REGIONAL – With deaths from opioid painkillers at all time highs, and with use of heroin surging, the issue of addiction to opiates/opioids has become a matter of acute interest. This has led to everything from over-the-counter sales of anti-overdose Narcan kits in drug stores to the state's new MAX program now available at Ellenville Regional Hospital.

MAX stands for Medicaid Accelerated eXchange Series Program, a year-long initiative where hospitals' emergency departments will focus on so-called "super utilizers," or that group of patients who come in to the emergency room again and again seeking prescriptions for opioids such as Oxycontin.

"We look at these people who are coming to us every other week, or more, with their MRI result and they're out of their meds and they want more," says ERH Clinical Director of Emergency Medicine Bob Donaldson. "They are a cohort of patients who come two or three times a month, forty to sixty visits a year in some cases, to the ER for chronic pain issues."

These patients have or had pain, often hard to diagnose by being centered in the back or abdomen. They have been using opioids for some time and inevitably the question that arises in the minds of those who treat them is "how real is this pain?" Are they actually using the opioids provided or are they selling them?

Donaldson explains the dilemma.

"We felt we were part of the problem," he adds. "People were coming to us and we had to treat pain, but there was no way to check levels of pain and here we were dispensing narcotics. In effect we could be at fault either way, but to deny pain relief to someone who really needs it? So we wrote prescriptions."

It's an issue that puts emergency room staff in a difficult place. Often the situations arise at night, when there's no alternative to the ER, nor any way to speak to a primary care provider about a patient's description of his or her pain. To refuse outright creates legal issues of its own. So prescriptions are provided and ER staff are left wondering if they're doing the right thing.

Meanwhile, out in the world, there's a market hungry for Oxycodone pills in any shape or form.

Ashima Butler, ERH Vice President of Quality, Compliance and Medical Staff Management, is running this program locally, and she too is enthusiastic about it.

"For this initiative we are partnered with the Institute for Family Health. The IFH will be providing care navigator coverage in our ER. The care navigator will be critical in connecting these patients with their primary care provider or assigning them an IFH provider if they do not have a PCP, to provide services immediately," she says. "The care navigator will also provide these patients with information on addiction/detox programs and link them with community resources such as physical therapy, acupuncture, chiropractor, dentist, massage therapist, neurologist, pain management specialist and such."

Donaldson is really pleased with the new program.

"So now it's wonderful — we have this new addition, a personal patient care coordinator. They are facilitating all the things that the MAX project sets out to do, to resolve the need for opioids. Part of that is that we're going to get some people off them," he explains. "Of course, there are others with real chronic pain and they need pain management and assistance from a specialist. Look, if someone is coming back to the ER again and again, then it's not working."

But now, the care navigator will step in. Some patients can be moved off opioids and into a variety of programs to manage and reduce their pain. Ultimately, prescriptions of opioids will go down and "wastage" will decline.

Ashima Butler, again: "The biggest challenge remains in breaking down established practice patterns. All providers from ERH and IFH in cooperation with the community providers are working towards the same goal of 'consistent' treatment options. We are vested in this project and have been making progress in changing the practice patterns to help prevent these patients from presenting to the ER — with the expectation that they will now be linked with their primary care provider and other community resources for their pain management and other healthcare needs."

Steve Kelley, Ellenville Hospital CEO, further notes how proud he is that Ellenville has become something of a poster child for the entire MAX program, leading the way in this fight against the over-prescription of opioids.

"Last year we saw about 2,000 visits to the ER from this population, out of a total of 15,000 visits," he points out. "Now, though, we can divert these patients into primary care where they will see a primary care physician who will adjust their medications and refer them to a pain management track if necessary, and into an addiction care track if that's necessary, and there's a psychological and psycho-social track too. The end result is to help people get the services they really need."