Hero in our midst, Part 2: Solutions to the prescription opiate crisis

Debra L. Glasser, M.D.

PHOTO BY GLORIA TOWNE

A JOLT OF HEALTH

Hero in Our Midst Part 1, Prescription Opiate Epidemic Revealed

Last column, we learned about Gary Franklin, M.D., our local hero and medical director of the WA Department of Labor and Industries (DLI), who alerted the nation of the prescription opiate crisis due to his research here in Olympia.  He and his staff ‘were on fire’ to uncover and reveal the forces that led to this tragedy. Now, in his mid-70s, Dr. Franklin is still ‘on fire’ continuing to work locally and nationally to reverse the deadly trend that began due to complex and collaborative forces that worked against (instead of for) the public interest.

By 2006 the CDC (Center for Disease Control) identified Washington to be in the highest third of state mortality from unintentional drug overdoses.  Dr. Franklin and his team were already hard at work on first uncovering and then solving the problem.

In Jan 2015, Dr. Franklin published an article in the American Journal of Public Health describing how Washington worked to apply solutions to reverse this epidemic of death and disability. He and his staff knew that state government must play a central role in protecting public health and began to lead and initiate state-level action to reverse this trend.

This endeavor has been COMPLEX and required extensive COLLABORATION for our state to be an innovative leader in its successful accomplishments for change.    

Warning: this is not light reading.

Key interventions

Here are some of the key interventions that have been put in place in our state beginning soon after the crisis was identified:

• It became clear that public payors for healthcare claimed a larger portion of prescription opioid-related deaths and complications. More than half of the deaths were in Medicaid
  • In early 2005, Medicaid implemented and created the Medicaid Lock-in program to review and coordinate the care of clients with a high risk of opiate overuse and addiction. This program began with 200 clients and burgeoned to 3800 by 2012. Emergency department (ED) visits declined by 33%, medical office visits declined by 37% and controlled substance prescriptions declined by 24% within seven months of patient entry into the program.
• Best practice guidelines for the use of opiates needed to be developed.
  • This amazing effort in WA involved extensive collaboration among WA agencies (Departments of Health, Employee Benefits, Medicaid, Corrections, and Worker’s Compensation) along with 15 clinical and academic pain experts. Changes were implemented in phases beginning with dosage guidelines for specific circumstances and eventually led to guidelines for the comprehensive use of opiates. One successful innovation in disseminating these guidelines was offering 2 FREE CME (continuing medical education) credit hours to physicians taking this course, endorsed by the WA State Medical Association.
• A law change was needed to succeed, and thus the cooperation of the WA State Legislature.
  • In January 2010, the legislature repealed the 1999 permissive pain rules (that were a big part of the start of this disaster). It mandated new rules to address opioid dosing criteria, when to seek pain consultation, guidelines for tracking clinical progress, and adherence by prescribers. Collaboration between five boards and commissions (of medical and osteopathic physicians, podiatrists, dentists, and advanced nurse practitioners) jointly developed new rules that became effective in January 2012.
• In 2011, the state’s emergency department (ED) physicians, in collaboration with WA Medicaid, the WA State Hospital Association, and the WA State Medical Association, passed a law requiring hospitals to implement 7 ‘best practices’ for opiate use. Within a year, Medicaid experienced a 24% decline in opiate prescribing after ED visits.
• With federal grants, WA developed a state Prescription Drug Monitoring Program (PDMP), which allowed Medicaid, DLI, and all prescribers to access a patient’s use of controlled prescription drugs. This allowed Medicaid to discover their clients paying cash for opioid prescriptions. While practicing at the Women’s Health Clinic at the American Lake Veterans Administration, it allowed me to discover if my patients were receiving opiates from multiple sources without my or the VA’s knowledge.
• In 2011 University of Washington (UW) launched a telemedicine consult program for chronic pain that practitioners could use for guidance on managing patients and free educational consultations.
• By July 2013, DLI implemented new guidelines for the use of opiates in acute and chronic pain, post-operative pain, tapering guidance, and how to assess meaningful improvement in pain and function of those injured over time.
• In 2003, WA became the second state nationally to adopt a naloxone-related Samaritan law which makes it legal to prescribe an overdose antidote to any person at risk or another person who could intervene in an overdose. This law remains important as a non-prescription opiate epidemic is now raging. Details on this effort, as well as the tragic non-prescription opiate crisis raging in our midst, are topics for subsequent columns.

Sometimes the doctor is the patient

Just days before this column was published, I underwent minor ENT surgery. Turns out the surgery center uses and practices these new post-operative (i.e., after surgery) guidelines developed by the extensive efforts noted above!

I was given detailed written instructions on managing pain after the procedure. This included an emphasis on using acetaminophen (Tylenol) and ibuprofen (Advil) alternating with a prescription for #10 oxycodone 5 mg for break-thru pain.

Every patient also receives the WA Department of Health Pub 631-079 Prescription Opioids for Surgical Pain. It is a brief history of our state’s prescription overdose crisis and what we need to know as a patient. The motto of the handout is:

Be informed. Be aware. Never Share.

The two-page handout includes brief paragraphs detailing the following points:

• What are the risks?
• Safe storage
• Possible side effects
• Proper disposal includes where to take back unused medications at https://doh.wa.gov/you-and-your-family/healthy-home/safe-medication-return and www.med-project.org.
• About Naloxone, the anti-overdose drug with more information available at org.

I was delighted to know that all their patients would receive this handout!

This crisis’ onset and solution has been complicated and required complex collaborative efforts. For me and hopefully, for you, the reader, this story demonstrates how important government both the legislature and state government (supported by tax dollars), data collection (more state-supported government agencies), science,  professional scientists (Dr. Franklin, academic and clinical neurologist and public health trained specialist and Dr. Mai his DLI colleague, clinical and research pharmacist) and professional organizations (WA Medical Association and others) are to our public health. And their collaboration is important to all of us in the state.

I hope you share my deep appreciation and gratitude for everyone working every day on our behalf.

References:

Understanding the Opioid Overdose Epidemic, online article published by the CDC, Last Reviewed: June 1, 2022.

Prescription Opioids for Surgical Pain, PDF published by Washington State Department of Health, October 2019.

A Comprehensive Approach to Address the Prescription Opioid Epidemic in Washington State: Milestones and Lessons Learned, Published online ahead of print January 20, 2015, | American Journal of Public Health

Debra L. Glasser, M.D., is a retired internal medicine physician in Olympia. Got a question for her? Write drdebra@theJOLTnews.com