Steve Park held the ultrasound wand to his corroded artery on the right side of his neck and pointed to the bundle of nerves magnified on the screen.
If Park, a nurse anesthetist at Henry County Health Center (HCHC), were having shoulder surgery, a regional anesthetic could be injected near that bundle of nerves to block the feeling in his shoulder and arm, numbing the nerves for up to 48 hours.
This is the technique doctors and nurse anesthesits are beginning to employ at HCHC. Rather than using opioids during surgery and in-patient recovery, they are on the forefront of the regional anesthetic technique, which is done with drugs like lidocaine and other drugs typically used by dentists. Although regional anesthesia takes more time to administer and is a more involved process than general anesthesia, doctors at HCHC say that if it prevents opioid addiction in their patients and helps them recover faster after surgery, it?s worth it.
Todd Ralls, Director of Anesthesia and Pain Management at HCHC, described anesthesia like this. If two people are talking on the phone, administering opioids for general anesthesia is like changing the language of one of the people speaking.
?If I give you pain medication, all of a sudden, I?m speaking Spanish. Opioids alter your perception of pain,? Ralls said. In contrast, regional anesthesia would be like cutting the phone cord. ?Transmission never makes it to the brain and spinal cord.?
?This is a huge advancement,? Park said. In his 38-year career, Park said he is beginning to see the use of ?old school? drugs such as ketamine and clonidine return to the scene in addition to regional anesthesia replacing the formerly much-relied on opioids for pain relief.
A Proactive Approach
Although health directors at HCHC said Henry County has remained sheltered from the national opioid epidemic so far, across Iowa the number of opioid overdoses has tripled in the past decade. In 2016, which is the last available data from the Iowa Department of Public Health, 180 Iowans experienced opioid-related deaths.
?As a whole, people are dying in droves,? said Dr. Michelle Tansey, general surgeon at HCHC. ?I think Henry County might be somewhat isolated. I don?t know why, but looking at similar-sized towns in Ohio or Indiana, they?re overdosing at a rate of about one person a day.?
Tansey was quick to say just because Henry County doesn?t see as many opioid-related deaths, doesn?t mean there are not people suffering from addiction. ?It?s a very important problem that gets put under the rug,? she said. ?There are people [who are] addicted in our community.?
In her office, Tansey said she will see someone with an opioid addiction about three to five times a year who is trying to get to the root of their chronic pain.
?Usually chronic pain is poorly identified,? Tansey said. ?Those people may have been on pain medicine for the last 10 years. They can be difficult to treat.?
In the ER, Director Lacey Harlan-Ralls said that they are seeing patients come in to get Nalaxone, a medication that reverses opioid-related overdose. That being said, HCHC isn?t seeing the ?big overdoses? like larger cities are, although Harlan-Ralls hasn?t tracked the number of patients who have come to the ER searching for opioids or suffering from an overdose, she said.
Even so, Harlan-Ralls agrees with other providers who say HCHC is being proactive when it comes to the opioid epidemic, saying the hospital is working to get ahead of the crisis through education.
Recently, HCHC even hosted a training about opiate overdose and Naloxone use taught by Mindy Sutak, an outpatient counselor at Alcohol and Drug Dependency Services (ADDS) in Burlington.
Sutak said that opioid addiction isn?t always obvious. For people dealing with chronic pain, their body may have become dependent on the prescription given to them from their doctor to the point that if they miss a dose, their body feels sick.
Naloxone can be for anyone who is taking opioids, whether it be for chronic pain or recovery from major surgery.
?Some of the talk is that if people have chronic pain and these opioid prescriptions, providers are suggesting they get Naloxone to have on hand,? Harlan-Ralls said, adding that these providers equate it to someone with a peanut allergy or someone allergic to bee stings having an EpiPen on hand.
?It?s the same thing with Naloxone,? she continued. ?If you start to get drowsy, are not responding well, get cool or clammy or unresponsive, [someone] can go ahead and administer the Naloxone.?
Naloxone will compete for the opioid-receptor sites in the brain and spinal cord, Harlan-Ralls said. If someone has a pain site and there is an opioid attached to it, the Naloxone will bump the opioid off the receptor and wake it up.
?It?s a reversal agent for the opioid,? Harlan-Ralls said.
Anyone can go to the pharmacy and request Naloxone, whether for themselves or for someone else. Sutak said this is because there?s a Standing Order in Iowa, which means doctors don?t have to prescribe Naloxone. It can be found at Hy-Vee Pharmacy or Walgreens.
?The Pendulum Swings?
While Naloxone can be a literal lifesaver in the event of an overdose, doctors educating their patients as they are treated is what can truly be effective in stopping an addiction before it starts.
But education requires more time from doctors with their patient in the office. In the past, health professionals have been ?very aggressive? in controlling people?s pain, Tansey said. Now, other pain controls such has physical therapy, taking ice or heat to the pained area or working toward weight loss are just as important factors in the healing process.
?It?s a totally different mind-set, and it?s changed the way we treat before, during and after surgery,? Tansey said. ?We have to redo the culture. We want our patients to be happy, but we want them to be safe too.?
?The body has pain for a reason ? to keep you safe and to keep you alive,? she added. ?But for years, we controlled pain and told [patients] they didn?t have to feel any pain.?
That?s why in HCHC?s Anesthesia and Pain Management Department, Ralls is working with his staff on getting to the bottom of what is causing pain rather than treating pain itself.
Matt Miller, who also works in Anesthesia and Pain Management, said they will give opioid medication as needed, but they consider it more of a secondary treatment nowadays.
?We?re going to manage your pain, there?s just a different way to do it,? Miller said.
?The pendulum swings,? Park said, as he picked up a 1992 book off a hospital shelf about giving patients more opioids. ?I could never imagine giving an anesthetic without Fentanyl, [which is an opioid more powerful than morphine]. Now I don?t use it like I used to.?
Ralls said it is rare anymore that he writes a prescription for an opioid. When a patient is referred to him from Family Practice or another specialty, he talks to them about pain management practices or other therapies that could relieve the pain.
That doesn?t mean he never writes a prescription for an opioid. Rather, he only does it for acute, short-term pain such as getting a patient to the point where they have lost enough weight to exercise pain-free or with less pain, or if they have a herniated disk, or are in recovery from a car accident.
Ralls said this change in practice isn?t necessarily because of the opioid epidemic, but because science is learning that this is a better way of doing things.
?We were out in front, ahead of it before it was even declared an opioid crisis,? Ralls said.
HCHC now practices techniques like the non-opioid technique of regional anesthesia. Miller is in awe of what non-opioid practices can do for patients, saying that previously patients who underwent total knee replacement surgeries were in the hospital recovering for four to five days. Now, there is a shorter length of hospital stay, with patients being released within two to three days.
Miller said this is because there?s a longer recovery process when a patient has been on opioids, which can make them more lethargic and nauseous and carry a host of other side effects.
?[Opioids] prevent people from being able to rehabilitate sooner,? Miller said. ?On regional anesthesia, they?re not too sleepy that they can?t get up.?
When it comes to regional anesthesia, ?seeing those results ? that made me a believer,? Miller said.
Ralls said that with so much talk about the opioid epidemic, he has patients come in asking for non-opioid anesthesia.
?Is there a stigma (surrounding opioids)? I think there?s beginning to be,? Ralls said. ?Do patients know exactly what an opioid is? Probably not.?
Monitoring Prescription Drug Use
Physicians at HCHC have also taken classes to identify patients who may be seeking opioids and how to address that and identify resources to help them through recovery.
Doctors are now able to see where and when patients get prescription pain medication and what they have been prescribed through the Prescription Monitoring Program (PMP) database. PMP is a tool through the Iowa Board of Pharmacy that allows practitioners to identify potential misuse of prescription pain pills.
Through this, Tansey can track when a patient last received pain medicine and if they received it from another hospital like the University of Iowa in Iowa City or Great River Health Systems in Burlington. Doctors can only login to see their patient?s database, using the patient?s name and date of birth.
?Patients don?t need pain meds from two different doctors,? Tansey said.
In the instances Tansey does prescribe an opioid pain-reliever, it is only enough pills to last from 24 to 48 hours, and she is very blunt with them about the prescription being a narcotic.
In the past, for a typical hernia surgery, most physicians were giving 10 opioid tablets. Tansey said that in studies of hernia surgeries from the past six months, most patients can be treated with just four opioid pills.
?If patients can get by with four tablets and we?re giving them 10, what happens to the other six?? Tansey said, saying that?s when it becomes easier for teenagers to take them to pill parties or for other people who weren?t prescribed the pills to get their hands on them.
Cleaning Out The Medicine Cabinet
From a law enforcement perspective, Mt. Pleasant Police Chief Ron Archer said that it?s always a good idea to get rid of unused medication.
?Especially if you have teenagers or house guests,? Archer said. ?Kids are curious. Sometimes grandma and grandpa?s medicine gets taken. We?ve stopped kids in junior high before that were taking some prescription meds that didn?t belong to them.?
The police department holds drug drops twice a year, with the next one on April 28, at the Mt. Pleasant Police station. Of course, anyone can drop off their prescription pills at any time, no questions asked. The department drops the pills into a box and sends it to the Drug Enforcement Administration (DEA) to be incinerated once the box is full.
?We don?t ask questions,? Archer said. ?It?s made for people to get rid of stuff.?
At the last drug drop, Archer said they collected close to 100 pounds of pills, including the bottles.
Archer said the police station does occasionally get calls from people whose prescription medicine has gone missing and they have to report it before they are able to get another prescription.
He wasn?t able to say if or how many drug overdose calls the police department receives because it would fall under an ambulance assist in the police records.
Continuing the Conversation
Harlan-Ralls knows doctors at HCHC can?t put their ?heads in the sand? and say the opioid epidemic can?t reach Henry County.
Physicians at HCHC say they want to have those conversations with their patients. Harlan-Ralls advises that when it comes to medication, to have one provider that sees a patient?s ?big picture? and is monitoring what prescription is most effective.