{"source_url": "https://urbanmilwaukee.com", "url": "https://urbanmilwaukee.com/2020/01/01/one-doctors-fight-to-handle-opioid-crisis/", "title": "One Doctor\u2019s Fight to Handle Opioid Crisis", "top_image": "https://urbanmilwaukee.com/wp-content/uploads/2020/01/rural_pain_management_10-1170x780-1024x683.jpg", "meta_img": "https://urbanmilwaukee.com/wp-content/uploads/2020/01/rural_pain_management_10-1170x780-1024x683.jpg", "images": ["https://urbanmilwaukee.com/wp-content/themes/urbanmilwaukee_responsive/images/urbanmilwaukee-logo.png", "https://urbanmilwaukee.com/wp-content/uploads/2019/11/Leafline-Labs_42-1170x780-185x122.jpg", "https://urbanmilwaukee.com/wp-content/uploads/2020/01/rural_pain_management_36-771x514.jpg", "https://pixel.quantserve.com/pixel/p-d8Fh9eDru8-7x.gif", "https://urbanmilwaukee.com/wp-content/uploads/2019/12/ReligiousHealthCare_Cover-771x752-185x122.jpg", "https://urbanmilwaukee.com/wp-content/uploads/2020/01/rural_pain_management_21-1170x780-1024x683.jpg", "https://urbanmilwaukee.com/wp-content/uploads/2019/11/Kathryn-Walczyk_child-1170x787-185x122.jpg", "https://urbanmilwaukee.com/wp-content/themes/urbanmilwaukee_responsive/images/partners/wcij.png", "https://urbanmilwaukee.com/wp-content/themes/urbanmilwaukee_responsive/images/um_store_map.png", "https://urbanmilwaukee.com/wp-content/themes/urbanmilwaukee_responsive/images/icons/reddit-64.png", "https://urbanmilwaukee.com/wp-content/uploads/2020/01/rural_pain_management_07-1170x780-1024x683.jpg", "https://urbanmilwaukee.com/wp-content/uploads/2020/01/rural_pain_management_47-1170x780-1024x683.jpg", "https://urbanmilwaukee.com/wp-content/themes/urbanmilwaukee_responsive/images/icons/facebook-64.png", "https://urbanmilwaukee.com/wp-content/themes/urbanmilwaukee_responsive/images/icons/linkedin-64.png", "https://urbanmilwaukee.com/wp-content/uploads/2020/01/rural_pain_management_23-1170x780-1024x683.jpg", "https://urbanmilwaukee.com/wp-content/themes/urbanmilwaukee_responsive/images/icons/twitter-64.png", "https://urbanmilwaukee.com/wp-content/uploads/2020/01/rural_pain_management_13-771x514.jpg", "https://urbanmilwaukee.com/wp-content/uploads/2020/01/rural_pain_management_10-1170x780-1024x683.jpg"], "movies": [], "text": "Get a daily rundown of the top stories on Urban Milwaukee\n\nDr. Angela Gatzke-Plamann didn\u2019t grasp the full extent of her community\u2019s opioid crisis until one desperate patient called on a Friday afternoon in 2016.\n\n\u201cHe was in complete crisis because he was admitting to me that he had lost control of his use of opioids,\u201d recalls Gatzke-Plamann, 40, the only full-time family physician in the central Wisconsin village of Necedah, population 916, nestled among bluffs and pines.\n\nThe patient had used opioids for several years for what Gatzke-Plamann calls \u201ca very painful condition.\u201d But a urine screening one week earlier had revealed heroin and morphine in his system as well. He denied any misuse that day. Now he was not only admitting it, but asking for help.\n\nBut Gatzke-Plamann had no resources to offer. Both she and the patient started searching the internet while still on the phone, trying to find somewhere nearby that could help. No luck.\n\nHere was a patient with a family and job who spiraled into addiction due to doctor-prescribed pain pills, yet the community\u2019s barebones health system left him on his own to find treatment \u2014 which he later did, 65 miles away. If that situation was going to change in Necedah, it was up to Gatzke-Plamann to change it.\n\n\u201cThat weekend I went home and I said, \u2018I\u2019ve got to do something different,\u2019 \u201d Gatzke-Plamann recalls.\n\nIn many ways, rural communities like Necedah have become the face of the nation\u2019s opioid epidemic. Drug overdose deaths are more common in rural areas than in urban ones. And rural doctors prescribe opioids more often by far, despite a nationwide decline in prescribing rates since 2012. Meanwhile, rural Americans have fewer alternatives to treat their very real pain, and they disproportionately lack access to effective addiction treatment like the medication buprenorphine.\n\nFor rural physicians like Gatzke-Plamann, the burden of responding to the opioid epidemic falls on their already-loaded shoulders.\n\nRural residents report more pain\n\nOne reason there are more opioid prescriptions in the rural United States: Those residents report more chronic pain. For one, rural communities skew older, meaning they disproportionately deal with painful conditions related to aging, such as arthritis. Injuries also appear to be more common among communities more dependent on jobs that call for physical labor, such as mining and logging.\n\nFor 62-year-old Necedah resident Michael Kruchten, the chronic pain stems from chemotherapy and radiation therapy treatments he received for lung cancer back in 2011.\n\nKruchten is cancer free now, but the treatments left him with neuropathy \u2014 permanent and severe nerve damage \u2014 in his hands and feet.\n\n\u201cIt\u2019s very hard to explain,\u201d Kruchten says of the pain caused by his neuropathy. \u201cSometimes it\u2019s a burning \u2014 a continuous burning. Sometimes it\u2019s just like a sharp jolt of pain. And then sometimes it\u2019s just pain, pain, pain.\u201d\n\nThe pain forced him to stop working at the ethanol plant in Necedah. Daily chores like chopping wood for his furnace or even carrying a plate of food became challenging. And maybe worst of all, the pain would keep him awake a night.\n\n\u201cA lot of nights I pounded the pillow trying to get to sleep, I\u2019d get so frustrated and restless,\u201d Kruchten says.\n\nGatzke-Plamann tries to avoid prescribing opioids when she can, but alternatives are limited around Necedah. The nearest physical therapy is in Mauston, a 17-mile drive south. Other treatments such as cognitive therapy for pain require an even further drive to Madison, Marshfield or La Crosse, each at least an hour away.\n\nShe first tried prescribing Kruchten gabapentin and then duloxetine, two non-opioid medicines for treating pain. Neither helped enough. Eventually she prescribed the opioid hydrocodone, two pills before bed in the evening. That finally gave Kruchten enough relief to sleep.\n\n\u201cWithout the sleep I was a couch potato,\u201d Kruchten says. \u201cOnce I started to get to sleep (at night), I got rid of my TV and the couch and started becoming more active.\u201d\n\nDoctor launches multi-pronged effort\n\nNecedah is not exactly at the center of the opioid epidemic, but it is not far from it either. The overdose death rate in Juneau County \u2014 home to Necedah \u2014 tracks with the state average, which itself is about average in the United States. But Juneau County shares a border with Adams County, which has one of the highest overdose death rates in the state.\n\nWhen Gatzke-Plamann came to Necedah in 2010, U.S. opioid prescriptions were peaking. She estimates she inherited 25 to 30 patients with monthly opioid prescriptions. Soon she, just like her peers around the country, noticed a rise in opioid overdose and misuse.\n\n\u201cWe were seeing that some patients were losing control of their ability to use these. It became very problematic,\u201d Gatzke-Plamann says.\n\nToday, Gatzke-Plamann\u2019s affiliated hospital sends her a monthly report of how many of her patients have opioid prescriptions. It varies from month to month, she says, but it is usually between seven and 10. And that is after her concerted effort.\n\nAround 2012, she stopped taking on new patients using chronic opioid medications so she could focus on her current opioid patients. She weaned many of them off of opioids altogether and tracked how many individual pills she prescribed for acute pain. Instead of defaulting to a month\u2019s worth of pills for a C-section patient, for example, she might only prescribe three to five pills.\n\n\u201cMost of the time those patients really only have that much pain for a couple of days,\u201d Gatzke-Plamann says. \u201cWe don\u2019t need to have those pain medications sitting in their medicine cabinets.\u201d\n\nGatzke-Plamann helped shape her community\u2019s wider discussion about opioids. That included joining the county\u2019s substance abuse prevention coalition and addressing her peers about best prescription practices.\n\nAgreements help opioid users\n\nAround 2016, Mile Bluff Medical Center \u2014 the hospital in Mauston with which she is affiliated \u2014 established a standardized medication treatment agreement, contracts with patients laying out rules for opioid prescriptions.\n\nPatients such as Michael Kruchten must agree to a litany of stipulations before getting a new prescription. That includes getting pills from only one doctor and filling prescriptions at just one pharmacy. Patients must also submit to random pill counts and urine screenings. Kruchten is something of a model patient in that regard, according to Gatzke-Plamann.\n\n\u201cYou come in for appointments regularly and you\u2019re always on time and you\u2019re respectful with the staff,\u201d she tells him as they review the contract at an appointment in November.\n\nGatzke-Plamann can stop prescribing opioids to patients who violate the agreement. But the contracts aim less to punish than to keep communication open. Each time she reviews the contract with a patient \u2014 at least once a year for chronic opioid patients \u2014 it allows them to revisit the risks and warning signs of addiction.\n\nOn his recent visit, Kruchten tells the doctor he only took one hydrocodone pill instead of his usual two the previous night, saying it was \u201csatisfactory\u201d in curbing the pain.\n\n\u201cAnd that\u2019s good that you don\u2019t take it to just put yourself to sleep,\u201d Gatzke-Plamann responds. \u201cBecause it\u2019s not a sleep medicine. You understand that. We\u2019ve talked about that one before.\u201d\n\n\u201cYep,\u201d Kruchten agrees.\n\nTreatment lacking in rural areas\n\nThe Friday call for help in 2016 made Gatzke-Plamann realize Necedah was missing a crucial resource in solving the pain puzzle: addiction treatment.\n\n\u201cWe don\u2019t have as many resources here,\u201d Gatzke-Plamann says of Juneau County, one of the poorest and least healthy in the state. \u201cWhen I see that there\u2019s a need for something, it\u2019s on me to do something about that.\u201d\n\nShe says that is what happened with buprenorphine.\n\nExperts say buprenorphine effectively treats addiction, but the medicine is particularly scarce in rural communities. More than 10 million rural Americans \u2014 more than one-fifth of the country\u2019s rural population \u2014 live in counties without a single clinician licensed to prescribe the drug. (The rural-urban disparity in access has, however, shrunk since 2017.)\n\nIn Wisconsin, 18 of 72 counties lack a buprenorphine provider, and 14 of those unserved counties are rural, according to an analysis by Wisconsin Public Radio and Wisconsin Watch.\n\nToday Gatzke-Plamann is one of only two people in Juneau County licensed to prescribe buprenorphine. The other is a physician\u2019s assistant she supervises. They treat about 10 patients in this small part of their practice that kicked off in October 2018.\n\nAdding addiction treatment to a family medicine practice that was \u201calready at capacity\u201d is not easy, Gatzke-Plamann says. But she took on the challenge, seeing the need in her community.\n\n\u201cThat\u2019s sort of how it is with family medicine in a rural area,\u201d she says.\n\nCatina Stoflet is among the buprenorphine patients who benefit.\n\nStoflet, now 35, got hooked on prescription opioids as a 16-year-old in 2001, during the first wave of the nation\u2019s opioid epidemic. She started getting kidney stones in high school. She has had more than 200 of the painful obstructions by her count, leading to many surgeries to remove them.\n\nThat first prescription was for Tylenol 3, a combination of acetaminophen and the opioid codeine. But doctors soon escalated her to stronger drugs: vicodin, percocet, oxycodone.\n\n\u201cIt was right around the time that people didn\u2019t know what (opioids were) doing to you,\u201d Stoflet says.\n\nStoflet says she spent years in recovery, including from about 2007 to 2014, and participated in Narcotics Anonymous. But she relapsed in 2014, progressing to harder drugs including heroin and methamphetamine.\n\nThis year she decided to quit for good. Stoflet says her primary care doctor introduced her to Gatzke-Plamann, who had just recently begun prescribing buprenorphine.\n\nJust like Gatzke-Plamann\u2019s opioid patients, her buprenorphine patients must sign contracts laying out terms of treatment, including agreeing to participate in a treatment program.\n\nStoflet works with a counselor and community recovery specialist at the Roche-A-Cri Recovery Center in Friendship, Wisconsin, about 20 miles from Necedah. The center opened in September 2018. Without its additional resources, Gatzke-Plamann says she would not feel comfortable prescribing buprenorphine.\n\n\u201cI am just one part of their treatment plan,\u201d Gatzke-Plamann says. \u201cI prescribe the medication but they need the counseling. They need the psycho-social support. They need the group meetings.\u201d\n\n\u201cAll of that happens because the recovery center opened up.\u201d\n\nStoflet lives about 30 miles from Roche-A-Cri and 40 miles from Gatzke-Plamann\u2019s clinic in Necedah. Even so, Stoflet calls the long, frequent drives for recovery worthwhile.\n\n\u2018It might be rocky\u2019\n\nAt an appointment in early November, for example, Stoflet was nervous about an upcoming surgery that would require her to briefly pause her buprenorphine treatment and go back to opioids for pain. Her check-up allowed her to talk through the angst and walk through the steps with Gatzke-Plamann.\n\n\u201cWe would potentially take you off the buprenorphine and do short-acting pain medications around that time,\u201d Gatzke-Plamann says. \u201cThe trouble is then, after your acute pain episode from the surgery is no longer as significant \u2014 then we need you to stop those pain medicines for at least 24 hours. And then you can start up on your regular buprenorphine dose.\u201d\n\n\u201cSo I will be able to go right to the regular dose,\u201d Stoflet says, \u201cand I should be fine?\u201d\n\n\u201cYes,\u201d Gatzke-Plamann reassures, adding, \u201cit might be rocky.\u201d\n\n\u201cI know it\u2019s going to be \u2014it\u2019s no treat,\u201d Stoflet replies. \u201c\u2026That\u2019s really fine with me. I was just really worried about how we were going to do this.\u201d\n\nStoflet did end up on opioids briefly after her surgery in late November. Then she resumed her buprenorphine treatment, just like Gatkze-Plamann said she would. December marks seven months on her medication-assisted treatment journey.\n\nThe opioid epidemic is too complicated to boil down to grim statistics about overdose deaths or pills prescribed in any given county. Nor can the stories of one or two patients fully describe it. But the crisis is real across central Wisconsin and beyond.\n\nDr. Angela Gatkze-Plamann knows that because she confronts it every day.\n\n\u201cI couldn\u2019t imagine not doing it, because \u2014 then who would?\u201d\n\nThis story comes from a partnership of Wisconsin Watch, Wisconsin Public Radio and NPR. Bram Sable-Smith is WPR\u2019s Mike Simonson Memorial Investigative Fellow embedded in the newsroom of Wisconsin Watch (www.WisconsinWatch.org), which collaborates with WPR, PBS Wisconsin, other news media and the University of Wisconsin-Madison School of Journalism and Mass Communication. All works created, published, posted or disseminated by Wisconsin Watch do not necessarily reflect the views or opinions of UW-Madison or any of its affiliates.", "keywords": [], "meta_keywords": [""], "tags": [], "authors": ["Bram Sable-Smith"], "publish_date": "Wed Jan  1 00:00:00 2020", "summary": "", "article_html": "", "meta_description": "Opioid addiction is rife in rural communities like Necedah. How should a doctor respond?", "meta_lang": "en", "meta_favicon": "https://urbanmilwaukee.com/wp-content/themes/urbanmilwaukee_responsive/images/um_favicon.ico", "meta_data": {"viewport": "width=device-width, initial-scale=1, maximum-scale=1", "description": "Opioid addiction is rife in rural communities like Necedah. How should a doctor respond?", "author": "Bram Sable-Smith", "fb": {"app_id": 142344658820}, "og": {"site_name": "Urban Milwaukee", "description": "Opioid addiction is rife in rural communities like Necedah. How should a doctor respond?", "title": "One Doctor\u2019s Fight to Handle Opioid Crisis", "url": "https://urbanmilwaukee.com/2020/01/01/one-doctors-fight-to-handle-opioid-crisis/", "image": {"identifier": "https://urbanmilwaukee.com/wp-content/uploads/2020/01/rural_pain_management_10-1170x780-1024x683.jpg", "width": 1024, "height": 683}, "type": "article"}, "twitter": {"card": "summary_large_image", "site": "@urbanmilwaukee"}, "tec-api-version": "v1", "tec-api-origin": "https://urbanmilwaukee.com"}, "canonical_link": "https://urbanmilwaukee.com/2020/01/01/one-doctors-fight-to-handle-opioid-crisis/"}