It’s a rare day at Alma Family Medicine when Dr. Caroline Kingston or her physician assistants don’t see a patient with back pain.
Like many primary care providers in a state with limited resources and few specialists, providers at the Santa Fe clinic are increasingly being asked to manage problems that exceed the scope of primary care, Kingston said. And often, that means working on the front lines of a growing pain management industry that has fueled a rise in opioid use and abuse in recent years, as well as a surge in overdose deaths in New Mexico and across the nation.
“You try not to go to narcotics” when treating chronic pain, Kingston said. When a patient complains of new pain, she begins with anti-inflammatory medications and physical therapy. She suggests diet changes, yoga, THC-free cannabidiol — it’s legal without a state medical marijuana card — and alternative therapies such as acupuncture, massage and naprapathy — a treatment akin to chiropractic that also works to ease tension in muscles and ligaments. But many of those treatments aren’t covered by insurance plans, forcing a patient to pay out of pocket or forgo them.
The easiest and cheapest pain treatment is most often just a pill.
The Santa Fe Prevention Alliance hopes to change that. Through a collaboration of organizations called Santa Fe Opiate Safe, the alliance will hold a conference for hundreds of doctors statewide Saturday to offer information about alternative pain therapies, treatment options for patients who are struggling with opioid addictions and tools to help prevent prescription opioid abuse, such as the state’s Prescription Monitoring Program. The group also hopes to raise awareness of a roadblock that doctors and patients face when trying to avoid addictive painkillers like oxycodone and hydrocodone — the need for insurance coverage of drug-free therapies.
“We want to give providers some responsible tools to try to clean up the mess that we are responsible in creating,” said Dr. Wendy Johnson, a conference organizer and the medical director at La Familia Medical Center in Santa Fe.
She called the introduction of new opioids in the 1990s a “hard-core Pandora’s box.” Drugmakers were aggressively marketing the time-release painkillers, such as OxyContin, as “magic” pills that wouldn’t lead to addiction or abuse. “They billed this medicine as a being good for any type of pain,” she said. Doctors began prescribing them at high rates to provide relief to patients who had been suffering for years.
“We basically flooded the market with these opioids,” Johnson said.
In Northern New Mexico, which was battling one of the nation’s worst drug epidemics, the new medications — combined with supplies of increasingly potent heroin from Mexico — created a “perfect storm,” Johnson said. Patients cut off from their prescription medications began turning to street drugs, with disastrous consequences.
The state Health Department reported in July that nearly 540 people had died from drug overdoses in 2014, a 20 percent increase from the previous year and one of the highest overdose death rates in the United States, even as the nation overall was seeing an alarming rise. A record 47,000 overdose deaths occurred in the United States in 2014, according to the Centers for Disease Control and Prevention. More than half of the overdose deaths in New Mexico in 2014, like those across the nation, were from prescription medications, officials said.
State and federal officials took notice.
President Barack Obama this year asked Congress for $1.2 billion to treat patients addicted to opioids and to expand the use of naloxone, an antidote to an opioid overdose. Measures are moving through the House and Senate. New Mexico lawmakers in this year’s legislative session also approved a bill to expand accessibility to naloxone, and law enforcement agencies across the state have begun officer training programs on naloxone use.
In March, the U.S. Food and Drug Administration began requiring stronger warning labels on the packages of narcotic painkillers.
But much of the work in preventing the spread of the opioid crisis falls to primary care doctors, who are most likely to encounter a patient with pain or a person struggling with addiction or substance abuse.
Shelley Mann-Lev, director of the Santa Fe Prevention Alliance and a prevention coordinator with the Santa Fe Public Schools, said Saturday’s conference — nine months in the works — is a chance for providers with little training in pain management to get more information on how to treat patients safely.
The issue is especially important to her because it’s affecting the students she sees. “Over the last five to 10 years,” she said, “we’ve seen an increasing trend in our young people using prescription opioids to get high.”
Most of the teens who use prescription opioids recreationally — about three-quarters — get them from their parents’ or grandparents’ medicine cabinets, she said. Others are prescribed opioid painkillers following dental work or treatment of a sports injury. Sometimes, the medical use of the drug turns to misuse. It also can lead to heroin.
According to a recent survey, Mann-Lev said, 6 percent of high school students in Santa Fe reported they had used heroin to get high within the previous month.
“The younger you are when you start using these drugs, the more serious the consequences,” she said.
Dr. Amy Jelliffe of Santa Fe, a psychiatrist who has shifted her focus to “medical therapeutic yoga” and one of the speakers at the conference, said she became discouraged several years ago by what she saw as an overuse of medication in her practice. She eventually turned to practices such as yoga, qi gong and tai chi to help treat a range of ailments, from anxiety to chronic pain. Though pain medication is not a permanent solution, she said, movement therapies can help a patient for a lifetime.
She’s had the most success with warm-water massage, she said. “It’s miraculous.”
Jelliffe is now working to help medical clinics integrate therapeutic yoga into their treatment programs. And health care organizations have become more open to such therapies, she said. Christus St. Vincent Regional Medical Center’s Holistic Health & Wellness center, for instance, offers yoga, massage, acupuncture, mindfulness training and similar services.
Dr. Kingston, at Alma Family Medicine, agreed that movement is key to overcoming most types of pain. But, she said, a patient has to be motivated to opt for a lifestyle change rather than a pill to make the treatment successful — and he or she has to be able to afford it.
While one primary barrier to drug-free pain treatment is the lack of insurance coverage, another problem, particularly for a person who already has been taking opioid painkillers, is the fear of facing pain again, she said.
But many patients will never be entirely free of pain, Kingston said. Part of the treatment process involves helping a patient modify his or her expectations: “You can be better. You can function. … You can still go out and do stuff.” But sometimes, she said, it’s going to hurt.