Each State Gets a Report Card

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You have got the check this out…an organization called Trust For America’s Health, or TFAH, supported by the Robert Wood Johnson foundation, has released a report called, “Prescription Drug Abuse 2013: Strategies to Stop the Epidemic.” You can find the report at their website at: http://www.healthyamericans.org

This report grades each state on its policies for managing the prescription pain pill epidemic.

The report begins with a description of the scope of the problem: current estimates say around 6.1 million U.S. citizens are either addicted to or misusing prescription medications. Sales of prescription opioids quadrupled in the U.S. since 1999, and so have drug overdose deaths. In many states, more people die from drug overdoses than from motor vehicle accidents. The costs of addiction and drug misuse are enormous; in 2011, a study estimated that the nonmedical use of prescription opioids costs the U.S. around 53.4 billion dollars each year, in lost productivity, increased criminal justice expenditures, drug abuse treatment, and medical complications.

The report identifies specific groups at high risk for addiction. Men aged 24 to 54 are at highest risk for drug overdose deaths, at about twice the rate of women, although the rate of increase in overdose deaths in women is worrisome. Teens and young adults are at higher risk, as are soldiers and veterans. (Please see my blog of October 19th for more information about veterans.) Rural residents are twice as likely to die of an overdose as urban residents.

TFAH’s report declares there are ten indicators of how well a state is doing to fix the opioid addiction epidemic. This report grades each of the fifty states by how many of these indicators each state is using. TFAH says these ten indicators were selected based on “consultation with leading public health, medical, and law enforcement experts about the most promising approaches.”

Here are their ten indicator criteria:
 Does the state have a prescription drug monitoring program?
 Is use of the prescription drug monitoring program mandatory?
 Does the state have a law against doctor shopping?
 Has the state expanded Medicaid under the ACA, so that there will be expanded coverage of substance abuse treatment?
 Does the state require/recommend prescriber education about pain medication?
 Does the state have a Good Samaritan law? These laws provide some degree of immunity from criminal charges for people seeking help for themselves or others suffering from an overdose.
 Is there support for naloxone use?
 Does the state require a physical examination of a patient before a prescriber can issue an opioid prescription, to assure that patient has no signs of addiction or drug abuse?
 Does the state have a law requiring identification to pick up a controlled substance prescription?

 Does the state’s Medicaid program have a way to lock-in patients with suspected drug abuse or addiction so that they can get prescriptions from only one prescriber and pharmacy?

I thought several of these were bizarre. Several are great ideas, but others…not so much. For example, I think a law against doctor shopping leads to criminalization of drug addiction rather than treatment of the underlying problem. The addicts I treat knew that doctor shopping was illegal, but still took risks because that’s what their addiction demanded of them. Such laws may be a way of leveraging people into treatment through the court system, however.

And where are the indicators about addiction treatment? Toward the very end of this report, its authors present data regarding the number of buprenorphine prescribers per capita per state, but make no mention of opioid treatment program capacity per capita for methadone maintenance. Buprenorphine is great, and I use it to treat opioid addiction, but it doesn’t work for everyone. And there’s no data about treatment slots for prolonged inpatient, abstinence-based treatment of opioid addiction.

Expanded Medicaid access for addiction treatment is a nice idea… but not if doctors opt out of Medicaid because it doesn’t pay enough to cover overhead. If expanded access is not accompanied by adequate – and timely! – payment to treatment providers for services rendered, having Medicaid won’t help patients. Doctors won’t participate in the Medicaid system. I don’t. I have a few Medicaid patients whom I treat for free. It’s cheaper for me to treat for free than pay for an employee’s time to file for payment and cut through red tape.

In one of the more interesting sections in this report, each state is ranked in overdose deaths per capita, and the amount of opioids prescribed per capita.

The ten states with the higher opioid overdose death rates are: West Virginia, with 28.9 deaths per 100,000 people; New Mexico, with 23.8 deaths per 100,000; Kentucky with 23.6, then Nevada, Oklahoma, Arizona, Missouri; then in eighth place is Tennessee, with 16.9 deaths per 100,000. In ninth and tenth places are Utah and Delaware. Florida came in at number 11, with 16.4 deaths per 100,000.

North Carolina placed 30th in overdose death rates. We’ve had a big problem with prescription drug overdose deaths. From 1999 until 2005, the death rate rose from4.6 per 100,000 to 11.4 per 100,000. But at least our rate has not increased since 2005. The rate in 2010 was still 11.4. It’s still way too high, but many agencies have been working together over the past six years to turn things around. In a future blog, I intend to list the factors I think helped our state.

Use of the ten indicators does appear to correlate with reduced rate of increase of overdose deaths. In other words, states with more laws and regulations have had a slower rise in overdose deaths than states with fewer laws and regulations, though there are some exceptions.

This report also compares states by the amount of opioids prescribed per year, in kilograms of morphine equivalents per state per 10,000 people. Florida, not surprisingly, came in at number one, with 12.6 kilograms per 10,000 people. Tennessee and Nevada tied for second and third place, with 11.8 kilos per 10,000 people. The next seven, in order, are: Oregon, Delaware, Maine, Alabama, West Virginia, Oklahoma, and Washington. Kentucky was 11th, with 9.0 kilos per 10,000. North Carolina doctors prescribe 6.9 kilos of opioids per 10,000 people per year, in 27th place and less than the national average of 7.1 kilos.

It appears to me that amount of opioid prescribed per capita does correlate, somewhat, with overdose death rates.

Let’s look closer at Tennessee, the state who, just a few months ago, rejected a certificate of need application for an opioid treatment program to be established in Eastern Tennessee. In 1999, Tennessee had an overdose death rate that was relatively low, at 6.1 per 100,000 people. By 2005, it zoomed to 10.4 per 100,000 people, and by 2010, rocketed to 16.9 per 100,000 people, to be in the top ten states with highest overdose death rates. Furthermore, Tennessee is now second out of fifty states for the highest amount of opioids prescribed per 10,000 people. Only Florida beat out Tennessee. And lately Florida has made the news for its aggressive actions taken against pill mills, which may leave the top spot for Tennessee.

West Virginia is no better. It was the worst state, out of all fifty, for overdose deaths, at 28.9 per 100,000 people in 2010. Wow. If you think lawmakers are asking for help from addiction medicine experts…think again.

West Virginia legislators recently passed onerous state regulations on opioid treatment programs. That’s right, lawmakers with no medical experience at all decided what passed for adequate treatment of a medical disease. For example, they passed a law that said an opioid addict had to be discharged from methadone treatment after the fourth positive urine drug screen. In other words, if you have the disease of addiction and demonstrate a symptom of that disease, you will be turned out of one of the most evidence-based and life-saving treatments know to the world of medicine. West Virginia passed several other inane laws regulating the medical treatment of addiction.

Getting back to the TFAH study, the report calculates that there are 21.6 million people in the U.S. who need substance treatment, while only 2.3 million are receiving it. This report identifies lack of trained personnel qualified to treat addiction as a major obstacle to effective treatment.

This report makes the usual recommendations for improving the treatment of addiction in the U.S… They recommend:

 Improve prescription monitoring programs. Nearly all states have them, except for Missouri and Washington D.C.

States should be able to share information, so that I can see what medication my North Carolina patients are filling in Tennessee. Right now, I have to log on to a separate website to check patients in Tennessee, so it takes twice as much time. Tennessee is already sharing data with several other states, but not with North Carolina, or at least not yet.

TFAH also recommends linking prescription monitoring information with electronic health records.

 Easy access to addiction treatment.

Duh. The report accurate describes how underfunded addiction treatment has been, and says that only one percent of total healthcare expenditures were spent on addiction treatment. We know how crazy that is, given the expense of treating the side effects of addiction: endocarditis, alcoholic cirrhosis, hepatitis C, gastritis, cellulitis, alcoholic encephalopathy, emphysema, heart attack, stroke, pancreatitis, HIV infection, gastrointestinal cancers, lung cancer…I could go on for a page but I’ll stop there.

Access to treatment is limited by lack of trained addiction professionals. Doctors abandoned the field back in 1914, when it became illegal to treat opioid addiction with another opioid. Even with the dramatic success seen with methadone and buprenorphine treatment of opioid addiction, there are relatively few doctors with expertise in this treatment.

This reports shows that two-thirds of the states have fewer than six physicians licensed to treat opioid addiction with buprenorphine (Suboxone) per 100,000 people. Iowa has the fewest, at .9 buprenorphine physicians per 100,000 people, and Washington D.C. had the most, at 8.5 physicians per 100,000 people.

North Carolina has 3.2 buprenorphine physicians per 100,000 people, while Tennessee has 5.3 physicians per 100,000. This makes Tennessee look pretty good, until you discover than many of Tennessee’s physicians only prescribe buprenorphine as a taper, refusing to prescribe it as maintenance medication. If these doctors reviewed the evidence, they would see even three month maintenance with a month-long taper gives relapse rates of around 91% (1)

I’m really bothered by the lack of attention to the number of methadone treatment slots per capita. That’s information I’d really like to have. But the authors of this report did not deign to even mention methadone. Even with forty-five years’ worth of data.

**Sigh**

 Increased regulation of pill mills.

 Expand programs to dispose of medications properly. In other words, make sure citizens have a way to get rid of unused medication before it’s filched by youngsters trying to experiment with drugs.

I know many tons of medications have been turned in on “drug take-back” days. But I’ve never seen any data about how much medication is addictive and subject to abuse, versus something like outdated cholesterol lowering pills.

 Track prescriber patterns. Another benefit of prescription monitoring programs is that officials can identify physicians who prescribe more than their peers. Sometimes there’s a very good reason for this. For example, a doctor who works in palliative care and end-of-life care may appropriately prescribe more than a pediatrician.

I get uneasy about non-physicians evaluating physicians’ prescribing habits, though. I think this is best left up to other doctors, enlisted by the state’s medical board to evaluate practices. Other doctors are better able to recognize nuances of medical care that non-physicians may not understand.

 Make rescue medication more widely available. In this section, the report’s authors make mention of Project Lazarus of Wilkes County, NC, a public health non-profit organization dedicated to reducing opioid overdose deaths, not only in that county, but state-wide. Project Lazarus is well-known to me, since I work at an opioid treatment program in Wilkes County.

 Ensure access to safe and effective medication, and make sure patients receive the pain medication they need. Obviously, we want opioids available to treat pain, especially for acute pain. Hey, you don’t have to convince me – read my blog from this summer about how grateful I was for opioids after I broke my leg. Opioids were a godsend to me in the short-term, and knowing what I do about opioids, I didn’t use them after the pain subsided.

It was an interesting report, though I saw some unfortunate gaps in their information, particularly regarding opioid addiction treatment availability.

But at least this is another agency looking at solutions and making some helpful recommendations.

1. Weiss et al, “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” Archives of General Psychiatry, 2011;68 (12):1238-1246.

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9 responses to this post.

  1. Posted by Joy Auren on October 27, 2013 at 1:12 pm

    knowledge is power! Thank you for always giving us keeping us informed! Thanks, Joy 🙂

    Reply

  2. They ought to do the same to all residential and out patient treatment facilities. Given that they are now most like Failing School with piss poor pititful outcomes that they get to blame the patients instead of figuring out where they are acting incompetently and fix it.

    Reply

  3. Have you dr. Ever gotten on suboxone or methadone and ever happened to gotten off because you cannot afford the $400 a month payment actually it was a hundred and eighty dollars a week you had to have or they detox you at 10 milligrams a day until you are off of it that is inhumane that is how the clinics treat clients they do not care about people just their money and if you think that coming off at 10 milligrams will not called very intense sickness unable to work or do anything that you normally do you ma’am need to really think about what you are teaching people you obviously haven’t done very much research as the US government has only put in 1 million dollars for a treatment that only takes one or two times without withdrawals.Obigaine Was only funded 1 million dollars for research by the government and there are no withdrawals that means that people won’t go back to heroin or whatever other opiate or opioid they are trying to get away from whats up having to go through methadone clinic hell or have to go through withdrawal from suboxone because you can’t pay $400 a month for the medicine and doctors prescriptions go back to medical school did try to be more humane teaching people about addiction because what you are suggesting is people to go back to their old drug of choice and possibly die from overdose when they do or get IV HIV AIDS or spend their money on the next fix and the kids won’t have their money to eat alone tonight or in the morning think about it Dr

    Reply

  4. This new opiate “epidemic” is being greatly exaggerated by politicians and by law enforcement, using the same scare tactics that they have been using for the past 40+ years because they have a vested interest in continuing this failed war on drugs, which is especially reprehensible because they KNOW it is a failed war, still it pays their salaries with billions of wasted dollars paid for by the taxpayer. After 40+ years of this brutal, destructive, expensive “war”, any so called health program using advice from law enforcement on how to “stop the epidemic” is either stupid or corrupt. themselves. And while I agree as TFAH states, that “drug problems” have cost the US many billions of dollars, the vast majority of those billions have been spent on salaries for law enforcement in order to brutalize poor people with drug problems, lock them up in places where mostly they get treatments’ exact opposite they get abuse. Until addiction is seen as and treated as, a health problem, every new drug “epidemic” or “crisis” ranted about on the 6pm news is more than a waste of resources. Will we ever learn?

    Reply

    • I agree with much of what you say, but the statistics of opioid addiction and opioid overdose deaths do meet the criteria for calling it an epidemic. Since 2008, more people die in the U.S. of overdose deaths than car crashes. It is not an exaggeration to call this situation an epidemic. And I agree with you that a disease epidemic needs to be treated as a health problem.

      Reply

  5. Once you have committed yourself in a methadone treatment center you can not go back to a pain management program (so it seems ) but I got trowed out of my pain management program for trying a methadone dose for my friend said it works better & longer for chronic pain and would same me money little did I know I was up for a urine sample the next doctors visit, Well I failed the drug test for methadone & my doctor sent a registered letter to my home saying I was no longer being treated for my chronic back pain . the only time I failed my drug screening & my doctor said that they did not prescribe methadone & never would at their office, like I was a monster or something . well I was my mothers hospice caretaker for she was dying from melanoma cancer and I had to do something & I could not find a new pain management doctor soon enough to maintain without the dreadful withdrawals so without thinking about my future healthcare & chronic back pain I had to join a methadone clinic because I had to work (electrical contractor) & take care of my mother cancers needs and all along I was getting sicker more everyday and I could not do all of these things that I had to do being deathly sick with severe withdrawals symptoms . Well in 2009 my mother passed away & me being the only child I had to take care of all the burial needs with little money & no life insurance for mother it took all the money I had left. I stay in the methadone clinic for 6 years and latley I had to do a financial discharge for I could not afford the 116.00 a week for treatment here in Tennessee, they methadone went up from 87.50 to 116.00 a week and I could no longer afford it . Now that pain medication addicion has went up through the roof around here in Knoxville TN. there’s only 2 clinics within 100 miles & the 2 clinics are owned by the same business partners ,they know the have the market cornered in this area and the price of treatment has risen to over 50.00 in 3 months and I think thats not right , they are making money on the backs of poor addicts & people with medical problems with chronic pain that can’t afford a real medical doctor so they turn to methadone to get by. and now I have obamacare insurance no one will take me in for pain management because I went in the methadone clinic for treatment and they said that they would not treat me because I was a opiate addict , but before when I was a patient with a doctor prescribing hydrocodone for my back problem I was just dependance on the medication that he prescribed but when I went in the methadone clinic I became an addict. i want off the methadone and back on my medication that I need to maintain a normal daily life and to go back to work feeling that I can handle the day without hurting constantly . So I guess I will have to lie about the methadone clinic & deny any methadone treatment that I had in the past and hope that it’s not on my medical record.

    Reply

  6. Posted by Jessica on March 30, 2015 at 1:58 pm

    Okay, I know this doesn’t have much to do with what you wrote, but I saw where you had mentioned that you do not take medicaid, but have a couple of patients whom have medicaid and you just treat them for free. I understand that it’s easier for you not to take medicaid, but you need to think of the patients too. The town I live is very small and I actually used to go to one of your clinics that is also in my town. But it got to be way too expensive and having to pay for all my home necessities plus I have a child and plus paying for the suboxone was just too much. I couldnt get back on my feet, which is what i thought treatment was supposed to help you do. Now I have to drive an hour away everyday to go to a clinic that does accept medicaid which takes a lot of gas and wear and tear on the car, but it’s still cheaper. There are alot of people I know, whom also live in the same town I do, who have to travel to that clinic as well. All because you don’t accept Medicaid. We all keep hearing rumors that you might start accepting that insurance, but then nothing ever happens.

    Reply

    • I meant I don’t take Medicaid in my own office-based practice; that’s because I couldn’t stay in business if I did.

      However, I do think that one of the opioid treatment programs where I work plans to start accepting Medicaid. There were just bought by a large hospital corporation, and this may have influenced the decision.

      Reply

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