People are People No Matter...

In our effort to cover the issue of opioid use in rural Michigan, we took to the hospitals, providers, and persons who are trying to have an impact on opioid use and overuse in our state. 

This Rural Mission is a podcast brought to you by Michigan State University College of Human Medicine. The podcast is produced with funds from the Herbert H and Grace A Dow Foundation and the Michigan State University College of Human Medicine Family Medicine Department. Welcome to season two. I'm your host, Julia Terhune, and I hope you enjoy this episode.

I'm sure none of you listening are surprised that we did an episode this season on the opioid crisis. The issue of opioid use, overdose and related deaths has been in the news media for several years now and at this point it seems to be synonymous with rural. But that is because this is a tremendous issue concerning rural populations. It affects every facet of life for many rural communities, from the healthcare system to schools to industries. Rural healthcare facilities are dealing with people addicted to opioids and the legislative policies tied to combating drug-seeking behavior every day. School systems are seeing younger and younger students either becoming addicted to opioids, dying from overdose, or living in homes where families have been impacted by drug addiction.

US census data shows that unemployment rates are highest in rural areas and the opioid crisis has done nothing to help. Poverty is a contributor to drug use, and yet if you can't stay clean, you can't get a job. But this episode is not about these distressing realities. Instead, we're talking about the people who are doing something to combat this crisis. I'm going to spoil the theme of this podcast and let you know in a word what we are hoping you get out of this. People.

We hope you understand that people need people, meaning if we are to make an impact in these communities concerning opioid use and overuse, we have to put people first. Today our stories are going to have a tiered effect. We're going to start at the top and talk about community impact, then we're going to take it down to the practice level, talking about what individual doctor's offices are doing. We're then going to get personal.

So starting off our conversations, we're going to talk about system policies that have made an impact on getting access to opioids. I spoke to Steve Barnett, the CEO of the McKenzie Health System in Sandusky, Michigan, a rural hospital in the thumb. In 2012, his hospital started an Oxy-free ED policy that stopped providing opioids for non-acute medical concerns.

You have people that are accessing the emergency department for real, acute reasons, and yet there's also people accessing the ED because they've run out of whatever substance they prefer and this is an easy way to come in and probably get a couple days worth or maybe even a month's worth of prescription to get them in and out of there. Rather than wasting resources in the ED and being part of the problem, we decided we wanted to try and at least provide some solution. It's just one door of multiple doors, you know, but it's at least taking a position that we're not going to be that place that pushes drugs.

Were you concerned about any unintended consequences of making this change in your ER?

Sure, we were. Our primary concern was that once they figured out, those patients that are seeking drugs through the emergency department, that we're not going to support that, then they'll simply move to other emergency departments locally and then we won't be viewed very kindly by those other hospitals who have an uptick in volume, but it's really drug-seeking volume. So we presumed, we assumed that that would happen and we talked to everybody, let them know that we were implementing this Oxy-free ED and they may see an uptick and we'd like to hear about it if that in fact occurs.

The other things that we were concerned about is how the patients would react that are seeking drugs when they come in, realize you have a policy and a process that doesn't provide them with what they're looking for, because they could become combative or unruly. So we want to make sure that we have support locally from police and community mental health. Being a County seat, all those services are right nearby anyway, so it was a good way to inform the community and try to get them on board and be supportive of this process that we're going to start implementing, policy implementation, and the way in which we're going to proceed.

And all of those concerns did not actually come to fruition. In fact, the policy positively impacted drug-seeking behavior and did reduce the number of people gaining access to opioids through the emergency room. In the five years this policy has been in place, the McKenzie Health System has seen a 90% reduction in the number of prescription opioids provided to patients. But more importantly, staff and physicians found their jobs less stressful, that patients were easier to discharge, and that their interactions with patients were of higher quality than in previous years. And can I just say that this was a dynamic way to build community. What gave you this idea? I mean, obviously, you're the leader of this hospital.

It was not my idea.

It wasn't your idea?

No. It was the medical director for our emergency department, Dr Hamed. He was reading an article about policies in the state of Washington where they were moving EDs into an Oxy-free environment in order to reduce traffic. He had an interest in doing that locally, so he came in and talked to me about those unintended consequences and would we support it as a hospital? And I said, yeah. And so it just began to roll out from that point in that way.

Part of the program that we implemented, which is fairly common today, was if there was a legitimate acute pain problem and the physician had accessed the MAPS software and could tell that this particular patient wasn't moving around and hadn't acquired multiple prescriptions, then they have the option of administering some narcotics for that patient, for that problem. But it would be a limited supply, maybe two or three days.

And the more important part is that they had to follow up with a primary care provider and so there was a contract established that required that to happen, and if it didn't happen and they showed up again, then they weren't going to see the same kind of prescription being administered. They either have to move on or they have to get help or something has to happen that's different than what they were doing before.

Now let's narrow down our discussion. Reducing access to opioids is one way to combat the crisis, but even without access through the emergency room, there are still people living with chronic pain and addiction. Dr Klee is a physician in Northern Michigan and the residency director at the Munson Family Practice Residency Program. He and his team have developed a better way of managing patients who have chronic pain or who use opioids. But when you hear what it is, I'm sure you'll agree it's the common sense approach that has not been very common.

You know, this is a big problem nationwide and Michigan for sure is one of the areas that is involved significantly. You know, in 2016 we had 11 million prescriptions for opioids in Michigan, which is more than the amount of people we have in Michigan.

Here at our residency we decided we wanted to try to address, how are we managing our patients with prescriptions? So what we did is we developed an algorithm to help all our providers and to figure out how we were going to manage our opioids. That starts with seeing our patients in the office and talking about non-opioid pain relievers.

So we started with that, asked people to make sure that we maximize these non-opioids and then if we are considering going on to opioids to use a validated risk assessment such as the Opioid Risk Score that looks at people's personal family history of addiction issues to see if they're someone that's more likely to become addicted and if opioids are really a good idea for them.

And we combine that with a functional assessment saying, all right, what can you not do right now because of your pain that we want to try to improve with opioids? Because a lot of times it may be we gave opioids for this issue, their pain's still not controlled and we haven't improved their function and so really we haven't added benefit with opioids. We just added potential complications.

And then if we are considering we want to progress to using opioids, then we're running a MAPS report, which is the Michigan Automated Prescription System report that's now mandated by Michigan law and also getting urine drug screens.

Have you noticed that it's an increase in workload to do this with patients?

Yeah, it is, but it takes a little bit more time with this to be able to do a good job with it. But I think we're doing a better service to our patients when we have these discussions and we do a little more regimented assessment of their risk and benefits.

One of the things that we do when we decide that we're going to be using opioids is we have a contract that we sign with the patient and we renew that every year and it is kind of the rules of engagement on using the narcotics. That includes doing annual, at least annual, urine drug screens on patients coming in to see us every three months, you know, not selling their medications and things.

With that agreement, when we do our urine drug screens or we have these visits, if we're seeing that the patient has broken the contract or they're positive on a urine drug screen for other issues, then it's a form where we can then say, all right, we can't continue to prescribe you opioids, but it does appear that you have an opioid disorder, use disorder. And so what can we do to help you with that? How can we help you combat that addiction?

You know, we care for people and these people have addictions and so if they fall out on the contract that they're not able to use the medication because they didn't comply appropriately by not using other medicines, we don't fire the patient. We just say, okay, we can't use these controlled substances, they're too risky for you, but we'll still be your physician. We'll still take care of you and we need to help manage all your medical problems including helping you have access to addiction services.

What comes to fruition as you're graduating from medical school is that now you're actually taking care of patients. You're not taking care of the heroin in room three. You're taking care of Johnny in room three that overdosed with heroin. I think that's an important part, is that we realize that these are people and learning about how to manage their blood pressure's important, but also learning about how to manage people's pain and how to address addictions and not to bring the biases that a lot of times that we do with that and not to internalize those biases.

But it can be a challenging group of people to work with, but it can be very rewarding too in being able to help some of these people and be the providers that are there that aren't turning their back.

Our final story takes us all the way down to the individual level. In preparation for this podcast, I spoke to a number of persons who are in recovery from drug addiction, but there was one story that struck me. To protect the identity of our next interviewee, I'm going to call him Ray.

Ray is now more than four years clean and owes much of his recovery to a recovery program called drug court, an alternative program that instead of putting people with substance abuse issues in jail, they are provided with opportunities to get clean, stay clean, and avoid charges that could keep them in a loop of drug abuse and poverty for the rest of their lives. Here's Ray's story.

I grew up in a loving home. Issues just like anybody. Just normal, you know? My dad wasn't real affectionate but he also wasn't abusive. But I grew up not understanding the feelings that I felt inside. I grew up not understanding why I felt so different, despite all the love and all the good qualities of my family. Excuse me. But then I just, I just couldn't be okay, so I started out acting out at school. Finally, my parents are trying to figure out what to do with me because they don't understand, because I don't understand. Really, nobody understands why I'm acting the way I am.

And just as they were like, really trying to help, I was sexually abused by an uncle, you know, and it changed my world. I felt like everybody could see me, see it. So I was like, okay, how can I be a man if I was sexually abused by a man? I remember having these thoughts. And it was just, it happened once.

How old were you?

10. I was 10. And I couldn't remember the pain, the physical pain, but like, it was instant humiliation, you know?

And then, man, my dad was sick all the time, so I begged my parents to let me go hunting with some other uncles. And they introduced me. You know, I remember drinking one night and I just, I can remember it like it was yesterday. Alcohol never became my drug of choice, except for if I didn't have any other drugs. But the feeling of being outside of myself and not having to care about what anybody thought, was the first time I ever drank. Nobody knew I was sexually abused. Nobody knew I was scared. So I was Superman.

After the years of drug abuse, failed relationships, minor offenses, and a spiral of depression and hopelessness, Ray was charged with running a meth lab and larger drug possession. But strangely enough, this is where the story takes a better turn.

21 year old kid walks up to me, he says, hey, you look like you want to die. And I said, you have no idea. Because that's what I was doing. I was literally trying to figure out a way to kill myself in jail. So I'm in jail, I'm cleaning up, and everything that I had done during those drug induced hazes became a reality. Real hard. He says, hey, let's go to this meeting with me tonight. I'm like, what's your name? Like, why are you ... He says, my name's Tucker. He's a good kid. He said, you look like you're in a lot of pain.

He takes me to this meeting and it ends up being an NA meeting. This guy across the table's telling me he's been, he was a drug addict and he hasn't done drugs in 20 years, and he's smiling. And I said, you lying son of a bitch. Nobody smiles about drugs. Maybe you weren't a drug addict like I was a drug addict. And then this guy started telling my story. He started talking and I'm like, how could you know that? What is this? What is this? What is recovery?

And I was sitting in jail and every Tuesday I was holding this NA book and every Tuesday I'd be there, just waiting for this guy to come in. How did I not know about this? You know, I've been on felony probation for seven years and I'm not trying to say that in a [inaudible 00:19:58] way, you know? I know it was my choice to pick up the first time. I also know that after the first time I picked up, I didn't have a whole lot of choice.

But I'm looking at three to five in prison with a 40 year tail. [inaudible 00:20:18]. They sent some guy in there and he's supposed to interview me and I lock up because all those old feelings come back. He talks to me and he says, tell me why I should let you on my program? How do I deserve that program, you know? I've been sexually abused, abusive father, like I got all these thoughts rolling through my head. Like, I don't deserve that.

At that time, nobody in my life had known I was sexually abused. I probably told the counselor like, three days after that because I finally broke and told someone. It was like, it was like the whole world helped open up to me. Drug court accepted me. The guy came back and interviewed me again. Drug court let me on. I didn't know the world of recovery existed. I didn't know people cared whether or not we lived or died, as addicts. In our world and I know it's a sad thing, but in our world where we live, in here in our heads or in the streets, nobody cares. We're the enemy. We're dirty. We're all these things.

When I hit drug court, that was the first time I really thought there was help out there and that the world wasn't against me. It was also the first time I didn't, the first time I remember feeling like God didn't hate me, if there was a God. I was convinced that He hated me, you know?

Then I got a taste of recovery. They sent me to a treatment center. I didn't know for a second. It's a treatment center. I didn't even know they existed. And then you get to love life. It was like, almost overnight. It was like a whole new world I didn't know.

How do I feel about myself? I feel I'm helping change lives. I don't feel like that would be an option if it wasn't for programs like that.

Let's go backwards now. Ray is a person. A person with real trauma that led him down a spiraling path of drug abuse. It wasn't until someone saw him for who he really is that he was able to start getting help for the hurt that drug abuse and addiction was masking.

Dr Klee and his residents are intervening in the lives of their patients to not just manage their pain but their needs. Treating the person and not the symptom. The McKenzie Health System is taking a look at the issue of opioid use at the community level and trying to help people when they need it most, but also helping the larger system by keeping more drugs out of circulation.

The point of all of this is that people are helping people. This is how we're going to combat this crisis, by taking it one system at a time, one practice at a time, and one person at a time.

You know, we're all Michiganders here and we have to understand that we have our differences, but we also have a lot of similarities. One patient may have, a person may have an opioid addiction, but other people may have their own crosses to bear and so we have to work with each other and take care of each other.

Thank you all for listening today. As always, I want to thank Dr Andrea Wendling for making this podcast a key priority of our program and for allowing me the flexibility to interview all of these different individuals.

There were many others that I interviewed for this particular podcast that you didn't hear today and I want to thank all of them. I want to thank Steve Barnett and Sandusky for taking time away from being a CEO to talk to me. It's always a pleasure to meet with him and this was no exception. I want to thank Dr Klee for also taking his lunch hour to give me a call and talk to me about his program.

I also want to thank Ray. Ray and I spoke for hours and hours and it was one of the most powerful conversations I've had to date. It was such a privilege to hear his story and for him to share his story with all of you and be so vulnerable. Ray, we thank you for all that you've done and are continuing to do in your sobriety and all the people that you've impacted with your story, your life, and your care.

Thank you to all of you. The opioid crisis doesn't seem to have an end in sight and every year the results and the statistics seem to be staggering as to the level of need and the level of care that is needed to combat this issue. With that, if you are considering a career in healthcare or you're considering a career in criminal justice, then I have one simple thing to say to you. Please consider making rural your mission.

Music today was provided by Bryan Eggers. Find Bryan's music on Spotify, Facebook, and Youtube.