Siskiyou County Physician Addresses Opioid Epidemic through Evidence-Based Practice and Community Partnerships
 
Dr. Sam Rabinowitz joined Fairchild Medical Center in Yreka, California in March 2014 as a Family Practice physician. He has since been involved with an initiative to develop standards for supporting chronic pain patients and addressing opioid addiction and abuse in Siskiyou County. In this interview, Dr. Rabinowitz shares how Fairchild Medical Center is working in partnership with their local Medi-Cal managed care plan, Partnership HealthPlan of California, community physicians, law enforcement and other partners to prevent opioid abuse.
 
How did you begin to address opioid abuse in Siskiyou County?
 
Almost immediately after joining Fairchild Medical Center I noticed that opioid use was prevalent with our patients. One contributing factor out of several was the clinic’s physician turnover and use of locum tenens; patients would rush to new physicians to get prescriptions.
 
Our initiative was initially started by a Family Nurse Practitioner who organized monthly clinical staff meetings to discuss the prescription of opioids to patients. Through these meetings we established the following policies and strategies:
 

• Requiring a signed pain contract with patients;
• Adopting a policy for urine drug screen every 3 months;
• Limiting patients to obtaining narcotics from only one pharmacy and from one provider;
• Searching the registry for narcotic prescriptions for information on patients;
• Reducing the maximum dosage to 120 mg morphine equivalents (tapered down patients or transferred them to pain management); and
• Implemented a policy of no narcotic prescription during the patient’s first visit.

 
We notified patients of the policy changes and that our clinic was taking a zero tolerance approach. For instance, we let patients know that if other substances show up in a toxicology screen, we will start to discontinue pain management services. We will still continue to see a patient for other medical services whose pain management services were discontinued, though.
 
What was it like implementing the changes and how long did it take?
 
Implementing these changes required a lot of work to educate and get all primary care providers on board. We also worked with the orthopedic providers towards adoption of the policy changes in their practices. We convene monthly meetings of the Fairchild Medical Center Opioid Committee, which includes physicians, NP/PAs, orthopedics, administrators, and pharmacists from the community to review questions on patients or disputes. In all it took about one year for full implementation.
 
How have you worked to engage the community in addressing opioid abuse?
 
We realized that it is important to invite Pharmacists into these conversations and to our meetings as they see patients trying to fill prescriptions from multiple providers.  We also reached out to all primary care physicians in the area and invited them to participate. The two Indian Health Programs in our County, Karuk Tribal Clinic and ANAV Tribal Clinic, also engaged with us in this work. We have a mutual understanding that we will not accept each other’s patients that have been dismissed due to violations of the pain contracts.
 
We also bring in special presenters to our meetings. The Yreka Chief of Police, for example, attended a meeting so that we could update him on what the Opioid Committee was doing and so that he could share from a police perspective how this issue is affecting the safety of the community. Partnership HealthPlan of California has also presented at our committee meetings to share updates on their Managing Pain Safely campaign.
 
Has your effort been successful?
 
We are starting to see some impact from our work. There was a history of diverting narcotics to the street through doctor shopping. The policy and changes we implemented are addressing this problem.
 
Do you think that working with your local healthcare collaborative will help grow this initiative?
 
Yes. We are working with the Siskiyou Healthcare Collaborative to establish a county-wide Opioid Coalition. We have a number of community partners involved, including the Chief of Police, the Siskiyou County Public Health Department, and the District Attorney. We are also applying for funding to support our work and grow the coalition. We aim to take what have accomplished at Fairchild Medical Center and spread it to a county-wide initiative so that patients can’t doctor shop moving from one community to another. We also need to work together to increase access to addiction treatment, including suboxone and access to naloxone in the community. We hope to bring in new community partners including community members, individuals who may be able to financially support this campaign (such as the business community), and substance use providers.
 
Working with the local healthcare collaborative may help us address some of the challenges ahead, such as the lack of financial sustainability of substance use services in the county, or creating policy changes that ease the ability to create substance use treatment services in our community. We also need to broaden our work outside of California to connect registries for different states (e.g., Oregon, Washington, and Arizona) so that we can search for patients with prescriptions in our neighboring states.