Efforts to Prevent and Combat Opioid Overmedication - Watch
opioid overdose deaths ranked by county,
When My Son or Daughter Goes Through Opioid Withdrawal?
I wouldnt wish it on my worst enemy, said Mike, a 24-year-old Naltrexone (Vivitrol) patient committed to recovery. Its the worst thing you could think of.
Because of learned responses in your loved ones brain that come from opioid use, once he or she has detoxed meaning that the body is free of the drug he or she is still highly susceptible to relapse.
In the video below, experts Alicia Murray, DO, a Board Certified Addiction Psychiatrist, and Adam Bisaga, MD, a Professor of Psychiatry at Columbia University, describe what opioid withdrawal is really like and how use of medications in a treatment plan can help ease (or alleviate) the brains learned responses and aid in your son or daughters recovery:
Cant My Kid Stop Using Opioids?
Watch experts Adam Bisaga, MD, a Professor of Psychiatry at Columbia University, and Alicia Murray, DO, a Board Certified Addiction Psychiatrist, discuss the changes that occur in the brain when heroin, prescription pain pills or other opioids are used, and how they can make your child think only about the drug:
problem of opioid addiction
The principle behind the program
In 2009, our physicians looked at the most frequently prescribed drugs for Kaiser Permanente members in Southern California. They were surprised to find that drugs for hypertension and diabetes were not at the top of that list. Instead, opioid medicines and highly addictive narcotics were the most common. In addition, people were getting prescriptions at higher doses than we had previously seen.
Around the same time, new research was being published on the hazards and ineffectiveness of opioids for the management of chronic pain. Given all this evidence, we decided we needed to break the cycle and find alternatives. Rather than risk patients being addicted and overdosing, we would seize the opportunity to improve the quality and safety of drug prescribing at Kaiser Permanente.
Starting in 2010, we launched the Safe and Appropriate Opioid Prescribing Program, a comprehensive initiative to transform the way that chronic pain was viewed and treated. We implemented several efforts to reduce opioid prescriptions, including prescribing and dispensing policies, monitoring and follow-up processes, and clinical coordination through our electronic health record system.
Changing prescribing patterns
Through this program, weve effectively and appropriately reduced:
Results continue to demonstrate that the program is reducing overprescription of opioids and reducing the risk of overdose and death in our members.
Beyond protecting our members, Kaiser Permanentes focus on prescribing the lowest effective dose and supply has helped reduce the risk of opioids getting to the street. We know that unused medications in the medicine cabinet can find their way into our communities.
Caring for chronic pain
According to current clinical evidence and the Centers for Disease Control and Prevention (CDC) guidelines, opioids are not effective in treating chronic pain. Therefore, Kaiser Permanente has turned to a more multidisciplinary approach. We focus on making sure patients get the most effective treatments based on current evidence. This could include non-opioid medications, physical therapy, acupuncture, exercise, injections, cognitive behavioral therapy, and other methods.
After implementing the Safe and Appropriate Opioid Prescribing Program across Southern California, patients themselves reported feeling generally positive about our new approach to pain management. Many are, in the end, feeling better once they are off the very large doses of opioids they were on in the past.
Replicating this program across the country
As a result of a systematic and
comprehensive set of strategies and tactics over several
years, were seeing similar results in other states
where Kaiser Permanente operates. Were encouraged for
the long term because other health care systems could
implement this program, too.
Opioid prescriptions dropped in most Oregon counties between 2010 and 2015, according to new federal data.
But there were four outliers: Malheur, Morrow, Union and Wallowa counties, where providers handed out more opioids per capita in 2015 compared with five years prior, according to data obtained by The Oregonian/OregonLive from the U.S. Centers for Disease Control and Prevention. The top 10 prescribing counties on a per capita basis were in rural parts of the state.
Though prescribing is dropping, the dips are not the same across the board. Oregon leads the country in seniors who are hospitalized for opioid abuse, dependence, overdose and adverse effects.
No. 1 Curry County is the top opioid prescriber in Oregon: 1,800 morphine milligram equivalents per person.
No. 2 Baker County ranked No. 2 on the CDC list, with 1,612 morphine milligram equivalents prescribed per person in 2015.
No. 3 Malheur County came in third, with nearly 1,600 morphine milligram equivalents prescribed per capita in 2015.
No. 4 Union County came in fourth in the CDC rankings, prescribing just over 1,560 morphine milligram equivalents per capita in 2015.
No. 5 Tillamook County providers handed out about 1,550 morphine milligram equivalents per capita in 2015, making it No. 5 on the list of opioid prescriptions per county in Oregon.
No. 6 Lincoln County In the CDC data, Lincoln County ranks No. 6 in Oregon, with about 1,540 morphine milligram equivalents prescribed per capita in 2015.
No. 7 Coos County came in seventh in the CDC data, with nearly 1,480 morphine milligram equivalents prescribed per capital in 2015.
No. 8 Josephine County came in as No. 8 in the CDC data, with about 1,420 morphine milligram equivalents prescribed per capita in 2015.
No. 9 Clatsop County came in ninth in the CDC data. Prescribers gave out nearly 1,410 morphine milligram equivalents per capita in 2015.
No. 10 Jackson County Rounding
out the list of the top 10 counties in terms of opioid
prescriptions is Jackson County. Prescribers there handed
out about 1,340 morphine milligram equivalents per capita in
U.S. in seniors hospitalized for opioids
Oregonians age 65 and up are landing in the hospital for opioid overdoses, abuse, dependence and adverse effects at a greater rate than any other state, federal figures show.
A dozen other states including Washington and California also show seniors with high hospitalization rates for opioids, including Vicodin, OxyContin and Percocet.
But Oregon's rate has nearly tripled in the past decade. The state has outpaced the country for three straight years climbing to a peak of 700 hospitalizations per 100,000 elderly patients in 2015. That translates to 4,500 people.
Addiction specialists didn't anticipate such stark results from data collected by the U.S. Agency for Healthcare Research and Quality and are calling for deeper study to figure out why.
"This is not something we can blow off," said Dr. Shorin Nemeth, regional medical director for palliative care at Providence Health and Services. "This is a vulnerable population."
Nemeth had no idea about the problem until contacted by The Oregonian/OregonLive. Startled to see the statistics, he talked to peers outside Providence. They had no clue either, he said.
Public health officials in Oregon are aware of opioid abuse among older people, but they haven't taken a step back to look at what's driving the phenomenon or told providers what to do about it. They're focused instead on curbing opioid use overall.
"It appears that we are moving in the right direction but we're not there yet," said Dr. Katrina Hedberg, the state epidemiologist and health officer. "We're hoping that prescribing fewer opioids will lead to fewer people who are hospitalized."
Two factors might make Oregon stand out: Doctors have continued to prescribe more opioids to older people and the state has been a national leader in encouraging more liberal use of medication for pain.
It's also possible that old age and the kinds of drugs prescribed to seniors are contributing to the spike. Some opioids are more powerful than others. Some linger longer in the body. Dose is important, too. As is the health condition of the patient.
"Anytime we see increased rates among certain populations or increased rates over time, that's something that needs to be looked at closer," said Gery Guy, a health economist and opioid specialist at the U.S. Centers for Disease Control and Prevention. "It is very concerning."
*This rate does not incllude emergency room visits
''Worst pain" in my life
Jerry Hall took 100 milligrams a day at the height of his opioid addiction five times the normal amount.
Like many people, he started relying on prescription medication for chronic pain but slowly slid into addiction.
Now 60 and living in Southwest Portland, Hall first developed back pain three decades ago when a ram charged at him on a farm in Newberg and threw him 40 feet into the mud.
"I didn't know where I was for a few minutes," Hall said.
Sometimes his pain was so severe that he couldn't work for days as a truck driver. His doctors prescribed Vicodin, he said, but he didn't get addicted.
That changed after a hernia surgery in 2010 and subsequent pain in his left hand. He suspects it was related to a misplaced intravenous line.
"It was the worst pain I'd had in my whole life," Hall said. "It felt like it had its own heart beat."
The agony didn't go away. His doctors gave him oxycodone, a common opioid.
The drug helped dull the persistent throbbing but his hand didn't heal.
The prescriptions kept coming.
Opioids pushed for pain
Oregon has been at the forefront of a movement to control people's pain, including an early emphasis on palliative care and hospice services.
When Hall first got injured, opioids were becoming more widely used as pain treatment in Oregon and nationwide.
In 1995, Oregon passed a pain treatment act, which protected doctors from discipline when they prescribed opioids for severe pain, provided they followed the law. The following year, the American Pain Society launched a nationwide campaign that called on doctors and nurses to ask people about their level of pain. This has become a routine medical practice.
State medical groups, accrediting bodies and even federal drug regulators encouraged the use of opioids for pain.
A national epidemic
The drugs mask symptoms by attaching to receptors in the brain. They block pain, slow breathing and have a calming effect.
"Those of us who were doing medical training in the '90s got a heavy dose of it," said Dr. Todd Korthuis, an addiction treatment specialist at Oregon Health & Science University.
Oregon doctors, often on the leading edge of palliative care, were generous in prescribing.
"We were all awash with it when I started here in 2002," Korthuis said. "Over half of my clinic patients were prescribed opioids."
He suspects the current rates stem from Oregon's liberal prescribing practices years ago. Providers, with a push from medical leaders and drug companies, didn't question how many pills they were prescribing. They were focused on treating pain.
"It was all about compassionately taking the best possible care of the patient as the field understood it," Korthuis said.
Opioid prescriptions in Oregon have dropped but not across the board.
An analysis by The Oregonian/OregonLive shows that the raw number of prescriptions for seniors rose slightly in 2016 compared with 2015. But the older population grew overall, pushing down the per-capita prescription rate by 4 percent.
For people 45 to 64, opioid prescriptions per capita dropped 7 percent among a population that stayed steady. That signals the efforts to stem prescriptions for this group are taking hold.
In 2012, Oregon providers handed out nearly 820,000 opioid prescriptions to those 65 and older. That jumped to 1.1 million in 2016, or 1.6 prescriptions per senior, according to the analysis of U.S. Census and state data.
Snagged for cheating
Jerry Hall's doctors became concerned about his continued opioid use around 2012, the same year he went on disability because of various health issues.
They put him on a monitoring program, made him sign an agreement to take only prescribed pills and introduced random urine testing to ensure he wasn't downing other narcotics.
They prescribed 20 milligrams of oxycodone a day, he said. He emptied the bottle in a couple of weeks. To fill the gap, he said he snagged pills from family, friends and neighbors. Some were free. Others cost up to $10 each.
Eventually, he got caught cheating.
In 2013, during a random urine test, doctors found unprescribed methadone in his system and they stopped his prescriptions.
Hall went into severe withdrawal.
"First you're freezing, then you're burning up," he said. "I couldn't have anything touch me. I couldn't lay down. I couldn't sleep."
He couldn't even hold his beloved cats.
He tried to quit but the symptoms raged, sometimes for four days at a time. With no idea how long they would last, he devoted his life to getting more pills.
He paid his rent and fed his cats. He spent all the rest on opioids, even eating from food pantries.
Hall's experience is far from unique, said Dr. Bryan Dixon, an addiction psychiatrist at Cedar Hills Hospital, a behavioral health treatment center in Portland.
"It doesn't matter if you're 18 or 80," Dixon said. "Once you're dependent, opiates are incredibly difficult to stop."
Hall knew he was addicted but he didn't tell his family, friends or acquaintances. He was too ashamed.
Providers curtail prescriptions
Federal and state health officials have been slowly tackling the overuse of opioids.
In Oregon, the focus on prescription drug abuse has centered on young people. In 2010, a summit including then-Gov. Ted Kulongoski revealed the state's 18- to 25- year-olds had the highest rate of prescription abuse in the country.
The state set up a prescription monitoring program the next year and in late 2015 issued a well-publicized public warning to announce that large medical groups in the Portland area had agreed to curtail opioid prescriptions for chronic pain.
The Centers for Disease Control and Prevention followed in a few months with extensive guidelines advising providers to limit the use of opioids. One section warns about the risk of seniors taking opioids. They can fall, become confused or experience a bad reaction if they take a cocktail of medications.
The Oregon Health Authority issued supplemental guidelines last year that call for the use of alternative treatments or the lowest effective dose of opioids, but the guidelines don't address age groups. Washington state has its own guidelines as well, including a section on seniors.
Hedberg, the state's top medical officer, said the state is trying to curtail opioid prescriptions for everyone, not just one age group.
It stands to reason that seniors with opioid problems would end up in the hospital more often than the general population, she added. Older people simply have more ailments, she said.
But so do seniors in other states that have much lower rates for those 65 and older, like Florida and New York.
It could be that Oregon has a higher rate of seniors with an opioid abuse problem or that state providers are more likely to hospitalize them for treatment, Hedberg said.
Public health officials have no plans to dive into this issue: They've adopted an overall strategy of curtailing prescriptions, tracking trends and trying to get more people with dependency issues on treatment.
This year, Oregon is getting an extra $7 million from the federal Health and Human Services Department to fight opioid addiction and overdoses.
The state plans to use the money to increase access to medication-assisted care. It will target Oregon tribes and rural areas, which lack treatment centers, Hedberg said.
There's no plan to focus on seniors.
Risk factors abound
The Oregonian/OregonLive interviewed pharmacy experts, primary care doctors, pain specialists and addiction experts in the Portland area about why Oregon has such a high rate.
None had a definitive answer.
Many people who started taking the pills a decade or two ago likely stayed on them or resumed treatment as they aged and experienced arthritis or had hip or knee replacements, said Dennis McCarty, a substance abuse treatment specialist at OHSU.
Doctors might overlook risks for substance abuse in older people because they consider addiction a problem of younger people, they're often focused on younger patients with addiction problems, said Dr. Steven Stanos, medical director of pain services at Swedish Hospital in Seattle and president of the American Academy of Pain Medicine.
Or they might associate symptoms such as falls, delirium and memory loss, with aging instead of opioids.
Seniors also may wind up in the hospital more often because they don't metabolize medications as well as younger people, and many take several medications, which can increase health risks.
Yet steering seniors away from opioids in some cases isn't always a good idea. The drugs aren't considered to be a problem for hospice patients or to treat pain associated with cancer.
"It's a challenge in these older patients because many times they have severe pain," Stanos said. "That keeps them from functioning."
Many pain medications that doctors might prescribe to avoid opioids can cause problems in seniors.
Amitriptyline and gabapentin, both used for nerve pain and depression, can cause delirium. Some anti-inflammatories, like ibuprofen, affect kidney function and can trigger stomach ulcers.
Oregon and other states with such high rates of senior hospitalizations should take the problem to doctors and insurers to investigate, specialists said.
"The data should be analyzed in terms of what is the cause of this," said Cynthia Reilly, a Pew Charitable Trusts specialist on substance abuse. "It's something they should take a closer look at."
New drug helps
Jerry Hall increasingly feared his addiction would kill him.
So in early 2015, he saw Dr. Brinton Clark, medical director of Providence Medical Group Northeast. She started him on Suboxone, a medication used to treat opiate dependence.
"That was the day that changed my life," Hall said.
Suboxone contains two elements, naloxone, which is used to treat a narcotic overdose, and buprenorphine, which treats pain but isn't as addictive as many other opioids.
It can still cause withdrawals.
Clark has tapered Hall's dose, starting with a moderately high dose of 20 milligrams a day. He's now down 3 milligrams.
"He's a star patient," Clark said. "He's close to being off."
Hall said if he had known opioids would take over his life and how difficult it would be to get off them, he never would have taken the drugs.
"I would have taken an aspirin," he
In 2000, nearly 58 people died of opioid-related causes statewide, according to the Oregon Health Authority. In 2011, that rose to 292 fatalities.
Overdoses from prescription painkillers have been a big cause.
In 2011, 216 people died from the painkillers in Oregon, compared with 122 heroin deaths.
The outlook has improved, with deaths from prescription painkillers and heroin falling by 2015 when pills killed 180 people and heroin accounted for 91 fatalities.
The following bar charts show death rates for all opioids heroin, prescription pills, methadone, even psychotropics -- over half-decade periods from 2001 to 2015.
Source: Source: Oregon Health Authority ; data are derived from death certificates that include heroin as cause or contributor to death. Known suicides are excluded.
Oregon has one
of the highest rates of prescription opioid misuse in the
Partners across Oregon are working to reduce this epidemic. We have made recent progress, but there is more work to be done.
Talk to your health care provider or visit the links below for treatment resources.
Pain management resources
Addressing the opioid epidemic involves many local, state and national partners. In Oregon, our Opioid Initiative Partnership includes the following groups: