December 20, Wisconsin Health News

An Assembly committee is planning to take up a bipartisan bill Wednesday that would allow providers in free and charitable clinics to apply for a loan forgiveness program that now targets those working in underserved areas.

The Wisconsin Office of Rural Health administers the program for those who practice in federally-designated shortage areas for healthcare providers or for federally qualified health centers. The bill would add workers at free and charitable clinics to that list.

Under the program, physicians and dentists working 32 hours a week for three years are eligible to have up to $50,000 of their loans repaid. Physician assistants, certified nurse midwives, dental hygienists and nurse practitioners who work the same amount of time may receive up to $25,000 in loan forgiveness.

Sara Nichols, executive director of Open Arms Free Clinic in Elkhorn, told lawmakers at a public hearing last week that they recently received a federal grant to hire a dentist and dental hygienist.

“We can’t hire a hygienist,” she said. “We can’t find them. We have no carrot to wave because we have no loan forgiveness program.”

Lake Area Free Clinic in Oconomowoc recently opened its own dental clinic and is planning to hire two full-time dentists, according to Medical Director Dr. Peter Geiss.

“We’re not really competitive right now, and it’s difficult for us to hire dentists as well as dental hygienists,” he said. The bill “would help us dramatically,” he said.

Katherine Gaulke, Wisconsin Association of Free and Charitable Clinics executive director, said they pursued the legislation in part because the Department of Health Services ended a waiver that allowed dentists to volunteer and serve BadgerCare patients in free clinics without having to be certified by the program.

“We just want to get on an even playing field with the other partners in the safety net,” she said.

The program now serves around 20 out of 50 applicants a year, said John Eich, director of the Wisconsin Office of Rural Health.

The proposal doesn’t add new money to the program, and Eich said that additional applicants would be judged “on equal footing” with existing applicants.

He doesn’t anticipate seeing many additional applicants under the bill as it’s “very unusual” for providers to volunteer that amount of time or be paid by a clinic. 

The Wisconsin Partnership Program has awarded almost $400,000 in two-year grants to eight projects in the state, according to a recent statement. They’re the first set of projects awarded through the program’s Community Catalyst Grant Program. The grants were: ·     $50,000 to WisconsinEye to create and distribute curriculum for a documentary featuring young Wisconsinites sharing their stories of opioid and heroin addiction and recovery. ·     $50,000 to Great Lakes Dryhootch to support development of an online space to provide peer-based mental healthcare to veterans. ·     $38,500 to Nehemiah Community Development Corporation to create a University of Wisconsin class on providing healthcare to incarcerated individuals. ·     $50,000 to the Milwaukee Inter-City Congregation Allies for Hope and Leaders Igniting Transformation to improve opportunities for Milwaukee youth at risk of expulsion and incarceration. ·     $50,000 to complete development of HealthConnect.Link, a website that aims to help residents of Dane, Rock and Sauk counties access healthcare and social services. ·     $50,000 to Centro Hispano of Dane County to create an educational program to train community health workers on how to reduce health disparities affecting Latina postpartum women. ·     $50,000 to Supporting Families Together Association to address health inequities associated with childhood abuse and neglect. ·     $50,000 to expand Wood County’s River Riders Bike Share Program.

The state Department of Justice continues to investigate the role pharmaceutical manufacturers played in creating the opioid epidemic.

Attorney General Brad Schimel announced in June that he was working with a bipartisan coalition of attorneys general in an ongoing investigation. He said Friday that they recently subpoenaed five drugmakers.

About two-thirds of Wisconsin counties have sued opioid manufacturers alleging that their marketing practices helped the epidemic. The companies have denied the allegations.

Two Democratic senators called on Schimel to hold drug companies accountable last month. 

December 13, 2017

Dear Partners: We are excited to share the findings of a new study conducted within the NIDA Clinical Trials Network, which suggests that a buprenorphine/naloxone combination and an extended release naltrexone formulation show similar patient outcomes in the treatment of opioid use disorder (OUD) once the medications are initiated. As hypothesized, it was more difficult for active opioid users to initiate treatment with naltrexone, since using this drug requires complete detoxification. "The good news is we filled the evidentiary void, and also learned that, for those who were able to initiate treatment, the outcomes were essentially identical, as were adverse events," said John Rotrosen, M.D., the study lead investigator. "This gives patients the freedom to choose a treatment approach that best suits their lifestyle, goals, and wishes." More on OUD Treatment Visit the NIDAMED Treatment Information page for other OUD treatment study findings and for resources on opioid and drug addiction treatment for both clinicians and patients. Share the News! Please share this message with members, peers, and colleagues and visit NIDAMED for updates on on the rapidly evolving field of opioid treatment. If you would like sample promotional material (e.g., social media messages, graphics, or brief text) to share this information, please contact the NIDAMED coordinator, Michelle Corbin. With kind regards, Follow NIDA on Twitter and Facebook.

By Steven Reinberg
HealthDay Reporter

WEDNESDAY, Dec. 13, 2017 (HealthDay News) -- Opioid painkillers after surgery can be the first step toward addiction for some patients. But a common drug might cut the amount of narcotics that patients need, a new study finds.

When patients received a non-opioid medication called gabapentin before and after surgery, the need for continued opioid painkillers was reduced by 24 percent, said researchers at Stanford University School of Medicine.

The finding comes amid an opioid epidemic in the United States. Since 1999, overdose deaths have quadrupled, in large part due to abuse of prescription painkillers such as OxyContin (oxycodone) or heroin.

"Our country is facing an opioid crisis, and a lot of people are exposed to opioids after surgery," said researcher Dr. Sean Mackey, chief of the division of pain medicine.

More than 51 million Americans undergo surgery each year, according to background notes in the study. Most are given opioid painkillers afterward, and up to 13 percent become habitual users.

"There are some people who are vulnerable to the addictive proprieties of these drugs," Mackey said. "We would prefer to find ways of not having people get into problems with opioids."

Gabapentin (brand names: Neurontin, Gralise) is used to help prevent seizures and ease nerve pain from shingles. It's available as a generic, so it is inexpensive and covered by most drug plans.

Now, it appears to reduce the time patients feel they need opioid relief by a "modest" amount, the researchers said.

"This means that people are less likely to become addicted to opioids and less likely to have the side effects of an opioid," Mackey said.

Those side effects can include sedation, nausea and constipation.

Surprisingly, the drug had no effect on how long it took for post-operative pain to subside, Mackey said. But it did effect how long patients needed opioids.

For the study, Mackey and his colleagues randomly assigned 410 surgical patients to receive gabapentin or a placebo before surgery and for three days afterward. Patients were followed for up to two years.

Procedures included chest surgery, knee replacements, and hand and breast surgery, to name a few. The study found that gabapentin seemed to help regardless of the type of operation.

It's not clear how gabapentin might reduce the need for opioids, Mackey said. Perhaps it's changing brain chemistry after surgery, he said.

"It's probably having pain-relieving properties along with the opioid, and you don't need so many opioids because the effects of the gabapentin are long-lasting," he said.

Gabapentin is considered nonaddictive.

Mackey said more work needs to be done to determine which patients would benefit most from gabapentin, at what dose and for how long.

It's also possible that gabapentin might benefit patients with pain from trauma. Given in the emergency room, it might help reduce the need for opioids, and thus help to prevent addiction in that setting, he said.

The findings were published online Dec. 13 in the journal JAMA Surgery.

Dr. Michael Ashburn is director of pain medicine at the Penn Pain Medicine Center in Philadelphia. He said this study may have important implications.

"This and other studies have reported that the duration of opioid administration may impact whether or not patients transition to chronic opioids after surgery," said Ashburn, co-author of an accompanying journal editorial.

Although gabapentin doesn't seem to reduce the length of time it takes for pain to cease after surgery, it "may allow for opioids to be discontinued more quickly following surgery," Ashburn said.

Giving gabapentin after surgery is already part of clinical practice at Lenox Hill Hospital in New York City, said Dr. Kiran Patel.

"I am constantly looking for ways to reduce opioid requirements and to get patients off opioids so they don't transition to chronic opioid use," said Patel, an anesthesiologist and pain management specialist at the hospital.

There are ways to manage pain aside from opioids and anti-inflammatories after surgery, she noted. "Incorporating them with the right patients, we might be able to reduce their overall use of opioids," she said.

More information

For more about opioid use, visit the U.S. National Institute on Drug Abuse.

SOURCES: Sean Mackey, M.D., Ph.D., chief, pain medicine, and director, Stanford Systems Neuroscience and Pain Lab, Stanford University School of Medicine, Palo Alto, Calif.; Michael Ashburn, M.D., M.P.H., professor, anesthesiology and critical care, and director, pain medicine, Penn Pain Medicine Center, Philadelphia; Kiran Patel, M.D., anesthesiologist and pain management specialist, Lenox Hill Hospital, New York City; Dec. 13, 2017, JAMA Surgery, online

Last Updated: Dec 13, 2017

Copyright © 2017 HealthDay. All rights reserved.

A team of partners from MCW, Dryhootch and Mental Health America of Wisconsin contributed to the development of this project.

By Medical College of Wisconsin - Dec 6th, 2017 01:12 pm

Pills by Tom Varco (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

Milwaukee, Dec. 6, 2017 – Military veterans can experience high levels of chronic pain due to their military service, and are at risk of developing addiction from the opiates used to treat their pain. Nationwide, opioid addiction and misuse is becoming an epidemic. The Milwaukee VA Medical Center, Medical College of Wisconsin and other partners are working aggressively to help reduce opioid misuse. Thanks to support from the Robert Wood Johnson Foundation (RWJF) Clinical Scholars Award, an interdisciplinary team of faculty at the Medical College of Wisconsin (MCW) is working with community partners in Milwaukee to prevent opioid use disorder (OUD) among U.S. military veterans.

Using a community-engaged research (CEnR) approach, Milwaukee Prevention of Opioid Misuse through Peer Training (PROMPT) integrates chronic pain treatment and trauma-informed care with input from local military veterans to develop innovative ways of addressing OUD. CEnR emphasizes community stakeholder involvement in all phases of the research including project/concept development, data collection and interpretation and dissemination of the results.

“Opioid misuse has been on the rise nationally and it has devastated many lives in the Milwaukee area,” said Syed Ahmed, MD, MPH, DrPH, senior associate dean for community engagement and professor of family and community medicine at MCW and the project’s principal investigator and clinical scholar. “One of the strengths of this project is the community-academic partnership structure that includes the voices and perspectives of community members and stakeholders affected by this issue. We are equal collaborators in the research process, and that is key to driving success.”

A team of partners from MCW, Dryhootch and Mental Health America of Wisconsin (MHA) contributed to the development of this project. Dryhootch is a nonprofit organization founded in 2008 by a Vietnam veteran with a mission of helping veterans and their families. MHA is an affiliate of the national non-profit dedicated to helping all Americans achieve wellness by living mentally healthier lives, and has extensive experience implementing programs for populations affected by opioid addiction.

“Veterans are trained to have the back of another brother or sister in combat. So peer mentoring is the most effective in reaching the veterans that we work with. Our goal is to provide wrap-around services and support to fellow veterans while building a sense of camaraderie,” said Bob Curry, Founder and President of Dryhootch. “It’s great that this research project involves us as equal voices at the table to hear our perspectives and understand our needs.”

Academic partners L. Kevin Hamberger, PhD, MCW professor of family and community medicine; Kajua Lor, PharmD, MCW chair of the department of clinical sciences and associate professor in the School of Pharmacy; and Robert Hurley, MD, PhD, professor and executive director of Pain Shared Services at Wake Forest Baptist Medical Center round out the team of RWJF Clinical Scholars. The project team also includes Zeno Franco, PhD, MCW associate professor of community engagement; Sarah O’Connor, MCW community engagement program manager, and Tiffiney Gray, MCW program coordinator; Bob Curry and Otis Winstead of Dryhootch; and Martin Gollin-Graves and Anne Ruiz of MHA.

This project is supported by the Robert Wood Johnson Foundation Clinical Scholars leadership development program, which funds teams of clinicians from different disciplines who collaborate to address a problem in their community.

Mentioned in This Press Release

People: Anne Ruiz, Bob Curry, Kajua Lor, L. Kevin Hamberger, Martin Gollin-Graves, Otis Winstead, Sarah O’Connor, Syed Ahmed, Tiffiney Gray, Zeno Franco

Organizations: Medical College of Wisconsin

December 6, 2017

Egalet Corporation recently announced that Egalet-002, an extended-release, abuse-deterrent form of oxycodone, demonstrated safety and efficacy endpoints for the treatment of moderate-to-severe chronic low back pain in a phase 3 trial.

The multicenter, double-blind, enriched enrollment, randomized withdrawal study evaluated how safe and effective Egalet-002 was in opioid-experienced and opioid-naïve patients with moderate-to-severe chronic low back pain compared with placebo.

The results showed that average pain intensity from randomization to week 16 was statistically and significantly different among patients with receiving Egalet-002 vs. placebo.

In a previous safety study of Egalet-002, the drug was found to be generally well-tolerated for up to 56 weeks in opioid-experienced patients with moderate-to-severe chronic noncancer pain.

The current study did not identify any new safety concerns.

“These results demonstrate Egalet-002, an abuse-deterrent, extended-release oxycodone, provided effective pain relief for patients with moderate-to-severe chronic back pain,” Bob Radie, president and CEO of Egalet, said in a press release. “Given the prevalence of chronic back pain combined with the prescription abuse epidemic, we believe development of more abuse-deterrent products like Egalet-002 is important for our communities.”

Disclosure:  Healio Internal Medicine was unable to confirm relevant financial disclosures at the time of publication.

HealthDay News — For reversal of opioid overdose, higher-concentration intranasal naloxone has similar efficacy to that of intramuscular naloxone administered at the same dose, according to a review published online November 27 in the Annals of Internal Medicine.

Roger Chou, MD, from the Oregon Health & Science University in Portland, and colleagues conducted a systematic review to synthesize evidence on the effects of naloxone route of administration and dosing for suspected overdose in out-of-hospital settings, and the need for transport to a health care facility after reversal of overdose with naloxone. Data were included from 13 eligible studies. 

The researchers found that 1 trial demonstrated similar efficacy between higher-concentration intranasal naloxone and intramuscular naloxone administered at the same dose (2mg/mL). One trial found that lower-concentration intranasal naloxone was less effective than intramuscular naloxone, but the risk for agitation was reduced (low strength of evidence). There was insufficient evidence to assess other comparisons for administration route. Low rates of death and serious adverse events were reported in 6 uncontrolled studies in non-transported patients after successful naloxone treatment.

"Higher-concentration intranasal naloxone (2mg/mL) seems to have efficacy similar to that of intramuscular naloxone for reversal of opioid overdose, with no difference in adverse events," the authors write. "Non-transport after reversal of overdose with naloxone seems to be associated with a low rate of serious harms, but no study evaluated risks of transport versus non-transport."

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More than half of Wisconsin counties have sued opioid manufacturers, as 20 more counties announced Tuesday that they are filing lawsuits.

The counties are led by the Milwaukee-based law firm Crueger Dickinson and Simmons Hanly Conroy, which has offices throughout the country and has filed similar suits in five other states.

The counties allege that the drug manufacturers' business strategies helped create the opioid epidemic.

There are now 48 Wisconsin counties that are seeking damages. Purdue Pharma, one of the companies named in the lawsuit, has denied the allegations. 

Milwaukee County officials highlighted $2.6 million in grants that will help them expand addiction treatment programs at a press conference Monday.

County Executive Chris Abele said that the funding is “a huge step forward” and will support local efforts to fight the opioid epidemic.

“As a country, we need to use every dime we’ve got,” he said. “We need to focus on an issue that is growing faster and killing more people than just about anything you can imagine.” 

Milwaukee County Family Drug Treatment Court is receiving $2.1 million over the next five years from the Substance Abuse Mental Health Services Administration.

“We are transforming these families,” said Milwaukee County Court Judge Joe Donald.

Robyn Ellis, who participated in the county’s family drug treatment court, started using alcohol as a child and illegal drugs as a teenager.

In 2013, she lost custody of her daughter. Then family drug treatment court got involved.

“It’s hard for me to stand up here and share all of this because I’m in such a different place today,” she said.

The court helped her get and stay sober, and she regained custody of her daughter in 2014.

An additional $506,000 grant from the Wisconsin Department of Health Services will allow the county’s Behavioral Health Administration to expand its alcohol and other drug addiction treatment and recovery services to 75 more people.

Those services include medication-assisted treatment, residential treatment, recovery housing and counseling.

“We really want the community to know that addiction is a disease,” said Mike Lappen, division administrator. “It can be prevented. It can be treated.”