Addiction, overdoses lead to new prescribing guidelines, monitoring

The Centers for Disease Control reports that more than 47,000 deaths in 2017 were linked to opioid overdoses. Although just 69 of those were attributed to Wyoming, the actual number of overdose deaths is likely higher than reported, according to Recovery Wyoming. (COURTESY PHOTO)

Editor’s Note: This story is the third in a series of stories to be featured in the Herald, delving into the opioid epidemic and its impacts in Uinta County. The final piece in the story will focus on warning signs of addiction and overdose, as well as patient education and prevention. 

EVANSTON — Hundreds of thousands of Americans have died from opioid-related overdoses since 1999, according to the Centers for Disease Control (CDC), with more than 47,000 of those deaths in 2017 alone. Opioids have reportedly been involved in the deaths of numerous celebrities, including Heath Ledger, Prince and Tom Petty. High-profile deaths, well-publicized lawsuits and the staggering numbers of lives impacted by opioid addiction have made headlines nationwide. 

Uinta County, where the opioid prescription rate is the highest in the state, and the entire state of Wyoming are not immune to the damage that can be wrought by opioid misuse and abuse. There were 69 reported drug overdose deaths in Wyoming in 2017, with the actual number of overdose deaths likely higher than that, according to Recover Wyoming. 

When discussing opioids, it’s important to understand the distinction between “opiate” and “opioid.” Though often used interchangeably, the two words do not mean the same thing. An “opiate” refers to a natural, poppy-derived drug, such as morphine or codeine. An “opioid,” on the other hand, can refer to natural opiates as well as semisynthetic or fully synthetic drugs, such as oxycodone, hydrocodone, fentanyl and methadone. 

Both opiates and opioids can be dangerous, but it is the semisynthetic and synthetic drugs in particular that have fueled much of the opioid epidemic. Drugs including oxycodone and hydrocodone were included in recent Washington Post reports on the number of opioids — approximately 76 billion — that were dispensed by retail pharmacies throughout the country from 2006-2012. Recover Wyoming reports that 20-30% of patients prescribed opioids misuse them and that about 80% of heroin users first misused prescription opioids. 

According to the CDC, fentanyl has become particularly problematic. Fentanyl is a fully synthetic opioid developed for use by patients in severe pain, especially pain related to advanced cancer. It can be prescribed in various forms, including transdermal patches or lozenges, and is 50 times more powerful than heroin and 100 times more powerful than morphine. Dramatic increases in the number of fentanyl-related overdose deaths, without similar increases in the number of fentanyl prescriptions, indicate that illicitly-manufactured fentanyl, which is often mixed with heroin and/or cocaine, is a growing problem. 

The National Vital Statistics System describes three waves in the opioid epidemic, with the first wave being a rise in prescription opioid overdose deaths from 1999-2005, the second a subsequent rise in heroin overdose deaths from 2006-2012 and a dramatic rise in the number of synthetic opioid overdose fatalities after 2013. While the numbers of heroin and semisynthetic opioid-related deaths have stabilized in many areas, the number of synthetic opioid-related deaths has continued to climb. 

Efforts to combat the opioid epidemic have resulted in many states passing legislation and adopting prescribing guidelines, misuse and addiction risk assessment tools and drug-monitoring databases, as well as a renewed focus on alternative methods of pain control. 

The Wyoming Board of Pharmacy developed its online Prescription Drug Monitoring Program (PDMP) in 2003. The PDMP is used to track controlled-substance prescriptions and can be accessed by healthcare providers to check on a patient’s prescription history. The goal is to help prevent diversion — the use of prescription drugs by anyone other than the person named on the prescription — as well as the practice of doctor shopping, or visiting multiple different providers in an attempt to obtain prescriptions. The PDMP is accessible 24 hours a day seven days a week by medical professionals. 

Multiple Wyoming stakeholders, including the state boards of dentistry, medicine, nursing and pharmacy, as well as the Prevention Management Organization of Wyoming and the UW School of Pharmacy, were involved in a Wyoming Rx Abuse Stakeholders (RAS) group that developed a Chronic Pain Management Toolkit (CPMT) for use by healthcare practitioners in prescribing opioids. 

The CPMT, which provides guidelines but is not regulatory in nature, includes statements from the American Academy of Pain Medicine that call for limiting inappropriate prescribing, considering opioids only after a thorough evaluation and consideration of alternatives, developing a treatment plan with ongoing monitoring and using opioids mainly when more conservative pain control measures are ineffective. 

When treating chronic pain, the CPMT guidelines include developing pain contracts between providers and patients, doing a thorough evaluation of potential risk factors for opioid misuse and/or abuse, urine drug screening to monitor for misuse/abuse and prescribing opioids only after pain scale assessments, exploration of alternatives and repeat visits. 

Healthcare providers in Uinta County, including at Evanston Regional Hospital, have also been grappling with how to handle opioid prescribing. Dr. Steven Babcock, ERH Chief of Staff, oversaw a task force designed to look into the issue of opioids and create hospital guidelines for prescribing. 

“The overuse of opioid prescription drugs is a national epidemic,” reads a written statement from ERH. “And it’s an issue that providers take seriously. To fight the epidemic, Evanston Regional Hospital has made significant efforts to improve patient safety and outcomes, decrease patient dependence and addiction, and deter prescription drug abuse.” 

The Wyoming Legislature passed legislation in 2019 to address opioid use, including limiting prescriptions for acute pain to a seven-day supply in a seven-day period for opioid-naïve patients, meaning a person who has not had an active opioid prescription in the preceding 45 days. However, the legislation does call for “reasonable exceptions” created in consultation with professional licensing boards and practitioners. 

When it comes to alternative pain management, Jill Bass, CNS, APRN, at the Southwest Wyoming Pain Center said there have been great strides in alternative therapies in recent years, including treatments like spinal cord stimulation. Additionally, TENS (transcutaneous electrical nerve stimulation) treatment, traction devices and cortisone injections may also help with pain control. Bass said she is hopeful the renewed focus on limiting opioid use will drive further research into pain control alternatives to help prevent the overuse and abuse of opioids. 

With the heightened awareness of the problems associated with opioid use, however, there are many people who are fearful of losing medications they may have been using for years to control their pain, said Bass. “There are some patients who have been on them for more than 20 years,” she said. “They’re scared of people playing with their medications and afraid of having them taken away.”

Matt Martineau with the Wyoming State Board of Pharmacy also emphasized that point, noting that many people do use opioid medications for legitimate medical purposes to control chronic or severe pain. When discussing the PDMP, he said, “People are concerned about privacy and about losing access to drugs that help them. The PDMP absolutely cannot be used to infringe on someone’s legal use of medications.” 

Discussions between medical practitioners and patients are absolutely critical in any efforts to combat the opioid epidemic. Patient education and informed decision making are key. 

“Opioids can really become a chain on people, even in the best of situations,” said Bass. “People need to really think about whether that’s a chain they want to deal with. ... This is Wyoming, where people have a real independent streak and think they can handle it, but when this drug bites people, it bites them for real.”

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