It was just over two years ago that doctors at Alexandria Clinic were given report cards detailing all the opioids they were prescribing to their patients on a daily basis.
“Everybody was in a state of shock in realizing where we were on that scale of prescribing,” said Dr. Deb Dittberner, chief medical officer for Alomere Health, which oversees the clinic. “There was a lot of, ‘This data can't be right.’”
Nearly a billion opioid pills were prescribed and dispensed in Minnesota at the peak of the opioid overdose epidemic, which continues to claim tens of thousands of lives each year across the country. Health experts say the epidemic in its early years was fueled by prescription painkillers like Oxycontin or Vicodin. Some of the state's highest numbers of opioids were prescribed in Douglas County in west-central Minnesota, where Alexandria is the county seat.
But after revolutionizing its approach to treating pain and addiction, Alexandria Clinic has reduced the amount of opioids it prescribes by nearly two-thirds.
Dittberner said it was the 2016 guidelines on opioid prescribing from the Centers for Disease Control and Prevention that spurred interest at the clinic in looking at how doctors were prescribing opioids.
“Physicians in the middle of the opioid crisis, we were really getting frustrated with our patients, with ourselves, with our partners on prescribing patterns,” Dittberner said. “How do we actually understand opioid addiction as a medical problem or a medical disease rather than just getting frustrated and giving pills?”
Dittberner said she thought just showing doctors the data would change how they prescribed. She quickly realized the clinic also needed to take concrete actions, like creating its own policies and procedures.
Clinic president Dr. Paul Kietzmann said it was a wake-up call to see that he was one of the top opioid prescribers.
“When you're called out and you see what your numbers are and you do that comparison, you start to wonder, ‘Are my prescribing habits different than everyone else?’” Kietzmann said. “If I'm prescribing a lot more than others, gosh, if I'm harming somebody, I certainly want to know about that."
Many of Kietzmann’s patients had come to him already on prescribed opioids. Some chronic pain patients had been on the same high levels of opioids for years. If it seemed like their health was stable and that they could still be active, most prescribers didn’t change anything.
“You kind of think, ‘Well, we must be good here,’” Kietzmann said. “‘Here's the same amount of prescriptions that I gave you last time.’”
But the reports on opioid prescribing — along with new guidelines on prescribing at both the state and federal levels — made it clear that doctors need to start asking whether keeping patients on high doses of opioids could sometimes worsen their conditions.
"Are the side effects you're getting from these really high dose opioids worse than I think they are? Are they actually more harmful for you?” Kietzmann said. “Can we get just as good a pain management with less pain medication?”
Dittberner said the clinic set up what it calls “care plans” with all patients who were receiving more than three opioid prescriptions a year.
“Those patients have to be seen every three months. They can only get their prescriptions from their physician or advanced practice provider. They can only use one pharmacy,” Dittberner said.
All of the burdens didn’t fall on patients. The clinic required prescribers to check the state’s prescription monitoring program when prescribing opioids to patients. It’s currently not mandatory in Minnesota for doctors to check a patient’s history when prescribing opioids, although prescribers are required to create an account with the program. Dittberner said the clinic is currently working to add the monitoring program as a tab in a patient’s medical records, which makes it easy for prescribers to access.
Alexandria Clinic also created an opioid task force made up of four doctors, a full-time nurse, a social worker and pharmacists to help guide treatment of people who were prescribed opioids. The team also monitors patients to ensure they aren’t being prescribed both benzodiazepines and opioids, which can be a deadly combination.
“The patients always stay with their physician, but that team makes recommendations on how to lower the medications,” Dittberner said.
But the doctors don’t simply dictate to patients who had been prescribed opioids for longer periods that they now have to cut back. Instead, Keitzmann said, they tailor each patient's treatment to their individual circumstances, explaining the health benefits of tapering down along the way. He explains that they’re not cutting back opioids “because the government says you have to do it” but that it will improve their overall health.
“It's painful and super uncomfortable to withdraw from opioids,” Kietzmann said. “You can do that in a slower way that doesn't produce those withdrawal symptoms if you have that relationship, and that belief and that trust on both sides of things — I think you can get there.”
Some of the reduction in opioid prescriptions came from sending patients home with only the pills they need for the procedure. They also were more careful not to prescribe new patients opioids off the bat.
But Keitzmann said about half of the reduction in opioid prescribing at the clinic came from changing how they treat chronic pain patients who were already on opioids. They’ve managed to get about half their chronic pain patients mostly off opioids in just two years.
Kietzmann sometimes found that once you pared down the opioids, it was clear the chronic pain had been covering up the real health problem. In some cases, the patients were just addicted.
“You're finding out that they're overusing, they're getting their pills from other places,” Kietzmann said. “It starts to uncover, this patient doesn't just have chronic pain, maybe they've got opioid use disorder.”
Kietzmann and another doctor at the clinic received authority to prescribe the medication Suboxone, which is used to treat addiction. The clinic tried to treat addiction as a medical issue that doctors could also play a role in. Some patients go to rehab programs as well, but some just get treated for addiction by their primary physicians.
“Those patients, you can get off their medications, but now they've got nothing except for cravings for opioids and they're finding other ways to get them.” Kietzmann said. “It became clear if we don't have a way to treat opioid use disorder, then we're going to end up leaving some patients out in the cold.”
Patients are benefiting from this new model. One man was spending $1,000 a month buying morphine on the street when he came to the clinic for help.
“He is also one of my most grateful patients — that he's now been clean,” Kietzmann said. “He's been on Suboxone rather than using street opioids, and holding a job, paying the bills. [He] really feels great about where his life is at now.”
Some have worried that prescribers concerned about opioid overdoses have been too aggressive in restricting patient access to opioids. State and federal policies generally discourage abrupt reductions for patients who have been on opioids for a long time.
Malia Cole of Roseville is an advocate for chronic pain patients and is prescribed opioids for her pain. She and others with chronic pain have felt pressure from doctors and clinics, who she said have continually made it more difficult to get the medication she says works for her.
”It’s frustrating,” she said. “When you’re already dealing with illness and you’re already fighting to keep yourself healthy and parent and work, it’s just insanely frustrating.”
But the Alexandria Clinic approach of doctors working closely with patients, explaining treatment choices and ensuring the pain is managed has appeal to Cole.
”That’s kind of the solution I think for all of us pain patients,” Cole said, “to have good doctors paying attention and carefully taking care of us.”
Dr. Charles Reznikoff, who practices addiction medicine at Hennepin Healthcare and has contributed to some of the state’s policies on opioid prescribing, said overrestricting access to opioids can damage a patient's health, leading to more pain and triggering withdrawal symptoms. It could also cause patients to seek less safe drugs elsewhere.
“Everyone has their own complex mix of reasons they’re in pain,” Reznikoff said. “Many people will respond to specifically tailored treatments better, then you succeed anyway lowering their dose.”
In recent years, the state has issued guidance for doctors on how best to prescribe opioids and how to taper patients off opioids when necessary. Opioid prescribing is down across the state, according to CDC data. The number of opioid prescriptions written in Minnesota has fallen by almost a third from its peak in 2012.
Reznikoff said there doesn’t appear to be just one reason that’s happened, but that increased education of doctors and awareness of patients about opioids is likely a contributing factor.
The state of Minnesota has also been working on similar tools to those used at the Alexandria Clinic, including reports that let doctors see for themselves how frequently they're prescribing opioid pills compared to their peers.
Before doctors at Alexandria Clinic took a close look at how they were prescribing drugs, some may have been fearful of treating patients who were addicted to opioids, Kietzmann said.
“You find out that opiate use disorder crosses all socioeconomic boundaries, all racial groups,” Kietzmann said. “It really opened our eyes to how many people and how many different types of people this can affect.”