Featured Articles: Pain Management/Opioids

What Follows "Hair on Fire"?

Thursday, August 10, 2017   (0 Comments)
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Lynn Gerlach, Tamarack Communication

 

Prescription overdoses killed more Americans across all demographics in 2014 than in any other year previously on record. By 2016, the opioid addiction problem had definitely captured the nation’s attention. By 2017, “drug overdoses now kill more people than gun homicides and car crashes combined,” according to the President’s Commission on Combating Drug Addiction and the Opioid Crisis. Unfortunately, the Northwest’s situation is no different from that of the rest of the country.

 

I well remember how HRSA Region X was dealing with this plight five years ago. In November of 2012 I posted an article to NWRPCA’s news database, via this very newsletter, referring to a “hair on fire” situation. If our hair should have been on fire then, how on earth are we to characterize the prescription opioid crisis we face today?

 

“Hair on fire” was my paraphrase of Gary Franklin, MD, MPH, Research Professor at the University of Washington and Medical Director for Washington State Department of Labor and Industries. Dr. Franklin had declared at the first National Opioid Summit, sponsored by Group Health Research Institute in Seattle, “our hair should be on fire.”

 

He had rung the alarm bell in 2006 because Washington’s workers’ compensation claims revealed three startling facts: 32 injured workers subsequently on opioid painkillers had died of overdoses of their prescription drugs; the number of Washington workers taking large quantities of opioids had grown to 10,000; and the dosages had increased by more than 50%. Dr. Franklin mobilized the state’s experts, and ultimately Seattle was the site of the first national opioid summit.

 

Even before that summit was convened, Washington had become the first state in the union to lay down opioid prescribing guidelines. Group Health (now Kaiser Permanente) had already reduced by half the percentage of its patients on high-dose opioids and had cut the average daily dose by a third. The University of Washington Pain Clinic, which had traditionally used alternative methods to treat pain such as counseling and physical therapy, was already considering a return to such practices in lieu of too much high-dose opioid prescribing. We felt that we were making progress; the summit was a positive event. What on earth happened?

 

What seemed like a crisis five years ago now almost feels like the good old days. Every one of Region X’s four states (Alaska, Idaho, Oregon and Washington) has been touched by this calamity. The good news is that each of those states has confronted its problem and taken action, and we can be cautiously optimistic that things might be starting to turn around – since they got a whole lot worse over the past five years.

 

Today we’ll take a look at the epidemic nationally and, for the Northwest, state-by-state. Next we’ll find out what our Region X health centers are doing to address the problem and how it is affecting them. (At the end of this article, please find a link to express your interest in sharing your CHC’s story.)

The National Landscape

In January the New York Times called opioid addiction “America’s 50-state epidemic.” Even five years ago, opioid painkillers were the most widely prescribed class of medication in the U.S. A mission of mercy, encouraged by drug makers who swore these medications were most unlikely to become addictive, and enhanced by pressure to question every patient about pain level and do the humane, compassionate thing - prescribe opioids - had become a force of death and destruction. In the early years of the new millennium, sales of painkillers had doubled.

 

In June 2015, Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, said that in 2012 American doctors wrote 259 million prescriptions for painkiller medication, enough to give every single adult in the United States a personal bottle of pills. The President’s Commission has just given us a new, jaw-dropping perspective on that statistic: “Americans consume more opioids than any other country in the world. In fact, in 2015, the amount of opioids prescribed in the U.S. was enough for every American to be medicated around the clock for three weeks.” And it turns out that people addicted to prescription opioids are 40 times more likely to become addicted to heroin, which is often much cheaper and more readily available. Now federal funding for states to address the opioid crisis is at an all-time high.

 

According to the CDC, in 2015 91 Americans died every day from an opioid overdose. That figure included both prescription opioids and heroin. More than 60% of drug overdose deaths involved an opioid. In fact, the number of such deaths had quadrupled in 15 years, keeping pace with the growing amount of opioid being prescribed in the US, although the amount of pain reported by Americans had not changed significantly.

 

The trend that has been building for years simply cannot be denied. From 1999 to 2008, overdose death rates and substance use disorder treatment admissions related to prescription pain relievers increased in almost lock-step with the growing sales of prescription opioids. The overdose death rate in 2008 was nearly four times the 1999 rate; sales of prescription pain relievers in 2010 were four times those in 1999; and the substance use disorder treatment admission rate in 2009 was six times the rate just ten years before.

 

How is it that sales of opioid painkillers remain strong? The Washington Times reported on September 18, 2016: “A joint investigation by The Associated Press and the Center for Public Integrity found that drug makers that produce opioid painkillers and allied advocacy groups spent more than $880 million on campaign contributions and lobbying over the past decade as they worked to influence state and federal policies. The groups have an array of political interests that include opioid advocacy, and their spending was eight times that of the gun lobby during the same period. By comparison, groups advocating for limits on opioid prescribing spent about $4 million.”

 

The report continues: “The AP and Center for Public Integrity found that drug makers and allied groups employed an annual average of 1,350 lobbyists in state capitals around the country and contributed to a total of 7,100 candidates for state-level office.” Again the President’s Commission, in its first draft interim report, gives a stark explanation of the results: “Half a million Americans died of drug overdoses between 1999 and 2015. Fewer than 20% of the over one million prescribers licensed to prescribe controlled substances to patients have training on how to prescribe opioids safely.” And that’s a snapshot of the situation across the country.

And in the Northwest? Let’s begin with Idaho

A drug treatment center is probably not the most objective source of information on this topic. Still, Northpoint Recovery in Boise, Idaho, makes a good point, and is in a position to know: “Idaho, which ranks 39th in the country for population, ranks #4 when it comes to the non-medical use of prescription painkillers among individuals aged 12 years or older.” In 2013 Idaho suffered 8 drug overdose fatalities per 100,000 people, which, to some states, doesn’t sound like a lot. But consider that it was double the Idaho rate in 1999. According to the Idaho Press, the Substance Abuse and Mental Health Services Administration estimates that illicit, over-the-counter, or prescription drug abuse kills an Idaho resident every 45 hours.

 

A 2013 report by Trust for America’s Health, Prescription Drug Abuse: Strategies to Stop the Epidemic, asserted that prescription opioids accounted for 62% of all seized controlled medications in 2015, and the amount of heroin seized by Idaho State Police jumped 800% between 2014 and 2015.

 

Just a few months ago Idaho’s Public Health Administrator, Elke Shaw-Tulloch, MPH, penned a disconcerting report in the Idaho Statesman about the prescription opioid abuse scenario the state faces today: There were 218 Idahoans who died from drug overdose in 2015. An alarming fact during that same year was that Idaho had one of the highest percentages (36 percent) of drug overdose deaths related to prescription drugs.” Shaw-Tulloch provided a catalogue of alarming facts, including these: “The annual number of drug-induced deaths more than doubled, from 111 deaths in 2004 to 227 deaths in 2013. During that same time, Idaho’s overall drug-induced death rate increased by 76.7 percent, while the national rate increased by 40 percent, with more than half of the drug-induced deaths being the result of an accidental poisoning.”

 

It can be hard to keep all the statistics and timelines clear, but it seems that all sources agree on one thing: Idaho has not escaped the epidemic.

 

Alaska Got Tough this Year

Alaska actually declared a state of emergency (which is just what the President’s Commission is now urging President Trump to do – nationwide). In May of 2016 the state created the Alaska Opioid Policy Task Force, co-facilitated by the state’s board on alcoholism and drug abuse, the Division of Public Health, and the state’s Mental Health Trust Authority. In January of 2017, the task force announced its twelve areas of focus, which included roles for law enforcement, insurance and Medicaid. They emphasized access to detox services, harm reduction practices, public education, and much more – all consistent with efforts across the country.

 

Among the final recommendations of the Alaska task force are these: Communities should establish convenient medication take-back and disposal programs. Collaborating authorities should work to prevent opioid importation on bush airlines, small planes, ferries, boats and other transportation unique to Alaska. Continue to optimize the Prescription Drug Monitoring Program (PDMP) and incentivize prescribers, recruiting as many prescribers to the program as possible. Health plans, both public and private, should reimburse alternatives to narcotic pain management.

 

Children and school-based programs should be targeted for risk reduction, including policies to prevent and mitigate the impacts of adverse childhood experiences. SBIRT is to take a front seat, promoted and reimbursed by health insurers. Mental Health First Aid classes are to be included in the Alaska State Trooper Academy curriculum. Pain management specialists are to be reimbursed for screening patients for depression or other mental health disorders that might be exacerbating pain and should provide warm hand-offs to mental health treatment.

 

The task force urged that Alaska adopt a chronic disease management framework for substance use disorder treatment policies and reform. The cost of Medication Assisted Treatment (MAT) such as buprenorphine therapy is to be reimbursed by payers. Further recommendations of the task force involve harm reduction, syringe exchange and payer reimbursement for recovery.

 

That report was published in January. In February Governor Bill Walker declared opioid abuse a public health disaster for Alaska, and in March he introduced legislation to change the way opioids are prescribed and monitored. The bill included these significant provisions:

  • Patients are to be given an opportunity to turn down opioids while in medical care.
  • Medical providers must earn continuing education in pain management and opioid addiction.
  • The initial prescription for opioids will be limited to no more than a seven-day supply for outpatient use.
  • Doctors must discuss the risks of opioid abuse with parents before prescribing to a minor.
  • The Board of Veterinary Examiners must educate veterinarians on the signs of opioid abuse in pet owners and participate in a prescription database.
  • The prescription drug database is to be updated daily instead of weekly. Additionally, it allows for disciplinary action against pharmacists or practitioners who do not review the database as required under current law.

In May 2017 Alaska received a $2 million federal grant to combat opioid abuse, and the Governor’s bill was approved by the state legislature. It’s still early in Alaska.

 

So, How Fares Washington?

Remember, this is the state that established those groundbreaking prescribing guidelines as far back as 2007 when the Department of Labor and Industries saw the handwriting on the wall. Actually, statistics show the prescribing guidelines did work: Deaths from prescription opioids peaked in 2008 at 512 and then steadily declined. And then death by heroin overdose doubled. The scourge morphed, but it didn’t go away.

 

In the spring of 2015, the University of Washington Alcohol and Drug Abuse Institute (ADAI) presented Opioid Trends across Washington State. The report compared data from the period of 2002-2004 with data from 2011-2013, and the news was not good. Crime lab data for police evidence testing involving opiates indicated an 85% increase statewide. Publicly funded drug treatment admissions for opioids as the primary drug increased 197% statewide, with increases in 38 of 39 counties. Drug-caused deaths involving opioids increased 31% across the state.

In November of 2015, the Washington Department of Health corroborated those sad findings in a report entitled Opioid Epidemic Continues in Washington. “Heroin killed 293 people in Washington last year, about twice as many as in 2008,” the report stated. “The state has set aside $6 million in new funding to treat opioid addiction, including medication-assisted treatment (MAT). Washington will also receive $3 million in federal funding to provide treatment services over the next three years. In addition, tax funding from retail marijuana sales will support an expansion in adolescent treatment and community-based prevention services.”

 

This Washington DOH report offered some statistics we hadn’t seen before: “Deaths from prescription narcotics are highest in the 45- to 54-year-old age group. In comparison, 25- to 34-year-olds have the highest heroin death rate. The largest increase in heroin overdose deaths from 2004 to 2014 occurred in the 15- to 34-year-old age group. Many heroin users first misuse prescription narcotics such as hydrocodone and oxycodone; the switch to heroin likely occurs because heroin is cheaper and easier to get.”

In October 2016, Governor Jay Inslee issued an executive order declaring opioid use a public health crisis. Citing two deaths in the state, on average, each day from opioid overdose, Inslee outlined this response plan, similar to Alaska’s:

  • Improve prescribing practices to prevent opioid misuse.
  • Expand access to treatment for opioid dependence.
  • Distribute naloxone to prevent deaths from overdose.
  • Optimize and expand data sources to monitor and evaluate the situation.

At the same time, Northpoint Recovery, mentioned in our Idaho discussion, published some interesting data about the Washington cities and counties most affected by the opioid crisis, in some cases drawing on the University of Washington data cited above. Here is a sampling:

  • Publicly funded admissions for drug overdose increased by 81% in King County from 2002 to 2013, and opioid related deaths increased by more than 21%.
  • During that same period (2002-2013) publicly funded admissions for drug overdose increased more than 188% in Spokane County. Fatal drug overdoses killed 73 people in 2013 and 104 in 2014, and heroin deaths, specifically, tripled in that one year.
  • Pierce County during that time saw an increase in publicly-funded treatment admissions of more than 152% and a 32% increase in opioid deaths. From 2005 to 2014, the county had a total of 704 fatal opioid overdoses. 129 people in the area sought treatment for the first time for opioid addiction in 2002, but by 2015, that number had shot up to 438.
  • In Bellevue, in 2010, first responders had to administer the anti-overdose drug Narcan 49 times. For the last three years, though, Narcan has been administered approximately 75 times a year, and treatment admissions are up 360% in Bellevue since 2012.
  • On National Prescription Drug Takeback Day, Kent police collected over 300 pounds of excess medication.
  • Since 2011, 134 people in the Yakima area have died of overdose. Publicly-funded treatment admissions for Yakima County increased by over 50% since 2002.
  • In 2013, the Thurston County Syringe Exchange Program collected more than 1 million used needles.

According to the UW ADAI, total hospital admissions for opiates, including heroin, in Washington State were just under 4000 at the turn of the millennium; in 2015 such admissions stood at 14,000+. There doesn’t seem to be any good news out of Washington State at this time.

Oregon is Complicated

The news in this state is both good and bad. Oregon has had a Prescription Drug Monitoring Program (PDMP) since 2011 and is also funded by the CDC for its Core State Violence and Injury Prevention Program (CSVIP). The CDC includes Oregon as one of four states successfully implementing PDMPs (along with Florida, Tennessee and New York). The Oregon Health Authority reported a 38% decline in prescription opioid overdoses between 2006 and 2013, work accomplished through its CDC-funded CSVIP.

Still, new data from Oregon’s Prescription Drug Monitoring Program (PDMP) shows that prescribed opioid use is pervasive among Oregonians. In 2013, almost 1 in 4 Oregonians received a prescription for opioid medication, and in a recent national survey, Oregon ranked second among all states in non-medical use of pain relievers (i.e. prescription pain medication).

 

Unlike nearly every state that has experienced a surge in prescription opioid deaths, the mortality rate in Oregon has begun to decrease. The PDMP is focused on helping health care providers assess the controlled substances prescription history of their patients, and to identify concerning behaviors (e.g. multiple prescriptions from multiple providers and pharmacies, high doses of opioids or opioids for extended periods of time, etc.) that lead to substance misuse or overdose. Nevertheless, the overdose death rate in 2013 remains 2.8 times higher than in 2000.   

 

According to the Oregon Health Authority’s dashboard:

  • Opioid prescribing over the past five years has remained fairly steady, with a slight uptick in 2014-2015 and a gradual decline over 2016.
  • Opioid overdoses climbed steadily from 2000 to 2011 and then began a gradual decline through the next three years.
  • Deaths from prescription opioids climbed rapidly from 1999 to 2006 and then declined overall – not necessarily steadily – until 2013 when they began another gradual climb.
  • Since early 2014, opioid prescriptions for patients aged 45 to 65 have declined most dramatically, although prescribing for all ages has been on the decline with the exception of patients over 75. That rate has not been steady and is, today, not much lower than it had been in early 2014.

Oregon Live reported in July of this year that “Oregonians age 65 and up are landing in the hospital for opioid overdose, abuse, dependence and adverse effects at a greater rate than any other state.” The report indicated that Washington and California are also seeing high hospitalization rates for seniors taking Vicodin, OxyContin, and Percocet. But “Oregon’s rate has tripled in the past decade.” Oregon Live reporters note that healthcare leaders in the state were surprised to learn of this fact, revealed by a national AHRQ study.

 

It is important to note that Oregon’s population is aging overall, and that, for those aged 45-65, opioid prescriptions per capita dropped by seven percent last year. Still, a comparison of U.S. Census data and Oregon prescribing data suggests the opioid prescribing rate for seniors is equal to 1.6 prescriptions for every senior in the state. And as far back as 2010 Oregon’s younger citizens, aged 18-25, had the highest rate of prescription abuse in the country. This year Oregon is getting an extra $7 million from the feds to deal with opioid addiction and overdose.

 

While opioid prescribing dropped in most Oregon counties between 2010 and 2015, four counties had an increase in opioid prescribing over that period. The top ten Oregon counties for morphine equivalent milligrams (the standard way of measuring opioid potency) per capita are all rural. Curry County takes the number 1 position, followed in descending order of milligrams per person, by Baker, Malheur, Union, Tillamook, Lincoln, Coos, Josephine, Clatsop, and Jackson counties.

 

In July KGW’s Sara Roth wrote an article that focused on rural Oregon: New data reveals Oregon’s opioid epidemic still dire in rural counties. She reported that Oregonians in rural counties are far more likely to be prescribed opioids and, with higher unemployment rates, lower incomes and less access to treatment centers, those who become addicted have more difficulty fighting back. According to the CDC, Oregon, like the rest of the country, saw a decrease in overall opioid prescribing from 2010 to 2015, but that drop was not consistent across the state.

 

Oregon’s urban counties, such as Multnomah, Clackamas and Washington, had far lower prescribing rates than most rural counties. Morrow, Wallowa, Malheur and Union counties, on the other hand, all had more opioid prescriptions in 2015 than in 2010. Baker, Umatilla, Crook and Jefferson counties all saw their numbers stay about the same. “The worst county for prescriptions is in deep southern Oregon,” Roth reported. “Curry County’s prescription numbers aren’t just high for Oregon. It’s the 74th worst county in the U.S. for opioid prescriptions. Opioids aren’t the only drugs doctors are prescribing, either. State data shows Curry County has the highest rate of benzodiazepine prescriptions, with 133 prescription fills per 1,000 residents in the first three months of 2017. Curry County is also the county with the second most muscle relaxant prescriptions, second-most methadone prescriptions and fourth highest non-benzodiazepine sedatives.

 

“Residents of Curry County struggle with high unemployment rates… and relatively low income… Rural counties often have less access to treatment centers and alternative pain management therapies, so doctors may prescribe at higher rates because fewer options are available.”

 

Roth interviewed Dwight Holton, the CEO of Lines for Life, which runs Oregon’s drug and alcohol health line and suicide crisis line. Holton said “someone who is prescribed opioids for 30 days has a 47 percent chance of still being on those prescribed drugs three years later. People who have a 90-day prescription have a 60 percent chance of being on opioids five years later.”

 

Alas, Oregon seems to be in the same boat as the rest of the Northwest. Clearly, we have not solved the problems of prescription opioid use, misuse, abuse and overdose. But there is that new President’s Commission on Combating Drug Addiction and the Opioid Crisis.

 

The Outlook for our Country

 

As noted above, the Commission has very recently submitted its first draft interim report to President Trump. Its recommendations are summarized below:

 

1.       Declare a national emergency under either the Public Health Service Act or the Stafford Act.

 

2.       Rapidly increase treatment capacity, including grant waiver approvals for all 50 states to quickly eliminate barriers to treatment resulting from the federal Institutes for Mental Diseases DRAFT 3 (IMD) exclusion within the Medicaid program. The Secretary of HHS “should be empowered to immediately grant waivers to each state that requests one. This is the single fastest way to increase treatment availability across the nation.”

 

3.       Mandate prescriber education initiatives with the assistance of medical and dental schools across the country to enhance prevention efforts. “Amend the Controlled Substance Act to require all Drug Enforcement Administration (DEA) registrants to take a course in proper treatment of pain. The commission cites “a lack of education on these issues in our nation’s medical and dental schools and a dearth of continuing medical education for practicing clinicians.” Implement the same initiatives New Jersey has just adopted, which require providers to take continuing education related to opioids and prescribers to discuss the risks of opioid dependence with their patients prior to the first prescription.

 

4.      Immediately establish and fund a federal incentive to enhance access to Medication-Assisted Treatment (MAT). “Require that all modes of MAT are offered at every licensed MAT facility and that those decisions are based on what is best for the patient.” The report notes that only 10% of conventional drug treatment facilities in the US provide MAT for opioid use disorder. CMS “should require all federally-qualified health centers (FQHCs) to mandate that their staff physicians, physician assistants, and nurse practitioners possess waivers to prescribe buprenorphine.”

  

5.      Provide model legislation for states to allow naloxone dispensing via standing orders, as well as requiring the prescribing of naloxone with high-risk opioid prescriptions. Put naloxone “in the hands of every law enforcement officer in the United States.” And better explain the “Good Samaritan” law to all Americans.

 

6.       Develop fentanyl detection sensors and give them to all DHS Customs and Border Protection, FBI, and DEA officers. “Fentanyl defies detection at our borders,” the report states, and it comes “predominantly through China.”

 

7.      Enhance interstate data sharing among state-based prescription drug monitoring programs (PDMPs). Ensure federal health care systems, including Veteran’s Hospitals, participate in state-based data sharing. “Direct the VA and HHS to lead the effort.”

 

8.      Better align patient privacy laws specific to addiction with HIPAA to ensure that information about SUDs be made available to medical professionals treating and prescribing medication to a DRAFT 8 patient. Lack thereof “is a particular hindrance to comprehensive health care.”

 

9.      Enforce the Mental Health Parity and Addiction Equity Act (MHPAEA) with a standardized parity compliance tool to ensure health plans cannot impose less favorable benefits for mental health and substance use diagnoses versus physical health diagnoses. “…not providing real parity is already illegal. The Commission urges you to direct the Secretary of Labor to enforce this law aggressively and to penalize the violators.”

 

What next? Region X community health centers are urged to email the author, offering input for next month’s article on how the health centers in our region are addressing this “50-state epidemic,” the challenges they face and the successes they have realized.

 

 

 

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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