Before the rising toll of opioid overdoses was labeled an epidemic, and before the death of pop star Prince showed that anyone could be a victim of painkiller misuse, there was a group of doctors in Little Falls, Minn., looking at their drug prescriptions and wondering what the heck they were doing.
Stunned by the number of opioid prescriptions and drug-related arrests, doctors with CHI St. Gabriel's Health in 2014 were among the first in the nation to launch a campaign to reduce opioid dependence.
Overprescribing painkillers gets people addicted, said Dr. Kurt DeVine of St. Gabriel's family medicine clinic, "and that fuels the heroin problem."
"At the time, we had no idea how bad the heroin problem was in our town," he said.
The solution worked so well that DeVine and colleagues are in Washington, D.C., on Wednesday to explain it to congressional leaders.
Through heightened addiction treatment and monitoring of prescriptions, the clinic has weaned 324 patients off controlled substances entirely. Prescriptions of controlled substances, mostly opioids, dispensed at a local pharmacy dropped from 48,000 per month to 37,000.
State and federal leaders hope to replicate that success elsewhere, because awareness alone hasn't stemmed the epidemic. Opioid prescriptions declined statewide from 2015 to 2016, but opioid-related deaths increased from 583 to 637, state reports show.
Health care leaders believe restricting opioids should reduce deaths by preventing patients from taking them long enough to develop addictions.
One addict's story
People already addicted are reacting by switching to heroin, though. State data show a rising proportion of deaths and calls to poison control involving heroin instead of painkillers such as hydrocodone.
Monica, a 25-year-old waitress in Little Falls, started using opioids at age 18 following a knee injury from a car wreck.
"I kept going back because I started liking them. It was so easy for me to get them," said Monica, who spoke on condition that only her first name be published.
When doctors cut her off, she bought them from friends. When a crackdown on prescriptions dried up that supply, she turned to heroin.
"It was cheaper. It was easier to get," she said. "I didn't have to worry about someone going to the doctor" and pretending to have pain to acquire opioids and sell them.
Doctors quickly discovered that Little Falls' opioid problem extended beyond locals. Patients were coming to St. Gabriel's clinic and ER from far away to obtain opioids.
Addicts are well-connected by mobile phones and know which clinics to tap, DeVine said. "We had people driving from the Iron Range and all the way from south of the Twin Cities."
The solution at St. Gabriel's started with a contract, which patients must sign to receive opioids from the clinic, that allows doctors to order drug tests and use electronic medical records to monitor patients' prescription histories.
Local police also alert the doctors if opioids they prescribe are found in the possession of someone other than their patients.
Patients abusing or selling opioids aren't punished, said Dr. Heather Bell, a St. Gabriel's family medicine provider. Instead they receive access to Suboxone — a nonaddictive drug that eliminates opioid cravings — and to a support team including a nurse and mental health specialist.
"We don't just fire them from our clinic," Bell said. "They … meet with our social worker, and if they are selling their meds to supplement their income, for instance, we try to hook them up with avenues that are a bit more positive to make money."
Reducing prescriptions and treating addictions has affected St. Gabriel's ER, where management of pain medications used to be the top reason for patient visits. Now it isn't even among the top 20.
U.S. Sen. Al Franken called the rise in opioid deaths "a national crisis that requires immediate action" and said in a statement that he hoped lawmakers would gain insights from the success in Little Falls: "CHI St. Gabriel's program demonstrates that through collaboration, communities can help combat opioid abuse."
St. Gabriel's leaders are looking for ways to finance the program now that a state grant has run out. Its success persuaded lawmakers this year to make $1 million available for other health systems to start similar programs.
Dealing with doctors
In addition to meeting with members of Congress, DeVine has talked with hospital leaders and met with doctors identified as liberal prescribers. Some have been hesitant to change, he said.
Doctors were urged to prescribe opioids two decades ago through drug company marketing and the American Pain Society's designation of pain as the "fifth vital sign" that needed to be treated. Further incentive came in 2007, when an advisory report from the Minnesota Board of Medical Practice suggested that doctors who undertreat pain are as negligent as doctors who overtreat it.
The reversal since that time has included a state Department of Human Services work group that has advised doctors to avoid turning to opioids for the long-term treatment of chronic pain because of the lack of evidence that they work.
Despite his push to reduce opioids, DeVine said he worries about overreacting. He still prescribes them in certain chronic-pain cases, such as for an outdoorsman who couldn't hike or chop wood if he didn't receive opioids for his back.
"We have to be careful that we do not go too far the other way," he said. "You have to give them a reasonable chance to have a better life and less pain."
Monica's better life started when she admitted her drug problem to her parents and sought help at St. Gabriel's. She had graduated from college with a nursing degree but couldn't afford to obtain a license and was evicted after spending rent money on drugs.
"I had tried to get off them by myself so many times," she said. "It was miserable. I would be laying in bed for 12 hours and at that point I was so miserable I didn't even care. I just wanted to take something to make me feel better. Toward the end, I wasn't even using them to get high. I was using them to feel normal, to go to work, to function."
DeVine prescribed her Suboxone, and worked with the local jail to keep her on the medication during an eight-day sentence related to her drug use. Check-ins from the clinic support team have helped, she said, and now she is living on her own, working, and hoping to go back to college and eventually buy her own house.
Reading is a pleasure again, she said. "When I was getting high, I would try reading and I would fall asleep or would get so agitated that I couldn't read a page."