It took Oregon practitioners only six months to write more than 1.4 million prescriptions for hydrocodone and oxycodone, according to Oregon Prescription Drug Monitoring Program’s report encompassing the first half of 2015.
“Oregon and other states have realized they’re actually prescribing way more of these drugs than they did 10 years ago,” said Multnomah County Health Officer Dr. Paul Lewis. “The more that’s prescribed, the more overdose deaths there are.”
He says preliminary analysis shows opiates were involved in 109 deaths in Multnomah County in 2014, with about half involving prescription opiates.
The Centers for Disease Control and Prevention estimates 46 Americans die of prescription opiate overdose every day – that’s almost one death every half-hour. In an effort to combat this nationwide epidemic, the CDC created a grant program to help select states prevent opiate-related deaths and in September named Oregon one of 16 states to be awarded between $750,000 and $1 million annually in federal funds over the next four years.
The grant coincides with coordinated efforts among health professionals already underway in the Portland-metro region. Additionally, Oregon Health Authority just approved its State Health Improvement Plan, which places opioid overdose as a top priority for the state. Among the plan’s targets is lowering prescription opioid deaths from four per 100,000 Oregonians to less than three deaths per 100,000 Oregonians.
Since June 2014, the Healthy Columbia Willamette Collaborative — a work group composed of HealthShare, FamilyCare, health providers, hospitals and officials within Multnomah, Washington, Clackamas and Clark counties’ health departments, including Lewis — has been developing guidelines and standards for prescribing opiates and looking at ways to reduce the risk of overdose.
Portland's tri-county area was one of the regions selected by Oregon Health Authority to receive support from the CDC grant. Both the local collaborative and state health authority are ramping up efforts this fall, with regional educational outreach and a statewide two-year performance improvement project aimed at improving opioid management.
At both levels, officials aim to decrease opioid prescriptions, reduce overlapping prescriptions and co-prescribing medications, and make naloxone, an opiate overdose-reversing drug, more widely available.
Naloxone stops an overdose by blocking the opiate receptors in the brain. Someone other than the person who is overdosing administers the life-saving drug.
To obtain naloxone in Oregon, a person must get a doctor’s prescription and obtain a training certification card, said Marcus Watt, executive director of Oregon Board of Pharmacy.
“I know there are concerns that access isn’t open enough, and there may be some other future legislative activity to open up access even more,” Watt said.
Oregon Health Authority’s Lisa Millet said, “We are in conversations with the Board of Pharmacy about establishing a standing order that would allow anyone to view the training video on the OHA website, download and sign the training certificate, and then take that certificate to a pharmacist to obtain naloxone.
“The current law doesn’t allow this,” she said.
Naloxone comes in several forms. There’s an injectable version, a nasal spray, and even an auto injector that talks the person administering the drug through the process. The more complex the medical device, the more expensive it gets, Watt said. “Cost has been one of the barriers.”
Most common is the nasal adapter, and some police departments around the state are keeping it in their squad cars, Watt said.
“I actually saw it used once, and it’s just incredible,” he said. “The person was half-dead and all of a sudden – boink – they’re sitting up.”
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In 2013, the federal Substance Abuse and Mental Health Services Administration reported Oregon had the highest rate of prescription pain reliever abuse in the nation, with 6.37 percent of people 12 and older reporting they took pain relievers recreationally.
Opioid prescriptions in the U.S. have increased four-fold since 1999, despite no change in the amount of pain Americans report, according to the CDC.
Dr. Richard Deyo, a primary care physician at Oregon Health & Science University, has researched issues around opiate prescriptions for approximately seven years. He said the drastic increase in opiate prescription rates correlates with a marketing campaign.
“In retrospect, many people would acknowledge the pharmaceutical companies have had an important role in this,” Deyo said. “The most dramatic increase in opioid prescribing really began approximately 20 years ago with the introduction of OxyContin and a brilliant marketing strategy that basically tried to argue that opioids are safer than doctors had previously thought – and more effective – and that it would be simply unethical not to prescribe them more frequently and at higher doses.”
In 2007, Purdue Pharma, the maker of OxyContin, which is a high-strength version of oxycodone, was found guilty of misbranding the drug by claiming it was less addictive than other opiates without any evidence, and was ordered to pay more than $600 million in fines and other payments.
In Oregon, unintentional prescription opioid hospitalizations increased 285 percent between 2000 and 2013, according to state health authority reports, with 156 Oregonians dying from prescription opioid overdose or poisoning in 2013.
“There are now far more deaths from prescription pill overdoses than there are from heroin,” Lewis said.
Starting this fall, Lewis said, the Portland-area collaborative tasked with finding solutions to opioid abuses will begin the outreach phase of its plan by educating prescribers, patients and the public about safer opiate prescribing standards and overdose prevention. It will focus on the guidelines its members agreed upon this summer.
Those recommendations include: screen for opioid risk and evaluate a patient’s substance abuse history before prescribing an opioid, refer those who become addicted during treatment to an addiction specialist or addiction treatment, consider a prescription for a naloxone rescue kit to high-risk patients, and discontinue opioids in favor of alternatives if goals are not met.
Deyo said there’s been a shift toward non-pharmaceutical approaches to treating chronic pain, and treatments such as spinal manipulation, acupuncture, massage, physical therapy and exercise have seemed to have a greater effect in returning patients to normal functioning – and they’re safer.
As concerns over drugs like OxyContin grew, pharmaceutical companies responded.
“What we’ve seen in recent years is a strategy of creating new opioids products to market and trying to develop strategies that either make them safer or less likely to result in addiction,” Deyo said. But in terms of their addictive qualities or levels of safety, he said, “we don’t know really what the long-term results will be.”
On Sept. 10, the FDA voted 23 to 1 against the approval of Purdue Pharma’s newest opioid painkiller over concerns there would likely be errors in administering the drug, leading to overdose.
Naloxone has effectively reduced heroin overdose deaths in areas where it’s made available to intravenous drug users. In an interview with Street Roots in September, Kim Toevs, harm reduction manager for Multnomah County, said more deaths could be prevented if there were a way to get naloxone to prescription opiate users, as well. This, Lewis said, is another goal the collaborative will continue to work on.
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On Sept. 23, CVS pharmacy announced it is now dispensing naloxone without a prescription at its retail stores in 12 additional states – having already made the drug available in Rhode Island and Massachusetts. More than 50 CVS pharmacies in California will make the drug available. California in 2014 passed a bill allowing the drug to be sold without a prescription, and CVS is the first pharmacy to stock the drug since the bill’s passage.
Michael DeAngelis, spokesman for CVS, said the nasal and injectable versions of the drug will be available at participating pharmacies at a cost of about $40 to $50 per dose.
“What we’ve heard,” Lewis said, “is even when it’s legal, if pharmacies don’t stock it, there’s no way for people to get it, so CVS seems to be filling that vacuum.”
For this reason, he said, the collaborative will soon ask local retail pharmacists whether they would stock naloxone and what it would cost.
“Why don’t we make this life-saving drug easy to get to?” Lewis said. “You can look back and say, ‘Why didn’t we do it 10 years ago,’ and the answer is, ‘Yeah – I wish we had.’”