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A time to reflect on pain prescriptions

November 21, 2017 GMT

Dr. Halena Gazelka admits to being nervous last summer before her colleagues published an unflattering report that revealed Mayo Clinic had been overprescribing pain-relieving opioids. Given the current climate, in which thousands of people have died in the U.S. due to addiction and overdose, she worried about holding a mirror up in front of her employer.

Months later, the veteran Mayo anesthesiologist says the hate mail never came and her team is starting to see the light at the end of the tunnel.

Gazelka, chairwoman of Mayo’s new Opioid Stewardship Program, and her team are roughly 18 months into an exhaustive process that seeks to overhaul acute and chronic prescription rates for opioids. After the July study found 80 percent of opioid prescriptions at Mayo exceeded the recommended guidelines, it’s likely Mayo will roll out new guidelines by the middle of 2018 that will significantly scale down dosages.

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“When we really started looking at our numbers, it was astounding what we were prescribing post-operation,” Gazelka said. “But if we have a problem at Mayo with prescribing, everyone has a problem.”

President Donald Trump recently declared opioids a “public health emergency” after about 59,000 Americans died from drug overdoses in 2016. That number includes more than 600 from Minnesota — about 400 of which have been attributed to opioids.

Risk begins early

Mayo started its opioid stewardship program after the Centers for Disease Control and Prevention inquired about Mayo’s opioid guidelines in March 2016, which uncovered a haphazard approach. A recent CDC report shows that patients who use opioids for 7-10 days have a “very high risk of addiction,” adding some urgency to Mayo’s push to create guidelines that can be implemented throughout the system.

Mayo physician Casey Clements touted Mayo’s new approach while meeting Wednesday with Sen. Amy Klobuchar’s staff at a public forum on opioids hosted in Rochester. Almost exactly a year ago, he admonished the medical community for its role in the opioid epidemic.

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“We’re working very hard at Mayo to help patients and providers set appropriate expectations,” Clements said, while also urging Klobuchar’s office to provide additional funding and programs to combat the epidemic. “You have an incredibly engaged community here that is working together. If you give us legs, we can run with these initiatives.”

Two specific pilot programs are currently being tested at Mayo. First, pharmacists have been meeting with patients to share a brief opioid education before medication is distributed, then following up with phone calls. That testing wraps up this week before the results will be compiled and shared with administration, which will decide whether it’s worth continuing.

Additionally, Mayo’s orthopedic surgery department — which had the highest opioid prescription rates in the aforementioned study — is currently the testing ground for the new program. Gazelka has implemented four levels of opioid prescription, depending on the type of surgery. The goal, Mayo says, is to “provide the lowest effective dose for the shortest period of time, decreasing the risk of opioid dependence or diversion.”

‘Doing what’s right’

Gazelka says her Mayo colleagues have been receptive to her suggestions for change and rallied around the cause — even if it’s called into question past opioid practices.

“It would be a rare, rare person who doesn’t see this in the news and doesn’t think this is terrible and we’ve contributed to this,” Gazelka said. “I think people are really interested in doing what’s right for patients.”

That includes an ongoing dialogue with other healthcare organizations in Minnesota, facilitated by Institute for Clinical Systems Improvement. Those discussions began in April 2017 and Gazelka says they’re expected to wrap up in the spring or summer of 2018.

Those coordinated efforts coincide with the Minnesota Opioid Prescribing Work Group proposing new limits on opioid prescriptions just last week; the state’s human services commissioner must approve them before they take effect. The task force was formed in 2015 in response to increasing death rates related to opioid use. According to the new rule, the Star Tribune reports that doctors participating in Medicaid could be removed from the program that covers about 20 percent of the state’s population.

Gazelka is cautiously optimistic about making progress in the months and years ahead.

“We’re talking about what we’re doing at our own institutions, and we’re hoping we can standardize our approach for throughout Minnesota,” Gazelka said. “That way patients can know what they expect when they come in, which reduces doctor shopping. It’s been really fun to be able to share what we’ve looked at … and figure out where we go from here.”