Thursday, March 23, 2017

PDMP and Opioids in Ohio

A recent article in the Journal of the American Pharmaceutical Association caught my eye, Strategies and policies to address the opioid epidemic: A case study of Ohio. The issue is seen having some urgency because it notes "Ohio has the fifth highest rate of drug overdose deaths (24.6 deaths per 100,000) in the United States." However, Statista.com reflects the top are West Virginia (41.5 deaths per 100,000 people), New Hampshire (34.3), Ohio and Kentucky (29.9) and Rhode Island (28.2) as the top 5. The rest of the top ten are Pennsylvania (26.3), Massachusetts (25.7), New Mexico (25.3), Utah (23.4), and Tennessee (22.1). This difference likely reflects the fact that overdose death rates are rising in many jurisdictions. 

As an aside, the Statista.com figures for 2015 reflect that Florida is right in the middle of the list, in 26th place, with a rate of 16.2 deaths per 100,000. Perhaps every state should be looking to the bottom ten, in hopes of discovering the secret to their success. They are Oregon (12), Kansas (11.8), California (11.3), Hawaii (11.3), Minnesota (10.6), Iowa (10.3), Texas (9.4), North Dakota (8.6), South Dakota (8.4), and Nebraska (6.9). That is an intriguing list, with large and small states, coastal, inland, north, central, and south. If there is a geographic or size equivalence it eludes me. 

The authors of the case study note that "unintentional drug overdose has become the leading cause of injury-related death in Ohio." The state has noted a significant volume (3,050 in 2015) of deaths from overdose and in 2015 over 12,000 "overdose events" in which lives were saved by medical responders administering medication to reverse the effects of opioid overdose. 

To address the state's concerns regarding opioid overdose, Ohio formed "the Governor's Cabinet Opiate Action Team," (GCOAT). This team resulted in implementation of study and regulation of opioids. Over a four year period, 2011 to 2015, prescriptions for opioids in Ohio decreased by 81 million, and far fewer overdose deaths were related to prescription overdose in 2015. While that is a significant figure, 700 million doses of opioids were still dispensed in 2015. And, it must be remembered that although prescription overdose is demonstrably decreasing, overdose in general is not. 

The study credits a multidisciplinary approach to the problem of narcotic overdose. But two components of the approach received significant attention in this study: the use of "prescription drug monitoring programs" and the empowerment of pharmacists to "engage in potentially difficult conversations with patients." 

A series of GCOAT guidelines were formulated and released. They addressed prescribing in Emergency rooms (acute care), in treatment of chronic pain, and in the treatment of acute pain. Each urged "prescribers to consider nonopioid therapies first and to encourage prescribers to check Ohio's prescription drug monitoring program (PDMP) before prescribing opioids."

The Ohio legislature also engaged regarding opioid prescriptions. By law, "Ohio prescribers" must now receive a Prescription Drug Monitoring Program (PDMP) report "before prescribing or personally furnishing an opioid." I have written about these PDMPs, see The PDMP is Showing Progress, Maine Makes Opioid Changes, and If it is Worth Having, Is it Worth Checking? In this last, I suggest that there may be value in mandatory PDMP checking. The Ohio law requires it upon initial prescription and periodically thereafter. 

A major issue in the opioid crisis has been "pill mills." Ohio has legislated changes in medical clinics to avoid their operation as "pill mills." It has barred "clinics that prescribe or dispense opioids without any legitimate purposes," and "prevents convicted felons from owning or operating pain clinics," and mandated "a drug take-back program." The state has also focused on decreasing access with "a closed prescription drug formulary," and increasing access to the opioid antagonist naloxone.

The case study acknowledges both progress/successes, and remaining challenges. Progress is documented in decreased opioid death rates and less "doctor shopping." There is discussion of integrating the PDMP database to facilitate easier access and convenience, further efforts to afford naxalone access, and efforts to more broadly address "opioid use disorder." Unfortunately, the progress and plans will be harder to adapt to the problem of illicit drug overdose and death, the growth area of overdose. A leading culprit in this challenge has been "illicit fentanyl," which has been involved in "nearly 40% of unintentional drug overdose deaths."

Essentially, while strides are being made to address prescription drug death and addiction, the illicit drug problem seems to be growing. According to NBC News, the Stark County, Ohio coroner's office recently made the news for its purchase of a "20-foot-long air conditioned trailer with room for 18 bodies." The equipment was needed "because the morgue was overflowing with bodies, nearly half of them victims of drug overdoses." In short, overdose is not decreasing, despite gains in the prescription drug segment. 

The case study concludes that addressing the overdose crisis "is a complex problem requiring a comprehensive and multifaceted approach." There appears to be room in the fight for a variety of professions and perspectives. The question I have asked before and will note again is simple: how many people have to die before we take this situation as seriously as it deserves? Why is there not more leadership on this subject? 

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