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As Ann Aschoff thumbs through the photos on her computer, she thinks aloud how she will never forget what her son looks like.
In her Coralville home in early January, Aschoff clicks through a slideshow of Zach, seeing him age from a child to an active 20-something. Aschoff, a 57-year-old nurse practitioner at the University of Iowa Hospitals and Clinics, said Zach was athletic, had a gentle side and loved to make people laugh.
“We didn’t know he had been using heroin until the police knocked on our door,” she said.
He died of a heroin overdose on Feb. 27, 2016, when he was 27 years old. He was found unresponsive by authorities at a nearby apartment, surrounded by needles.
Zach was among the 42,000 people in the United States this past year who were killed in what the Centers for Disease Control and Prevention describe as a nationwide epidemic — the opioid crisis.
Opioid drugs can be illicit substances such as heroin or — more commonly — prescription painkillers given to patients by health care providers.
These painkillers currently are recommended for active cancer treatment or end-of-life care, according to the CDC, but in recent years, more patients were prescribed the medication to address chronic, non-cancerous pain.
Doctors “triggered this,” said Dr. Tony Myers, director of system quality and population health at Mercy Medical Center in Cedar Rapids.
Those who study the opioid crisis agree clinicians helped tip the scales on what the issue is today. But some questions remain on whether health care professionals are receiving enough education to find a solution.
The opioid epidemic began, said Iowa Department of Public Health Director of Opioid Initiatives Kevin Gabbert, when physician training in the 1980s shifted to address pain more thoroughly. Around the same time, pharmaceutical companies pushed a new product called OxyContin.
In combination with studies that suggested these opiate pain relievers were non-addictive, the rate of prescriptions boomed. In 2012, health care providers wrote 259 million prescriptions for opioids — enough for every American adult to have a bottle of pills, according to the CDC.
As more users become addicted, the CDC states, opioid overdose deaths quadrupled between 1999 and 2015.
As use of opioid painkillers rapidly increased, heroin usage also became more common.
‘Have you considered treatment?’
Aschoff said her family since has learned Zach, who was living with Ann and her husband at the time, started using heroin the previous December.
She also found out he had nearly overdosed on Jan. 2 and ended up at the emergency department of UIHC.
In 2012, health care providers wrote 259 million prescriptions for opioids — enough for every American adult to have a bottle of pills.
- CDC data
According to the discharge papers Ann found in his room after his death, the doctors noted Zach had symptoms of aspiration pneumonia, loss of hearing and numbness in his throat. The follow-up appointment made for him was to the ears, nose and throat clinic.
No mention of heroin addiction. No documentation that Zach was referred on to treatment to address the near-overdose.
“Maybe he was offered more than I know of,” Ann said. “I like to think somebody — some nurse, some resident — engaged him and said, ‘You ought not to be using heroin’ or ‘Have you considered treatment?’ ”
While she doesn’t blame the hospital staff for her son’s death, Ann is concerned local providers may not be doing enough to address addiction. It’s a conversation more doctors and hospitals are taking on as the prevalence of opioid use in Iowa continues to grow.
“If you’re going to be willing to prescribe opioids, you should be willing to treat them if they end up having a problem with addiction,” said Dr. Nicole Gastala, a physician at Primary Health Care, a federally qualified health center in Marshalltown.
While Iowa overdose rates are not as big as in other areas of the country — such as Ohio, which saw more than 4,000 overdose deaths in 2016 — some experts in Iowa are working to address the issue now to stem the problem farther down the road.
Part of that solution should include educating doctors on the epidemic, said California-based psychiatrist and renowned addiction expert Dr. David Mee-Lee.
Mee-Lee was in Coralville this past January to lead a conference on substance use disorders. It was open to local medical professionals and was designed to build awareness on the issue and offer tools to appropriately treat addiction in patients.
However, while the interest was there among Iowa’s health care professionals, Mee-Lee said he believes there still is not enough done at the academic level nationwide.
“I’m afraid in medical schools and specialty training, there’s often a requirement they get some addiction training, but it’s very minimal,” Mee-Lee said during the conference. Students “don’t have teachers who are inspiring people about addiction training because they weren’t trained and aren’t passionate about it.
“There are some teachers that are, but there’s too few in medical schools and specialty training who get into specific knowledge about addiction and how to treat it.”
Sarah Ziegenhorn, a second-year medical student at the University of Iowa Carver College of Medicine, agrees. The 29-year-old from Iowa City said she believes there was not enough on addiction or substance use disorder during her first two years at school.
“I don’t think it’s any individual’s fault for that, but I think the curriculum is so busy and that the (Association of American Medical Colleges) mandates the inclusion of so much content into the curriculum that it doesn’t leave enough time for people to moderate their curriculum to respond to contemporary community health issues,” she said.
The curriculum at the Carver College of Medicine recently was reconfigured and implemented in 2014, said Dr. Anthony Miller, a psychiatrist at the Veterans Affairs Health Care System in Iowa City and a clinical professor at the school.
The new content includes several lectures on substance use disorders and addiction, with specific discussions on the opioid overdose epidemic, he said.
But in 2016, Ziegenhorn and other students created the University of Iowa Harm Reduction Summit to introduce students to the concept of harm reduction, which promotes syringe exchange programs and overdose reversal drugs to reduce the spread of infectious disease and decrease overdose death.
The second annual summit was held this past September, and was well received by the school administration and students, Ziegenhorn said.
“It was well attended,” she said. “It made a lot of students excited to feel they have a role they can play. The experience of the student can be infantilizing because you’re told to just learn and wait until you’re done with training, then you’ll be able to respond to societal crisis.”
Nonetheless, without that training during their academic years, some doctors such as Gastala in Marshalltown only experience the issue firsthand once they become full-time physicians.
Gastala, who completed her residency at the University of Iowa Hospitals and Clinics, said it wasn’t until she was in practice “that I saw how many patients were on opioids.”
Some Iowa hospitals — such as the Cedar Rapids-based UnityPoint Health-St. Luke’s — are requiring continued education for its physician staff on the issue to maintain accreditation.
“That’s something we do with a lot of medical conditions is come up with a standard approach,” Chief Medical Officer Dr. Dustin Arnold said. “It’s one thing to tell doctors, ‘Don’t prescribe them,’ and then not give them the tools to handle it.”
However, some believe some providers throughout the state still lack knowledge on the issue. Myers at Mercy Medical Center believes medical professionals must be at the forefront of combating the opioid crisis.
“As doctors, we are the ones that will control it at the end of the day,” he said. “We are the ones who write the prescriptions, and we have absolute control. We’ve got to be at the forefront.”
CDC’s guidelines for prescribing opioids
In 2016, the Centers for Disease Control and Prevention issued new recommendations for clinician practice in prescribing opioid medications for chronic pain in light of the nation’s opioid crisis. The 12-step recommendations include:
1. Nonpharmacologic therapy or nonopioid drug therapy are preferred for chronic pain.
2. Clinicians should establish treatment goals with patients before pursuing opioid therapy.
3. Clinicians should discuss known risks and benefits of opioid therapy, as well as other nonopioid therapies available.
4. Clinicians should prescribe immediate-release opioids instead of long-acting opioids.
5. Patients should be given the lowest effective dosage.
6. Do not prescribe long-term opioids for acute pain. A three-day prescription or less should be sufficient, and more than seven days is rarely necessary.
7. Clinicians should evaluate harms and benefits with patients within one to four weeks of starting opioid therapy for chronic pain, and should re-evaluate at least every three months.
8. Risk factors should be evaluated throughout opioid therapy.
9. Clinicians should check the Prescription Monitoring Program data to determine if the patient is getting prescriptions from other providers.
10. Annual urine drug testing should be conducted for patients who have been prescribed opioids for chronic pain, to ensure they are not using other, additional substances.
11. Clinicians should avoid opioids and benzodiazepine, a minor tranquilizer, whenever possible.
12. For patients with an opioid use disorder, clinicians should arrange treatment.
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