Comments at the media event announcing the release of the new PA Safe Opioid Prescribing Task Force guidelines on “Treating Pain in Patients with Opioid Use Disorder” – event as part of the Stop Overdoses in PA Week

Dr. Scott McCracken | Pa. Department of Health News Conference | Talking Points | 9/18/19 

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Thank you for that introduction, Doctor Levine, and thank you for inviting me to be a part of this event marking Stop Overdoses in PA Week. 

As a family physician in the midst of the opioid crisis, I am often described as being on the “front lines” of the problem.  In my practiceas well as in the exam rooms of family physicians, nurse practitioners, and physician assistants across the stateit is no exaggeration to say that we take care of patients directly affected by opioids EVERY SINGLE DAY. 

We take care of workers with chronic back pain, young adults with mental health problems, and mothers and their children, struggling with opioid use disorder and neonatal abstinence.  

From an exam room with a patient, it’s sometimes hard to appreciate the scope of a public health problem. 

But when I see patients affected by the opioid crisis – hour after hour and day after dayit’s clear that this is one of the great chronic diseases of our time.  Too often, I hear the story of a patient who overdosed and went to the emergency room, or worse, I find out in the obituariesanother tragic chapter in the crisis.  

These all-to-frequent encounters create burden, complexity, and downstream effects which, in turn, impose a massive stress on the commonwealth’s primary care offices, both emotionally and as a resource. In this context, it can be incredibly challenging to help patients.  

As a primary care physician, I ask myself: 

How do I assess someone who takes opioids for chronic knee pain, but has just fallen and possibly re-injured themselves?  

How do I treat the pregnant mother who struggles with depression and uses heroin to ease her sorrows?  

How can I advise a patient with opioid use disorder, who is taking buprenorphine medicationassisted therapy, but needs dental surgery? 

A few years ago, The Pennsylvania Department of Health heard questions like this from family physicians and others across the state. That’s what led to the creation of the Pennsylvania Safe Opioid Prescribing Task Force.  

As a practicing family physician at WellSpan Community Health Center in York, and as a representative of the PA Academy of Family Physicians, it has been my honor and privilege to work with the Task Force. 

Together, our task force has distilled the most up-to-date and advanced research on advising front-line physicians, providers, and health care workers, on best practices in opioid prescribing. The most recent addition to these guidelines, titledTreating Pain in Patients with Opioid Use Disorder,” adds another key tool for frontline healthcare providers to use at the point of care.  

With the expert leadership of Dr. Michael Ashburn at the University of Pennsylvania, our Task Force was able to provide guidance to physicians who treat patients with substance use disorders both on and off medication assisted therapythrough periods of increased pain, such as an accident or a needed surgery.  

Pain and substance use disorder are intensely personal experiences for patients, and successfully treatment can vary widely. But this new guideline provides valuable information on the safest and best options to help patients achieve pain control while, at the same time, minimizing the risk of relapsing, or overdosing, on opioids.  

I can’t overstate how difficult an area this is in medicine. 

These Pennsylvania guidelines are among the first in the nation to address this very challenging and increasingly common group of patients. 

I personally manage patients with opioid use disorder and prescribe buprenorphine for some of those patients. And I have already used these guidelines to help successfully manage patients through some challenging pain management.  

In closing, I’d again like to thank Dr. Levine and Sarah Boateng for their support of my practice, colleagues, and patients. 

And I look forward to continued work in helping to reduce the burden of the opioid crisis in Pennsylvania. 

Treating Pain in Patients with Opioid Use Disorder

Really excited to have been able to contribute in the PA Safe Opioid Prescribing Task Force’s guideline on Treating Pain in Patients with Opioid Use Disorder (OUD). A very challenging area – and practical! I’ve already used it three times in helping manage peri-operative pain in patients with OUD.

 

https://www.health.pa.gov/topics/Documents/Opioids/Prescribing%20Guidelines%20for%20Individuals%20with%20OUD.pdf

“Prioritize climate change”

My Letter to the Editor, printed in the 7/18/2019 edition of York Daily Record

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Here’s the text:

Prioritize climate change

These days in central Pennsylvania, with flood warnings seeming common, allergy warnings expected, and repeated record rainfalls, you don’t have to travel far to feel the effects of climate change.

Climate change is creating a public health emergency.

People are experiencing heat illness, worsening respiratory conditions like asthma, declining mental health, and infectious and insect-borne diseases – all health impacts that are directly related to impacts of climate change, like increased air pollution, water contamination and longer, hotter heat waves.

Climate change threatens the very foundations of what we need to thrive: clean air, clean water, nutritious food for all and vibrant communities.

While the health and well-being of all Americans is at risk, the United States National Climate Assessment has determined that health impacts of climate change are not evenly shared. Many of the most vulnerable people in the U.S. – including pregnant women, children, the elderly, people with chronic illnesses, outdoor workers, and people in low-income communities and communities of color – are most at risk. According to the American Lung Association’s “State of the Air” report, over 67,500 people with asthma or COPD live here in York County, 8,780 of whom are children, and all of whom face greater health risks.

Policy choices our leaders make today will determine the magnitude of the health harms caused by climate change on future generations. The health sector is taking action to promote and protect health in the era of climate change, but we cannot do it alone.

The Climate, Health and Equity Policy Action Agenda https://climatehealthaction.org/cta/climatehealth- equity-policy/ is endorsed by 74 organizations (including the American Academy of Family Physicians, of which I’m a member) representing more than half a million doctors, nurses, health systems, public health professionals, and patients. It provides a roadmap for local, state and national leaders to act now to stop climate pollution, promote resilient communities, and support the health of all Americans.

To protect human health from the harms of climate change, we call on our leaders in government, business and the civil sector, including our representatives to the Pennsylvania and U.S. legislatures, to heed the urgent call of health professionals and health organizations and immediately take steps to limit climate disruption and build climate resilience.

We call on our leaders to prioritize health outcomes in climate policy solutions at all levels of government, business and the social sector.

We urge our leaders to support policies that strengthen commitments to reducing greenhouse gas emissions, transition rapidly away from the use of coal, oil and natural gas, and transition to zero-carbon transportation systems. Maximize the energy savings that are available by improving energy efficiency.

Move to sustainable farms and food systems, including best soil health to achieve maximum carbon sequestration, and ensure that everyone has access to safe drinking water.

Action taken now can and will help prevent the worst impacts of climate change, have a direct impact on our most vulnerable communities, and protect the health of all families. We cannot wait any longer.

D. Scott McCracken

Springettsbury Township

 

my FAAFP announcement

Date: October 12, 2018
FOR IMMEDIATE RELEASE

Local Physician Receives Honorary Degree
From the American Academy of Family Physicians

NEW ORLEANS, LA — Douglas Scott McCracken, MD, FAAFP, a family physician in York, PA, has achieved the Degree of Fellow of the American Academy of Family Physicians (AAFP), the national medical association representing nearly 131,400 family physicians, residents and medical students. The degree was conferred on more than 250 family physicians during a convocation on Friday, October 12th, in conjunction with the AAFP’s annual meeting in New Orleans, LA.

Established in 1971, the AAFP Degree of Fellow recognizes family physicians who have distinguished themselves through service to family medicine and ongoing professional development. This year’s fellowship class brings the total number of AAFP Fellows to more than 17,500 nationwide. AAFP Fellowship entitles the physician to use the honorary designation, “Fellow of the American Academy of Family Physicians,” or “F.A.A.F.P.”

Criteria for receiving the AAFP Degree of Fellow consist of a minimum of six years of membership in the organization, extensive continuing medical education, participation in public service programs outside medical practice, conducting original research and serving as a teacher in family medicine.

The AAFP was the first national medical specialty organization to require its members to complete a minimum of 150 hours of accredited continuing medical education every three years. It is the only medical specialty society devoted solely to primary care.

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About the American Academy of Family Physicians
Founded in 1947, the AAFP represents nearly 131,400 physicians and medical students nationwide. It is the only medical society devoted solely to primary care.

Nearly one in four of all office visits are made to family physicians. That is 208 million office visits each year — nearly 83 million more than to the next medical specialty. Today, family physicians provide the majority of care for America’s underserved and rural populations.

In the increasingly fragmented world of health care where many medical specialties limit their practice to a particular organ, disease, age or sex, family physicians are dedicated to treating the whole person across the full spectrum of ages. Family medicine’s cornerstone is an ongoing, personal patient-physician relationship focused on integrated care. To learn more about the American Academy of Family Physicians and about the specialty of family medicine, please visit http://www.aafp.org.
AAFP Community Facebook Twitter American Academy of Family Physicians
11400 Tomahawk Creek Pkwy | Leawood, KS 66211
(800) 274-2237 | (913) 906-6000 | aafp@aafp.org | http://www.aafp.org

I Know Hardly Anything About Opioid Addiction

You might read the title of this blog, coming 7 months after my last, as somewhat of a repeat topic. Well, it is. And I’m not ashamed. In fact, I think I’ll go ahead and just promise that in another 7 months, you can count on hearing it some more. But I’ll take a different angle this time.

A few disclaimers: I’m going to use the colloquial term “addiction” over the medical term “abuse”, since it’s an easier read. And, the following quasi-historical tale has been edited for your sanity and to better support my thesis.

About 6,000 years ago in Eastern Europe, a person experienced pain. We’ll call him “the minstrel.” He didn’t like it, and sang a song of heartache. A gatherer discovered, right there on God’s green Earth, the opium poppy, and gave it to the minstrel. At first, all seemed great: not only did the plant relieve the minstrel’s pain and reduce his singing, he also became very happy. But then the pain came back, and the euphoria faded, and the minstrel returned to his painful song. This cycle continued, with the minstrel becoming insufferable, “needing” more and more opium, which eventually made him unable to breathe right, and he eventually died. And there was much rejoicing. (yes, a long way to go for a movie quote joke, but we got there)

Of course, over the ensuing millenia, people repeatedly found that opium (and the chemical morphine, contained in it) could really mess someone up, and that a person who used it a lot would kind of become a drag on the colony or tribe or whatever group they were living in. So, gradually it’s use was restricted to some healers and certain ceremonies, because otherwise the society (or at least the part using it too much) would fail.

But then in the 19th century, Europe decided to share opium – and its addiction problem – with the rest of the world, including Asia (ostensibly to cover trade debt, but I digress). This created problems in those places which had not known or been accustomed to opium’s power. Around the same time, the drug – and it’s purified form, morphine – became instrumental in allowing the advent of surgery.

Fast forward to the 1980’s. Pharmaceutical manufacturers could now create, synthetically, chemicals like oxycodone – nearly identical to morphine, but with less side effects. And their effects lasted longer – up to several hours. Which was great. But it still left one major problem unsolved: what of when the medication wore off, and the patient’s pain returned? Sometimes he slowly got better, and after a few doses, didn’t need the medication any more. But sometimes he didn’t get better, and like the proverbial minstrel, the pain kept coming back, and he kept needing more drugs. Eventually, his injury might heal, but he might still have discomfort once the drug wears off. Withdrawal. Sometimes the patient intensely craved the drug, and would seek it out, even months or years after his last dose. Addiction. It turns out there were lots of people – millions – who had this experience. Nevertheless, without evidence, papers as early as the mid-1980’s began to espouse these new synthetic opioids as safe treatments for chronic pain (in medical lingo, we call these “expert opinion,” the least reliable form of evidence).

Enter Purdue Pharmaceuticals, who had developed a new, longer-lasting version of the oxycodone medication – OxyContin. In fact, it wasn’t the first of it’s type, but Purdue was the first to try to develop and market the drug for long-term use.

OxyContin’s FDA approval process was murky at best – no studies went past 12 weeks, the effectiveness of the medication was mediocre (about 40%), and rates of addiction were high (about 8%). So by the early 1990’s, armed with a longer-lasting drug and the tacit approval of medical journals, Purdue started aggressively marketing OxyContin. Then, in 1998, the Federation of State Medical Boards – and afterwards the VA, the Joint Commission, the American Pain Society, and other medical bodies – designated “Pain” as the “5th Vital Sign” (pain scoring has since been shown, in numerous studies, to be almost useless as an actual vital sign, in that it is not reproducible, and is a poor predictor of future worsening or recovery). So doctors started prescribing a lot of OxyContin.

By the late 1990’s, patients and doctors started noticing very high numbers of people struggling with addiction to opioids. But since no one (least of all Purdue) had a vested financial interest in demonstrating the long-term dangers of these medications, studies were never performed. Because of the sheer magnitude of the problem, opioid overdose deaths began showing up on epidemiological radars by around 2002. Population health-level data from the Institute of Medicine showed that we were in fact seeing numbers similar to those shown in the original studies (i.e., 8% addiction), and, moreover, up to 50% of prescriptions were being misused, abused, or diverted (sold or given out on the street).

By 2008, several lawsuits had been brought against Purdue (basically alleging false advertising regarding the safety and effectiveness of OxyContin in the treatment of chronic pain). Under the auspices of the FDA, drug manufacturers were required to develop Risk Evaluation and Mitigation Strategy (REMS) programs for opioids, to help educate doctors about the appropriate prescription of opioid pain killers in chronic pain. Unfortunately, as I mentioned, we lacked any meaningful data regarding the safe use of long-term opioids, or the effectiveness of REMS training.

So, here we are. It’s 2016. About 10 million people take opioids for chronic pain. About 1 million of them are addicted. About 24,000 die each year from overdose. Numerous states and specialty societies have published guidelines or rules for opioid prescribing. The CDC recently published guidelines for the prescription of opioids in chronic pain. There are precisely two evidence-based interventions that reduce opioid overdose deaths – (1) Prescription Drug Monitoring Programs (PDMP’s), where doctors can check a statewide database to see how many prescriptions of controlled substances a patient has gotten and where (currently available in 49 states, but not Pennsylvania), and (2) naloxone, which immediately reverses the toxic respiratory-depressing effects of opioid overdose (and, in Pennsylvania, is available behind-the-counter, without a prescription). In short (stop me if you heard this before), we have still have little actual data to guide prescribing opioids for chronic pain or avoiding opioid addiction.

Chronic Pain, Addiction, and Primary Care Medicine

As a family physician, I am licensed to treat addiction and chronic pain, and have not, to my knowledge, ever practiced beyond my license. I am not a specialist in addiction, nor a specialist in chronic pain.

I have, through medical school and residency, and my ongoing “real world” training of family medicine practice, known hundreds of patients who suffer from addiction. Addiction is a physical and behavioral adaptation of a human body to an external substance. I’ve studied, observed, and had the privilege to treat the risks and symptoms of addiction. I’ve cared for people through withdrawal, recovery, and remission. I’ve seen enough patients, in rough numbers, that I have realized the predominantly published 10-20% “success rate” of remission our current medical system can achieve in treatment of addiction. I continue to care for and struggle along with the 85% who haven’t quite gotten there.

I’ve also known hundreds of patients who suffer from chronic pain. Chronic pain is caused by any number of conditions (arthritis, cancer, headaches among them), but its central tenet is that chronic pain does not go away. I’ve studied, observed, and had the privilege to treat the risks and symptoms of chronic pain. I’ve cared for people using medication, counselling, and therapy. I’ve seen enough patients, in rough numbers, that I agree with published studies that our medical treatments for chronic pain are, at best, mediocre. I continue to care for and struggle along with the many patients who continue to search for wellness with pain.

I have patients walk through my door daily with addiction and chronic pain. Try to distinguish for yourself using Dr. Google: you’ll find the withdrawal syndromes from opioid pain killers (a common treatment for chronic pain) are strikingly similar to the symptoms of chronic pain. From the first moment I meet them, many chronic pain patients are sitting on a fulcrum, an uneasy balancing point between two inextricably linked problems.

Our community should care about addiction because of abuse, illegal drugs, heroin, overdose, crime, organized crime, and so on. But more than that, we should all care because of the lives touched, indirectly and directly, by addiction. It is a complex problem – there is not one solution, and none of the solutions are easy.

I see my role in addiction management as an opportunity to connect a patient’s symptoms with his spirit and his perception and his choices. Studies have shown that wellness – not smoking, exercising regularly, eating well, and having a healthy weight – is more effective in treating chronic pain than most medicines. But wellness takes determination, and work. So we move slowly, visit by visit, adding a few minutes of therapy here and tincture of time there. What are your goals? Get through your next day of work? See your kid perform in the school play? Enjoy time with friends? Travel? How can we balance wellness, and the risks and benefits of treatment, so that your lever (mostly) tips on the “success” side of that fulcrum? As a primary care physician, I’m often more of a teacher or a counselor than a pill-prescriber.

But you can help, too. For yourself, make a commitment to wellness. For your family, your neighbors, your friends: lend an ear, and perhaps provide a little motivation. Understand that mental health and substance addiction are drivers of physical symptoms like pain – not that it’s “all in your head,” but that a path to healing embraces activity of both body and mind. Have empathy for the weak, and remind yourselves (and your legislators) how important it is to continue to address addiction, for it’s benefit to the community, and to individuals. (for example…shameless plug: you could encourage the PA legislature to fund and implement the Department of Health’s controlled substance prescriptions database.)

And if you have questions, or just need a person to talk to, see your family doctor. We’re listening.