Follow the opioids: How the U.S. got into the crisis and how physicians and tech are beginning to undo the damage

In 2017, 72,000 people died of a drug overdose in the United States, or about one every 10 minutes.¹ In the time it might take you to read this article, another person will die from a drug overdose in the United States.

Of those tens of thousands of deaths, nearly two-thirds involved prescription drugs — not meth, or cocaine or fentanyl, but substances found in medicine cabinets across the nation: hydrocodone, Percocet and the like.

That’s not to say fentanyl is not a problem — it’s one of the fastest-growing causes of overdoses in the nation, doubling about each year.

How did we get to this point? “Follow the opioids,” says Rob Valuck, PhD, EPh, FNAP, a professor of pharmacy at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Studies. Valuck, who teaches in the pharmacology department and the School of Public Health, has been a drug safety researcher for more than two decades. He also directs the Colorado governor’s statewide taskforce on the opioid crisis. As he puts it, he lives and breathes the opioid crisis every day, all day, as his job.

It’s part of what led him to become co-founder of a technology company called OpiSafe, which developed software to help prescribers and patients use opioids safely and meet the increasing burdens that physician practices face in terms of regulatory mandates, payer expectations and simply delivering quality care.

“With something this large, an awful lot of forces are pushing and pulling practices and providers,” Valuck says. “All of that stuff that practitioners are supposed to be doing is introducing a lot of complexity into workflows and daily life for providers.”

How we got here      

Over the past two decades, U.S. practitioners have increased the overall rate of opioid prescribing on a per-capita basis by four. “We really hit the gas pedal on giving everybody opioids for everything,” Valuck says, to the point that, in 2013, there were 260 million prescriptions that went out at retail pharmacies with more than 12 billion dosage units within them — about 55 tablets for every American adult at the time.²

Areas of the country that saw higher concentrations of prescriptions dispensed then saw higher rates of overdose, death and treatment admissions. “Where the opioids go, the problems will follow, and they do,” Valuck says. “Nearly perfect correlation, better correlated than anything else in medicine … There’s almost no clinical variability — if we prescribe a lot, we put people at more risk.”

The willingness to prescribe opioids at such rates was born partially out of a sentiment against providers in the late 1980s when physicians were accused of under-recognizing pain and being “opiate-phobic,” Valuck says. “Pain became the fifth vital sign,” he added — an idea championed by the American Pain Foundation, which operated as a de facto arm of the pharmaceutical industry to prepare the market for the launch of OxyContin.

“One of the best shams ever perpetrated on the American medical system was ‘pain is the fifth vital sign,’” Valuck says. “Everybody asked everybody about it at every visit. It’s the perfect thing if you’re selling pharmaceuticals.” This movement, paired with billions of dollars in drug company advertising and promotion convinced untold numbers of Americans that they should be seeking pain medication from their healthcare providers.

And the providers handling the influx of inquiries about opioid prescription drugs often received very little training on the medications. “I’m a pharmacologist, and I can tell you I got two hours [of training] on opioid pharmacology and all the opioid receptors and how all the opioids work,” Valuck says, which is out of step with the number of prescriptions being filled: About 1 in 10 of every prescription in the United States is an opioid, “but we don’t teach people how to prescribe them, how to monitor them, how to handle them,” despite them being highly addictive if not used properly.

Patients receiving these prescriptions also face issues in understanding how addictive the medications are. “Highly addictive changes in the body start on first dose,” Valuck says. “People start to feel physiologic dependence and withdrawal symptoms as early as nine days.”

That then feeds the trend for seeking black-market alternatives once providers no longer continue a prescription, which includes doctor shopping, pill mills and seeking out unused medications from others. Excess pills left in medicine cabinets are a leading source for non-medical use of opioids,³ Valuck notes. “When you ask people who non-medically use opioids and ended up in a bad way … over 70% of them will say, ‘I started off with the leftovers in my friend or family member’s medicine cabinet,’”⁴ which is why most of Valuck’s work in Colorado has focused on safe disposal and drug takebacks to reduce the number of prescription opioids in circulation.

What’s working

Despite the direness of what the country has experienced and the numerous, bleak headlines about the opioid crisis, there is good news, Valuck says: Prescribing levels are decreasing. “Depending on which data set you look at,” prescribing of opioids peaked sometime between 2011 and 2013, and “is coming down roughly 8% per year.⁵

“We still have some serious rolling back to do to get back to kind of the early ’90s era, pre-OxyContin, where we think we need to be,” Valuck says. “We still have a long way to go to get down there.”

Laws and regulations pertaining to opioids have played a significant part, including the now-common mandates of checking a state’s prescription drug monitoring program (PDMP) — more than 50% of physician practices nationwide are in states with mandatory PDMP checking of some sort, Valuck says.

But PDMP checking alone does not ensure that healthcare providers have the best information available or are using optimal workflows. While the Centers for Medicare & Medicaid Services (CMS) has encouraged integration between PDMP data and EHR systems, separate logins still exist for many providers, and interoperability is a hurdle many have not cleared. CMS is advising for PDMP integration into health information exchanges to connect them to “pharmacy data, shared care plans, drug utilization review programs” and more.⁶

The addition of Centers for Disease Control and Prevention’s opioid prescribing guidelines was something of a sea change for providers, as it “spurred on an awful lot of conversation amongst specialty societies,” Valuck says, and those specialty groups built their own guidelines for their own purposes. Added in with workers’ compensation program guidelines and state-specific Medicaid guidelines in development, and it makes for a very complicated landscape for determining proper prescribing guidelines.

Tech solutions

Bridging the gap between a practice’s existing platforms and state PDMPs is just one area of technological advance being used to address the opioid crisis. Valuck points to a variety of mobile apps developed to help patients and providers, which can:

• Estimate opioid dosing and morphine equivalents of various medications
• Track daily pain via calendar-based diaries
• Establish a tapering schedule for opioid medication

In addition to his academic work, Valuck helped found OpiSafe, which has developed a platform for monitoring guideline adherence levels, PDMP database checking and dashboard visualization of the information stored in an average PDF report from a PDMP or a toxicology report from a lab.

Valuck points to software apps being able to ask patients about symptoms related to opioid use — constipation, sleep disturbance, emerging anxiety and depression, for example — to continue monitoring reactions to prescription use and track aberrancy.

Technological integrations between a practice’s EHR and a PDMP also help practice leaders benchmark how their providers are adhering to prescription guidelines. “One of the most highly motivating things to professionals, whether it’s doctors, lawyers, airline pilots … is to tell them you’re below the rate of your peers,” Valuck says. Being able to share scores with physicians offers an “instant motivation” for their personal improvement.

These improvements play a major part in continuing to confront the opioid crisis on the front lines of healthcare, which can mean the difference between life and death for patients who may already be on opioids and looking for a new doctor.

Those legacy patients are “one of the most intractable problems we’re facing right now,” Valuck says. Without healthcare providers to step in, recognizing that they did not cause the patient’s substance use issues, those patients face a higher likelihood of shifting to heroin and death.

“People say, ‘Well, I don’t want them in my practice.’ I always tell them, ‘They are in your practice — you may not see them, but they are in your practice,’” or intersecting with your practice in some way, Valuck says. Even if your providers don’t treat a given patient, Valuck says it’s time for healthcare providers to have the conversation with patients about the right way to manage their pain.

Data insights

The MGMA Research & Analysis report, Combating the Opioid Epidemic: Effective Policies and Communication Strategies, presents survey data, case studies and in-depth interviews with practice leaders on three key areas — communication, technology and referral management — for physician practices to maximize success when developing or modifying an opioid prescription policy. Members can access the report for free at mgma.com/opioid-report.

Legal/regulatory efforts to address the opioid crisis

• Mandatory PDMP checks
• Mandatory e-prescribing of controlled substances
• Opioid supply limits (days before refill)
• Mandatory CME courses for providers
• Mandatory naloxone co-prescribing with medication
• Mandatory locking pill vials (LPVs)
• Mandatory coverage of abuse deterrent formulations (less easy to crush for snorting or dissolving for injection)

Notes:

1. “Morbidity and mortality weekly report.” Centers for Disease Control and Prevention. 2018. Available from: cdc.gov/mmwr.
2. Volkow ND et al. “Medication-assisted therapies—tackling the opioid-overdose epidemic.” N Engl J Med. 2014; 270:2063-2066.
3. CDC.
4. Substance Abuse & Mental Health Data Archive. National Survey on Drug Use and Health (NSDUH-2009). Accessed Oct. 31, 2018. Available from: bit.ly/2JHWrem.
5. “Medicine Use and Spending in the U.S.: A review of 2017 and outlook to 2022.” IQVIA Institute for Human Data Science. April 19, 2018. Available from: bit.ly/2HMCnXi.
6. Slabodkin G. “Questions swirl on the utility of current PDMP role in opioid crisis.” HealthData Management. Oct. 26, 2018. Available from: bit.ly/2AHYX1a.

Podcast

Hear directly from Rob Valuck, PhD, EPh, FNAP, about successes in combating the opioid epidemic in Colorado and the unique issues that physicians face when e-prescribing controlled substances. Click here.

Dig deeper

MGMA writer/editor Christian Green, MA, takes a closer look at how the Colorado Consortium for Prescription Drug Abuse Prevention built a strategic plan for addressing the opioid crisis and created a model for other states. Click here.