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As Dr. Michael Fine, Director of the RI Department of Health, said at the start of our March 6, 2012 workshop: “We need to eliminate deaths from prescription drug overdoses.” RI has the third highest opioid pain-killer use in the country. And prescription drug overdose is now the leading cause of unintentional death in the state.

“Many, many people are involved with many, many prescription drugs, all prescribed by RI physicians and pharmacists.” These drugs are killing people. Dr. Fine’s goal is to work with the healthcare community to minimize misuse and still provide access to effective chronic pain management.

Good to Know

In describing the patterns of substance abuse in women, Panelist Catherine Friedman, MD, described it as an “exploding epidemic.” Opioids were available to women in tonic form 100 years ago and sold as “Mother’s Little Helper.” Women still tend to use prescription drugs as a coping mechanism. Teenagers get the drugs from their parent’s medicine cabinet. Pregnant girls have the highest rate of use, and the rate of depression is higher in opioid users. Also, the patterns are telescoping: users are more likely to progress from experiment to abuse and dependence in a shorter period of time; 3 years for women vs. 6 years for men.

RI has initiated a prescription drug monitoring task force, with the goal of creating a database to track all prescription medications prescribed and used, so that they can identify misusers earlier and intervene before they become addicted.

RI Medicaid has 175,000 members, nearly one-fifth of the population. Women with chronic pain use twice the number of services as men, at double the monthly cost. (Medicaid: Men $1200 average; women $2400).

Methadone has a much longer half-life than originally thought. It should be used with caution, especially when other opioids are prescribed.

Roadmap to Care

Allison Croke, MHA, introduced the “Communities of Care” program begun 2 years ago by RI Medicaid. This targeted intervention provides short-term case management, using an interdisciplinary team, for people who have used the ER 4 or more times in a 12-month period where chronic pain has been the significant driver.

The integrated treatment plan includes a pain management program, a team of supporters including a peer navigator, and self-responsibility combined with complementary care. Holistic nurses who are trained in outreach meet with the patient to develop their treatment plan. In addition to medication, the program supports the patient’s well-being with both physical and behavioral healthcare, chiropractic treatments, acupuncture and massage.

In Your Practice

Michael Maher, MD acknowledged that managing patients with chronic non-malignant pain is very difficult, and that “we are under-educated” about the drugs we are using. Originally there were no standards for how to manage patients on pain medication. Today standards include RI Department of Health Guidelines which require a physician and patient relationship, patient history and a physical exam.

Dr. Maher added strong suggestions for improved care that include determining the functional impact of the patient’s pain, and screening for substance use disorders. Other recommendations include:

  • Patient responsibility contract
  • History from pharmacies of patient drug use
  • On-going screen for drug misuse, abuse or diversion,
  • Urine screening
  • Scheduled meetings

Providers should recognize that treating pain is not just about bringing down the pain number; it is about improving the patient’s functionality. Can they go out and take care of themselves in a better way? Do they meet functional improvement goals? Rather than just handing out the next month’s prescription, ask if this medication is helping. Because these are dangerous medications, “If they are not helping the patient, get them off it.”