Over prescribed and Underfunded: Illinois Surge in Overdose Deaths

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Heroin related death rates in Illinois

Chris Nielsen’s future looked bright. A senior in high school, he played catcher on his school’s baseball team in a Chicago suburb and was offered a full scholarship to play the sport at Michigan State University. But at age 17, after his first knee surgery, he was prescribed Percocet and Dulotin to help ease post-surgery pain.

 

Nielsen grew up around drugs. Both of his parents were addicted to heroin, and his father died from an overdose when Nielsen was just a few years old, he said. His uncles also used, and drugs and addicts became common fixtures in Nielsen’s childhood.

For the rest of the article from “Me
dill Reports Chicago” go here.

Best intentions gone awry: Origins of the opioid epidemic

Millions of Americans live with acute or chronic pain. Many of them rely on prescription drugs to improve their ability to function and maintain their quality of life. While all prescription drugs have some risk of misuse, some drugs, identified by the Drug Enforcement Administration (DEA) as controlled substances, are particularly dangerous. Specifically, prescription opioids have high abuse potential and can lead to life-threatening adverse events when taken in excess or in combination with other drugs.1

Opioids are a class of drugs that include the illegal drug heroin, as well as legal prescription pain relievers like oxycodone, hydrocodone, codeine, morphine, fentanyl and others.2

Drug overdose is the leading cause of accidental death in the U.S., with 47,055 lethal drug overdoses in 2014.2 Opioid misuse, abuse, addiction, and overdose accounts for over 60% of this epidemic, with four in five new heroin users starting out misusing prescription painkillers. In 2014 there were 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin.2

Here is a graphic depiction of the rising wave of opioid deaths. Notice in particular the sudden acceleration in recent heroin deaths:

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This graph puts the death toll into perspective. After 20 years of heavy combat in South Vietnam, U.S. military casualties represented only one-third of the death toll from 10 years of opioid overdoses.

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But simply focusing on the number of deaths – tragic as they are – actually obscures the true dimensions of the problem. According to the National Survey on Drug Use and Health (NSDUH), in 2012 an estimated 2.1 million Americans were addicted to opioid pain relievers and 467,000 were addicted to heroin. These estimates do not include an additional 2.5 million or more pain patients who may be suffering from an opioid use disorder because the NSDUH excludes individuals receiving valid opioid prescriptions.1

How did we get here?

Physicians trained in the 1960s and 1970s were taught to reserve opioids for the most severe forms of pain, such as cancer or end-of-life care. That approach continues to be appropriate.3 Then in the late 1990’s, opioid prescribing policies changed. Patient advocacy groups and pain specialists (with some not-so-subtle help from pharmaceutical companies) began to argue that doctors were undertreating common forms of pain that could benefit from opioids, such as backaches and joint pain.3

Around this time the American Pain Society introduced the “pain as the 5th vital sign” campaign, (adding pain to the four original vital signs representing essential body functions: heartbeat, breathing rate, temperature, and blood pressure). 4

This effort garnered impressive institutional support, including sponsorship by the Joint Commission on Accreditation of Healthcare Organizations, the National Pharmaceutical Council, and the U.S. Department of Veteran’s Affairs.5

According to the National Pharmaceutical Council, the “5th vital sign” message was built on a simple logic:

  • That pain is the most common reason individuals seek health care. Each year, an estimated 25 million Americans experience acute pain due to injuries or surgery and another 50 million suffer chronic pain.6
  • The adverse consequences of undertreated pain may cause serious medical complications, impair recovery from injury or procedures, and can progress to chronic pain. Undertreated chronic pain can impair an individual’s ability to carry out daily activities and diminish quality of life.6

Advocates for enhanced pain treatment successfully lobbied state medical boards and state legislatures to change statutes and regulations. One particular goal was to lift any prohibition of opioid use for non-cancer pain. In Washington State, for example, state law was modified to stipulate that “no disciplinary action will be taken against a practitioner based solely on the quantity or frequency of opioids prescribed.”1

In at least 20 states, these new guidelines, statutes, regulations and laws dramatically liberalized the long-term use of opioids for chronic non-cancer pain, reflecting the prevailing thought at the time that there is no clinically appropriate ceiling on maximum opioid dosing.1

Here is a view of the guide issued by the Department of Veteran’s Affairs that describes their approach to more aggressive pain management: http://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf.

The “fifth vital sign” pain relief message was amplified by multimillion-dollar promotional campaigns aimed directly to prescribers.1 Newlong-acting drugs like OxyContin® were promoted as less addictive.4

The combination of a more aggressive approach to pain management and pharmaceutical company marketing efforts led to a dramatic increase in prescription opioid sales. Subsequent studies have shown a strong, linear relationship between opioid sales volume and the morbidity and mortality rates associated with these products.1

Looking back with the benefit of hindsight, it seems clear that the 5th vital sign initiative badly misfired. Whatever advantages gained in terms of alleviating pain were swamped by steeply increased opioid utilization and subsequent epidemic of addiction and overdose. These abuses led the U.S. Centers for Disease Control and Prevention (CDC) to see a need for new prescribing guidelines for narcotic painkillers.

New guidelines

In March of this year, the CDC published The Guideline for Prescribing Opioids for Chronic Pain aimed at improving patient care and safety and preventing opioid overdose.9

Out of the 12 recommendations that comprise the new guideline, three stand out as key:

  • First, non-opioid therapy is preferred for chronic pain. (Aside from active cancer, palliative, or end-of-life care.) When used, opioids should be added only when their expected benefits are likely to outweigh their substantial risks.10
  • Second, use the lowest possible effective dose to reduce the risks of opioid use disorder and overdose. The rule of thumb is “start low and go slow.”10
  • Third, doctors should monitor all opioid-using patients closely. This includes, for example, avoiding concurrent use of conflicting drugs, reviewing data from prescription-drug monitoring programs, and having a clear “off-ramp” plan to taper and discontinue therapy.10

Here is a sample online banner message aimed at changing doctor prescribing patterns for opioids:

In general, the new CDC guidelines try to shift the entire perspective on opioid use by stressing the importance of avoiding opioid prescriptions as the first-line of treatment for patients with chronic pain.3 Doctors are being asked to question whether they need to prescribe opioids as early in treatment as they have become accustomed. The guidelines also remind prescribers that the evidence in support of starting opioid treatment early and keeping people on them for prolonged periods is thin. It sets stricter limits on who should be eligible for treatment with chronic opioids, the maximum dose that should be used, and the kind of cautions they need to understand in order to avoid serious risk. The guidelines also establish new rules for monitoring patients who are taking opioids.9

What will doctors do?

While the new CDC prescribing guidelines are welcome, they are only a first step toward a solution. At this point, the tendency to aggressively treat pain using opioids is firmly entrenched in the medical community. For example, just this year the National Safety Council conducted a national survey of physicians who spend over 70% of their time seeing patients for pain. What they found was revealing:

  • 99% of doctors prescribe highly addictive opioids for longer than is recommended by the CDC (three days).11
  • 74% of doctors incorrectly believe morphine and oxycodone – both opioids – are the most effective way to treat pain.11
  • 99% of doctors have seen a pill-seeking patient or evidence of opioid abuse, but only 32% usually refer the patient to treatment.11
  • 67% of doctors are, in part, basing their prescribing decisions on patient expectations.11

Many question just how much, or how fast the average doctor will actually change his or her prescribing behavior. Recently, CDC Director Dr. Tom Frieden admitted as much when the new guidelines were released, saying that changing medical practice is not quick, or easy.3

One question that arises is whether there are external influences acting on doctors that make it harder for them to limit opioid use. Some cite the time constraints affecting physicians’ practice in this era of healthcare reform that emphasizes quality and value-based payment. This argument says that it’s much easier for a busy clinician to prescribe a 30-day supply of oxycodone or Percocet to treat a patient’s chronic pain than it is to convince him or her to do physical therapy.3

Do hospital rankings play a role?

Another potential external influence acting on opioid prescribing patterns concern the ways hospitals are ranked and reimbursed. As part of the 2010 the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) developed the value-based purchasing program to shift from pay for volume to pay for value.7

Hospitals are scored based on their performance on various measures, including outcomes of care, readmission rates, efficiency and the patient experience. Crucial for this discussion, the patient experience includes patient scoring of their satisfaction with their pain control.4

Hospital administrators were quick to develop initiatives to improve their scores and avoid penalties. For example, many hospitals have instituted readmission avoidance programs because these scores are closely monitored.7

Because CMS attached significant reimbursement penalties to patient satisfaction, some doctors believe that administrators began to hold physicians directly responsible for patient satisfaction, to the point of withholding pay or bonuses. As a result, some physicians felt pressured to prescribe opioids when patients demanded them.4

In a recent editorial in the Journal of the American Medical Association, CMS responded to suggestions that pain management questions should be taken out of the satisfaction survey in order to remove any potential for misaligned incentives to prescribe opioids.8 They began by insisting that effective pain control is a critical quality issue for inpatients, and that therefore they ought to measure that part of the patient experience. CMS went on to point out that nothing in the survey suggests that opioids are a preferred way to control pain. Finally, they observed that there is no empirical evidence showing that failing to prescribe opioids lowers a hospital’s patient satisfaction scores.8

Where do PBMs fit in?

There are at least two potential ways PBMs can participate in a solution to the opioid epidemic. The first is via their clinical management programs such as step therapy or prior authorization. These are simple measures that can directly influence both physician prescribing patterns and patient use.

There is undoubtedly going to be a major effort to re-orient physicians away from opioid prescribing over the coming years. The data in this chart, published in 2015, shows that, while some areas of specialization have dramatically cut opioid use, in others the trend is still high and rising.

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The second way PBMs can help is through a more forensic approach designed to uncover instances of fraud or abusive prescribing patterns that contribute to excessive opioid use. Most PBMs already perform prescription claims reviews to uncover potentially fraudulent use of dangerous drugs.9 For example, OptumRx uses retrospective claims analysis to identify members who meet certain criteria, such as using multiple prescribers, multiple dispensing pharmacies, and multiple controlled substance claims over a set period. The next step is to proactively work to get this patient specific data into the hands of the prescribers, so each of them can have a complete picture of the patient’s behavior.

Going forward, these existing programs could be enhanced with new enabling legislation.1 For example, PBMs could vastly enhance their insight into individual behaviors if they had access to each patient’s complete controlled substance claims history, including cash claims, and access to state-run prescription-drug monitoring programs (PDMP). However, at the present time many state laws prohibit PBMs from accessing this data.1

Summary

The new prescribing guideline constitutes an important step toward a solution for the opioid crisis by presenting the best available evidence to provide options for patients and clinicians. But, it is just one step. Experts agree that, while guidelines are important, much more action will be required in order to translate guidelines into new patterns of behavior. These will necessarily include not just doctors, hospitals and PBMs, but also pharmaceutical manufacturers, educators, addiction treatment specialists and communities.1

A combined Optum response

At Optum, we recognize that controlling the opioid epidemic will require a comprehensive approach. Therefore, we are preparing to deploy the resources from across the entire United Health Group family of companies – not just OptumRx.

Optum companies help deliver better outcomes in three key ways: by connecting all parts of the health system to the right data for better outcomes; by advancing beyond traditional pharmacy cost management by engaging members in programs to improve their health; and by empowering consumers with self-managed well-being and care programs, to better manage their health and take control of their own wellness.

Please watch for much more about this major initiative in 2016.

References

  1. Johns Hopkins Bloomberg School of Public Health. The Prescription Opioid Epidemic: An Evidence-Based Approach. Nov. 2015. Accessed at: http://www.jhsph.edu/research/centers-and-institutes/center-for-drug-safety-and-effectiveness/opioid-epidemic-town-hall-2015/2015-prescription-opioid-epidemic-report.pdfon 05.02.2016.
  2. American Society of Addiction Medicine (ASAM). Opioid Addiction: 2016 Facts & Figures. [PDF].
  3. Modern Healthcare. CDC opioid prescribing guidelines unlikely to affect physicians’ practices. March 15, 2016. Accessed at: http://www.modernhealthcare.com/article/20160315/NEWS/160319936on 05.02.2016.
  4. The opioid epidemic: It’s time to place blame where it belongs. April 6, 2016. Accessed at: http://www.kevinmd.com/blog/2016/04/the-opioid-epidemic-its-time-to-place-blame-where-it-belongs.htmlon 05.02.2016.
  5. Joint Commission on Accreditation of Healthcare Organizations; National Pharmaceutical Council. Pain: Current Understanding of Assessment, Management, and Treatments. Dec. 2001.
  6. National Pharmaceutical Council. Pain: Current Understanding of Assessment, Management, and Treatments. Accessed at: http://www.npcnow.org/publication/pain-current-understanding-assessment-management-and-treatments?page=17&Research=1on 05.04.2016.
  7. Health Affairs. Medicare Hospital Readmissions Reduction Program. Nov. 12, 2013. Accessed at: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=102on 03.28.2016.
  8. Measurement of the Patient Experience: Clarifying Facts, Myths, and Approaches. Published online March 10, 2016. doi:10.1001/jama.2016.1652. Accessed at: http://jama.jamanetwork.com/article.aspx?articleid=2503222on 05.02.2016.
  9. Drug Benefit News. Opioid Prescribing Guideline Strikes Needed Balance in Pain Care, Plans Say. April 8, 2016.
  10. New England Journal of Medicine. Reducing the Risks of Relief — The CDC Opioid-Prescribing Guideline. 2016; 374:1501-1504 April 21, 2016DOI: 10.1056/NEJMp1515917. Accessed at: http://www.nejm.org/doi/full/10.1056/NEJMp1515917?af=R&rss=currentIssueon 05.03.2016.
  11. National Safety Council. Prescriber attitudes and behavior related to prescription opioid pain medication. March 13, 2016. Accessed at: http://www.nsc.org/NewsDocuments/2016/Doctor-Survey-press-briefing-32416.pdfon 05.16.2016.

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Senator Durbin visits ‘extraordinary’ Lake County drug collection program

durbinAs communities across America continue to be plagued by an opioid-addiction crisis, Lake County boasts “the largest and most successful” pharmaceutical collection program in Illinois, officials told U.S. Sen. Dick Durbin Thursday as he visited the Gurnee-based agency that manages the effort.

NOTE: Thanks to the News Sun for the original article.

The Solid Waste Agency of Lake County (SWALCO) has collected and destroyed more than $1.2 million worth of controlled substances to date, the agency said. More than 20 law enforcement agencies deliver the drugs they have collected to SWALCO every few months for sorting, weighing and incineration, Durbin’s office said in a news release.

On the last drug disposal day in August, 10 departments dropped off more than 1,500 pounds of drugs, taking $113,000 in controlled substances off the street, according to the release.

The longtime Democratic senator called the SWALCO program an “extraordinary commitment to deal with this issue” and said “there’s nothing like this” elsewhere in Illinois. But he also said the pharmaceutical industry has to “be a part of the solution” as a new wave of heroin addiction has swept the country. Many people who become addicted to opioid painkillers such as hydrocodone and oxycodone turn to heroin because it is often cheaper and easier to find.

“They have flooded the market,” Durbin said of the pharmaceutical industry. “We’re asking pharma … to accept responsibility. And I don’t think that’s unreasonable.”

In June, Durbin introduced legislation that would strengthen the federal Drug Enforcement Agency’s authority to limit the number of addictive painkillers available in the United States every year, his office said in a news release. The bill would also have drug manufacturers “establish a national drug disposal program and help fund substance abuse treatment programs.”

Walter Willis, executive director at SWALCO, agreed that more programs like the one at his agency could be improved and established statewide if drug manufacturers helped fund them.

“They’re making money on the products,” Willis said. “But there’s a consequence on the back end that we think they should take responsibility for.”

He and William Gentes of the Lake County Underage Drinking and Drug Prevention Task Force said the number of overdose deaths in Lake County has gone down in the wake of the SWALCO program. While they couldn’t say for sure whether the program caused the reduction, they agreed it couldn’t have hurt.

In the last five years, SWALCO has increased its drug collections from law enforcement agencies sixfold, from about 2,000 pounds in 2011 to about 12,000 in 2015. Meanwhile, deaths from prescription drugs decreased from about 40 to 15 during that same period, according to numbers provided by Gentes. The establishment of the SWALCO building in Gurnee for drug collection allowed law enforcement agencies, many of which didn’t have the space to store and dispose of drugs before, to participate more fully in the collection effort.

“The moment we offered this space on a regular basis,” Gentes said, “the police departments were ready to go.”

Durbin wants to increase awareness surrounding opioid addiction, an issue that “touches all of us,” he said. He hopes more people begin to consider addiction a disease rather than a moral failing. He also urged parents to consider who has access to pain pills that may be in a medicine cabinet or a drawer. Nearly 60 percent of Americans have leftover narcotics in their homes, his office said, and an estimated seven of 10 prescription opioid abusers obtained pills from a family member or friend.

“It isn’t just a matter of standing up and saying, ‘Just say no,’” Durbin said.

New Walgreens Disposal Boxes

Safe Medication Disposal Kiosks Available at Three Lake County Walgreens Locations

unnamedNew medication disposal kiosks at three Lake County Walgreens locations will allow individuals to safely and conveniently dispose of their unwanted, unused or expired prescriptions, including controlled substances, and over-the-counter medications, at no cost. The kiosks offer one of the best ways to ensure medications are not accidentally used or intentionally misused by someone else.

Local and state elected leaders, including Lake County Board Chairman Aaron Lawlor, State’s Attorney Mike Nerheim, Undersheriff Raymond J. Rose, along with State Senator Terry Link, joined Walgreens Regional Vice President Joe Willey to announce Walgreens’ Safe Medication Disposal Program in Lake County on Wednesday.

The officials unveiled a safe medication disposal kiosk at the Walgreens store located at 1811 Belvidere Road in Waukegan—one of three public safe medication disposal receptacles in Lake County and 45 across the state.

Lake County Board Chairman said, “We know that less supply equals less likelihood for opioid addiction. Walgreens has stepped up to combat drug abuse with this program, and I encourage Lake County residents to take action—Go through your medicine cabinets and take your unused or unwanted medications to one of these boxes. This issue didn’t happen overnight, and it won’t be solved overnight. We must continue to work together at the federal, state and local levels to fight this crisis that is destroying families and having a detrimental effect on our communities.”

“Prescription Drug Disposal Saves Lives. Period. We have seen too many tragic examples of lives destroyed by the misuse of prescription medication, particularly opiates. This is one way our community can help make a difference. Lake County has been a leader in our collective efforts to drive proper drug disposal. I applaud Walgreens for their leadership,” said State’s Attorney Nerheim.

Undersheriff Raymond J. Rose said, “At the end of 2014, Lake County had 17 prescription drug disposal boxes in law enforcement offices. Today, we have 28. I’m pleased to report that Lake County law enforcement collected 7,623 pounds of unused or expired prescription drugs since January. We are serious about preventing prescription drugs from getting in the wrong hands and disposal boxes are easy and convenient for the public. We thank the folks at Walgreens for joining us and adding disposal boxes at three Lake County Walgreens locations, providing the public three more spots to dispose of prescription drugs.”

“By making safe medication disposal kiosks available in select Illinois stores, including the ones in Lake County, Walgreens is taking an important first step to curb the misuse of medications throughout the country,” said Joe Willey, Walgreens Regional Vice President. “As a pharmacy, we are committed to playing a role in what must be a comprehensive solution to prevent prescription drug and opioid abuse.”

Walgreens is installing 500 safe medication disposal kiosks in select stores throughout the country. The kiosks at Walgreens pharmacies are available during regular pharmacy hours (24 hours a day at most kiosk locations). The Lake County locations include:

Buffalo Grove Walgreens – 15 N Buffalo Grove Rd
Deerfield Walgreens – 780 Waukegan Rd
Waukegan Walgreens – 1811 Belvidere Rd

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Panel Discussion on Heroin and Opioids

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100 Naloxone Saves in 20 Months

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Today we saved our 100th life with Naloxone since Christmas Day 2014. In those 20 months. The program has grown to every police department in Lake County.

More to come on this, but wow!

Want to see the details? Go here.

Dirty Jobs: Pharmaceuticals Collection Program

Wall Street Journal: Obama Administration Loosens Controls on Medication to Ease Opioid Cravings

wall-street-journal-logo-940x350In an effort to expand treatment for opioid addiction, the Obama administration is loosening strict controls of a medication doctors prescribe to ease cravings for heroin and other opioid drugs.

The Department of Health and Human Services says it will now allow doctors to prescribe the medication, called buprenorphine, to 275 patients at a time, up from 100 previously.

The limits were put in place to try to keep tight control of the medication, which addicts sometimes buy and sell on the black market because it prevents painful withdrawal symptoms from heroin and other drugs. Federal officials believed that keeping a tight lid on prescribing would thwart this black-market trade.

To read the rest of the article go here.