Featured Articles: Pain Management/Opioids

Opioid Crisis: Sometimes it Takes Just One Pioneer

Tuesday, November 14, 2017   (0 Comments)
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By Lynn Gerlach, Tamarack Communication

- an interview with Dr. Thomas Tocher, Community Health Center of Snohomish County -


A half-million Americans are likely to die from opioid addiction or misuse in the next decade, according to STAT, a Boston Globe Media national publication dedicated to “fast, deep, and tough-minded journalism” from science, medicine and biotech sectors. STAT’s June, 2017, report tells of a Subway customer in Anchorage who dropped over while ordering his lunch and a Massachusetts mother sprawled in the aisle of a Family Dollar store.


NWRPCA began to report on this challenge in 2012, spurred on mostly by the work of Dr. Malcolm Butler of Columbia Valley Community Health. A few months ago we reprised the issue with a national and Northwest overview of this crushing burden, “What Follows ‘Hair on Fire’?” Today we begin a series of reports on six Region X health centers who have recently stared down opioids in their service areas and addressed the problem in a way appropriate to their own communities.


We begin this month with the story of one Washington pioneer who has been fighting for years for a better response to the opioid crisis.


“If the issue were polio, zika or anthrax, would anyone even question the need to take action? So why are people dragging their feet on the opioid addiction problem?” asks Tom Tocher, MD, Medical Director for CHCs of Washington’s Snohomish County. He was the ninth physician in the state of Washington to be buprenorphine waivered.


That was back in 2003. Today Washington has about 230 physicians licensed to provide Medication-Assisted Treatment (MAT) for drug-addicted patients. So why is the problem now worse than it was 14 years ago? Dr. Tocher is not particularly interested in “why.” He’s more interested in “how.”


“MAT should be part of routine primary care – it’s that simple,” Tocher says. “It’s the most gratifying work I do, and getting the waiver is now a lot easier than it was in 2003.” Practicing in North Everett, where the opioid and heroin addiction problem was evident well before 2003, Tocher treated addicted patients all the way from Seattle to the Canadian border. In the years 2012-2016, Snohomish County enjoyed the dubious honor of having more deaths per 100,000 residents from opioid overdose than any other Washington county.


Physician resistance is one of the biggest obstacles to solving the opioid addiction problem, Dr. Tocher believes. “Very few of Washington’s private primary care providers are waivered,” he said, “and it’s remarkable how many CHCs are also failing to step up. Few leaders have dropped the hammer on their providers. Once providers begin to offer MAT, they will be surprised at how many patients have been hiding their need for this kind of help.”

Tocher administers all the primary care programs for Snohomish CHCs except dental, but he retains a small clinical practice. When he saw the need for MAT and earned his waiver, he tried to interest other physicians in following suit. “I presented at NWRPCA conferences,” he explains, “but there was just no interest. I was glad to see the work Malcolm Butler was doing in the Wenatchee Valley some years later, but it’s been a real struggle to get my Washington colleagues involved.”


The health center now has six waivered providers, and they accept into their MAT practice only established health center patients. They don’t advertise their services on the Suboxone web site either. “We’d be overrun with addiction patients from outside our practice,” he explained.


Dr. Tocher has now established a sound program for safely managing all Suboxone patients. “Fourteen years ago it was a different story here,” he said. The state would cover only six months of buprenorphine; after that patients had to pay for it themselves. Chemical dependency treatment was not required for all opioid patients. “We lacked structure, and it was pretty frustrating.”


Today the health center focuses on accepting only highly motivated patients into the MAT program. To that end, they developed a screening checklist and hired a chemical dependency specialist as a “gatekeeper.” No prescriptions are issued at the intake visit, and treatment options discussed include inpatient treatment, Intensive Outpatient Program, and relapse awareness meetings. Patients who wish to go forward sign the Buprenorphine Management and Safety Agreement, are evaluated, and are then are scheduled with a CHC buprenorphine-waivered provider. Then begin the appointed 20-minute meetings: Weekly visits until stable - usually 4‐8 weeks; biweekly visits for 2-4 months; monthly visits after that.


“We also adopted Dr. Butler’s opioid review committee for managing chronic pain patients,” Dr. Tocher explained. The committee includes Tocher (the Medical Director), another MD, a PA, a pharmacist, a behavioral health specialist and the QA manager. Each member is responsible for reviewing 4-6 patient charts monthly. Then the group meets regularly to quickly review each opioid patient, spending more time on those that have been marked as worrisome.


In September the health center received a $175K AIMS grant to expand its program. This will allow Dr. Tocher to have all his providers buprenorphine waivered by next July, supply Narcan kits to uninsured patients, pay for urine drug screens as necessary, and purchase pain management educational material for indigent patients.


CHCs of Snohomish County have had success. Recently Senator Patty Murray visited the Everett Clinic, and one of the program’s original patients told his story. Happily, he is now tapering off Suboxone, on his way to full recovery. Together the primary care staff has reduced the number of patients on very high MEDs and significantly lowered the risk of addiction. “We’re here to respond to our community’s needs,” Dr. Tocher said. “It was a patient who first encouraged me to get my waiver nearly 15 years ago, because he needed my help. I’m glad I did it.”



NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.


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