By SUSAN JONES

Western Pennsylvania has been and still is one of the epicenters of the opioid crisis, which certainly hasn’t gone unnoticed at Pitt.

Over the past several years, myriad initiatives and research projects have been started to look at ways to reduce overdose deaths and get dangerous drugs off the streets. (See below)

From Jan. 1, 2018 to Dec. 7, 2019, there were 19,652 emergency room visits in Pennsylvania for opioid overdoses. Deaths in the state from opioid overdoses in 2017 and 2018 totaled nearly 10,000, with most concentrated in Pittsburgh and Philadelphia and their surrounding counties, according to information collected by the state.

One of the most direct ways doctors and researchers at Pitt are combatting the epidemic is by trying to reduce the number of opioids that are prescribed for pain.

The School of Dental Medicine made a dramatic move in the fall to commit to opioid-free prescribing for routine dental procedures and became the first school of dental medicine in the United States to establish opioid-free pain management guidelines for the vast majority of procedures performed in all of its dental clinics.

Just this month, a new report led by Katie Suda, of the Pitt School of Medicine’s Department of Medicine, found that more than half of adult dental patients between 2011 and 2015 were prescribed opioids that exceeded the government standards for the recommended three-day supply to manage acute pain. The study looked at nearly 550,000 dental visits. 

"About one in 10 opioid prescriptions in the U.S. are written by dentists," Suda told Reuters Health. "But up until recently, dentists have not been included in the public conversation which is focused on finding solutions to the opioid epidemic."

Bernard Costello, dean of Pitt School of Dental Medicine, wants to be part of that conversation. Dentistry is estimated to account for about 15 percent of pain medications, he said, and significantly, “It happens to be a fair number of young individuals where it’s the first time that they get an opioid, specifically with removal of third molars or what people refer to as wisdom teeth.”

About four and a half years ago, he instructed a new trainee fellow to cut back on the amount of narcotics being prescribed for very young children who had undergone cleft palate or cleft lip repairs.

“He interpreted this as … Costello doesn’t really like narcotics, and actually scaled back … really significantly on a number of the patients at Children’s Hospital (getting narcotics) — patients that were either having outpatient surgery or even ones that were staying overnight and then going home,” Costello said.

It was four months before Costello realized the trainee was doing this and even expanding it to teenage patients. Then he asked, “Aren’t you getting a lot of calls on the weekends, especially if we operate like Thursday or Friday? What are you telling the parents? Aren’t they mad if the patients are in pain and we have to re-prescribe narcotics? And he said to me, ‘I’m not getting any calls.’”

Some have argued that there was more emphasis on the sales of the narcotic medications than on care, Costello said. “But it was also this kind of high-level interest in making sure that we in health care provided what we thought was the very best pain management, which at the time was opioids, opioids, opioids, for everything.”

If you got your wisdom teeth out or your knee operated on, the doctors would send you home with a bottle of Percocet or Vicodin, he said. “And a lot of those individuals never took that medication or took very little of it, and it went on the shelf. … in some cases it got misused, and in some cases got sold elsewhere.”

After his training fellow’s revelation, Costello decided to not use narcotic pain medications in all his outpatient procedures and some that required overnight stays. They found that ibuprofen or Tylenol, for example, are even better choices in some instances than Vicodin or oxycodone-related medicines, both in pain reduction and management along with side effects and complications.

He started working with Paul Moore, a pharmacologist in the School of Dental Medicine who has been involved in pain medication research for decades and has been a spokesman for the American Dental Association on the opioid issue. “He came to me and said, ‘I think we can do more,’ ” Costello said.

Not only is the school not automatically prescribing narcotic pain killers, but it also is making that philosophy part of its curriculum. “We have a set of guidelines that our students now have access to, and people indeed are emailing us from all over the country and the world to get a copy of it,” Costello said.

Another change that has made it easier to not send home a bottle of painkillers with a patient is that Pennsylvania and several other states have mandated that opioids can be prescribed electronically when previously there had to be a paper prescription. Now if a doctor is sending a patient home, particularly over the weekend, “we have the capability, should they need to be rescued on a Sunday afternoon or Saturday afternoon, they don’t have to drive all the way back to Pittsburgh to pick up the paper prescription.”

“But the data, the studies, our experience all tell us you’re going to be good with this pain management strategy without narcotics. And, by the way, we don’t incur the risk of having your child potentially become addicted.”

Costello said they plan to “study this moving forward to see how this goes. We have an electronic health record here and we can see prescribing habits and modify as needed.”

Other prescribing approaches

The dental school is not the only group on campus looking at the overprescribing of opioids.

Ben Davies, a professor in the School of Medicine and chief of urology at UPMC Shadyside, first became attuned to the dangers of narcotics in medical school when a good friend died from a heroin overdose. 

Now, he said, it would be impossible not to be aware of the problem in Western Pennsylvania. “I give these talks, and when I ask, how many people in the room have been affected by the opioid crisis, everybody raises their hand.”

All of Davies’ patients are dealing with some sort of cancer — prostate, kidney, bladder, testicular — which makes them more anxious about pain than many getting oral surgery. But still, he wanted to know, in a study he did several years ago, “how many pills people ready need.”

Davies said he does four or five prostate removals a week with a minimally invasive procedure. Prior to about five years ago, patients would be sent home with 40 oxycodone pills. The study asked about 200 patients how many of the pills they were actually using. “They were only taking four or five tablets each. So there was a large reserve of narcotics being left in the community, ready to be diverted to improper use and potentially addicting other people.”

He then asked 10 or 15 “forward-thinking” patients if they’d be willing to have non-narcotic surgery, using nonsteroidals, Tylenol and different pain blocks before surgery, and they all were fine. “I was personally shocked because I’d never done it before and, frankly, nobody in the country had really done it with prostate (surgery).”

The next step was another study — which is about to be published in a leading medical journal — showing how to convince everyone in his department to stop automatically prescribing opioids for minimally invasive surgery. He called it the “nudge project.”

The project started with a series of educational programs for all the surgeons, after which “we handed out little cards … about what would be the max amount of narcotics you could give people based on our prior work, and really you should get to zero.”

A monthly email was sent to the department that included each surgeon’s name, number of procedures done and the amount of narcotics prescribed per patient, which Davies would follow up with a personal email. 

“It was a series of psychological moves, and we did that over six months,” he said. “We got our narcotic prescription rate from where were prior at 40 to zero across the board. And now, we simply do not give narcotics for minimally invasive surgery in our department, unless we have cause to.”

They also check patient-reported outcomes to make sure they weren’t creating other problems. In post-surgery surveys, they found that all the markers — pain, mobility, bowel movements, anxiety — were “across the board, better if you didn’t take narcotics.”

Now, he says, “I’m not aware of really any surgical department, urology or general surgery, that actively says we don’t use narcotics with minimally invasive surgery.”

Back pain first contact

Mike Schneider, an associate professor in the Department of Physical Therapy, has spent many years researching low back pain, including ways to treat it without performing invasive surgery or prescribing opioids. Schneider and Pitt’s School of Health and Rehabilitation Sciences are now bringing this effort into the classroom with the Primary Spine Practitioner Certification Program, designed to train physical therapists and chiropractors to be the first-contact providers for patients with spinal problems. 

Schneider and Tara Hankin, vice chair and director of the school’s post-professional education programs, said the certification is unique in that it combines physical therapy and chiropractic in a multi-disciplinary training program, which allows patients to avoid going to an emergency room for back pain and getting an opioid prescription.

“If patients see a physical therapist or chiropractor, they wouldn’t be prescribed opioids because neither profession dispenses prescription medications,” Schneider told Pittwire. Read more about the program here.

Not a new phenomenon

Donald Burke, professor of Health Science and Policy, Epidemiology, and dean emeritus of the Graduate School of Public Health, has been looking at the overall trajectory of the opioid epidemic, including what impact overprescribing has had. 

A new paper, which has been accepted into a leading science journal, looks at “the age and generational structure of who’s dying and looks at it over a pattern over the last 50 years, and that’s been changing over time,” Burke said.

The overprescribing of the most recent kinds of opioids, such as oxycodone, began about 1995, Burke said. “The first peak was largely middle-aged, older, more female than traditional drug overdoses. And then about a decade ago, there was a transition to a younger population that was mostly male, much younger and initially started as the prescription drugs but rapidly transitioned to heroin and injection drugs.”

This second peak is larger than the first but is mostly caused by diverted drugs from overprescribing. When a push started to cut back on overprescribing, those who were already addicted needed to find a replacement for the diverted prescription drugs. 

“And the cartels were happy to (provide) it,” Burke said. “It was a wonderful business opportunity because the market had already been created.

“We’ve got now this other … existing problem, which is essentially untethered to overprescribing,” he said. “You can make a good case that the national response hasn’t quite caught up to dealing with this second wave, which is a much harder problem.”

This is a cycle, Burke said, that the United States has gone through before. In the 1850s, the purified component of opium — morphine — became available, mostly in a medical setting. But it was completely unregulated and created many addicts. Then in the 1890s, heroin was synthesized and “it was advertised as a drug that had no addictive properties, and that it could be themost effective cough suppressant,” said Burke, who gave a talk on this history, titled “How Long has This Been Going On,” at the Pitt Health Science’s alumni gathering, the Winter Academy, last week in Naples, Fla.

Then in 1914, the Harrison Act made prescriptions necessary for all narcotics and shortly after, heroin was banned completely. “So again, a market had been created and then withdrawn. … It created economic situations where it was profitable to produce and sell illicit drugs.”

Burke said this is not the first historical time where well-meaning physicians prescribed a new preparation of drugs that were thought to be safe — in today’s case, mostly oxycontin — and later were shown to be wrong.

“I think the message here is to be damn careful of unintended consequences of psychoactive drugs,” Burke said. 

While drug overdose deaths have declined in the past few years, particularly in Western Pennsylvania and Eastern Ohio, Burke said he’s worried that some might think the crisis has passed. But really, the number of deaths, which shot up “hyper-exponentially” with the introduction of fentanyl, has returned to just an exponential trajectory.

“Something has happened, and I’m not at all sure that it has anything to do with our national or state policies,” he said. “It may have everything to do with drug supply.”

Other opioid research at Pitt

Just a sampling of some of the projects at Pitt that focus on the opioid epidemic:

• Pitt Pharmacy’s Program Evaluation and Research Unit (PERU), in the last year, has trained 1,023 health care professionals and 936 health care professional students on substance use disorder and opioid use disorder prevention, intervention and treatment processes, according to Chancellor Patrick Gallagher’s budget presentation to the state.

• Six faculty in the Graduate School of Public Health have led pilot research projects on opioid addiction and the overdose crisis, including Jeanine Buchanich on profiling Pennsylvania mortality 1999-2015; Zan Dodson on social media and mapping opioid-use clusters; Julie Donohue on prescribing; Mary Hawk on community-engaged research into optimizing health and survival; Christina Mair on mapping the problem with public data; and Tom Songer on unintentional poisoning. 

• In November, researchers from Pitt and UPMC were awarded nine grants totaling more than $32 million from the National Institutes of Health to improve prevention and treatment strategies for opioid misuse and addiction and to enhance pain management.

• Physicians who received gifts from pharmaceutical companies related to opioid medications were more likely to prescribe opioids to their patients the following year, compared to physicians who did not receive such gifts, according to a new analysis led by health policy scientists at the Graduate School of Public Health. The research, published in October in the Journal of General Internal Medicine, was led by Mara Hollander, a doctoral student in Pitt Public Health’s Department of Health Policy and Management.

• The Pitt Division of General Internal Medicine received a $5.8 million grant from the National Institutes of Health in June to facilitate opioid research in Appalachia. Jane Liebschutz, chief of the Division of General Internal Medicine, in partnership with Judith Feinberg, of West Virginia University, and Sarah Kawasaki, of the Penn State, will establish the Appalachian Node of the National Institute on Drug Abuse Clinical Trials Network to conduct opioid-related research in the region over the next five years. The emphasis will be placed on reaching rural and other underserved populations.

Susan Jones is editor of the University Times. Reach her at suejones@pitt.edu or 412-648-4294.

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