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JTC hosts opioid summit

Local physician decries big pharma’s claim of ‘safe pain medicines’

Posted: April 2, 2018 4:44 p.m.
Updated: April 3, 2018 1:00 a.m.
Martin L. Cahn/C-I

Jackson Teen Center Executive Director Brian Mayes (far left, standing) introduces the panel of speakers at the beginning of a special opioid summit at the center Monday evening. On the panel (from left) are KershawHealth Emergency Services Director April Wach, KershawHealth CMO Dr. Tallulah Holmstrom, guest speaker Janine Hagopian, ALPHA Center Executive Director Paul Napper, Kershaw County Sheriff Jim Matthews and 5th U.S. District Rep. Ralph Norman.

In addition to her position as KershawHealth’s chief medical officer, Dr. Tallulah Holmstrom continues to be a practicing physician in Lugoff. During an opioid summit hosted by the Jackson Teen Center (JTC) on March 26, Holmstrom said her viewpoint of the opioid crisis is that of a local doctor who has seen the effects of such drugs in Kershaw County since she began her practice in the mid-1990s.

“I’m not an opioid expert. I’m not an addiction expert. I’m a doc who simply works in a small town who sees what happens every day with the challenges that we face,” Holmstrom said.

She talked about how hospital patients are provided questionnaires about their stay that includes questions regarding pain.

“Back in the 1990s, Medicare and Medicaid started grading hospitals and grading doctors on how well we address pain,” Holmstrom said. “You probably got a questionnaire that asked, ‘During this hospital stay, did you need medicine for pain?’ “During this hospital stay, how often was your pain well controlled?’ And, ‘During this hospital stay, how often did the hospital staff do everything they could to address your pain?’ Suddenly, we were setting expectations that pain should be negated. Unfortunately, there’s a lot about medicine and a lot about life that’s painful.”

Around that same time, Holmstrom said, members of the pharmaceutical industry started developing what those companies called “safe pain medicines,” including Oxycontin, developed by Pardue Pharmaceuticals in the late 1990s.

“They told us it was safe. They educated me and my physician colleagues and my nurse practitioner colleagues and my nurse colleagues and my hospital administrator colleagues that we had safe medicines to address (patients’) pain. They spent a lot of money and conducted over 20,000 physician education seminars in the few years after the launch of their now considered ‘safe’ medication,” Holmstrom said.

Since then, she said, people have expected their pain to be removed and that, if it isn’t, the response is one of physicians and hospitals not doing their job.

Holmstrom said doctors wrote more than 5 million prescriptions for opioids during 2017 in South Carolina, which she said only has a population of around 4 million.

“This is happening in every community across the state,” she said. “We’re just like every other community.”

Holmstrom said one in four people for whom prescriptions are written suffer from addiction.

“Addiction is a chronic medical condition, but addicts aren’t necessarily bad people,” she said, pointing out that four out of five heroin users start with prescription medications. “Remember, we have this expectation that we shouldn’t have pain. We have insurance companies grading us on that and you have hospital systems being graded on whether or not they remove your pain.”

Holmstrom also said that one in four teenagers have misused or abused a prescription drug at least once.

“Last year, nationally, 65,000 people died of overdoses and over half of those were opioid related. In South Carolina alone, there were 600 opioid deaths each year and those are just the ones we know about,” she said.

Holmstrom said many death certificates mention nothing of opioids, and that many people die from a combination of medicines that physicians never know about.

“Their families didn’t want to speak about it. Their doctor didn’t want to put it on the death certificate. Sometimes, one doctor doesn’t know what the other doctor has prescribed and the patient doesn’t necessarily know what they had is a potentially lethal cocktail,” Holmstrom said.

She said despite the overwhelming risk and impact, there are things that can be done, including raising the level of awareness and setting appropriate expectations of pain management.

There are long-lasting treatment options focused on therapy, Holmstrom said, adding, “It took us over 20 years to get us into this situation. We’re not going to fix it in a week, we’re not going to fix it in a month, we’re not going to fix it in six months, but we can start to fix it today.”

In addition to Holmstrom, Monday’s panelists included KershawHealth Emergency Services Director April Wach, guest speaker Janine Hagopian (see sidebar), ALPHA Center Executive Director Paul Napper, Kershaw County Sheriff Jim Matthews and South Carolina 5th District U.S. Rep. Ralph Norman.

JTC Executive Director Brian Mayes served as host and kicked off the summit by admitting he was naïve about the opioid crisis.

“My wife did a little experiment. We kind of put some feelers out to some kids with the story that, maybe, I was having trouble sleeping. And you would be amazed -- within 20 minutes, we knew what to get, where to get it and pretty much who to get it from,” Mayes said. “The thing about it is, the students were giving us advice like doctors. Do not take this on an empty stomach, don’t take this and don’t do it this way. So, with that, that opened my eyes real quickly that we got a problem that we need to deal with. But this is the right county to fight problems we need to correct, right?”

Norman said Camden’s is the second opioid summit he’s attended. He said the first was in Rock Hill. There, he said some 300 people showed up, including people he knew.

“Children that I knew. Parents that I knew, and I said then, we’ve got to expose it. Everything starts with a conversation. Everything starts with education. And that’s what I want for Camden and let each one of you ask questions of our panel here in just a minute,” Norman said.

He said education is key to coming up with solutions, and that he hopes more people get involved with finding solutions as they continue to learn more about the issue.

According to Norman, Kershaw County -- with a population of approximately 63,605 people in 2016 -- had 74,494 opioid prescriptions written that same year.

“That’s more than one for every man, woman and child in this county,” he said.

Norman also said Kershaw County EMS administered 76 doses of Narcan, the drug that counteracts the deadly effects of opioid overdose, during 2017. That figure did not count doses used by law enforcement or others, he said.

Citing Matthews, Norman said there were 15 opioid-related deaths in Kershaw County in 2017.

“Already in Kershaw County we’ve had seven die (this year),” Norman said.

He said drug deaths from opioids have increased 66 percent across the country, with 65 - 66,000 people dying every year from opioids.

Norman said the federal government has budgeted $17 billion in block grants to be disbursed across the country to deal with the opioid crisis.

“It’s going to be up to each one of us to make sure it’s going to the right cause that, hopefully, fixes the problem,” he said.

Wach tagged on to some of the things Holmstrom mentioned.

“I don’t think anyone sitting in this room woke up one morning and said, ‘You know what, I think I want to be an addict,’” she said. “It doesn’t start that way, and I think there’s a lot of stigmatism around admitting you’re an addict or that you have a problem.”

Wach went so far as to acknowledge that becoming an opioid addict may be due to something healthcare providers created because of the pain management expectations Holmstrom talked about.

She went on to describe a “day in the life of an emergency department,” starting with a patient who comes into the department after having a total knee replacement.

“Now, they’re written for Percocet, which is an opioid,” Wach said. “They go home and take a Percocet. Now, we’re starting rehab and kind of transition to Motrin. It’s really not helping, so go get another prescription. Before you know it, you’ve transgressed to, maybe, you don’t really have knee pain, but you can’t make it through the day without that Percocet. Now, you’re coming to the ER because well, your back hurts, or your leg hurts.”

Because of this, Wach said, South Carolina has developed a “Scrips program” where hospitals will treat patients for pain, but after checking their prescription history.

“We want to treat that pain; we don’t want you to hurt,” she said; but, if they’ve found you filled 90-day prescription of Percocet the day before, “We’re not going to writing you a prescription at that point.”

Wach said KershawHealth has partnered with the ALPHA Center for two years in order to provide help to those who end up in an opioid crisis.

“I think it’s great that this community is coming together. I think we’re probably leading the way; I don’t see very many other communities in South Carolina having these forums and allowing people to ask questions and looking at this problem holistically the way we are in Kershaw County,” Wach concluded.

The panel also took questions from the audience, most of which were read out by ALPHA Center Deputy Director Mara Jones. Subjects included:

• Drop-off locations for unused, expired or unwanted prescriptions drugs are available at all law enforcement agency headquarters in Kershaw and Lee counties. Napper said on the first day those drop-off points became available, people dropped off at least 175 pounds of drugs.

• Are pharmaceutical company executives being prosecuted for opioid-related harm? “Not to my knowledge,” Norman said, saying that pharmaceutical companies have a “huge lobby” in Washington, D.C. In response to a follow-up question about laws to deal with the misinformation pharmaceutical companies have allegedly perpetrated concerning opioids, Norman said that could happen, but that his main objective right now is getting the opioid crisis exposed.

• Norman indicated he supports requiring drug manufacturers to re-label their products to include the long-term side effects, adding that he wants to make sure the wording is right so that it has the same effect of the warnings added to cigarette packages.

• Regarding the overprescribing of opioids, Matthews said the majority of opioids in the county have been prescribed legally. However, he said there is one physician in the county he believes “greatly overprescribes” opioids. Matthew said he informed both the U.S. Drug Enforcement Agency (DEA) and the S.C. Department of Health and Environmental Control (DHEC) about the doctor. “They are aware of him, but they say he knows just how far to go before getting into trouble,” he said. Matthews added that his department has a five-person narcotics unit, with one permanently assigned to a DEA taskforce. He said that taskforce is combating the opioid crisis in South Carolina, mostly dealing with fentanyl -- the drug from which pop star Prince died -- which Matthews said mostly comes from China and Mexico. Matthews also said the focus in Kershaw County is on heroin. “There is always a demand for the opioids, for the heroin, for the fentanyl. As long as there’s a demand, there’s going to be somebody who’s going to rise to the occasion and start selling it. We do our best … to root them out. We target the dealers, not the users. If we come across a user, we’re not going to let him go, but our focus is on the dealers,” Matthews said.

• In response to a request for information about research into cannabis for pain management, Holmstrom said medical marijuana is restricted to a very few conditions. She said she personally does not have any experience regarding medical marijuana, although she acknowledged there is data that shows it can be beneficial in certain cases, and reminded the audience marijuana is still an illegal drug in South Carolina. Holmstrom also pointed out that Monday’s summit was focusing on opioid misuse. “There are a lot of people in this room right now who may be taking opioids appropriately, who may be prescribed opioids appropriately. I don’t want people to feel demonized,” Holmstrom said. “Opioids have a very legitimate and appropriate place in the delivery of healthcare. What we want to focus on is opioid misuse and how that appropriate use gets diverted.”

• Responding to a question about treatment, Napper said treatment and therapy to get people off opioids do work. “Shamefully to say, for the first time in the history of the ALPHA Center, if you call me today, it’ll be seven weeks before you can get an appointment because of the opioid crisis that we have,” Napper said. “In the last seven months, we’ve spent $830,000 on opioid addicts. It’s breaking us, and it takes my counselors about three times longer to deal with an opioid addict and put them on medically-assisted treatment than it does a marijuana addict … or someone of that nature.” Napper also said he opposes the legalization of marijuana because he considers it a “gateway drug” and that more young people will try it who wouldn’t otherwise.

• An audience member asked about the underreporting of drug overdoses, including those from opioids and what actually ends up on death certificates. Wach said most death certificates likely do not list drugs as the underlying cause of death. She also noted that hospital emergency staff may not know a patient’s emergency, such as a heart attack, is actually due to the use or misuse of opioids. The same, she said, goes for those who die of conditions actually caused by opioids. Wach said it takes six to eight weeks for autopsy results to reveal whether an opioid was involved; by then, a death certificate has already been signed. “In short, we probably have a bigger problem than we think we have right now,” Wach said of opioids in the state.

• Other people asked about the signs of opioid addiction and how easy or hard it is to come off them. Holmstrom said one of the problems is that opioids -- whether prescribed or obtained illicitly -- can be administered in a variety of ways: pills, patches, films that dissolve under the tongue, liquids, and by injection. She said opioids can be safe, but just like anything else they can be used in unsafe ways. “It’s when certain people have certain genetic predispositions … to where the center in the brain that receives pleasure is stimulated by opioids,” Holmstrom added. “So, they take opioids and something is happening internally that is different when they’re given the opioids. The other parts of the brain go, ‘Get more of that.’” She also reiterated her call for reasonable expectations regarding pain. “That’s what, in my opinion as a medical provider, it boils down to.” Holmstrom also said some people have very little difficulty getting off opioids, while others take longer because of differing brain chemistries. “Mr. Napper’s correct: treatment works. The longer you stay in therapy, the better the outcomes are…. For some people, it’s very hard to come off opioids, but it’s never impossible.” As for the signs of opioid addiction, Holmstrom included appearing sedated, pupils may be small, people may be distracted and unable to concentrate.

• Answering another question, Matthews and Napper both said their agencies have Narcan available for use. Matthews said every deputy has Narcan sprays on hand, and must notify DHEC whenever a dose is administered. Napper said the ALPHA Center has Narcan vouchers available. He said that, early on, they were only given to opioid abusers, but the center made vouchers available -- with training -- to family members so they can administer it at home, if necessary.

• Norman took the last question on not only what the community can do to help, but what he, as a congressman, can do.
“One, bring the awareness like we’re doing tonight,” Norman said; adding that parents need to try to be more aware of what their children are doing and spend more time with them. “I can’t pass a law to stop this. We can make progress with it … but I can’t tell you that I can go to Washington, D.C., and pass a law.”

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