US Sales of prescription opioid drugs for medical use have risen dramatically since 1999. While these drugs have therapeutic benefit, their use can lead to accidental overdose and long term addiction if risks are not carefully managed through patient education and oversight. Not only patients, but also their families and the surrounding community can be impacted. Prescriptions that are stronger than needed, in greater quantities than necessary, or duplicate other prescriptions can all lead to dangerous outcomes for patients.
A new effort called Prescribe Safe Monterey County, is bringing together providers, government and law enforcement to promote safe use of opioids in our region.
Nationally, opioid sales, prescription opioid related deaths, and admissions for opioid addiction treatment all increased dramatically in the last decade.
Risk factors from opioid availability might be reduced by limiting the number and/or size of opioid prescriptions written for patients. When opioid prescriptions are truly necessary, ensuring patients are educated about the risks of opioids, and making sure treatment is available for those struggling with dependency are two important elements to an overall strategy for managing prescriptions responsibly.
In Monterey County, Emergency Department visits related to opioids doubled in 2007, and have remained at similar levels since then.
Studies have shown that people who develop a dependency to prescription opioids sometimes switch to heroin as it can be cheaper to obtain. This can increase heroin related problems. Monterey is experiencing a rise in heroin related ED visits.
A Monterey County man's story:
Before his injury he had been healthy but the opiates he received as treatment led him to addiction: He was now a recovered opiate addict. A bull rider, he had suffered a rib injury while competing. He was initially started on hydrocodone for pain, and was ultimately started on oxycodone as his pain continued. He ultimately became dependent on opiates, often feeling the effects of withdrawal when not taking his pain pills. As it became harder for him to get prescription pain pills, he turned to heroin, and struggled with heroin addiction for 6 years. The man spoke at a town hall event about his experiences and the audience learned how heroin was never about getting "high" for him - it was just about trying to feel better when he was withdrawing from opiates. Ultimately, he was able to get sober, and proudly shared that he was sober for 6 years. He now works as a drug counselor. He is a patient that became addicted as he was never warned about the addictive potential of prescription opiates. Like many young athletes, his addiction began with an injury that was treated with prescription opiates - and progressed to heroin.
Prescription Drug Monitoring Programs (PDMPs) give healthcare providers knowledge of a patient's existing prescriptions. They serve as a useful tool to assist prescribers in delivering appropriate treatment while reducing the amount of opioids prescribed to just what is needed for the patient. This keeps "leftover" medication out of the hands of non-patients.
California's PDMP is called the Controlled Substance Utilization Review and Evaluation System (CURES) and is available to all physicians and pharmacists in the state.
"We started on this whole thing because we were on a mission to help people in pain but the long-term outcomes for many of these patients are appalling and it is ending up destroying their lives."
Here in Monterey County, the Prescribe Safe Initiative is a collaborative effort between local law enforcement, prescribing physicians, and four hospitals located in the county. It serves as a valuable resource to physicians and patients in promoting the safe use of opioid medications. Below are links to Prescribe Safe Monterey County resources, and some highlights of their work.
Physicians and other Medical Providers can locate:
-Substance abuse and pain management referrals
-Patient handouts and other resources.
-Referrals for complementary medicine providers.
(right): Prescribe Safe, Emergency Room Brochure makes important opioid drug safety messages clear to patients. Available in English and Spanish.
Patients and Family Member resources:
-Opioid prescription education
-Alcohol and drug counseling and treatment referrals.
-Safe medication disposal sites
-Complementary Medicine: alternatives to help with pain management.
-Handouts describing what parents need to know about opiates and how to help teens who might be using.
HIGHLIGHTED WORK of Prescribe Safe Monterey County: Promoting Treatment Alternatives to Opioids.
Doctors Casey Grover and Reb Close, of the Community Hospital for Monterey County (CHOMP).
Over the last year we spent a significant amount of time working on increasing the use of non-opiate therapies to treat pain. This has involved getting new medications available for use in the hospital, as well as working with insurance companies to improve coverage of new non-opiate therapies. In looking at our prescribing from 2012-2014 compared to 2014-2016, our use of topical lidocaine patches for pain has increased by 320 percent, our use of non-steroidal anti-inflammatories such as toradol and ibuprofen is up by about 150 percent, and our use of medications for nerve-related pain such as gabapentin has increased by 330 percent. We have developed new orders for physicians to make it easier to prescribe non-opiate therapies, and are constantly looking for new medications to treat pain without exposing patients to opiates. As of 11/16/16, we added two new non-opiate intravenous medications for pain to the list of medications that can be used in the Emergency Department for pain control.
-Dr. Grover, 2016
The result: patients' pain is effectively managed with lower risks of overdose and long term dependence. These risks can be avoided for many patients.
Buprenorphine can be an invaluable intervention to help patients who have become dependent on prescription opioids.
Like many patients, the bull rider from Monterey County (whose story we heard earlier) used opiates predominantly to just feel better when he was in withdrawal. This highlights the importance of using medications like suboxone (buprenorphine), to manage withdrawal in patients who want to stop using opiates but can't because they feel so badly when in withdrawal. We are actively fighting to increase access to buprenorphine in Monterey County - and just secured funding to train more Monterey County doctors to use buprenorphine. We also are working out a partnership with new addiction clinics to increase access for our patients to be treated with buprenorphine.
-Dr. Grover, 2016
Increasing the use of buprenorphine as a treatment option by physicians located throughout the county is a goal of Prescribe Safe.
While the number of Monterey County physicians waivered to prescribe buprenorphine has risen from 17 to 21 over the period from 2010 to 2013, the number of physicians who actively prescribe the drug treatment for opiate addiction has remained at 13 every year over this period. In 2013, all waivered physicians were located in just 2 zip codes.
Providing Naloxone with every opiod prescription puts a potentially life saving intervention into the hands of every patient and emphasizes to patients and their families the potentially life threatening severity of opioid misuse.
Naloxone (trade name Narcan) has been used for years in emergency medicine to prevent the lethal effects of opioid overdoses in unresponsive individuals. The drug can be administered as a nasal spray to inhibit the action of opiates in the body. Prescribe Safe Monterey County has coordinated with local pharmacies to enable providers to include Naloxone prescriptions with any prescription for opiates. When designated with an opiate prescription, Naloxone prescriptions may be filled at many local pharmacies, including CVS, Walgreens, Ordway, and Rite Aid. Even if it's never needed, receiving Naloxone with an opioid prescription may serve to emphasize the seriousness of overdose risks for patients.
Improvements over Time in Monterey County
The efforts of Prescribe Safe Monterey County have contributed to a decrease in the number of opioid prescriptions used. Since the end of 2012, there has been a 13% decrease in the rate of prescriptions in Monterey County. In 2014 the county rate dropped below the state rate for the first time since 2010. Other data from the California Healthcare Foundation shows the morphine milligram equivalents (MME) for patients receiving new prescriptions has also decreased during the same time. These trends suggest physicians are adopting new pain management strategies that treat patients while reducing their exposure to potentially addictive opioids. Continuing this work and building on these successes is the goal of Prescribe Safe Monterey County.
Decreasing death rate
Overdose deaths attributable to prescription opioids have declined in Monterey County since 2012 and have been below the statewide rate for California since 2013. This occurred as Prescribe Safe Monterey County pursued many collaborative efforts to educate patients about opioid risks and inform providers of alternative pain management methods. Continuing to build on these efforts is essential to maintaining this positive trend in patient outcome.
Prescribe Safe Monterey County's Website has more information for patients, family, and prescribers.
Physicians and other prescribers can learn about effective pain management methods that don't carry the potential addiction and overdose risks that come with opioids.
Others can learn how to help ensure you, your family, friends, and community use opioid medications safely.
Prescribe Safe Monterey County Website:
CDC guidance for prescribers:
click here-http://www.cdc.gov/drugoverdose/prescribing/resources.html (US Centers for Disease Control and Prevention)