How Colorado leaders are fighting the opioid epidemic
The nation’s drug epidemic kills someone in Colorado about every 9 hours and 36 minutes, a fact that rings like a siren for state leaders who are combating the leading driver: prescription and illicit opioids.
A bipartisan panel of lawmakers last week supported a package of six wide-ranging bills designed to prevent and treat the state’s drug overdose crisis, building on five years of work from Gov. John Hickenlooper’s administration to identify holes in the current system.
The approach — which, according to experts, puts Colorado in the top tier among states nationwide for its response — has been boosted by a $35 million infusion
from the federal government to test solutions to what President Donald Trump has labeled a national public health emergency.
Addressing the epidemic
Colorado’s response to the rising rates of opioid-related overdoses began in 2012 when the governor ordered a plan to combat prescription drug abuse and later formalized the state’s effort with the Colorado Consortium for Prescription Drug Abuse Prevention.
Now, five years later, the state is spending $1 million to create a drug-abuse research center at the University of Colorado Anschutz Medical Campus in Aurora that will focus on expanding prevention, treatment and recovery initiatives.
The attention to the issue so far offers promise to policymakers. Even though drug overdoses killed 912 people in 2016, the rate of prescription opioid-related deaths may have plateaued at 300 deaths the same year.
The most alarming trend is the rate of heroin deaths. The number of overdoses caused by heroin, an opioid, continues to skyrocket, contributing to 228 deaths last year, compared with just 79 five years earlier, according to state figures.
The proposed legislation “is not by any means solving the problem that we are in,” said state Rep. Brittany Pettersen, a Lakewood Democrat who led the General Assembly’s opioid study committee. “This is going to be five to 10 years of work.”
Checking the database
To limit prescription opioid abuse and so-called doctor shopping, studies show one of the most effective tactics is a prescriptiondrug monitoring program, or PDMP.
The vast majority of states require clinicians to check the database before writing most opioid prescriptions, and some saw a significant decrease in the amount prescribed, the Centers for Disease Control and Prevention reported.
The White House’s opioid commission endorsed a mandatory check for health care providers last week. But a day earlier, Colorado lawmakers gave early approval a more lenient approach that would require a check only for refills of opioid prescriptions in the next three years. The proposed legislation also would exempt certain facilities and patients — two additional loopholes.
Doctors argued that the drugmonitoring system is too onerous because it takes at least 20 clicks to check a patient’s history and consumes precious time from providing care. The state is currently studying how to streamline the system.
Like the database check, Colorado is considering another measure to stop the problem before it starts. The same bill that requires limited checks of the drug monitoring database would impose a limit on opioid prescriptions for some patients.
Limits on prescriptions
Colorado lawmakers initially pushed to limit initial opioid prescriptions to seven days for most patients — with exemptions for those who have chronic pain, cancer or palliative care — following the lead of 24 states that are moving in a similar direction. At least 17 states set the limit at seven days or less, according to the National Conference of State Legislatures, a bipartisan organization based in Denver.
But the organizations representing doctors resisted. So now, the proposed seven-day limit would only apply to patients who are new to opioids and it gives doctors the ability to bypass the rule, a situation that doctors acknowledged will create an arbitrary system. The limit also would be repealed after three years.
CDC research shows that a person is significantly more likely to continue using prescription opioids if they are given more than three days’ supply on the first prescription.
The federal health agency issued prescribing guidelines in March 2016 that are more restrictive than Colorado’s standards. The state is looking at updating its policies, but the changes must receive approval from six boards, which, if successful, would not occur until early next year.
“Report cards” for doctors
To educate doctors about the dangers of overprescribing opioids, Colorado is testing a relatively new idea that is showing early results — prescriber report cards.
The reports, also known as scorecards, will give clinicians a summary of their prescriber history and how they rank with their peers in the same specialty in terms of dosage, duration and type of drug.
“The idea is that for prescribers that might be prescribing more than average for their particular specialty, they’ll say, ‘Oh, I better look at things more closely,’ ” said Lindsey Myers at the Colorado Department of Public Health and Environment, who is a leading authority on the state’s opioid crisis. “What we are hoping to see is a change in prescriber behavior.”
Early studies from other states, including Arizona, show evidence of change with fewer prescribers being described as outliers and greater usage of the prescription drug tracking database, according to experts.
Colorado is conducting a pilot program, and the initial report cards will be sent to prescribers early next year.
Treatment options a challenge
According to policymakers, Colorado’s initial efforts to restrict opioid prescriptions may have an unintended effect: pushing addicts to opioids such as heroin or fentanyl. The trend is spotlighting the limited treatment options for drug users who want help.
A national survey estimated that 128,000 people in Colorado, or 3 percent, abused or became dependent on illicit drugs in 2014, and only 19,000 received treatment, according to a major state report. Other studies show more treatment admissions in recent years with heroin and opioids as growing concerns.
But only 11 counties in Colorado have access to all four types of substance abuse treatment available, a recent report showed, and most areas only offer one option. In six counties, mostly located in southwestern Colorado, no treatment options were available at the time.
The state’s human services department contracted with 10 additional medication-assisted treatment centers in the past three months to increase access, bringing the state’s total to 23. None are in the underserved counties.
These clinics saw nearly 5,000 people in one day, according to the most recent daily census, treating patients with private insurance and Medicaid, and the uninsured. The state covers the cost for those without insurance using federal and state money.
Medication-assisted treatment, or MAT, is one of the most effective options, according to the CDC, but it remains stigmatized, particularly in rural communities. In such a program, a person struggling with an addiction receives other types of opioids and therapies to gradually reduce the physical dependence on prescription or illicit drugs.
“Even though it’s not for everyone, for those who are using it, they have better outcomes, they are less likely to relapse, they are less likely to have continued illicit drug use and they are less likely to die,” said Cristen Bates an opioid policy specialist in the state’s Office of Behavioral Health.
In legislation set for introduction in January, lawmakers are looking at other ways to remove barriers to treatment, particularly from insurance companies, and expand Medicaid coverage for residential treatment programs.
The federal health care program for lower-income residents makes residential treatment an optional benefit for states, and Colorado does not currently offer the coverage.
The opioid antidote
Naloxone is a rescue drug that reverses an overdose and gets credit for saving thousands of lives each year in Colorado. A smartphone app that tracks its use by law enforcement registered 259 overdose reversals so far this year.
Colorado made naloxone essentially an over-the-counter drug in 2015 and maintains an order to help increase availability. Two years earlier, lawmakers passed a law to provide criminal and civil immunity for those who act in good faith to dispense the drug to a person suspected of an overdose. More than 500 pharmacies in Colorado now carry naloxone, which can cost $150 for two nasal doses.
Still, reports show that the opioid antidote remains tougher to find in rural counties, particularly in the southwestern and northeastern corners of the state.
Attorney General Cynthia Coffman’s office has used settlement funds from a lawsuit with pharmaceutical companies to purchase 4,000 naloxone kits since September 2016 for law enforcement officers and first responders and to train them on how to use them.
About 150 law enforcement agencies in the state now carry the reversal drug, more than a sixfold increase from the 23 departments that carried it at the start of the program, the office reported.
“We are living our prime objective, which is the preservation of human life,” said Evans Police Chief Rick Brandt, who helped lead the statewide training and recommends every officer carry a naloxone kit. “The long-term hope is that these folks will be motivated to get into some sort of treatment or recovery to overcome their addictions.”