loaded shoulders.

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The nonprofit news outlet Wisconsin Watch provided this article to The Associated Press through a collaboration with Institute for Nonprofit News.

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One reason there are more opioid prescriptions in the rural United States: Those residents report more chronic pain. Rural communities skew older, meaning they disproportionately deal with painful conditions related to aging, such as arthritis. Injuries also appear to be more common among communities more dependent on physically demanding jobs, such as mining and logging.

For 62-year-old Necedah resident Michael Kruchten, the chronic pain stems from chemotherapy and radiation therapy treatments he received for lung cancer in 2011.

Kruchten is cancer free now, but the treatments left him with permanent and severe nerve damage in his hands and feet.

“Sometimes it’s a burning — a continuous burning,” Kruchten said. “Sometimes it’s just like a sharp jolt of pain. And then sometimes it’s just pain, pain, pain.”

The pain forced him to stop working at the ethanol plant in Necedah. Daily chores became challenging. The pain would keep him awake a night, leaving him pounding his pillow in frustration.

Gatzke-Plamann tries to avoid prescribing opioids when she can, but alternatives are limited. The nearest physical therapy is in Mauston, a 17-mile drive south. Treatments such as cognitive therapy for pain require drives to Madison, Marshfield or La Crosse, each at least an hour away.

She first tried prescribing Kruchten gabapentin and then duloxetine, two non-opioid medicines. Neither helped enough. Eventually she prescribed the opioid hydrocodone, finally allowing him to sleep.

“Without the sleep I was a couch potato,” Kruchten said. “Once I started to get to sleep (at night), I got rid of my TV and the couch and started becoming more active.”

Necedah is not exactly at the center of the opioid epidemic, but it is not far from it either. The overdose death rate in Juneau County — home to Necedah — tracks with the state average, which itself is about average in the United States. But Juneau County shares a border with Adams County, home to one of the state’s highest overdose death rates.

When Gatzke-Plamann came to Necedah in 2010, U.S. opioid prescriptions were peaking. She estimates she inherited 25 to 30 patients with monthly opioid prescriptions. Soon she, like many peers around the country, noticed a rise in overdose and misuse.

Today, Gatzke-Plamann’s affiliated hospital sends her a monthly report of how many of her patients have opioid prescriptions. It varies each month, she said, but usually ranges from seven to 10. That is due to her efforts.

Around 2012, she stopped taking on new patients using chronic opioid medications to focus on current opioid patients. She weaned many off of opioids and tracked how many pills she prescribed. Instead of defaulting to a month’s worth of pills for a C-section patient, for example, she might only prescribe three to five pills.

“Most of the time those patients really only have that much pain for a couple of days,” Gatzke-Plamann said. “We don’t need to have those pain medications sitting in their medicine cabinets.”

Gatzke-Plamann helped shape her community’s wider discussion about opioids. That included joining the county’s substance abuse prevention coalition and educating her peers.

Around 2016, Mile Bluff Medical Center — the hospital in Mauston with which she is affiliated — standardized a medication treatment agreement with patients, laying out rules for opioid prescriptions.

Patients such as Michael Kruchten must agree to stipulations before getting a new prescription. That includes getting pills from only one doctor and filling prescriptions at just one pharmacy while also submitting to random pill counts and urine screenings. Kruchten is something of a model patient in that regard, according to Gatzke-Plamann.

“You come in for appointments regularly and you’re always on time and you’re respectful with the staff,” she told him as they reviewed the contract at an appointment in November.

Gatzke-Plamann can stop prescribing opioids to patients who violate the agreement. But the contracts aim to keep communication open rather than punish. Reviewing the contract with a patient allows them to revisit the risks and warning signs of addiction.

On his recent visit, Kruchten told the doctor he only took one hydrocodone pill instead of his usual two the previous night, saying it was “satisfactory” in curbing the pain.

“And that’s good that you don’t take it to just put yourself to sleep,” Gatzke-Plamann responded. “Because it’s not a sleep medicine. You understand that. We’ve talked about that one before.”

“Yep,” Kruchten agreed.

The Friday call for help in 2016 made Gatzke-Plamann realize Necedah lacked a crucial tool for solving the pain puzzle: addiction treatment.

“We don’t have as many resources here,” Gatzke-Plamann said of Juneau County, one of the poorest and least healthy in the state. “When I see that there’s a need for something, it’s on me to do something about that.”

She said that is what happened with buprenorphine.

Experts say buprenorphine effectively treats addiction, but the medicine is particularly scarce in rural communities. More than 10 million rural Americans — more than one-fifth of the country’s rural population — live in counties without a single clinician licensed to prescribe the drug. (The rural-urban disparity in access has, however, shrunk since 2017.)

In Wisconsin, 18 of 72 counties lack a buprenorphine provider, and 14 of those unserved counties are rural.

Today Gatzke-Plamann is one of only two people in Juneau County licensed to prescribe buprenorphine. The other is a physician’s assistant she supervises. Catina Stoflet is among about 10 patients they treat in this expansion of a practice that Gatzke-Plamann considered “already at capacity.”

Stoflet, 35, got hooked on prescription opioids as a 16-year-old in 2001, during the first wave of the nation’s opioid epidemic. She started getting kidney stones in high school. She has endured more than 200 of the painful obstructions by her count, leading to many surgeries to remove them.

That first prescription was for Tylenol 3, a combination of acetaminophen and the opioid codeine. Doctors soon escalated her to stronger drugs: vicodin, percocet, oxycodone.

“It was right around the time that people didn’t know what (opioids were) doing to you,” Stoflet said.

Stoflet said she spent years in recovery beginning in 2007. But she relapsed in 2014, progressing to heroin and methamphetamine. This year she decided to quit for good. Stoflet said her primary care doctor introduced her to Gatzke-Plamann, who had recently begun prescribing buprenorphine.

Just like Gatzke-Plamann’s opioid patients, buprenorphine patients must sign contracts, including agreeing to participate in a treatment program.

Stoflet works with a counselor and community recovery specialist at the Roche-A-Cri Recovery Center in Friendship, Wisconsin, about 20 miles from Necedah. The center opened in September 2018. Without its additional resources, Gatzke-Plamann said she would not feel comfortable prescribing buprenorphine.

“I am just one part of their treatment plan,” Gatzke-Plamann said. “I prescribe the medication, but they need the counseling. They need the psycho-social support. They need the group meetings.”

Stoflet lives about 30 miles from Roche-A-Cri and 40 miles from Gatzke-Plamann’s clinic in Necedah. Even so, Stoflet said the long, frequent drives for recovery are worthwhile.

At an appointment in early November, Stoflet worried about an upcoming surgery that would require her to pause her buprenorphine treatment and return to opioids for pain. She talked through the angst with Gatzke-Plamann.

“We would potentially take you off the buprenorphine and do short-acting pain medications around that time,” the doctor said. “The trouble is then, after your acute pain episode from the surgery is no longer as significant — then we need you to stop those pain medicines for at least 24 hours. And then you can start up on your regular buprenorphine dose.”

“So I will be able to go right to the regular dose,” Stoflet said, “and I should be fine?”

“Yes,” Gatzke-Plamann reassured, adding, “it might be rocky.”

“I know it’s going to be — it’s no treat,” Stoflet replied.

Stoflet did briefly use opioids after her late-November surgery. Then she returned to buprenorphine. December marks seven months of treatment.

The opioid epidemic is too complicated to boil down to grim statistics or the stories of one or two patients. But the crisis is real across Wisconsin and beyond, and Gatkze-Plamann confronts it every day.

“I couldn’t imagine not doing it, because — then who would?”