Opiate misuse leads to tools for prevention

Imagine a man or woman who has worked in the logging or fisheries industry for years. They have injured themselves or developed chronic work‑related pain from repeated hard physical work. Imagine that 10 years ago they went to their physician for help for their pain and were treated with prescription painkillers new to the market that had promised healthcare providers and their patients a pain‑free life without the risk of addiction or dependency. Imagine that 10 years later that man or woman is still using prescription pain killers, has become dependent on them and needs increasingly higher doses to manage his or her pain. What if that woman has accidently overdosed on her prescription and died, or a family member has been regularly raiding the medicine cabinet for recreational drug use or to turn a profit by selling pills at the going market rate. Or a neighbor knows the drugs are in the house and steals them in order to fuel an addiction.
These scenarios and more were described at a meeting held for healthcare professionals on the evening of July 8 in Washington County to discuss the management of acute and chronic pain while also preventing drug diversion, a growing problem in the state and the country. The scenarios are not an imagined world. They are real.
In Maine total prescriptions for opiates in 2012 were 675,615 for women and 547,313 for men. These totals do not include benzodiazepines and stimulants, which if included add over one million additional prescriptions to the mix. The number of prescriptions for just these types of drugs is well over the total state population of 1,330,000. "It's the most important issue of today; it's a pandemic," stated Dr. Tamas Peredy, medical director for the Northern New England Poison Center. A national report issued in 2011 notes that the state has the highest rate of residents seeking treatment for addiction to prescription narcotics.

Bringing it home
Washington County has an average of 2.28 prescriptions of schedule II-IV drugs per person, compared to the state average of 1.91. However, the number of prescriptions gives only a small indication of the challenges of over‑prescribed pain relief as well as the diversion of these drugs to other markets. For example 24.5 million tablets of Oxycodone HCL were dispensed in 2012. A total of 89.2 million tablets were dispensed of just the top five drugs that are of concern to law enforcement officials because of diversion. Between 2007 and 2012 pharmacy‑narcotic drug arrests rose from 21% to 40%, while drug arrests from crack/cocaine to methamphetamines ranged from 6% to 17%.
However, with the bad news there is some good. Along with educational campaigns for both the healthcare community and the public, a growing number of tools are being developed and refined for use in monitoring prescription drug use and diversion. In addition the medical community is recognizing the need to move from drug management to pain management. Maine Medical Association Executive Vice President Gordon Smith explains that several years ago the Joint Commission on hospital accreditation started including a standard of acute and chronic pain management partially based on patient satisfaction scores. Peredy noted that when the opiates for pain management first came on the market the intentions were good, but that as the medical community has gained experience and seen the results it needs to consider whether the short-term goal combined with long-term risks does the patient harm. He said that conversations between the patient and healthcare professional need to include a statement such as, "By writing this scrip I am increasing your risk of dying."
At the July 8 meeting, Smith said, "We have been talking about tools to help prevent abuse and diversion. Practitioners are really trying to do the right thing. Changing the culture takes a long time. It's going to take a community effort. It's not just on the backs of healthcare practitioners; it's going to take the families, patients, taxpayers and insurance companies." He noted that some of the changes beginning to take place are driven by patients. "They read the papers," he explained, and see the stories about over prescribing, drug diversion, burglaries and more.
In 2010, two million people across the nation reported using prescription painkillers non‑medically for the first time within the last year C nearly 5,500 a day. Given the fact that the method most used for obtaining opiates for non‑medical use is still through family and friends, with 53% reporting that they got them from a friend or relative for free, changing the culture will be critical. Of those people who met the definition of dependent/abuser of opiates, 37.5% got them from a friend or relative for free, 20% bought from a friend or relative, 13.6% got through a prescription from one doctor, 12.5% bought from a dealer or stranger, and 6.3% took from a friend or relative without asking. Diversion of opiates is now considered a $25 billion a year industry with the market rate from 50 cents to $1 per milligram of opioid.

Toolkit expands
Legislative changes have been wending their way through the system. Medicare now pays for an increase in chronic pain treatment options such as osteopathic manipulative treatment, chiropractic services, physical therapy, cognitive behavioral and acceptance commitment therapies. Smith is hopeful that commercial insurance carriers will follow suit. In addition, there are now restrictions on dosing minimums and maximums with a limit on total daily opioids. Also, opioid coverage will be discontinuing for certain kinds of chronic pain, such as headaches, back and neck pain and fibromyalgia unless a second opinion supports the use of opioid medications. There are selected situations that do not fall into the above scenarios, such as end‑of‑life care, cancer pain, nursing home patients, inpatient care and people living with HIV/AIDS.
The Prescription Monitoring Program (PMP) and the Maine Diversion Alert Program are two tools that help the medical community in Maine keep drug diversion down, and they're beginning to show positive results. The Maine PMP was put into law in 2003. It maintains a database of all transactions for schedule II, III and IV controlled substances dispensed in the state. The database, which is available online to prescribers and dispensers, is searchable online and generates patient reports on prescription activities. It automatically sends threshold reports to prescribers who are above the average in their prescription practices. Clinicians are able to use the program to check the history of a new patient and to monitor on‑going treatment as well as "doctor shopping" and "pharmacy hopping," two techniques used to garner multiple prescriptions of the same drug.
There are still some holes in the PMP. Program Coordinator John Lipovsky noted that while the Veterans Administration does not provide data it has said that it may join the program later this year. Indian Health Services has been working with the state to create a memorandum of understanding to protect confidentiality. "It's being worked on," Lipovsky said. In addition, he added, Suboxone treatment centers have not been participating.

Spreading awareness
According to figures provided by the Maine Department of Health and Human Services (DHHS) Office of Substance Abuse, which maintains the state's PMP, as of 2009 31% of 4,400 Maine prescribers were using the registry. In June 2013 that number had risen to 57%. In 2007 only 1.9% or 19 Washington County prescribers had signed up to use the registry. By the end of 2009 that number had tripled to 63 registered requesters, and to 81 by 2013. Threshold reports have dropped from almost 1,700 in the second quarter of 2011 to 945 in the second quarter of 2013, and the number of patients exceeding thresholds has decreased from about 70 in 2009 to about 50 in 2012, an indicator that prescription monitoring is beginning to work. PMP reports generated have almost tripled in three years, now reaching 46,200 for the first quarter of the year.
The Maine Diversion Alert Program is relatively new and funded by the Maine Attorney General's Office. It alerts healthcare providers to patients who have been arrested for diverting or abusing prescriptions, among other services. Criminal history record information is public information; however, Program Director Clara Desrosier stressed that participants have responsibilities to use the data in a manner consistent with professional and ethical standards. The program is working, she noted. "In 2009 an Aroostook County provider came to us saying that he had had no idea of the number of patients diverting or prescription shopping."
Smith said that along with the Joint Commission's standard of pain management for hospitals, the World Health Organization "still considers the under‑treatment of pain as an epidemic." The other mover in the pendulum, he noted, is the pharmaceutical industry. In 2007 the maker of Oxycontin paid a $600 million fine and pled guilty for having misled regulators, doctors and patients about the drug's risk of addiction and its potential to be abused. However, Smith suggested that no one disagrees with the need to help people manage their pain. "In this day and age they should have pain management." However, he noted, current practices