Opioids
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Countering the problem of opioid
addiction
The United States is in the middle of a public health epidemic, with more than 40 people dying each day from prescription opioid overdoses. Health care systems across the nation are racing to implement policy and practice interventions to address the epidemic. At Kaiser Permanente, our Safe and Appropriate Opioid Prescribing Program has been one of our most successful efforts to confront the problem — not only for our members, but in the communities we serve.
The principle behind the program
In 2009, our physicians looked at the most frequently prescribed drugs for Kaiser Permanente members in Southern California. They were surprised to find that drugs for hypertension and diabetes were not at the top of that list. Instead, opioid medicines and highly addictive narcotics were the most common. In addition, people were getting prescriptions at higher doses than we had previously seen.
Around the same time, new research was being published on the hazards and ineffectiveness of opioids for the management of chronic pain. Given all this evidence, we decided we needed to break the cycle and find alternatives. Rather than risk patients being addicted and overdosing, we would seize the opportunity to improve the quality and safety of drug prescribing at Kaiser Permanente.
Starting in 2010, we launched the Safe and Appropriate Opioid Prescribing Program, a comprehensive initiative to transform the way that chronic pain was viewed and treated. We implemented several efforts to reduce opioid prescriptions, including prescribing and dispensing policies, monitoring and follow-up processes, and clinical coordination through our electronic health record system.
Changing prescribing patterns
Through this program, we’ve effectively and appropriately reduced:
- Prescription of high-risk, long-acting opioids
- Prescription of opioids at high doses and in large quantities
- The combined prescription of opioids with carisoprodol (known as Soma) or Benzodiazepine
Results continue to demonstrate that the program is reducing overprescription of opioids and reducing the risk of overdose and death in our members.
Beyond protecting our members, Kaiser Permanente’s focus on prescribing the lowest effective dose and supply has helped reduce the risk of opioids getting to the street. We know that unused medications in the medicine cabinet can find their way into our communities.
Caring for chronic pain
According to current clinical evidence and the Centers for Disease Control and Prevention (CDC) guidelines, opioids are not effective in treating chronic pain. Therefore, Kaiser Permanente has turned to a more multidisciplinary approach. We focus on making sure patients get the most effective treatments based on current evidence. This could include non-opioid medications, physical therapy, acupuncture, exercise, injections, cognitive behavioral therapy, and other methods.
After implementing the Safe and Appropriate Opioid Prescribing Program across Southern California, patients themselves reported feeling generally positive about our new approach to pain management. Many are, in the end, feeling better once they are off the very large doses of opioids they were on in the past.
Replicating this program across the country
As a result of a systematic and comprehensive set of
strategies and tactics over several years, we’re seeing
similar results in other states where Kaiser Permanente
operates. We’re encouraged for the long term because
other health care systems could implement this program,
too.
Source: https://thrive.kaiserpermanente.org/thrive-together/live-well/countering-the-problem-of-opioid-addiction?wt.tsrc=email_pih&cat=2d_coverage
What drugs are the most commonly
abused?
Each year, the National Institute on Drug Abuse (NIDA)
tracks drug use trends among high school students (8th, 10th
and 12th grades) through the Monitoring the Future Study
(MTF). The following is a list of the most commonly abused
drugs among 12th graders, starting with the most frequent:
marijuana, Adderall, Vicodin, tranquilizers, cough medicine,
sedatives, hallucinogens, MDMA/ecstasy, OxyContin, cocaine,
salvia and Ritalin.
Source: www.ncadd.org/about-addiction/underage-issues/frequently-asked-questions-from-young-people
Oregon has
one of the highest rates of prescription opioid misuse in
the nation
In Oregon, more drug poisoning deaths involve prescription opioids than any other type of drug, including alcohol, methamphetamines, heroin and cocaine. An average of 3 Oregonians die every week from prescription opioid overdose, and many more develop opioid use disorder.
Partners across Oregon are working to reduce this epidemic. We have made recent progress, but there is more work to be done.
- What you should know about opioid pain medication
- Naloxone can save a life
- For health care professionals and CCOs
Getting Help
Opioid use disorder can be treated
Talk to your health care provider or visit the links below for treatment resources.
- Substance use helpline: 1-800-923-4357 or text "SOS" to 741741
- Opioid treatment program directory
- Southern Oregon treatment and recovery resources
- Oregon Addictions and Mental Health Services (AMH)
Pain management resources
- Oregon Pain Guidance website
- PainWise website (Benton, Lincoln and Linn counties)
- Chronic disease self-management programs
- How to manage your pain safely and effectively (CDC website)
- Understanding pain and what to do about it (6:00 video from the Department of Defense and Veterans Health Administration)
Publications
- Prescription Drug Poisoning/Overdose in Oregon (1 page PDF)
- Prescribing and Overdose Data Dashboard for Oregon
- Oregon Prescription Drug Monitoring Program website (31 page PDF)
Partners
Addressing the opioid epidemic involves many local, state and national partners. In Oregon, our Opioid Initiative Partnership includes the following groups:
In Oregon
- Coordinated Care Organizations
- Emergency Departments
- Local Public Health Departments
- Curry County
- Opioid Treatment Programs in Oregon
- Oregon Chapter of the American College of Emergency Physicians
- Oregon Coalition for the Responsible Use of Medications
- Oregon Health Leadership Council
- Oregon High-Intensity Drug Trafficking Areas Program
- Oregon Medical Association (40 page PDF)
- Oregon Pain Management Commission
- Pain Management Clinics
- Public Safety
Source: www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Pages/index.aspx
Top 10 Oregon counties for prescribing opioids
The top 10 counties in Oregon for opioid prescriptions
Opioid prescriptions dropped in most Oregon counties between 2010 and 2015, according to new federal data.
But there were four outliers: Malheur, Morrow, Union and Wallowa counties, where providers handed out more opioids per capita in 2015 compared with five years prior, according to data obtained by The Oregonian/OregonLive from the U.S. Centers for Disease Control and Prevention. The top 10 prescribing counties on a per capita basis were in rural parts of the state.
Though prescribing is dropping, the dips are not the same across the board. Oregon leads the country in seniors who are hospitalized for opioid abuse, dependence, overdose and adverse effects.
No. 1 Curry County is the top opioid prescriber in Oregon: 1,800 morphine milligram equivalents per person.
No. 2 Baker County ranked No. 2 on the CDC list, with 1,612 morphine milligram equivalents prescribed per person in 2015.
No. 3 Malheur County came in third, with nearly 1,600 morphine milligram equivalents prescribed per capita in 2015.
No. 4 Union County came in fourth in the CDC rankings, prescribing just over 1,560 morphine milligram equivalents per capita in 2015.
No. 5 Tillamook County providers handed out about 1,550 morphine milligram equivalents per capita in 2015, making it No. 5 on the list of opioid prescriptions per county in Oregon.
No. 6 Lincoln County In the CDC data, Lincoln County ranks No. 6 in Oregon, with about 1,540 morphine milligram equivalents prescribed per capita in 2015.
No. 7 Coos County came in seventh in the CDC data, with nearly 1,480 morphine milligram equivalents prescribed per capital in 2015.
No. 8 Josephine County came in as No. 8 in the CDC data, with about 1,420 morphine milligram equivalents prescribed per capita in 2015.
No. 9 Clatsop County came in ninth in the CDC data. Prescribers gave out nearly 1,410 morphine milligram equivalents per capita in 2015.
No. 10 Jackson County Rounding out the list of the
top 10 counties in terms of opioid prescriptions is Jackson
County. Prescribers there handed out about 1,340 morphine
milligram equivalents per capita in 2015.
Source: www.oregonlive.com/health/index.ssf/2017/07/oregons_rural_counties_have_hi.html
Oregon leads U.S. in seniors
hospitalized for opioids
The opioid epidemic sweeping the country has taken a heavy toll on older people in Oregon as nowhere else – an unexpected trend that has caught doctors by surprise.
Oregonians age 65 and up are landing in the hospital for opioid overdoses, abuse, dependence and adverse effects at a greater rate than any other state, federal figures show.
A dozen other states including Washington and California also show seniors with high hospitalization rates for opioids, including Vicodin, OxyContin and Percocet.
But Oregon's rate has nearly tripled in the past decade. The state has outpaced the country for three straight years – climbing to a peak of 700 hospitalizations per 100,000 elderly patients in 2015. That translates to 4,500 people.
Addiction specialists didn't anticipate such stark results from data collected by the U.S. Agency for Healthcare Research and Quality and are calling for deeper study to figure out why.
"This is not something we can blow off," said Dr. Shorin Nemeth, regional medical director for palliative care at Providence Health and Services. "This is a vulnerable population."
Nemeth had no idea about the problem until contacted by The Oregonian/OregonLive. Startled to see the statistics, he talked to peers outside Providence. They had no clue either, he said.
Public health officials in Oregon are aware of opioid abuse among older people, but they haven't taken a step back to look at what's driving the phenomenon or told providers what to do about it. They're focused instead on curbing opioid use overall.
"It appears that we are moving in the right direction but we're not there yet," said Dr. Katrina Hedberg, the state epidemiologist and health officer. "We're hoping that prescribing fewer opioids will lead to fewer people who are hospitalized."
Two factors might make Oregon stand out: Doctors have continued to prescribe more opioids to older people and the state has been a national leader in encouraging more liberal use of medication for pain.
It's also possible that old age and the kinds of drugs prescribed to seniors are contributing to the spike. Some opioids are more powerful than others. Some linger longer in the body. Dose is important, too. As is the health condition of the patient.
"Anytime we see increased rates among certain populations or increased rates over time, that's something that needs to be looked at closer," said Gery Guy, a health economist and opioid specialist at the U.S. Centers for Disease Control and Prevention. "It is very concerning."
*This rate does not incllude emergency room visits
''Worst pain" in my life
Jerry Hall took 100 milligrams a day at the height of his opioid addiction — five times the normal amount.
Like many people, he started relying on prescription medication for chronic pain but slowly slid into addiction.
Now 60 and living in Southwest Portland, Hall first developed back pain three decades ago when a ram charged at him on a farm in Newberg and threw him 40 feet into the mud.
"I didn't know where I was for a few minutes," Hall said.
Sometimes his pain was so severe that he couldn't work for days as a truck driver. His doctors prescribed Vicodin, he said, but he didn't get addicted.
That changed after a hernia surgery in 2010 and subsequent pain in his left hand. He suspects it was related to a misplaced intravenous line.
"It was the worst pain I'd had in my whole life," Hall said. "It felt like it had its own heart beat."
The agony didn't go away. His doctors gave him oxycodone, a common opioid.
The drug helped dull the persistent throbbing but his hand didn't heal.
The prescriptions kept coming.
Opioids pushed for pain
Oregon has been at the forefront of a movement to control people's pain, including an early emphasis on palliative care and hospice services.
When Hall first got injured, opioids were becoming more widely used as pain treatment in Oregon and nationwide.
In 1995, Oregon passed a pain treatment act, which protected doctors from discipline when they prescribed opioids for severe pain, provided they followed the law. The following year, the American Pain Society launched a nationwide campaign that called on doctors and nurses to ask people about their level of pain. This has become a routine medical practice.
State medical groups, accrediting bodies and even federal drug regulators encouraged the use of opioids for pain.
A national epidemicEvery day, 1,000 people of all ages across the country are treated in emergency rooms for misusing prescribed opiates.
Besides the human toll, prescription opioids cost the United States nearly $79 billion a year.
In 2015 (latest data available):
- Nearly 13,000 people died from heroin, including 102 in Oregon
- About 15,000 people died from overdoses on prescription opioids
- 2 million had prescription opioid use disorder
Source: U.S. Centers for Disease Control and Prevention.
The drugs mask symptoms by attaching to receptors in the brain. They block pain, slow breathing and have a calming effect.
"Those of us who were doing medical training in the '90s got a heavy dose of it," said Dr. Todd Korthuis, an addiction treatment specialist at Oregon Health & Science University.
Oregon doctors, often on the leading edge of palliative care, were generous in prescribing.
"We were all awash with it when I started here in 2002," Korthuis said. "Over half of my clinic patients were prescribed opioids."
He suspects the current rates stem from Oregon's liberal prescribing practices years ago. Providers, with a push from medical leaders and drug companies, didn't question how many pills they were prescribing. They were focused on treating pain.
"It was all about compassionately taking the best possible care of the patient as the field understood it," Korthuis said.
Opioid prescriptions in Oregon have dropped but not across the board.
An analysis by The Oregonian/OregonLive shows that the raw number of prescriptions for seniors rose slightly in 2016 compared with 2015. But the older population grew overall, pushing down the per-capita prescription rate by 4 percent.
For people 45 to 64, opioid prescriptions per capita dropped 7 percent among a population that stayed steady. That signals the efforts to stem prescriptions for this group are taking hold.
In 2012, Oregon providers handed out nearly 820,000 opioid prescriptions to those 65 and older. That jumped to 1.1 million in 2016, or 1.6 prescriptions per senior, according to the analysis of U.S. Census and state data.
Snagged for cheating
Jerry Hall's doctors became concerned about his continued opioid use around 2012, the same year he went on disability because of various health issues.
They put him on a monitoring program, made him sign an agreement to take only prescribed pills and introduced random urine testing to ensure he wasn't downing other narcotics.
They prescribed 20 milligrams of oxycodone a day, he said. He emptied the bottle in a couple of weeks. To fill the gap, he said he snagged pills from family, friends and neighbors. Some were free. Others cost up to $10 each.
Eventually, he got caught cheating.
In 2013, during a random urine test, doctors found unprescribed methadone in his system and they stopped his prescriptions.
Hall went into severe withdrawal.
"First you're freezing, then you're burning up," he said. "I couldn't have anything touch me. I couldn't lay down. I couldn't sleep."
He couldn't even hold his beloved cats.
He tried to quit but the symptoms raged, sometimes for four days at a time. With no idea how long they would last, he devoted his life to getting more pills.
He paid his rent and fed his cats. He spent all the rest on opioids, even eating from food pantries.
Hall's experience is far from unique, said Dr. Bryan Dixon, an addiction psychiatrist at Cedar Hills Hospital, a behavioral health treatment center in Portland.
"It doesn't matter if you're 18 or 80," Dixon said. "Once you're dependent, opiates are incredibly difficult to stop."
Hall knew he was addicted but he didn't tell his family, friends or acquaintances. He was too ashamed.
Providers curtail prescriptions
Federal and state health officials have been slowly tackling the overuse of opioids.
In Oregon, the focus on prescription drug abuse has centered on young people. In 2010, a summit including then-Gov. Ted Kulongoski revealed the state's 18- to 25- year-olds had the highest rate of prescription abuse in the country.
The state set up a prescription monitoring program the next year and in late 2015 issued a well-publicized public warning to announce that large medical groups in the Portland area had agreed to curtail opioid prescriptions for chronic pain.
The Centers for Disease Control and Prevention followed in a few months with extensive guidelines advising providers to limit the use of opioids. One section warns about the risk of seniors taking opioids. They can fall, become confused or experience a bad reaction if they take a cocktail of medications.
The Oregon Health Authority issued supplemental guidelines last year that call for the use of alternative treatments or the lowest effective dose of opioids, but the guidelines don't address age groups. Washington state has its own guidelines as well, including a section on seniors.
Hedberg, the state's top medical officer, said the state is trying to curtail opioid prescriptions for everyone, not just one age group.
It stands to reason that seniors with opioid problems would end up in the hospital more often than the general population, she added. Older people simply have more ailments, she said.
But so do seniors in other states that have much lower rates for those 65 and older, like Florida and New York.
It could be that Oregon has a higher rate of seniors with an opioid abuse problem or that state providers are more likely to hospitalize them for treatment, Hedberg said.
Public health officials have no plans to dive into this issue: They've adopted an overall strategy of curtailing prescriptions, tracking trends and trying to get more people with dependency issues on treatment.
This year, Oregon is getting an extra $7 million from the federal Health and Human Services Department to fight opioid addiction and overdoses.
The state plans to use the money to increase access to medication-assisted care. It will target Oregon tribes and rural areas, which lack treatment centers, Hedberg said.
There's no plan to focus on seniors.
Risk factors abound
The Oregonian/OregonLive interviewed pharmacy experts, primary care doctors, pain specialists and addiction experts in the Portland area about why Oregon has such a high rate.
None had a definitive answer.
Many people who started taking the pills a decade or two ago likely stayed on them or resumed treatment as they aged and experienced arthritis or had hip or knee replacements, said Dennis McCarty, a substance abuse treatment specialist at OHSU.
Doctors might overlook risks for substance abuse in older people because they consider addiction a problem of younger people, they're often focused on younger patients with addiction problems, said Dr. Steven Stanos, medical director of pain services at Swedish Hospital in Seattle and president of the American Academy of Pain Medicine.
Or they might associate symptoms such as falls, delirium and memory loss, with aging instead of opioids.
Seniors also may wind up in the hospital more often because they don't metabolize medications as well as younger people, and many take several medications, which can increase health risks.
Yet steering seniors away from opioids in some cases isn't always a good idea. The drugs aren't considered to be a problem for hospice patients or to treat pain associated with cancer.
"It's a challenge in these older patients because many times they have severe pain," Stanos said. "That keeps them from functioning."
Many pain medications that doctors might prescribe to avoid opioids can cause problems in seniors.
Amitriptyline and gabapentin, both used for nerve pain and depression, can cause delirium. Some anti-inflammatories, like ibuprofen, affect kidney function and can trigger stomach ulcers.
Oregon and other states with such high rates of senior hospitalizations should take the problem to doctors and insurers to investigate, specialists said.
"The data should be analyzed in terms of what is the cause of this," said Cynthia Reilly, a Pew Charitable Trusts specialist on substance abuse. "It's something they should take a closer look at."
New drug helps
Jerry Hall increasingly feared his addiction would kill him.
So in early 2015, he saw Dr. Brinton Clark, medical director of Providence Medical Group Northeast. She started him on Suboxone, a medication used to treat opiate dependence.
"That was the day that changed my life," Hall said.
Suboxone contains two elements, naloxone, which is used to treat a narcotic overdose, and buprenorphine, which treats pain but isn't as addictive as many other opioids.
It can still cause withdrawals.
Clark has tapered Hall's dose, starting with a moderately high dose of 20 milligrams a day. He's now down 3 milligrams.
"He's a star patient," Clark said. "He's close to being off."
Hall said if he had known opioids would take over his life and how difficult it would be to get off them, he never would have taken the drugs.
"I would have taken an aspirin," he said.
Source: www.oregonlive.com/health/index.ssf/2017/07/oregon_has_top_rate_in_us_of_s.html
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Source: www.oregonlive.com/trending/2017/07/oregon_opioid_overdose_deaths.html
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