A few years ago a dark cloud began to encroach on the pastoral landscape of
Berkshire County in western Massachusetts. The abuse of opioid pain
medications there was rising alarmingly, just as it was doing in cities and
towns across the country.
In fact, deaths from opioid abuse there increased to the point where they
surpassed the number of deaths due to suicide. This pernicious trend mirrored
what was occurring in other parts of Massachusetts and in other parts of the
So Berkshire Health Systems (BHS), a private, nonprofit health care
organization and major provider of care in Berkshire County, decided to tackle
the problem with an innovative program called the Berkshire Community Pain
Management Project. The project, implemented in 2005, is an effort to improve
chronic pain management while also combatting opioid abuse and diversion.
Some of the leaders of the BHS project described it in depth at APA's 2008
annual meeting in Washington, D.C., in May. They were John Rogers, J.D., vice
president; Alex Sabo, M.D., chair of psychiatry; Jennifer Michaels, M.D., a
substance-abuse expert; and John Harrington, Ph.D., a clinical
Patients in the county who suffer from chronic pain can, for example, seek
relief at a multidisciplinary clinic established as part of the project and
headed by Harrington and Douglas Molin, Ph.D., a physiatrist. There, patients
are assessed for pain as well as comorbidities, and a treatment plan for them
is initiated. The plan consists of cognitive-behavioral therapy and exercise
and may include opioids.
John Harrington, Ph.D.: "CBT plus exercise should be a
first-line treatment for chronic pain, especially for patients at risk of
Credit: Joan Arehart-Treichel
Harrington provides the CBT. "There is a lot of evidence that CBT can
help chronic-pain patients and also some evidence that combining CBT and
exercise can do so as well," he told Psychiatric News."
At the same time, there is little evidence that long-term use of
opioids will counter pain, and substance abuse from such long-term use is a
Even though a CBT-exercise treatment regimen lasts only six weeks, it seems
to be helping patients, Harrington said. To date, 41 chronic pain patients
have participated. On a 0-to-10 scale, they rated their pain at 6 at the start
of treatment and at 5 afterward—a statistically significant difference.
The patients also experienced significantly less anxiety and depression after
treatment, and their energy levels and social lives were also boosted by it,
The project also includes treatment for chronic-pain patients in the county
who have become addicted to opioid pain medications. The major component of
the treatment consists of placing patients on buprenorphine rather than on the
opioid pain medications that they have been taking. The treatment is provided
Jennifer Michaels, M.D.: "When patients are on...
buprenorphine, we can get a better handle on pain."
Credit: Joan Arehart-Treichel
Since buprenorphine is an opioid, it is not a cure-all for opioid
dependence, she explained. Yet it does stabilize them and help reduce their
craving for, and withdrawal from, the opioid pain medications they have been
using. And once their craving and withdrawal have been reduced, she is better
able to manage their pain. In other words, "When patients are abusing
opioids such as heroin, oxycontin, Percocet, et cetera, pain management
becomes difficult to impossible," she said.
In fact, several of her patients have reported that once they switched to
buprenorphine, they started receiving pain relief from aspirin and other
nonsteroidal anti-inflammatory drugs, which was not the case as long as they
were taking opioid pain medications.
If buprenorphine does not reduce pain sufficiently in chronic pain patients
who are opioid addicted, Michaels may refer them to Harrington for CBT and
exercise as well.
"It seems these patients are doing about as well as Harrington's
other pain patients, but the numbers are still too small to be sure,"
Finally, another way that project staff are trying to better manage chronic
pain is to promote the use of evidence-based guidelines for treatment of
chronic pain. To achieve this goal, they developed a manual that includes
standardized pain-assessment and pain-management tools and distributed the
manual to all BHS physicians.
As for the team's efforts to reduce abuse of opioid medications, one such
initiative requires that BHS physicians who prescribe these medications use
Another strategy is to work with the Massachusetts Department of Public
Health to make data about opioid-medication prescribing in Massachusetts
available to BHS physicians. The data let BHS physicians know whether their
opioid-prescribing patterns are in line with those of their peers in
Massachusetts. "Most physicians who may overprescribe opioids currently
have no ready means of comparing their prescribing practices with those of
other physicians," Rogers said.
Electronic medical records, which are standard at BHS, are likewise being
deployed to reduce opioid abuse. BHS physicians who prescribe opioids for a
patient makes a special notation in the record. This way other BHS physicians
will be alerted that the patient is already on opioids and will not
unwittingly prescribe more than the patient
Finally, pharmacists in Berkshire County are being brought on board the
project to improve communication between them and BHS opioid prescribers, with
the goal of identifying individuals who are trying to obtain opioid
medications fraudulently. Indeed, the importance of pharmacists' cooperation
cannot be overemphasized, Sabo stressed, since during 2005 they filled almost
3 million doses of Schedule II opioid medications—four times the number
dispensed a decade earlier.FIG2
Moreover, because of its leadership on this issue, BHS has been selected by
the federal Agency for Healthcare Research and Quality to assist Brandeis
University and the Massachusetts Department of Public Health in testing secure
electronic prescribing as a way to reduce prescription tampering and
duplication and diversion of opioid pain medication.
"The challenge of a project like this is to balance a number of
competing interests," Rogers said. "If you do, you can make
Since opioid abuse is rampant across the United States, Rogers, Sabo,
Michaels, and Harrington believe that health care providers in other areas
might want to establish a community pain-management project similar to
Indeed, Paul Cote, past commissioner of the Massachusetts Department of
Public Health, has called the project a "leading-edge program."
And at the APA annual meeting, Nathaniel Katz, M.D., an adjunct assistant
professor in analgesic research at Tufts University and an authority on pain
management, stated, "This group has really knuckled down to developing a
community coalition to solve the pain management—opioid abuse problem.
In my experience, their balanced and enlightened approach is
Information about BHS is posted at<www.berkshirehealthsystems.com>.▪