New ways to com­bat state opi­oid cri­sis sought

Tulsa World - - Our Lives - By Jeff Ray­mond and Mollie Bryant Ok­la­homa Watch

Ok­la­homa is among the nation's lead­ers in com­bat­ing the opi­oid epi­demic in some ways, but it lags in oth­ers.

The ques­tion of what more Ok­la­homa can do to re­duce the hun­dreds of fa­tal over­doses from pre­scrip­tion painkillers each year will hover over the 2018 leg­isla­tive ses­sion. A com­mis­sion chaired by At­tor­ney Gen­eral Mike Hunter plans to rec­om­mend by Dec. 1 new strate­gies for at­tack­ing the prob­lem. Some or all of its pro­pos­als will be folded into leg­is­la­tion.

The lat­est over­dose statis­tics show that Ok­la­homa has made progress in re­cent years in rev­ers­ing opi­oid deaths. But health and law en­force­ment ex­perts say the cri­sis is far from over. And even as opi­oid fa­tal­i­ties have de­clined, over­doses from metham­phetamine and heroin are in­creas­ing.

The Bureau of Nar­cotics and Dan­ger­ous Drugs Con­trol re­ports that in 2016, a record 899 Ok­la­homans died from drug over­doses — a 68 per­cent in­crease since 2007.

Yet the state has seen suc­cesses, as well. The num­ber of deaths in which opi­oids were in­volved fell by 8 per­cent from 2012 to 2016, to 585, the bureau's data shows. Ok­la­homa's pre­scrip­tions for con­trolled, dan­ger­ous drugs dropped to 9.3 mil­lion in 2016 after peak­ing at 10 mil­lion three years prior.

Be­cause the opi­oid epi­demic per­me­ates so many as­pects of pub­lic and pri­vate life, it's un­clear who bears the brunt of re­spon­si­bil­ity, even if the en­tire state feels its im­pact.

“The great plagues of our so­ci­ety have one thing in com­mon, ... that no one owns them,” Sen. AJ Grif­fin, R-Guthrie, told the state opi­oid com­mis­sion in an Aug 29 hear­ing,

About Ok­la­homa Watch

Ok­la­homa Watch is a non­profit, non­par­ti­san me­dia or­ga­ni­za­tion that pro­duces in-depth and in­ves­tiga­tive con­tent on pub­lic-pol­icy is­sues fac­ing the state. For more Ok­la­homa Watch con­tent, go to

ok­la­homawatch.org.

the first planned.

But what other changes would make a dif­fer­ence? And are they po­lit­i­cally and fi­nan­cially achiev­able?

Alex Ger­szewski, a spokesman for Hunter, said com­mis­sion mem­bers don't know yet what their fi­nal rec­om­men­da­tions will be but they are “look­ing at what we could do bet­ter, where we're lack­ing.”

Ok­la­homa Watch ex­am­ined spe­cific ideas that arose out of the Au­gust hear­ing as well as what some other states are do­ing to con­front the is­sue. Men­tal health of­fi­cials em­pha­size that while new ap­proaches are im­por­tant, the un­der­ly­ing is­sue re­mains a lack of pre­ven­tion and treat­ment pro­grams. of five hear­ings

Pre­scrip­tion mon­i­tor­ing

The state was first to es­tab­lish a pre­scrip­tion mon­i­tor­ing data­base (although ac­cess was lim­ited to law en­force­ment for decades) and was the first to have real-time re­port­ing of pre­scrip­tions as they are filled. Ok­la­homa has tight­ened opi­oid pre­scrib­ing by re­quir­ing pre­scrip­tions for those drugs and other con­trolled dan­ger­ous sub­stances to be writ­ten or filed elec­tron­i­cally — rather than called in to phar­ma­cies — and elim­i­nat­ing re­fills. But un­like some other states, it has no lim­its on ini­tial opi­oid pre­scrip­tions, only a rec­om­men­da­tion that the amount be as lit­tle as nec­es­sary.

Whether the Leg­is­la­ture would toughen re­quire­ments is un­clear. Doc­tors fought off pro­pos­als for years to re­quire them to check the on­line Pre­scrip­tion Mon­i­tor­ing Pro­gram for ev­ery opi­oid pre­scrip­tion.

Then, in 2015, they agreed to a com­pro­mise: Physi­cians must check the data­base for all new pa­tients who are seek­ing pre­scrip­tions for cer­tain highly ad­dic­tive drugs and at least once ev­ery 180 days after that. Doc­tor shop­ping has dropped by about a third, state re­search shows.

Don Vogt, who man­ages Ok­la­homa's PMP, said pre­scrip­tion mon­i­tor­ing has had un­in­tended con­se­quences. Fif­teen per­cent of the state's physi­cians have stopped pre­scrib­ing con­trolled dan­ger­ous drugs, par­tic­u­larly opi­ates, which he sug­gested causes pa­tients in ru­ral Ok­la­homa to seek pain man­age­ment treat­ment else­where, in­clud­ing neigh­bor­ing states. With de­creased ac­cess to the pre­scrip­tions, ad­dicts quit cold turkey, lead­ing to with­drawal, or they tran­si­tion from opi­oids to heroin.

One con­tin­u­ing gap in the sys­tem is the abil­ity to com­mu­ni­cate with other states. All states but Mis­souri have pre­scrip­tion mon­i­tor­ing sys­tems, but Mark Wood­ward, spokesman for the Bureau of Nar­cotics, said Ok­la­homa's can only com­mu­ni­cate with those in 11 other states.

Elec­tronic pre­scrib­ing

Some states have made strides in the opi­oid epi­demic by re­quir­ing elec­tronic pre­scrib­ing. New York, for in­stance, has re­quired elec­tronic pre­scrip­tions for all drugs since last year.

Although doc­tors may pre­scribe opi­oids elec­tron­i­cally, most Ok­la­homa physi­cians tend to pre­scribe them on pa­per, said Terri White, men­tal health com­mis­sioner.

That al­lows pa­tients or med­i­cal staff to al­ter pre­scrip­tions or write fraud­u­lent ones us­ing a pre­scrip­tion pad.

“Many physi­cians don't know they can elec­tron­i­cally pre­scribe opi­oids, but even if they did, many don't have an elec­tronic pre­scrib­ing sys­tem with that section in it,” White said.

Cindy Fain, chief com­pli­ance of­fi­cer for the Ok­la­homa State Board of Phar­macy, said the pub­lic can buy the type of pa­per used for pre­scrip­tion pads, and high-qual­ity print­ing tech­nol­ogy makes for very con­vinc­ing fakes.

“They are so good that it's nearly im­pos­si­ble to tell whether it's a forgery or not with­out call­ing the doc­tor,” she said.

In March 2016, the Cen­ters for Dis­ease Con­trol and Pre­ven­tion is­sued more re­stric­tive opi­oid­pre­scrib­ing guide­lines for pri­mary-care providers.

In line with those, Ok­la­homa lim­its pre­scrip­tions to no more than the amount pa­tients need for short-term re­lief of acute pain, though that amount isn't spec­i­fied. Many other states have threeto-30-day lim­its. At least 15 states have opi­oid pre­scrip­tion lim­its, though some ap­ply only to Med­i­caid re­cip­i­ents, state in­sur­ance plan par­tic­i­pants or mi­nors, or deal only with ini­tial pre­scrip­tions, ac­cord­ing to a July re­port from the Na­tional Gov­er­nors As­so­ci­a­tion.

Dr. Kevin Taub­man, pres­i­dent of the Ok­la­homa State Med­i­cal As­so­ci­a­tion and a Tulsa sur­geon who pre­scribes opi­oids, em­pha­sized that they are a nec­es­sary part of some pa­tients' care.

“You don't want peo­ple to come in and put oner­ous lim­i­ta­tions on your prac­tice . ... It's the rou­tine use we need to think about,” he said.

Over­dose re­verser

In re­cent years, state agen­cies and phar­ma­cies have ex­panded the avail­abil­ity of nalox­one, a drug that can pre­vent opi­oid over­doses. Phar­ma­cies pro­vide nalox­one with­out a pre­scrip­tion. How­ever, Ok­la­homa lacks a “Good Sa­mar­i­tan” law that shields in­di­vid­u­als from pros­e­cu­tion or civil lit­i­ga­tion for ad­min­is­ter­ing the drug.

Good Sa­mar­i­tan bills have been in­tro­duced four times in the Leg­is­la­ture but failed to make it out of com­mit­tee. Forty states and Wash­ing­ton, D.C., have a ver­sion of this leg­is­la­tion.

Med­i­caid cov­ers nalox­one in Ok­la­homa, and a state pro­gram pro­vides the drug for free to those 19 or younger or those who know a youth at risk of over­dose.

A state Depart­ment of Health pro­ject trains first re­spon­ders to use nalox­one, and, us­ing fed­eral money, the Ok­la­homa Depart­ment of Men­tal Health and Sub­stance Abuse Ser­vices pro­vides the opi­oid re­verser to ev­ery law en­force­ment of­fi­cer in the Tulsa area and in Ok­la­homa City.

The men­tal health depart­ment has trained 70 law en­force­ment agen­cies across the state, mostly in ru­ral ar­eas, ac­cord­ing to depart­ment data.

Ed­u­cat­ing doc­tors

The state Med­i­cal As­so­ci­a­tion and Ok­la­homa Med­i­cal Board have dis­cussed adding con­tin­u­ing ed­u­ca­tion cour­ses on ad­dic­tion medicine and pain treat­ment, said Lyle Kersey, ex­ec­u­tive di­rec­tor of the board.

Although ad­dic­tion medicine is not part of M.D.s' re­quired 60 hours of con­tin­u­ing med­i­cal ed­u­ca­tion ev­ery three years, sem­i­nars in th­ese ar­eas have been reg­u­larly avail­able, he said.

Os­teo­pathic doc­tors must take 16 hours of con­tin­u­ing med­i­cal ed­u­ca­tion a year, of which one hour ev­ery other year must be de­voted to opi­oids and other con­trolled dan­ger­ous sub­stances.

Physi­cians spend “in­nu­mer­able hours” learn­ing how opi­oids and other med­i­ca­tions work and how to pre­scribe them ap­pro­pri­ately, said Taub­man, of the med­i­cal as­so­ci­a­tion.

Yet “even with all those years of ed­u­ca­tion ... we still have a lot of learn­ing to do.”

In gen­eral, Taub­man said, physi­cians are open to ways to re­duce opi­oid pre­scrib­ing, pro­vided they don't interfere with the doc­tor-pa­tient re­la­tion­ship.

“At the end of the day, I'm not sure where those borders are un­til we see the sug­ges­tions come for­ward,” he said.

AP FILE

OxyCon­tin pills are shown at a phar­macy. Ok­la­homa has worked to re­duce the num­ber of pre­scrip­tion drug over­dose deaths.

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