VOL. LIX • NO. 1 • 2018 by Journal MSMA

VOL. LIX • NO. 1 • 2018

OPIOID SPECIAL EDITION JOURNAL MSMA

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VOL. LIX • NO. 1 • JANUARY 2018

SCIENTIFIC ARTICLES

THE ASSOCIATION President William M. Grantham, MD

Origins of Opioid-Related Deaths: What is the Evidence? McKenzie Johnson and Richard D. deShazo, MD

President-Elect Michael Mansour, MD

Update on the US Drug Overdose Epidemic Scott Hambleton, MD

Special Article: Governor’s Opioid and Heroin Study Task Force Report

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer W. Mark Horne, MD

DEPARTMENTS

PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD and the Editors

Speaker Geri Lee Weiland, MD

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD

Vice Speaker Jeffry A. Morris, MD Executive Director Charmain Kanosky

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com.

Top 10 Facts You Should Know about Naloxone 12 Meagan Taylor, DO; Jason Fisher, DO; Brian Rifkin, MD; Heather Rifkin, PharmD

From the Editor – The Physician’s Role in the Opioid Epidemic Lucius M. Lampton, MD, Editor

President’s Page: Everyone is Talking about It… William M. Grantham, MD

American Medical Association – Opioid Task Force Progress Report

Poetry and Medicine: Paean to My Poets John D. McEachin, MD

Una Voce: Painkiller Panic – From Pandemic to Pandemonium Dwalia S. South, MD

EDITORIALS A View from Behind the Counter Heather Rifkin, PharmD

Gun Violence, Opioid Addiction, and the Role of Physicians Logan H. Ramsey, M3

How Primary-Care Physicians Can Integrate Addiction Screening, Referrals into their Practices R. Stephen Pannel, DO

A Plan to Reduce Narcotics in Mississippi by Twenty Percent Ben E. Kitchens, MD

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The Other Side of the Opiate Crisis: Why Increasing Opiate Hurdles 32 May Negatively Impact End of Life Patient Care Kurt Merkelz, MD

ADVERTISING RATES: furnished on request. Jill Gordon, MSMA Director of Marketing, Ph: 601-853-6733, ext. 324, Email: JGordon@MSMAonline.com

A Safer Approach to Pain Exists Sherry McAllister, DC

POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548.

Opioid Summit: A Slippery Slope? D. Stanley Hartness, MD

The Rural Difference Timothy Arnold, MD

Opioid Addiction from an Emergency Room Physician’s Perspective Philip L. Levin, MD

The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2018 Mississippi State Medical Association.

ABOUT THE COVER

Official Publication

MSMA • Since 1959

Opioid Special Edition: Scored with the fatal death symbol, the pills on the cover (lower right-hand corner) are indicative of editorial content on opioid use and abuse. Look for this icon in future issues of our Journal MSMA to follow our continued coverage of this vital subject. —Ed. n

VOL. LVIX • NO. 1 • 2018

SPECIAL OPIOID EDITION JOURNAL MSMA

JOURNAL MSMA

F R O M

T H E

E D I T O R

The Physician’s Role in the Opioid Epidemic

hile physicians are not the cause of the current opioid epidemic, they are essential in its solution. The opioid crisis’s solution is three-fold: prevention, enforcement, and treatment. Two of the three legs of that stool, prevention and treatment, are clearly in medicine’s court, and the third requires medical guidance for success. A comprehensive and coordinated response by physicians and our partners in law enforcement is clearly demanded. WHAT IS OUR ROLE IN PREVENTION? Physicians must intensify our efforts to prescribe opiates responsibly, utilizing evidencebased pain approaches and alternatives to opiate prescribing. This requires advancing chronic pain education on our part, and the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain offers a helpful starting-point. Physicians simply must write fewer opiate Lucius M. prescriptions and attempt deprescribing or tapering with every patient visit. Physicians must use with regularity prescription monitoring Lampton, MD programs, urine drug screens, and drug contracts. Cognitive behavioral therapy, physical modalities, and non-opioid pharmacologic Editor approaches must also be utilized. Patient access to prescription opioids must be maintained when medically needed, however, in those situations, we must do more than just write an opiate prescription: we must relieve suffering in a multi-faceted manner, cognizant of the dangers of addiction. WHAT IS OUR ROLE IN ENFORCEMENT? Physicians must reach out to the law enforcement community as responsible partners and scientific advisors for policies to decrease rates of opioid use and overdose. We must promote tools which prevent diversion (PMPs, drug screens), as well as develop relationships of trust to better coordinate our efforts. John Dowdy, Mississippi’s director of the Bureau of Narcotics, discussed with me the necessity for physicians and law enforcement to work together as a team to battle this crisis, especially in advocating the urgent need for improved mental health and drug treatment options for those addicted. WHAT IS OUR ROLE IN TREATMENT? Physicians must learn to recognize signs of addiction in our patients and appropriately refer for inpatient rehab or for medication-assisted treatment (MAT). The stigma associated with both addiction and MAT needs to be eliminated. Addiction must be seen as a disease and not a moral failing. As well, patients receiving MAT and physicians who prescribe it should be supported in their efforts to utilize a proven medical approach to decrease morbidity and mortality associated with addiction. n

— Lucius M. Lampton, MD, Editor

Contact me at lukelampton@cableone.net.

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD

EMERGENCY MEDICINE Philip Levin, MD

MEDICAL STUDENT John F. G. Bobo- M2

ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD

EPIDEMIOLOGY/PUBLIC HEALTH Mary Margaret Currier, MD, MPH Thomas E. Dobbs, MD, MPH

NEPHROLOGY Jorge Castaneda, MD Harvey A. Gersh, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W Bethea, Jr., MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD J. Edward Hill, MD Ben Earl Kitchens, MD James J. Withers, MD

OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Darden H. North, MD

CARDIOVASCULAR DISEASE Cameron Guild, MD Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD Nisha S. Withane, MD, Fellow CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

2 VOL. 59 • NO. 1 • 2018

GENERAL SURGERY Andrew C. Mallette, MD HEMATOLOGY Vincent E Herrin, MD INTERNAL MEDICINE Daniel P. Edney, MD W. Mark Horne, MD Daniel W. Jones, MD Brett C. Lampton, MD Jimmy Lee Stewart, Jr., MD

ORTHOPEDIC SURGERY Chris E. Wiggins, MD OTOLARYNGOLOGY Bradford J. Dye, III, MD PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD PEDIATRICS Michael Artigues, MD Owen B. Evans, MD

PLASTIC SURGERY William C. Lineaweaver, MD Chair, Journal Editorial Advisory Board PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RHEUMATOLOGY Shweta Kishore, MD C. Ann Myers, MD UROLOGY W. Lamar Weems, MD

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S C I E N T I F I C

A R T I C L E

Origins of Opioid-Related Deaths: What is the Evidence? McKENZIE JOHNSON AND RICHARD D. DESHAZO, MD

“If we find out that your prescription habits are causing addiction problems, we’ll come find you. If we have overdose deaths related to your prescribing habits, let this serve as notice to the health care professionals in this state, we’re not playing around anymore.” — Mississippi Bureau of Narcotics, 2017

4 VOL. 59 • NO. 1 • 2018

Introduction There is a global pandemic of deaths caused by natural and synthetic opioid use. Canada and the United States rank first and second in per capita opioid use respectively and consume the majority of the hydrocodone (99.9%), oxycodone (87.3%), morphine (60.1%), and methadone (51.8%) produced.1 Drug overdose has become the leading cause of accidental death in the United States Lethal drug overdoses numbered 52,404 in the United States by 2015, and 33,091 of those deaths were opioid-related.2 Although Mississippi’s per capita opioid death rate is among the lower rates in the United States (Figure 1), the number of opioid deaths per year continues to increase (Figure 2). Everyone wants to know, “Who is to blame?,” and there is active finger pointing. Fortune Magazine used Survey Monkey to ask unscientifically the blame question to 3,645 American adults by inquiring, “What group is most responsible for American’s present epidemic of opioid-related deaths?”3 Forty-percent of responders knew someone who was addicted to an opioid, and 23% knew someone who had overdosed on an opioid. Twenty-nine percent of responders blamed the opioid crisis on the users themselves, 19% on doctors, 15% on pharmaceutical companies, 11% on pharmaceutical prescription drug distributors, and 7% on drug manufacturers in that order (Figure 3). In that regard, several national pharmaceutical companies recently settled claims against them for complicity in the epidemic with the federal government (Table 1). Eighteen-percent of responders were not sure whom to blame or blamed others.

Table 1. Settlements by Pharmaceutical Distributors with the Federal Government for Complicity in the Opioid Epidemic McKesson AmerisourceBergen Cardinal Health

150 m 13.2 m 44 m

2017 2008 2017

Many law enforcement agencies have been quick to blame medical providers and doctors, in particular, for the opioid epidemic in the United States. Most healthcare providers admit to being part of the problem but not the only or largest contributor to it. For instance, medical colleagues argue that except for a very small number of health care providers with criminal intent, the physician contribution has resulted from a double-bind created by a combination of good intentions gone wrong, practice guidelines issued with inadequate evidence to validate them, and regulatory malfeasance. In this article, we reviewed the scientific literature to understand better the root causes of opioidrelated deaths and, in particular, how those forces interact to perpetuate opioid addiction and the consequences of the disease. Our hypothesis was that the origins of the pandemic of opioid-related deaths are multifactorial and that a multifaceted, collaborative approach to address them is more likely to solve it. We hoped to find evidence-based data to determine the more important causes on which collaborations among providers, regulators, professional organizations, licensure boards, and law enforcement could focus. Methods We used the computer-based search engines, PubMed, EMBASE,

author information: Department of Medicine and Pediatrics, University of Mississippi Medical Center, Jackson, MS. (Johnson and deShazo). corresponding author: Richard D deShazo, MD, Billy S. Guyton Distinguished Professor, The University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216. (Rdeshazo@umc.edu). conflicts of interest/disclosures: The authors report none. acknowledgement: The authors appreciate the assistance of Kathryn Rodenmeyer in the review of this manuscript. abstract The most likely approach to address the global pandemic of opioid-related deaths is one that addresses all of its root causes. In this paper, we searched the scientific literature to find high-quality evidence of what they are. Using multiple computer search engines to find systematic reviews and meta-analyses, we found a single systematic review that sought to do so. We also identified 3 additional informative articles, 2 meta-analyses and 1 systematic review that provided epidemiology of opioid-related deaths associated with one or more causes of this pandemic. After reviewing these data, we conclude that although physician prescriptive behaviors are among the contributing determinants of the present pandemic, many other contributing causes exist and are interactive. Moreover, it is improbable that any one of these determinants is predominant. That said, a thoughtful, coordinated, and collaborative approach would be necessary to stem the tide of opioid abuse.

and Google Scholar to identify systematic reviews and meta-analyses published for all years through 2017 on opioid-related deaths. We used the search terms, “risk factors for opioid-related mortality” and “root causes of opioid-related deaths.” Inclusion criteria were meta-analyses and systematic reviews on the topic written in English through 2017. Review articles, individual reports, and editorials were excluded. We also searched the reference lists of the articles reviewed for additional systematic reviews and meta-analyses. Results Our search produced 8 articles, all of which were reviewed. Only 4 of these studies met inclusion criteria. No additional articles meeting inclusion criteria were found from a review of the reference lists in these articles. On further reading, 3 of these articles limited their research to the global epidemiology of opioid-related deaths.4, 5, 6 Two of the 3 included both a systematic review and meta-analyses of their findings. Only 1 of the 4 articles was a systematic review that identified specific causes of opioid-related deaths.7 The information from the 3 epidemiologic studies informed the study on causation and some of those findings are included in this paper. EPIDEMIOLOGIC DATA ON OPIOID-RELATED DEATHS The 3 systematic reviews of the pandemic of opioid-related deaths summarized the best available epidemiologic data. Those studies addressed what patient populations were involved, how opioid-related deaths were geographically distributed, and the drugs of abuse. All 3 JOURNAL MSMA

Figure 1. Prescription Opioid Overdose Deaths and Death Rate per 100,000 Population (Age-Adjusted) Overdose Deaths per 100,000 Population, 1999-2015

21-221

228-548

588-864

Overdose Death Rate per 100,000 Population, 1999-2015

873-1,800

3-6

6-11

11-17

20-29

Prescription Opioid Deaths in the U.S. Kaiser Family Foundation Analysis of Centers for Disease Control and Prevention Data from National Center for Health Statistics, 1999-2015. Accessed at http://www.kff.org/other/state-indicator/ prescription-opioid-overdose-deaths-and-death-rate-per-100000-population-age.

papers included authoritative data from governmental sources. The results of their analyses are summarized in Table 2. For the purposes of this paper, the primary focus will be on data from the United States All 3 emphasized that understanding the North American opioid epidemic required the context of the larger global pandemic. Studies of opioid deaths at the international level have found a “wide variability in the prevalence of drug-related mortality rates” among countries.4 Most international studies noted an increase in deaths from prescription opioid use and decreasing deaths from illicit drug use like that seen in the United States after 2000. Similarly, drug overdoses were no longer just an urban problem as major increases in overdose-related deaths became apparent in rural areas as well.8, 9 Cocaine, prescription opioids, and heroin were the drugs most commonly associated with unintentional drug overdoses worldwide with a shift from the predominance of cocaine overdoses in the 1990s to prescription opioids overdoses in the 2000s.4 Between 1990 and 2006, the mortality rate from drug overdoses tripled in North America and in industrialized countries like in Australia, exceeding motor vehicle deaths and suicides to become the leading cause of unintentional death in the 24 to 64 year old age group.4, 10 European opioid mortality rates were stable in 14 of 30 of the European countries since 2005, with an average of about 20 deaths per million. However, 7 countries had rates of over 40 deaths per million.11 The highest rates per million citizens were in Estonia (127), Norway (70), and Sweden (70).

Figure 2. Mississippi Prescription Opioid Overdose Deaths and Death Rate per 100,000 Population (Age-Adjusted) Mississippi Overdose Deaths per 100,000 Population, 1999-2015 120 110 100 90 80 70 60 50 40 30 20 10 0 1999

2001

2003

2005

2007

2009

2011

2013

2015

Prescription Opioid Overdose Deaths in the US. Kaiser Family Foundation. Analysis of Centers for Disease Control and Prevention Data from the National Center for Health Statistics, 1999-2015. Accessed at http://www.kff.org/other/ state-indicator/prescription-opioid overdose-deaths-and-death-rate-per-100000-population-age.

Figure 3. Findings of Response to the Question, “Who is Most Responsible for the Nation’s Opioid Crisis” from a Random Survey by Fortune Magazine

29% DRUG USERS

19%

18%

15%

11%

PHYSICIANS

OTHER/ DON’T KNOW

DRUG COMPANIES

DRUG DEALERS

DRUG DISTRIBUTORS

Findings of Response to the Question, “Who is Most Responsible for the Nation’s Opioid Crisis” from a Random Survey by Fortune Magazine. Summary of Results of Fortune Magazine Poll on Who Is to Blame for the Opioid Pandemic. Adapted from http://fortune.com/2017/06/21/opioid-epidemic-blame-doctors/ Used with permission from Fortune Magazine, May 2017.

6 VOL. 59 • NO. 1 • 2018

The United States National Center for Health Statistics noted that the number of opioid-related deaths in the United States more than tripled from 1999 to 2006 (Figure 4). 12 When the global increase in opioidrelated deaths became apparent in the late 1990s, methadone, newly prescribed for chronic pain management, became the drug associated with a high portion of those deaths.12 That initial observation was a harbinger of what became a rapidly changing period of opioid use and overdose. It quickly became apparent that there was considerable variation in opioid prescription writing in the United States, and Mississippi opioid prescriptions were in the top quartile on this statistic (Figure 5). Moreover, increasing sales of opioids were associated with increases in deaths from both synthetic and natural opioids, including heroin, and admissions to medical facilities for treatment (Figure 6). An important correlate of drug overdose has been the characteristics of the users. In 2003, the United States Centers for Disease Control and Prevention reported that the highest proportion of drug overdose deaths from prescription opioids was in non-Hispanic White women followed by American Indian or Alaska Natives women aged 45 to 54 years old.13 More recent prescription opioid overdose data show that overdose rates of opioids have become highest among a broader age range of women from ages 25 to 54 years. Men were more likely to die from opioid overdose of any opioid, but the mortality gap or death from prescription opioids between men and women began to close. 14 Local data often differ from national data in the United States and elsewhere. For instance, a study of fatal accidental drug overdoses in New

Table 2. Systematic Reviews of Global Epidemiology of Opioid Overdose and Mortality. Authors, Journal, Date, Reference Number Degenhardt, L. et al., Addiction, 2011, 5

Focus

Key Findings

Global systematic review 58 articles included. CMR very and meta-analysis of heterogeneous among countries. mortality among global Overall CMR was 2.09 / 100 person regular drug users years (CL 1.93 – 2.26). Out of treatment periods had higher mortality risks than in treatment periods. On multivariable regression analysis, there was a correlation with mortality rates with country of origin, percentage of injection users, country versus regional reporting and year of the report.

Mathers, BM et al. Bulletin World Health Organization, 2013, 6

Martins, SS. et al., AJPH 2015, 4

Meta-analysis and systematic review of global rates and cause of death among injection drug users

67 articles included. CMR was 2.35 / 100 person years (CL 2.12 – 2.58).

Global systematic review of unintentional overdoses 1980-2013 to determine prevalence, time trends, mortality rates and correlates

169 articles included.

CMR rates were higher in low and middle income cohorts, HIV+ injection users, and during periods when individuals were out of treatment.

CMR in drug users ranged from 0.04 – 46.4 / 100,000 person years Cocaine prescription opioids and heroin were the drugs most commonly associated with overdoses A trend for increasing prescription opioid abuse and decreasing deaths from illicit drug use was present Non-fatal OD occurred in a mean of 45% of users CMR from drug ODs tripled in the US from 1990-2006 and exceeded the number of deaths from MVA from 2008 onward. OD deaths were higher in non-Hispanic Blacks and Hispanics compared to non-Hispanic Whites. Both urban and rural areas have seen increasing overdoses

Abbreviations: OD = overdose, CMR = crude mortality rate, CL = confidence limits, AJPH = American Journal of Public Health, HIV+ = human immunodeficiency virus seropositive, MVA = motor vehicular accident

York City between 1990 and 1998 found that overdose deaths were higher among non-Hispanic Blacks and Hispanics compared with nonWhites. Cocaine was the most frequently used drug of abuse among non-Hispanic Blacks, whereas opioids and alcohol were more prevalent among Hispanic and non-Hispanic Whites. 15 Another study evaluated the connections between opioid and heroin overdoses in patients admitted to a hospital for treatment.16 The authors found that Whites, women, and middle-aged individuals had the largest increase in both prescription opioid overdoses and heroin overdoses. Heroin overdose rates have increased since 2007. The authors suggested that the focus on decreasing prescription drug-related overdoses might explain “a shift to heroin rather than minimizing the reduction in harm.” 17 Opioid deaths in the United States have been found to be associated with co-administration of alcohol, benzodiazepines, opioid-receptor

agonists, and fentanyl, a drug 80 times more potent than morphine.18,19,20 Epidemiologic studies have provided little data on whether prescription drug overdoses occurred because of overuse of prescription drugs alone or from their use for non-medical purposes. One study that attempted to differentiate overdoses from prescription drugs taken for non-medical use found that 73% of those who died had previously received prescription opioids, 46% had been prescribed tranquilizers, and 45% had been prescribed stimulants. 21 A SYSTEMATIC REVIEW ON CAUSATION The single systematic review on causation of opioid-related deaths by King et al., included articles published between January 1990 and September 2013, identified computer searches of 3 data bases. Of the 3,142 titles identified, 47 met inclusion criteria and served as the basis for their analysis. The authors found, “a complex, multifaceted and geographically-varied web of determinants of increased opioid-related mortality.” They placed the consensus determinants (causes) into 3 categories: prescriber behavior, user behavior, and environmental and systematic determinants. Within the 3 categories, they found evidence for 17 unique determinants of opioidrelated mortality and morbidity increases from 1990 to 2013 (Table 3). We will briefly review their findings. Prescriber Behavior There was evidence to support 5 ways that the behavior of opioid prescribers has contributed to opioid-related mortality. One study convincingly showed that the top quintile of prescribers were highvolume prescribers and issued opioid prescriptions 4.5 times more frequently than the next quintile.22 Those prescribers wrote the final opioid prescriptions for 63% of individuals who died of opioid-related overdoses. However, since there was only 1 study on this topic, the available data were inadequate to convincingly conclude that highvolume prescribing was a direct driver of increased mortality. Prescription sales of opioid analgesics rose 4-fold between 1990 and 2010.23 In 2006, this represented prescriptions of 115, 272 kg of opioids in the United States, twice as much as prescribed in 1997. In particular, prescriptions for non-cancer pain increased and by 2005, 11.5 million American adults were on long-term opioid therapy.24 Studies in Canada, showed correlations between mortality and consumption of the prescription opioids fentanyl, morphine, oxycodone, and hydromorphone and demonstrated correlations between opioid prescribing rates and mortality rates.25 Therefore, an increase in the sales of opioids and prescriptions appears to be a root cause of opioid-related mortality. Dosages of long acting opioids increased by 50% between 1996 and 2002.26 Increased dosages were statistically associated with overdose rates, opioid-related mortality, and all-cause mortality. There was a dose response effect between maximum daily-prescribed dose and the risk of death. Fourteen studies provided evidence for the contribution of methadone prescriptions to increased opioid-related mortality, perhaps related to its small therapeutic window and lower cost than the patented opiates that likely stimulated abuse early in the opioid epidemic.27 JOURNAL MSMA

One study conducted in the United States found that methadone was the primary cause in twice as many single drug deaths compared to any other opioid.28 A Utah study between 1997 and 2004 found that population-adjusted methadone prescription rates increased 727% and opioid-related mortality increased 1770%.29 During this early period of the opioid epidemic, rates of heroin abuse and admissions to substance abuse facilities remained unaffected, suggesting that the increased prescriptions and mortality resulted from the increasing use of methadone for treatment of chronic pain.29 For example, a New York study found that while methadone-related deaths were more prevalent among Blacks than Whites in 1990, this trend had reversed by 2006. The authors proposed that this may have reflected a shift in methadone prescriptions from substance abuse treatment to pain management. 18 Federal regulations may have affected the nation’s methadone-related mortality rates. In 2006, the Food and Drug Administration issued warnings about the cautious prescribing of methadone and revised the interval for the recommended starting dosages. In addition, in 2008, at the request of the Drug Enforcement Administration, manufacturers limited distribution of the largest methadone formulation (40 mg). Methadone-related death reached an all-time high in 2007 and then decreased in 2008 and 2009 as the amount of methadone distributed and abused decreased.28

Table 3. Possible Determinants of Increased Opioid Mortality * Determinants

Number of Studies

PRESCRIBER BEHAVIOR High volume prescribing Opioid prescription or sales Opioid dosage Prescription of oxycodone Prescription of methadone

1** 8 7 7 14

USER BEHAVIOR AND CHARACTERISTICS History of substance abuse 4 Diversion 6** Doctor or pharmacy shopping 5 Drug substitution 2 Polydrug toxicity 14 Sociodemographic characteristics 22 ENVIRONMENTAL AND SYSTEMATIC DETERMINANTS Area urbanization or socioeconomic status 5 Geography 2 Guidelines, policies, and consensus statements 5 Interventions 2 Media coverage 1** Prescription drug monitoring programs 2 * Adapted from reference 7 ** The authors were unable to identify convincingly high volume prescribing, diversion, and media coverage as significant causes of increased mortality. Two determinants were supported by only 1 paper and the quantitative data on diversion were inadequate to allow analysis.

During the period of increasing opioid-related deaths, prescriptions for more potent opioids of increasing potency including methadone and long acting oxycodone (OxyContin®) increased. Long acting opioids, especially OxyContin® in its original formulation were associated with increased opioid-related mortality. The original formulation released in 1995 facilitated abuse with pill crushing which transformed the drug to a more-immediate form. Repeated use to increase or maintain euphoria leads to overdoses.30 Studies in Ontario, Canada showed that annual 8 VOL. 59 • NO. 1 • 2018

opioid-related mortality rates increased 41% and oxycodone-related mortality increased 416% after OxyContin® was added to the provincial formulary. Oxycodone was involved in one third of all opioid-related deaths between 2006 and 2008. 31 The authors of the systematic review concluded there is adequate evidence to attribute an increase in opioidrelated deaths to oxycodone. User Behavior and Characteristics Four studies provided evidence that a previous history of substance abuse is a determinant of opioid-related deaths. One study of methadonerelated deaths found that almost all of the deaths involved individuals who were presently abusing or had abused drugs in the past.27, 32 Diversion, defined as “the act of distributing a drug to individuals by others than the prescriber,” was associated with an increased risk of opioid-related mortality.33 However, rates differed according to location, gender, age, and type of drug. A study of unintentional poisonings in the United States between 1990 and 2002 found that age and gender clustered as male and middle aged in individuals who died from drug abuse. In contrast, those who suffered from chronic non-cancer pain and died from opioid overdose were more likely to be female and older.27 There was little evidence to demonstrate changes in the rates of diversion in the past 20 years. Thus, although diversion appears to be a determinant of mortality, it was not established to be a direct driver of increased mortality in the analysis. 7 The practice of “doctor shopping” (going to numerous physicians to obtain opioid prescriptions) and “pharmacy shopping” (going to numerous pharmacies to fill opioid prescriptions to avoid detection of drug abuse) for prescription opioids has become a popular trend. A New Mexico study noted that risk of overdose increased with rising numbers of prescriptions, prescribers, and pharmacies visited, with pharmacies visited having the strongest association.30 The availability of opioids on the Internet has also provided the opportunity for increases in doctor or pharmacy shopping.34, 35 However, studies failed to establish that there is a significant correlation of internet procurement and opioid mortality rates. Only 0.4% of adults and 1.0% of high schoolaged students in the United States obtain narcotics on the Internet.36 Two studies provided evidence that “drug substitution,” the practice of replacing one prescribed drug with another that is expected to have the same clinical or psychological effect, has played a role in increased prescription opioid-related deaths. 19, 37 Because prescription opioids have a reputation of safety and are in common use, experimentation with them is common. Opioid-related deaths often occur in association with other prescription medications (polypharmacy), especially benzodiazepines, sedative-hypnotics, and antidepressants, alcohol, illicit drugs, and one or more prescription opioids. Many studies demonstrated that polydrug abuse correlates with opioid-related mortality. 30, 37, 38, 39, 40, 41, 42 Studies of sociodemographic characteristics to include race/ethnicity, gender, age, socioeconomic status, and rural-urban residence, have established associations with the rise of opioid-related deaths. As previously noted, mortality rates for opioid-related deaths in many studies are higher among men, non-Hispanic Whites and American

Guidelines, policies, and consensus statements have been associated with opioid-related deaths. For instance, the American Academy of Pain Medicine and the American Pain Society issued a joint consensus statement in 1997 and the American Society of Anesthesiologists issued practice guidelines endorsing use of opioids for chronic non-cancer pain in 2000.45, 46 Five studies provided evidence that such guidelines, policies, and consensus statements have likely played a role in increased opioidrelated mortality. One study showed a major increase in the number of calls to a poison control center concerning adolescent opioid abuse and an increased number of deaths related to opioid overdoses during the 7 years after the release of the 2000 Joint Commission on Accreditation of Healthcare Organizations Pain Standards (JCAH), supporting adequate pain management as the “fifth vital sign.” 47 In response to the epidemic of opioid-related deaths, law enforcement, government, and medical organizations have begun to implement interventions focused on reducing opioid-related mortality. However, very little data on the effects of these interventions is available. A study conducted in Massachusetts demonstrated that implementation of overdose education and naloxone distribution programs in communities significantly reduced fatal overdose rates while having no effect on nonfatal overdoses.48 Attention to print, television, motion picture, and social media non-medical opioid use, the culture of drug abuse and opioid-related mortality may have played a role in the pandemic. One study showed that increased media coverage of opioids preceded increased rates of opioid mortality by 2 to 6 months and accounted for 88% of the variation in mortality.49 Multiple studies also speculated that increased media coverage may lead to “diagnostic suspicion bias,” causing medical examiners and coroners to screen more carefully for opioids as a cause of death or report opioids as a cause of death at lower blood levels.30,,37,49 Although another study revealed little evidence of that. So, this determinant is not well substantiated and remains a topic for research. Two studies provided evidence that prescription drug

16 14 Deaths per 100,000 population

Environmental and Systemic Determinants An overlap of reporting demographic data on behaviors of drug users and environmental and systemic determinants of opioid-related deaths occurred in the studies reviewed. Six environmental and systemic determinants were found to be probable contributors to the epidemic of opioid-related deaths. Five studies provided evidence of urbanization and socioeconomic status (SES) as factors in increased opioid-related death. A United States study showed significant variation and change overtime in locations of opioid-related deaths. In 1999, large metropolitan areas had the highest opioid-related mortality rates and rural areas had the lowest rates. By 2004, rural areas had the highest rates and had experienced the largest relative increase during that time period.44 Two studies provided evidence that geographic factors may have played a role in increased opioid-related mortality. However, the exact causes of the geographic variations across the country remain unclear. 30, 44

Figure 4. Age adjusted rate* of drug overdose deaths** and drug overdose deaths involving opioids — United States, 2000-2014

12 10 8 6 4 2 0

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2002

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ALL DRUG OVERDOSE DEATHS

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2014

DRUG OVERDOSE DEATHS INVOLVING OPIOIDS

Increase in US Prescription Opioid Deaths as reported by US Vital Statistics System. Accessed at https://www.cdc.gov/ mmwr/preview/mmwrhtml/mm6450a3.htm. Source: National Vital Statistics System, Mortality file. * Age-adjusted death rates were calculated by applying age-specific death rates to the 2000 U.S. standard population age distribution. ** Drug overdose deaths are identified using International Classification of Diseases, Tenth Revisions underlying cause-of-death codes X40-X44, X60-X64, X85, and Y10-Y14. Drug overdose deaths involving opioids are drug overdose deaths with a multiple cause-of-death code of T40.0, T40.1, T40.2, T40.3, T40.4, or T40.6. Approximately one fifth of drug overdose deaths lack information on the specific drugs involved. Some of these deaths might involve opioids. Opioids include drugs such as morphine, oxycodone, hydrocodone, heroin, methadone, fentanyl, and tramadol.

Figure 5. Variability in Opioid Prescriptions among States Number of Painkiller Prescriptions per 100 People 52-71 72-82.1 82.2-95 96-143

Variability in Opioid Prescriptions among States as reported by IMS, National Prescription Audit®, 2012, used with permission. This color-coded US map shows the number of painkiller prescriptions per 100 people in each of the 50 states plus the District of Columbia in 2012. Available at https://www.cdc.gov/drugoverdose/data/prescribing.html.

Figure 6. Increasing sales of prescription drugs were associated with increases in deaths and treatment center admissions from natural and synthetic opioids. 8 7 6 5 Rate

Indian and Alaska Natives, middle aged individuals, drug users in rural areas, and those of lower socioeconomic status. However, there is heterogeneity among mortality rates nationally and the demographic may be changing. For instance, consistent increases in opioid-related mortality have occurred among some groups of women. 39, 43

4 3 2 1 0

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TREATMENT

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(PER 10,000 PEOPLE)

(ADMISSIONS PER 10,000 PEOPLE)

Rates of opioid sales, deaths and treatment admissions as reported by US Drug Enforcement Administration. National Vital Statistics System, 1999-2008; Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), 1999-2010; and Treatment Episode Data Set, 1999-2009. Available at https://www.cdc.gov/ vitalsigns/painkilleroverdoses/infographic.html.

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monitoring programs (PDMPs) may be a positive factor in decreasing opioid-related mortality. 50, 51 CONCLUSIONS The first systematic review of the determinants of opioid-related mortality in North America identified a diverse and regionally variable set of determinants of increased opioid-related mortality during the past two decades. Based on their analysis, the authors felt there was satisfactory evidence to demonstrate that 14 of 17 possible determinants identified are valid and, rather than operating independently, interact in complex ways according to the geography and population studied. A number of commentaries, editorials, and reviews have identified root causes of the epidemic of opioid-related deaths on a hypothetical base. 52 Although many of them have little scientific support and were not included in the analysis of King et al, those authors argue “absence of evidence should not be taken to imply evidence of absence.” Moreover, they note that there were serious methodology issues in many of the studies included in their analysis. They also concluded that prevention of further opioid-related mortality would require interventions that address multiple determinants tailored to specific locations and populations. To date, the US governmental efforts to reduce opioid-related mortality have stressed suppression of importation, distribution, and sales of illicit opioids by monitoring and securing the supply of scheduled drugs, and prescriber and patient education programs.53, 54 Although some endorse focusing on single factors such as physician opioid dispensing competence or detection and treatment of user mental health, 55 curbing any pandemic to include this one, will likely require application of proven public health approaches that are not presently within the scope of law enforcement efforts.56 Moreover, federal agencies are not known to collaborate well with each other without external pressure, especially when they include law enforcement (DEA), regulatory (FDA) and epidemiology (CDC) bureaucracies often at cross-purposes. Mirror agencies and silos at the state level compound this problem. So far, efforts to coordinate efforts among them through task forces, wars on drugs and similar efforts have not been effective, especially in a period where national efforts to legalize illicit drugs such as marijuana produce cognitive dissonance. It will take collaborating among public health professionals, federal and state agencies, legislators, and other stakeholders to design and implement evidence-based programs that gather, analyze data, and track results over time to identify those that are effective. The epidemic of opioid-related deaths is a public problem, not simply a law enforcement problem, and public health methodologies are required to solve it. Finally, the differences in opioid-related death rates among those in and out of treatment speak volumes about how best to lower the death rate. All of this said, we now face a new challenge: the arrival and distribution of cheap, 74% pure Mexican heroin to the United States through infrastructure already in place from earlier black tar heroin marketing. The combination of readily available and inexpensive heroin and the explosion of synthetic opioids of the fentanyl family (40 times more potent than heroin per gram) do not bode well for a drug policy driven by finger pointing. 58 n

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International Narcotics Control Board. Narcotic Drugs: Estimated World Requirements for 2013; Statistics for 2011. New York, NY: United Nations; 2012. 2 Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths – United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016; 65:1445– 1452. 3 Fry, E. (2017). Here’s who Americans blame most for the opioid epidemic. Fortune 500. Available at http://fortune.com/2017/06/21/opioid-epidemic-blame-doctors/. 4 Martins SS, Sampson L, Cerdá M, Galea S. worldwide prevalence and trends in unintentional drug overdose: A systematic review of the literature, Am J Public Health. 2015;105(11):2373. doi: 10.2105/AJPH.2015.302843a. 5 Degenhardt L, Bucello C, Mathers B, Briegleb C, Ali H, Hickman M, McLaren J. Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies. Addiction, 2011;106:32–51. doi:10.1111/ j.1360-0443.2010.03140.x. 6 Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, Mattick RP. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet, 2008;372(9651),1x733-1745. 7 Nicholas B. King, Veronique Fraser, Constantina Boikos, Robin Richardson, and Sam Harper, Nicholas B. Determinants of Increased Opioid-Related Mortality in the United States and Canada, 1990–2013: A Systematic Review, Am J Pub Health 104, no. 8 (August 1, 2014): pp. e32-e42. 8 Clark MJ, Bates AC. Nonfatal heroin overdoses in Queensland, Australia: an analysis of ambulance data. J Urban Health. 2003;80(2):238–247. 9 Degenhardt L, Hall W, Adelstein B. Ambulance calls to suspected overdoses: New South Wales patterns July 1997 to June 1999. Aust N Z J Public Health. 2001;25(5):447–450. 10 Centers for Disease Control and Prevention. Wide-Ranging Online Data for Epidemiologic Research (WONDER). 2010. Available at: http://wonder.cdc.gov. Accessed September 06, 2017. 11 2012 Annual Report on the State of the Drugs problem in Europe, Lisbon, Portugal: European Monitoring Centre for Drugs and Drug Addiction; 2012. 12 Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2006. NCHS data brief, no 22. Hyattsville, MD: National Center for Health Statistics. 2009. 13 Centers for Disease Control and Prevention. Prescription painkiller overdoses: a growing epidemic, especially among women. 2013. 14 Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database, released 2015. Data are from the Multiple Cause of Death Files, 1999-2014, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. 15 Galea S, Alhern J, Tardif K et al. Racial/ethnic disparities in overdose mortality rends in New York City, 1990-1998. J Urban Health. 2003;80(2)201-211. 16 Unick GJ, Rosenblum D, Mars S, Ciccarone D (2013) Intertwined Epidemics: National Demographic Trends in Hospitalizations for Heroin- and Opioid-Related Overdoses, 1993–2009. PLOS ONE 8(2): e54496. https://doi.org/10.1371/ journal.pone.0054496. 17 Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med 2016; 374: 154-63. 18 Cerdá M, Ransome Y, Keyes KM, et al. Prescription opioid mortality trends in New York City, 1990–2006: examining the emergence of an epidemic. Drug Alcohol Depend. 2013;132(1-2):53–62. 19 Green TC, Grau LE, Carver H, Kinzly M, Heimer R. Epidemiologic trends and geographic patterns of fatal opioid intoxications in Connecticut, USA: 1997–2007. Drug Alcohol Depend. 2011; 115(3):221–228. 20 Soloway RA. Street-smart advice on treating drug overdoses. Am J Nurs. 1993;93(9):65–72. 21 Silva K., Schrager S.M., Kecojevic A., Lankenau S.E. Factors associated with history of non-fatal overdose among young nonmedical users of prescription drugs. Drug and Alcohol Depend. 128 (1–2) (2013), pp. 104-110, doi: 10.1016/j. drugalcdep.2012.08.014. 22 Dhalla IA, Mamdani MM, Gomes T, Juurlink DN. Clustering of opioid prescribing and opioid-related mortality among family physicians in Ontario. Can Fam Physician. 2011;57(3):e92–e96. 23 Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011; 60(43):1487–1492. 1

Manchikanti L, Singh A. Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician. 2008;11(suppl 2):S63–S88. Fischer B, Jones W, Rehm J. High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005–2009. Pharmacoepidemiol Drug Saf. 2013;22(4):438–442. Franklin GM, Mai J, Wickizer T, Turner JA, Fulton-Kehoe D, Grant L. Opioid dosing trends and mortality in Washington State workers’ compensation, 1996–2002. Am J Ind Med. 2005;48(2):91–99. Paulozzi LJ, Logan JE, Hall AJ, McKinstry E, Kaplan JA, Crosby AE. A comparison of drug overdose deaths involving methadone and other opioid analgesics in West Virginia. Addiction. Centers for Disease Control and Prevention. Vital signs: risk for overdose from methadone used for pain relief—United States, 1999–2010. MMWR Morb Mortal Wkly Rep. 2012;61(26):493–497. Sims SA, Snow LA, Porucznik CA. Surveillance of methadone-related adverse drug events using multiple public health data sources. J Biomed Inform. 2007;40(4):382– 389. Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med. 2006;31(6):506–511. Madadi P, Hildebrandt D, Lauwers AE, Koren G. Characteristics of opioid-users whose death was related to opioid-toxicity: a population-based study in Ontario, Canada. PLoS One. 2013;8(4):e60600. Hall AJ, Logan JE, Toblin RL et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. 2008;300(22):2613–2620. Hernandez SH, Nelson LS. Prescription drug abuse: insight into the epidemic. Clin Pharmacol Ther. 2010;88(3):307–317. Manchikanti L. National drug control policy and prescription drug abuse: facts and fallacies. Pain Physician. 2007;10(3):399–424. McLellan AT, Turner B. Prescription opioids, overdose deaths, and physician responsibility. JAMA. 2008;300(22):2672–2673. Maxwell JC. The prescription drug epidemic in the United States: a perfect storm. Drug Alcohol Rev. 2011;30(3):264–270. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15(9):618–627. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85–92. Mueller MR, Shah NG, Landen MG. Unintentional prescription drug overdose deaths in New Mexico, 1994–2003. Am J Prev Med. 2006;30(5):423–429. Wunsch MJ, Nakamoto K, Behonick G, Massello W. Opioid deaths in rural Virginia: a description of the high prevalence of accidental fatalities involving prescribed medications. Am J Addict. 2009;18(1):5–14. Ling S. Trend analysis on drug-related deaths in Nova Scotia: a study on prescription and illicit drugs. Can J Addict Med. 2013;4(1):11–17. Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 2012;50(6):494–500. Centers for Disease Control and Prevention. Increase in poisoning deaths caused by non-illicit drugs—Utah, 1991–2003. MMWR Morb Mortal Wkly Rep. 2005;54(2):33–36. Paulozzi LJ, Xi Y. Recent changes in drug poisoning mortality in the United States by urban-rural status and by drug type. Pharmacoepidemiol Drug Saf. 2008;17(10):997– 1005. Haddox JD, Joranson D, Angarola RT et al. The use of opioids for the treatment of chronic pain. Clin J Pain. 1997;13(1):6–8. Wilson PR, Caplan RA, Connis RT et al. Practice guidelines for chronic pain management—a report by the American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Anesthesiology. 1997;86(4):995–1004. Tormoehlen LM, Mowry JB, Bodle JD, Rusyniak DE. Increased adolescent opioid use and complications reported to a poison control center following the 2000 JCAHO pain initiative. Clin Toxicol (Phila) 2011;49(6):492–498. Walley AY, Xuan Z, Hackman HH et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346(5):f174. Dasgupta N, Mandl KD, Brownstein JS. Breaking the news or fueling the epidemic? Temporal association between news media report volume and opioid-related mortality. PLoS One. 2009;4(11):e7758. Paulozzi LJ, Kilbourne EM, Desai HA. Prescription drug monitoring programs and

death rates from drug overdose. Pain Med. 2011;12(5):747–754. Paulozzi LJ, Stier DD. Prescription drug laws, drug overdoses, and drug sales in New York and Pennsylvania. J Public Health Policy. 2010;31(4):422–432. Webster LR, Cochella S, Dasgupta N, et al. An analysis of the root causes for opioidrelated overdose deaths in the United States. Pain Med. 2011;12:S26–S35. Beletsky L, Rich JD, Walley AY. Prevention of fatal opioid overdose. JAMA. 2012;308(18):1863–1864. Nelson LS, Perrone J. Curbing the opioid epidemic in the United States: the risk evaluation and mitigation strategy (REMS) JAMA. 2012;308(5):457–458. Lynch ME, Fischer B. Prescription opioid abuse: what is the real problem and how do we fix it? Can Fam Physician. 2011;57(11):1241–1242. Klein SJ, O’Connell DA, Candelas AR, Giglio JG, Birkhead GS. Public health approach to opioid overdose. Am J Public Health. 2007;97(4):587–588. Centers for Disease Control and Prevention. Increase in poisoning deaths caused by non-illicit drugs—Utah, 1991–2003. MMWR Morb Mortal Wkly Rep. 2005;54(2):33–36. Ciccarone D. Fentanyl in the US heroin supply: A rapidly changing risk environment. Int J Drug Policy. 2017; 46:107-111. Kaiser Family Foundation analysis of Centers for Disease Control and Prevention (CDC), National Center for Health Statistics. Multiple Cause of Death 1999-2015 on CDC WONDER Online Database, released 2016. Data are from the Multiple Cause of Death Files, 1999-2015, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Available at http://wonder.cdc.gov/mcd-icd10.html. Accessed March 2, 2017. Age adjusted rate of drug overdose deaths and drug overdose deaths involving opioids (National Vital Statistics System, Mortality file) Available at https://www. cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm. Accessed March 2, 2017. Opioid painkiller prescribing infographic. 2012. IMS, National Prescription Audit (NPA TM), 2012. National Vital Statistics System, 1999-2008; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), 1999-2010; Treatment Episode Data Set, 1999-2009.

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Top 10 Facts You Should Know about Naloxone MEAGAN TAYLOR, DO; JASON FISHER, DO; BRIAN RIFKIN, MD; HEATHER RIFKIN, PHARMD

1. NALOXONE HAS BEEN USED EFFECTIVELY FOR MORE THAN 50 YEARS. Naloxone was approved for opioid overdose by the Food and Drug Administration in 1971.5 It is on the World Health Organization’s List of Essential Medicines, the most effective and safe medicines.6 The price for a package of two auto-injectors in the US, however, has increased from $690 in 2014 to $4,500 in 2016.7 2. NALOXONE CAN BE USED TO REVERSE THE ADVERSE EFFECTS OF DRUGS MADE FROM OPIUM, OR PRESCRIPTION OPIOIDS. Naloxone has a higher affinity for the mu opioid receptor compared to opioids. Naloxone will displace the opioid, causing complete reversal of its effects (Figure). Naloxone is not effective in treating overdoses of benzodiazepines or stimulants such as cocaine and amphetamines.8 From the period of 1996 to 2014, the CDC estimates over 26,000 cases of opioid overdose have been reversed using naloxone. 9 3. NALOXONE CAN BE EFFECTIVELY ADMINISTERED IN MULTIPLE FORMS. Naloxone is available as an intranasal spray, subcutaneous auto-injector, intramuscular injection, and an inhaled form for patients on mechanical ventilation. Naloxone, in its various forms, is effective within minutes of administration. The effects of naloxone last about half an hour to an hour.4 4. NALOXONE HAS MINIMAL SIDE-EFFECT. Essentially there are no side-effects, other than withdrawal symptoms if a patient is opioid addicted. Withdrawal symptoms include agitation, nausea, vomiting, tachycardia, and diaphoresis. To prevent withdrawal, small doses every few minutes can be given until the desired effect is obtained.4 5. A PRESCRIPTION MAY NOT BE NECESSARY FOR PATIENTS TO OBTAIN NALOXONE. Dispensing naloxone by medical professionals (including physicians or other licensed prescribers) at the point of service is subject to rules that vary by jurisdiction. A prescription from a medical professional is still required in Mississippi.10 Recent legislation in Mississippi does allow physicians to write standing orders to one or more pharmacies that allow the public to purchase naloxone without an individual prescription.11 The high price of naloxone, coupled with the requirement for a prescription limits the public’s access to this life saving treatment.

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6. NALOXONE CAN BE ADMINISTERED BY NON-MEDICAL PROFESSIONALS. Anyone can be taught to administer the subcutaneous injectable form of naloxone in just a few minutes. No special training is required to administer the intranasal form. Both forms are designed for use by laypersons, including family members and caregivers of opioid users at-risk for an opioid emergency, such as an overdose. In more than half the U.S. and the District of Columbia, Good Samaritan laws protect a person who helps someone during an overdose.8 Recent legislation in Mississippi allows first responders to administer opioid antagonists as clinically indicated.11 7. MULTIPLE DOSES OF NALOXONE MAY BE REQUIRED TO GET AN EFFECTIVE RESPONSE. If minimal or no response is observed within 2–3 minutes, dosing may be repeated every 2 minutes to the maximum dose of 10 mg.3 If no response occurs at the maximum dose, an alternative diagnosis and treatment should be pursued. Following administration of naloxone patients should be monitored for respiratory rate, heart rate, blood pressure, and level of consciousness. 12 8. NALOXONE MAY HAVE EFFECTS ON PATIENTS WITH PREEXISTING CARDIOVASCULAR DISEASE. Naloxone should be used with caution in people with cardiovascular disease. There have been reports of abrupt reversals with opioid antagonists leading to pulmonary edema and ventricular fibrillation.13 Patients with underlying heart disease have a higher risk for acute changes in blood pressure and arrhythmias.14 9. THERE IS NO RISK OF TOLERANCE OR DEPENDENCE WITH NALOXONE. If naloxone is administered in the absence of concomitant opioid use, no effects occur, except the inability for the body to combat pain naturally.13 In contrast to direct opiate agonists, which elicit opiate withdrawal symptoms when discontinued in opiate-tolerant people, there is no evidence that indicates the development of tolerance or dependence on naloxone.15 10. NALOXONE CAN BE USED IN PEDIATRIC PATIENTS AND DURING PREGNANCY. The auto-injector and intranasal forms of naloxone are acceptable for use in children in a non-hospital setting.14 Naloxone can be used in emergent situations to save the life of a pregnant woman. It does cross the placenta and may lead to withdrawal symptoms in both the mother and fetus.

OPIOIDS WILL CLAIM A RECORD NUMBER OF LIVES IN MISSISSIPPI THIS YEAR AS THE DEATH TOTAL NEARS 200 IN 2017, NEARLY DOUBLE THE NUMBER OF DEATHS RECORDED IN 2016.1 NALOXONE IS A NON-SELECTIVE AND COMPETITIVE OPIOID RECEPTOR ANTAGONIST.2,3 IT WORKS BY REVERSING THE DEPRESSION OF THE CENTRAL NERVOUS SYSTEM AND RESPIRATORY SYSTEM CAUSED BY OPIOIDS.4 NALOXONE CANNOT BE TAKEN BEFORE DRUG USE TO AVOID AN OVERDOSE.

Figure 2. The Naloxone Kit contains all the essentials conveniently packaged. Injecting into the muscle of the upper thigh or upper arm with a syringe is a very common way to administer naloxone. Naloxone kits come with a syringe and a vial or a pre-filled cartridge of naloxone which can be administered through clothes.

author information: PGY-3, Family Medicine Residency, Forrest General Hospital (Taylor and Fisher); Division of Nephrology, Hattiesburg Clinic (B. Rifkin); Pharmacist and President of the Mississippi State Medical Association Alliance (H. Rifkin). corresponding author: Brian Rifkin, MD; 415 South 28th Ave., Hattiesburg, MS 39401. conflicts of interest/disclosures: None

Apel, Therese. MS opioid related deaths set to hit another record this year. Clarion Ledger, November 2, 2017. www.clarionledger.com/story/news/local/2017/11/02/ mississippi-opioid-related-deaths-hit-record-high/824813001/ Accessed November 18, 2017. 2 Malenka RC, Nestler EJ, Hyman SE, Sydor A, Brown RY, ed. Molecular Neuropharmacology: A Foundation for Clinical Neuroscience (2nd ed.). New York: McGraw-Hill Medical. 2009;190–191,287. ISBN: 9780071481274. 3 “Narcan Prescribing Information” (PDF). United States Food and Drug Administration. Adapt Pharma, Inc. January 2017. www.fda.gov/downloads/drugs/ guidancecomplianceregulatoryinformation/guidances/UCM554404.pdf. Accessed November 19, 2017. 4 “Naloxone Hydrochloride”. The American Society of Health-System Pharmacists. Archived from the original on 2 January 2015. www.drugs.com/monograph/ naloxone-hydrochloride.html Accessed November 18, 2017. 5 Yardley, William (14 December 2013). Jack Fishman dies at 83- Saved many from overdose. New York Times. Archived from the original on 15 December 2013. www. nytimes.com/2013/12/15/business/jack-fishman-who-helped-develop-a-drug-totreat-overdoses-dies-at-83.html Accessed November 19, 2017. 6 “WHO Model List of Essential Medicines (19th List)” (PDF). World Health Organization. April 2015. Archived (PDF) from the original on 13 December 2016. www.who.int/medicines/publications/essentialmedicines/EML2015_8-May-15. pdf Accessed November 19, 2017. 7 Ravi Gupta, Nilay D. Shah, and Joseph S. Ross (December 8, 2016). “Perspective: The rising price of naloxone — risks to efforts to stem overdose deaths. N Engl J Med. 2016;375(23):2213–2215. doi:10.1056/NEJMp1609578. 8 Treating a Drug Overdose With Naloxone, WebMD. Available at https://www.webmd. com/mental-health/addiction/drug-overdose-naloxone#1. Accessed November 19, 2017. 9 “The History of Naloxone - Cordant Solutions”. Cordant Solutions. 2017-07-05. Available at http://cordantsolutions.com/the-history-of-naloxone/. Accessed November 18, 2017. 10 Everything You Need to Know About Narcan. Ambrosia Treatment Center. July 20, 2016. Available at https://www.ambrosiatc.com/addiction/narcan/ Accessed November 19, 2017. 11 http://billstatus.ls.state.ms.us/documents/2017/pdf/HB/0900-0999-HB0996SG.pdf 12 “UpToDate: Naloxone Monitoring Parameters” Waltham, MA: UpToDate Inc. Accessed November 18, 2017. 13 “UpToDate: Naloxone: Contraindications” Waltham, MA: UpToDate Inc. Accessed November 19, 2017. 14 Buck, ML (2016, March). Use of Intramuscular Subcutaneous and Intranasal Naloxone Products for Pediatric Opioid Overdose. Available at https://med.virginia. edu/pediatrics/wp-content/uploads/sites/237/2015/12/Mar16_Naloxone_ PedPharmaco.pdf. Accessed November 28, 2017. 15 Daily Med. National Institutes of Health, U.S. National Library of Medicine. April 22, 2014. NALOXONE HYDROCHLORIDE injection, solution. Available at https:// dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=df501ed0-c0f4-11e3-8a330800200c9a66&audience=consumer. Accessed November 18, 2017. 1

Figure 1. Narcan® nasal spray overdose antidote. Source: http://adaptpharma. com/news-events/press-kit/

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Update on the US Drug Overdose Epidemic SCOTT HAMBLETON, MD

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The latest statistics about accidental drug overdose deaths in the United States is abysmal. Provisional data from the CDC suggests that over 64,000 Americans died from accidental drug overdoses in 2016, compared to 52,000 deaths in 2015.1 Of the deaths in 2016, over 15,000 involved use of heroin and over 20,000 involved use of fentanyl.1 The fentanyl related deaths represent a 540% increase in the three years ending in 2016.1 Fentanyl is a schedule II synthetic opioid that is approximately 50 times as potent as heroin and 100 times as potent as morphine, according to the National Forensic Laboratory Information System.2 Analogs of fentanyl, such as the elephant tranquilizer carfentanil, which is 10,000 times as potent as morphine, are also showing up on the street.2 According to the DEA, the majority of these drugs are clandestinely produced and trafficked, and are not diverted prescription medications.2 Drug dealers mix fentanyl or carfentanil with heroin to increase its potency and their profits and the results are deadly. According to the CDC, opioid addiction, which was originally driven by opioids prescribed for chronic, non-cancer pain, is driving the increase in overdose deaths.3 The overprescribing of opioids is associated with initiation of heroin use, and according to the Substance Abuse and Mental Health Services Administration, 79.5% of recent heroin initiates report previous abuse of prescription opioids.4 Fortunately, prescriptions for opioids are actually declining. The total number of dispensed opioid prescriptions declined by 2.2% in 2014, 6.8% in 2015, and are projected to decrease by 2.9% by year-end 2016.5 Now, as prescriptions for opioids are decreasing nationally, the number of deaths from heroin and fentanyl are increasing.3 This is not surprising, because fentanyl and its analogues are inexpensive to manufacture illicitly, and a single dose the size of a grain of salt can be fatal.2 In 2016, Mississippi ranked 4th nationally in number of prescriptions for opioids dispensed per 100 persons.6 Recommendations from The Governorâ&#x20AC;&#x2122;s Opioid and Heroin Study Taskforce and the MSMA combined with changes being initiated by the Mississippi State Board of Medical Licensure will likely result in significant reductions in prescriptions for opioids in Mississippi. The potential harms associated with long-term chronic opioid therapy are well established, and a reduction in utilization of this therapy is warranted. Unfortunately, a decrease in supply of legally prescribed opioids may result in increased use of illicitly obtained opioids, including heroin and fentanyl.7 Other unintended consequences will likely include continued increases in overdose deaths and spread of infectious diseases such as Human Immunodeficiency Virus and Hepatitis C Virus. However, in my estimation, these unintended consequences do not justify the continued practice of inappropriate utilization of chronic opioid therapy, and significant measures to decrease prescribing rates of opioids are warranted. In a September 2017 report, the Council of Economic Advisors estimates that in 2015 the economic cost of the opioid epidemic was $504 billion, or 2.8% of GDP.8 Over 20.5 million Americans have a substance use disorder and 2 million of these are addicted to opioids.9 As many as 25 percent of patients in primary care practices have a substance use disorder.10 Considering the enormity of the underlying problem of addiction, it is shocking that so little time is devoted to education of physicians about its diagnosis and treatment.

One certainty is that our current approach is not working and much change is needed. Access to all forms of treatment is a necessity, and should not be limited to buprenorphine for opioid replacement therapy. However, use of buprenorphine for treatment of opioid use disorder will need to increase, as will reimbursement for all treatment services. In 2016, Mississippi ranked last in terms of public funding by state for buprenorphine prescriptions used to treat opioid addiction.11 That year, only 4% of buprenorphine prescriptions were filled through Medicaid in Mississippi, compared to a national average of 24%.11

ONE CERTAINTY IS THAT OUR CURRENT APPROACH IS NOT WORKING AND MUCH CHANGE IS NEEDED. Guidelines for use of buprenorphine for opioid replacement therapy will need to be promulgated. Appropriate use of this modality is indispensable. In my opinion, concurrent prescribing of buprenorphine with other controlled substances should be tightly regulated, and based on current prescribing practices will likely become more problematic, as this modality becomes more frequently utilized. Hopefully, this national crisis will precipitate effective change.

Scott Hambleton, MD is a Distinguished Fellow in the American Society of Addiction Medicine and is Medical Director of the Mississippi Physician Health Program.

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Ahmad FB, Rossen LM, Spencer MR, Warner M, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. November 13, 2017. https:// www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Accessed November 22, 2017. 2 U.S. Drug Enforcement Administration, Diversion Control Division. NFLIS Brief: Fentanyl, 2001–2015. Issued 2017. Springfield, VA: U.S. Drug Enforcement Administration. https://www.deadiversion.usdoj.gov/nflis/2017fentanyl.pdf. Accessed November 7, 2017. 3 Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths – United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016; 65:1445– 1452. DOI: http://dx.doi.org/10.15585/mmwr.mm655051e1. 4 S Muhuri PK, Gfroerer JC, Davies MC. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. Center for Behavioral Health Statistics and Quality Data Review. Issued August 2013. https://www.samhsa.gov/data/sites/default/ files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm. Accessed July 1, 2016. 5 Pezalla EJ, Rosen D, Erensen JG, Haddox JD, Mayne TJ. Secular trends in opioid prescribing in the USA. J Pain Research. 2017; 10:383-387. doi:10.2147/JPR. S129553. 6 United States prescribing rates. Centers for Disease Control and Prevention web site. https://www.cdc.gov/drugoverdose/maps/rxstate2016.html. Published July 31, 2017. Accessed November 13, 2017. 7 Opioid data analysis. Centers for Disease Control and Prevention web site. https:// www.cdc.gov/drugoverdose/data/analysis.html. Published February 29, 2017. Accessed December 2, 2017. 8 The underestimated cost of the opioid epidemic. The Council of Economic Advisors. The Executive Office of the President of the United States web site. https://www. whitehouse.gov/sites/whitehouse.gov/files/images/The%20Underestimated%20 Cost%20of%20the%20Opioid%20Crisis.pdf. September 2017. Accessed December 3, 2017. 9 Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. HHS Publication No. SMA 16-4984, NSDUH Series H-51. Substance Use and Mental Health Services Administration web site. https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/ NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf. Published September 2016. Accessed November 1, 2017. 10 Jones EM, Knutson D, Haines D. Common problems in patients recovering from chemical dependency. Am Fam Phys. 2003; 68(10):1971-8. http://www.aafp.org/ afp/2003/1115/p1971.html. Accessed July 1, 2014. 11 ## IMS Institute for Healthcare Informatics. Use of opioid recovery medications: Recent evidence on state level buprenorphine use and payment types. https://www. imshealth.com/files/web/IMSH%20Institute/Reports/Healthcare%20Briefs/IIHI_ Use_of_Opioid_Recovery_Medications.pdf. Published September 2016. Accessed January 4, 2017. 1

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P R E S I D E N T ’ S

P A G E

Everyone is Talking about It… WILLIAM M. GRANTHAM, MD MSMA PRESIDENT, 2017-2018

Everyone is talking about it. Your MSMA is doing something about it as well. Opioid misuse is a national crisis and it has hit home here. In late September, the State Board of Medical Licensure (SBML) filed with the Secretary of State more than 20 pages of new and modified rules regarding prescribing by physicians, PAs, and podiatrists. MSMA reviewed and discussed the proposed regulations. Then, we sent a letter to the SBML outlining the association’s position, and I testified (along with some 30 other physicians) on November 15, 2017. We asked the SBML to swiftly adopt three limited provisions. We believe that these three changes would alter the way we prescribe schedule II opioids and significantly reduce the number of opioids prescribed. MSMA also asked the SBML to delay adoption of all other proposed changes until these three rules have been uniformly adopted by other licensing agencies and reviewed for effectiveness and impact. We made sure the specialty societies were involved and we invited the other boards

that license prescribers to embrace this three-rule proposal. There’s another action that I believe would go even further to reduce misuse of prescription opioids. Let’s take a close look at the really high prescribers and invite those physicians (and others) to explain their actions. Why punish the many for the acts of a few? MSMA is the state’s leading physician association, and we have been engaged on the opioid issue from the beginning. We will continue to push ourselves and our partners for solutions. This is a large, complex matter with many moving parts. By bringing prescribers, law enforcement, lawmakers and the recovery community together, we can make a difference.

Sincerely, William M. Grantham, MD

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A View from Behind the Counter HEATHER RIFKIN, PHARMD MSMA ALLIANCE PRESIDENT

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As a pharmacist, I have seen the look of desperation on patients’ faces. From the addict’s side, they are desperately seeking the fix, needing the prescription. From the family’s side, you can see the same look, only this time hoping that their loved one is out of refills or it is too early for the prescription to be filled.

author information: Heather Rifkin, PharmD, received her doctorate in pharmacy from Duquesne University. Practicing as a pharmacist has influenced Heather’s desire to make a positive impact on the opioid crisis. She is currently serving as president of the Mississippi State Medical Association Alliance and on the AMA Alliance opioid initiative project. She enjoys traveling with her family, volunteering in her childrens’ schools, weight lifting and crafting. She has two boys and is married to Brian, an interventional nephrologist.

I’ve seen the look of relief, too. Relief when the bottle is in the addict’s hands, but also from family members when someone tells the addict it’s too soon for more medication. They live in a parallel universe, the addicts and their families, trying to survive daily life, while the pharmacist walks a fine line between belief in the greater good of others and skepticism, between trust in the patient and pure gut instinct.

need for peace. As a pharmacist, it is heartbreaking to watch a patient become addicted to the very medication prescribed to help him or her. No one told me how difficult this particular aspect of the job of a pharmacist would be.

The face of an addict seen from behind the pharmacy counter appears no different than your face or mine. You see, addiction can happen to anyone. Although there isn’t a “look” to an addict, it is possible to see so much written on their faces. Pain and anguish, anger and frustration, denial and sorrow. The “funny” thing about addiction is that it has the same effect on family members.

Dispensing any medications, including opioids, requires sensitivity, respect and confidentiality. It’s been suggested that community pharmacists are the most accessible healthcare practitioner. No one can deny that they interact with the public daily. Pharmacists are the gatekeepers of opioids, and in many ways, they’re the last line of defense in preventing prescription drug diversion or abuse.

It is hard to put into words the looks you see from behind the counter, looks on the faces of people with lives and families and hopes and dreams. These things aren’t written in any textbook and can’t be taught in a classroom. How to comfort these people also isn’t covered in any textbook I ever read.

Pharmacists are taught that we have a corresponding responsibility, along with the prescribing physician, to ensure the validity and appropriateness of the prescriptions we are presented. This is the balancing act our profession has become. From behind the counter you do all you can: advise and counsel, show care and compassion, document and discuss. But pharmacists can’t do it alone. It will take everyone to be ready to end the cycle of addiction.

I don’t observe as many of these looks anymore since semi-retiring to raise my boys; however, the desire I feel to help has become even stronger with the rise of the current opioid crisis. I have found a new outlet to, hopefully, make a difference through the Mississippi State Medical Association Alliance and the health awareness projects we have developed. The faces I saw from behind the counter will never be forgotten, but if I can help just one person through the work being done by our county, state and national medical society Alliances the struggle and effort will be so worthwhile.

ALTHOUGH THERE ISN’T A “LOOK” TO AN ADDICT, IT IS POSSIBLE TO SEE SO MUCH WRITTEN ON THEIR FACES. PAIN AND ANGUISH, ANGER AND FRUSTRATION, DENIAL AND SORROW.

Once the vicious cycle of addiction has shown its face, not much will change until the person addicted is ready to admit the problem and seek help. Somehow the looks of longing, for a reprieve, from friends and family, can go unnoticed. The sadness and despair never seem to cease for the person addicted or their family. We need to see those things before we can truly make a difference.

You see from behind the counter that the looks are the same, the pain and hurt are equivalent. If you weren’t looking at names on the prescriptions it would be difficult to distinguish the addicted patients from their family members. The daily struggle is parallel for the family and the addict. Family members and addicts experience similar physical and emotional symptoms. Physician families are not granted immunity either. Addiction doesn’t give anyone a free pass. There is no pattern, no usual suspect. It is not uncommon for someone to begin using pain medication for a legitimate purpose at a normal dosage, but eventually the need becomes greater – the need for more pills to make it through the day, the need for relief, the

You may be asking what you can do to help alleviate this painful opioid epidemic? I want you to know that you don’t have to be behind the counter to make a difference. As a physician, the opportunities are equal. Here are some ideas: Gather a list of local resources to have available for anyone in need, including local treatment facilities, Addicts Anonymous support groups, support groups for family members, literature on opioid addiction or anything relevant to your area. There’s a lot of information out there that can be disseminated into your communities and to the people who need it. There are excellent materials available from the American Medical Association and on the AMA Alliance website.1

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I encourage all providers to find out the rules and regulations for Naloxone availability in your area. Does your community or facility have a pharmacy that carries Naloxone? If not, you can sign a standing order to make it more readily available. Find out and see if you can provide assistance in making this life-saving drug more readily available in your community. Determine if your community has collection boxes for unused medications and encourage your patients to use them. Promote them on social media. Clean out your own medicine cabinet. Take the extra time to educate your patients about the dangers of incorrect opioid use and ways to keep it out of the wrong hands. Educate yourself on the current laws and regulations regarding opioid prescribing. If there’s pending legislation to tighten up prescribing or any other legislation to help alleviate the crisis, let your elected officials know you support it. Organize other concerned people to make phone calls, write letters, attend rallies, and visit legislators in their offices to let them know you want them to use their legislative power to help deal with this crisis. Align yourself with the MSMA Alliance and inquire how you can distribute their co-branded (with the AMA Alliance) materials for local distribution to schools, community organizations, church groups, student groups and your own patients. The MSMA Alliance also has a limited number of safe medication disposal pouches available for distribution thoughout the state. Please visit www.msmedicalalliance.webs.com for more information about how you can be involved in the MSMA Alliance health project for 2017-2018. The AMA Alliance has made outstanding materials, including an informative post card, brochure, and DVD, available to the public as well as to Alliance members at the local, state, and national level. More information about these materials and AMA Alliance efforts to help reduce opioid misuse can be found on the Prescription Opioid Misuse Prevention page2 of the AMA Alliance website. Additional resources are provided and materials can also be ordered on this page or obtained through your own MSMA Alliance. Before prescribing opioids be sure you have checked the patients profile on the Prescription Drug Monitoring Program, exhausted all other viable alternatives, prescribe only the minimum amount of medication necessary, and follow up with your patient if you have any concerns. Most importantly, trust your gut, and use caution in dubious situations. You don’t have to do all of these things. Just do one or two. Find one small way to combat the issue because it will take all of us working together to overcome this opioid epidemic and keep our loved ones and communities safe. n

Mississippi State Medical Association Alliance. Contact us. http://www. msmedicalalliance.webs.com. Accessed November 27, 2017. 2 AMA Alliance. Prescription Opioid Misuse Prevention. http://www.amaalliance. org/advocacy-opioid. Accessed November 27, 2017.

PERSONAL MEDICATION DISPOSAL SYSTEM YOUR PRESCRIPTION FOR PREVENTION IT’S IN THE BAG.

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TOGETHER WE ARE STRONGER www.msmedicalalliance.webs.com

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Gun Violence, Opioid Addiction, and the Role of Physicians LOGAN H. RAMSEY, M3, UMMC SOM Public health epidemics are complex and multifactorial, affecting numerous aspects of society across the globe. Two areas of concern have received increasing attention over recent years in the United States: gun violence and opioid addiction. Both are current public health crises with deleterious impacts on the welfare of our nation. The statistics associated with both of these crises are sobering. In 2015, over 36,000 deaths related to gun violence and more than 33,000 deaths due to opioid overdose occurred in the US.1,2 In 2017, the deadliest mass shooting in US history took place in Las Vegas, claiming the lives of over 50 men, women, and children.3 These issues represent truly challenging obstacles for the medical community and society as a whole. When taking a closer look at gun violence and opioid addiction, it is necessary to consider the impact of mental health on both crises. Mental health disorders remain common for a substantial number of patients, with up to 25% of the US population affected by some type of mental illness.4 In 2015, over 60% of gun deaths in the US occurred as a result of suicide.1 Recent research has also associated disproportionately higher use of opioids in patients with illnesses such as anxiety and depression.5 Given the severity of these issues, many of the involved stakeholders hope to discover solutions to the problems. In some cases, physicians have been placed in the spotlight and framed as prescribers of unnecessary opioid medications.6 The lack of comprehensive mental health resources is also highlighted as a largely unmet need.7 Certainly, the search for causes of opioid addiction and gun violence is important and well intentioned. However, physicians and other health care providers are uniquely positioned to become part of the solution to the crises. By utilizing screening mechanisms and counseling, physicians can directly combat opioid misuse and gun violence due to suicide. For example, up to 45% of patients whose deaths are due to suicide visited a primary care physician in the month preceding their death.8 The therapeutic physician-patient relationship provides an effective opportunity to protect patients at risk. Although numerous screening protocols are reported in the literature, it is difficult to incorporate lengthy questionnaires when time with a patient is limited. However, two screening measures are notable for their brevity along with high sensitivity and specificity. Smith et al. report accurate identification of drug use after asking primary care patients a single screening question, “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”9 This screening 22 VOL. 59 • NO. 1 • 2018

addresses a wide range of substance use, including opioids, and offers the chance for additional conversation and counseling as needed. While the US Preventive Services Task Force (USPSTF) concludes current evidence is insufficient to recommend suicide screening for the general asymptomatic population, the USPSTF does recommend screening for depression in the general population.10,11 The two question Patient Health Questionnaire (PHQ-2) inquires about anhedonia and depressed mood, while providing the same level of efficacy as lengthier instruments.12 It also helps identify patients in need of additional assessment for suicidal ideation and planning, which includes screening on access to firearms. Physicians can also educate patients on the mental health resources available within the community and offer referral when appropriate. Through these interventions, physicians can play a vital role in lowering the number of deaths due to suicide and heroin or prescription opioid overdoses. While a long road ahead remains before the issues of gun violence and opioid addiction are resolved, a crucial step forward is the willingness of physicians to advocate for public and mental health, along with including preventive screenings during encounters with patients. n

Bauchner H, Rivara FP, Bonow RO, et al. Death by Gun violence – A public health crisis. JAMA Psychiatry. 2017;74(12):1195-1196. 2 Gostin LO, Hodge JG, Noe SA. Reframing the opioid epidemic as a national emergency. JAMA. 2017;318(16):1539-1540. 3 Shultz JM, Thoresen S, Galea S. The Las Vegas shootings – Underscoring key features of the firearm epidemic. JAMA. 2017;318(18):1753-1754. 4 Reeves WC, Strine TW, Pratt LA, et al. Mental illness surveillance among adults in the United States. MMWR Suppl. 2011;60(3):1-29. 5 Davis MA, Lin LA, Liu H, Sites BD. Prescription opioid use among adults with mental health disorders in the United States. J Am Board Fam Med. 2017;30(4):407-417. 6 Dineen KK, DuBois JM. Between a rock and a hard place: Can physicians prescribe opioids to treat pain adequately while avoiding legal sanction? Am J Law Med. 2016;42(1):7-52. 7 Rubens M, Shehadeh N. Gun violence in the United States: in search for a solution. Front Public Health. 2014;2:17. 8 McDowell AK, Lineberry TW, Bostwick JM. Practical suicide-risk management for the busy primary care physician. Mayo Clin Proc. 2011;86(8):792-800. 9 Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170(13):1155-1160. 10 LeFevre ML, Force USPST. Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(10):719-726. 11 Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315(4):380-387. 12 Maurer DM. Screening for depression. Am Fam Physician. 2012;85(2):139-144. 1

Committee Seeks Candidates for Vacancies in MSMA Offices Delegates attending the 150th MSMA Annual Session August 17-18, 2018, in Jackson will cast ballots to fill new terms of office for a number of association posts. The Nominating Committee is seeking input from the membership as the committee prepares a slate of candidates. The slate developed by the Nominating Committee will be published to the entire membership in June. All nominees must be active members of the association. No physicians may be put forth on the ballot unless that physician has expressed a willingness to serve if elected. The chart below lists the vacancies that will be filled by election in 2018. The names of incumbents and the incumbentâ&#x20AC;&#x2122;s eligibility to be re-elected are indicated. Terms of office follow. The Nominating Committee is composed of the nine most recent Past Presidents of the association residing in Mississippi. The Immediate Past President is the chair. OFFICERS & TRUSTEES

INCUMBENT

President-elect at large Trustee District 1 Trustee District 3 Trustee Resident/Fellow Trustee/Student

Michael Mansour Roderick C. Givens John R. Mitchell Chelsea Rick Avani K. Patel

2 1

4 5 7 6

COUNCILS INCUMBENT Accreditation at large Accreditation at large Budget & Finance at large Budget & Finance at large Constitution & Bylaws Ethical & Judicial Affairs Ethical & Judicial Affairs-Stud Legislation District 4 Legislation District 5 Legislation Resident Legislation Student Medical Education District 6 Medical Education District 7 Medical Education District 8 Medical Service District 6 Medical Service District 7 Medical Service District 8 Medical Service Resident Medical Service Student Public Information District 7 Public Information District 8

Ralph Didlake Sonya R. Shipley Jennifer D. Gholson Nathan Williamson Meredith Travelstead Timothy Wright Kerry West Bryan Barksdale John C. Halbrook, III Brock Banks Mary Elizabeth Butts J. Stephen Beam Blaine Mire Rickey L. Chance Thomas Dobbs Michael L. Davis Erin A. Dewitt David Green Kandice Bailey Patrick S. Bynum Gregory A. Patino

JOURNAL MSMA INCUMBENT Associate Editor

Stanley Hartness

Terms of Office: President-elect: 1 year 2018 - 2019; Officers, Trustees & Councils (physicians): 3 years 2018 - 2021; Trustees & Councils (students & residents): 1 year 2018 - 2019. Journal Associate Editor: 2 years 2018 - 2020. Incumbents NOT eligible for re-election are noted in gray type. Email Nominations to CKanosky@MSMAonline.com or any member of the Nominating Committee: Lee Voulters, MD; Daniel P. Edney, MD; Claude D. Brunson, MD; James A. Rish, MD; Steve Demetropoulos, MD; Thomas E. Joiner, MD; Timothy J. Alford, MD; Randy Easterling, MD; J. Patrick Barrett, MD.

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How Primary-Care Physicians Can Integrate Addiction Screening, Referrals into their Practices R. STEPHEN PANNEL, DO MEDICAL DIRECTOR • OXFORD TREATMENT CENTER

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When you refuse to refill a patient’s OxyContin prescription, the response is screaming, threats, or even physical damage to your office. Have you just witnessed a manic swing from bipolar disorder? Or is there something else going on? Embarassing scenes like that are a red flag for addiction, but many physicians would not recognize it as such or know what to do to help the patient. For most doctors and surgeons, mental healthcare and addiction were not part of their education and training. Those fields have been largely segregated from the broader healthcare system and from hospitalbased physician networks, making the gap even wider. As the opioid epidemic arrives in Mississippi, however, physicians in this state are finding themselves on the front lines of the crisis. All primarycare practices now need to consider whether they are equipped to help their patients avoid or recover from addiction. Fortunately, this does not require becoming an expert in treating addiction and co-occurring mental health disorders. Your practice can make a significant difference by adding small steps to the systems you already have in place to screen patients for potential problems and to refer them out for specialized care. Here are three steps we recommend: 1. UNDERSTAND THE PREVALENCE. According to the National Institute on Drug Abuse, an estimated 8.6 percent of Americans are in need of treatment for problems related to drugs or alcohol. Particularly in the case of the current opioid epidemic, we have seen that addiction spans all social classes without discrimination. No matter the makeup of your particular practice, consider that one out of every 10 to 12 patients you see has a problem with drugs or alcohol. Ask your office manager how many patients you currently have in your practice, and do the math. The figure may be hard for you to believe, but those struggling with drugs or alcohol often hide it well, at least for a while. Your practice also includes people who have not yet developed a substance use disorder, but who are vulnerable to addiction due to a genetic, physiological or psychological predisposition. Consider this: A treatment path that may be medically appropriate and effective for 90 percent of patients can accelerate chemical dependency issues for the remaining 10 percent, due to existing substance use disorders or addiction vulnerability. For that reason, to routinely prescribe Xanax for anxiety or Lortab for pain, without considering certain patients’ vulnerability to addiction, will cause problems for them and for your practice. 2. SCREEN AND ENGAGE PATIENTS. Despite the stakes, it can seem extraneous and time-consuming to engage patients on the subject of their drug or alcohol use when they have come to your office for medical care. To streamline the process, introduce a screening tool into the paperwork that patients already complete during check-in. Choose one for your practice by reviewing the forms provided in the Clinical Practice section of the SAMHSA-HRSA Center for Integrated Health Solutions website.

author information: Dr. Pannel oversees medical detox, medication management, and treatment planning as Medical Director of Oxford Treatment Center. He specializes in treating dual diagnosis issues. He is certified by the American Board of Psychiatry and Neurology and the American Board of Addiction Medicine.

The DAST-10 screening tool, for example, is only 10 questions long and can be completed in minutes. It asks patients whether they have ever used more than one drug at a time, whether they’ve experienced blackouts or withdrawals, and whether their family members have ever complained about their drug use. By utilizing a simple check-in screening tool, physicians have a better chance of determining whether drugs or alcohol might be causing problems in a patient’s life – before a new prescription potentially sends them deeper into dependency. 3. DEVELOP REFERRAL RESOURCES. Of course, the catch in trying to determine whether patients have a problem with drugs or alcohol is, what are you going to do with that information? Primary-care practices need to build out their referral resources in the areas of mental and behavioral health, especially in communities where those fields are still isolated from broader healthcare systems. When a patient admits to having a drug problem, or when a patient throws a fit in full-blown denial, you don’t want to have to make 10 different calls to find someone who can help. To identify quality treatment centers, look for appropriate licensing and credentials. A center should be certified by the Department of Mental Health and be accredited by the Joint Commission or CARF.

ACCORDING TO THE NATIONAL INSTITUTE ON DRUG ABUSE, AN ESTIMATED 8.6 PERCENT OF AMERICANS ARE IN NEED OF TREATMENT FOR PROBLEMS RELATED TO DRUGS OR ALCOHOL. Referrals for treatment should be made within the context of each patient’s access to care. If they have a current insurance plan, reach out to the insurance company’s provider service network and ask for a referral for substance use disorders and/or mental health issues. Many practices routinely use insurers’ services to refer patients to in-network providers for a range of medical problems; physicians may not realize the same service can also help them refer out for mental and behavioral healthcare. Addiction and co-occurring disorders are closely linked to physical wellbeing. Patients struggling in theses area many times present with

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medical complaints that are not clearly defined and also do not respond to treatment interventions. This may lead to frequent return visits. This is a good time to consider addiction and co-occurring disorders and integration of treatment for these with your patients. This will help your patients return to good health and stay healthy. n

Comments from attendees in 2017: “Wonderful course. I will definitely take it again even just for CME. It is a very good source for review.” “After going to this conference, my confidence in passing the exam has measurably increased and I am less anxious about it.”

NIDA. (2011, March 1). Treatment Statistics. Available at https://www.drugabuse.gov/ publications/drugfacts/treatment-statistics. Accessed December 2, 2017.

Gavin, DR, Ross, HE, Skinner, HA. (1989). Diagnostic validity of the DAST in the assessment of DSM-III drug disorders. Br J Addict. 198;84(3):301-7.

COURSE

February 21-24, 2018 Loews Royal Pacific Resort Universal Orlando

the

Brown RL, Leonard T, Saunders LA, Papasouliotis O. The prevalence and detection of substance use disorder among inpatients ages 18 to 49: An opportunity for prevention. Prev Med. 1998;27:101-110.

BOARD REVIEW

Lipari RN, Van Horn SL Trends in substance use disorders among adults aged 18 or older. The CBHSQ Report: June 29, 2017. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD.

FAFP

“Overall great course. One of the best I have been to. Thank you!”

Center for Behavioral Health Statistics and Quality. (2015). Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Available at http://samhsa.gov/ data/. Accessed December 2, 2017.

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Help Us Hold The Memories

As we prepare to celebrate the 150th Anniversary of our Annual Session, we are looking for stories, historical items and insights that you may have. We would love to have input and anecdotes from you on: • MSMA Deﬁning Events • Little-known Historical Facts • Medical Milestones in Mississippi • Pioneers in Mississippi Medicine • And More! If you have something to share or if you want to donate money to the celebration, just email our Managing Editor Karen Evers: KEvers@MSMAonline.com.

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A Plan to Reduce Narcotics in Mississippi by Twenty Percent BEN E. KITCHENS, MD FAMILY PHYSICIAN • IUKA

Our emergency departments are rampant with drug seekers. It is reported on the CDC website that every day more than 1,000 people are treated in ERs for not using their prescription opioids as directed.

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With my letter from the U.S. Attorney General bulging my shirt pocket and pen in hand, I will briefly propose a plan to de-escalate Mississippi’s mounting opioid crisis. I have stumbled upon this plan out of desperation. In my experience, for most problems there is usually a solution, but the one at hand involving opioid abuse has been especially elusive. At the time of the Attorney General’s urgent appeal a year ago, results of the opioid epidemic were devastating. Today they are even worse! Readers of the following proposal are already well aware of the surmounting opioid problems of our state and nation. Overdose deaths involving prescription opioids quadrupled from 1999 to 2015 and so have sales of these prescription drugs. In this period of time, more than 183,000 people have died in the U.S. from overdoses related to prescription opioids with more than 15,000 dying in 2015 alone. Our emergency departments are rampant with drug seekers. It is reported on the CDC website that every day more than 1,000 people are treated in ERs for not using their prescription opioids as directed. In my experience, I would expect the number to be much higher. Although heroin and illicit opioids appear to be driving the current explosion in increasing opioid deaths, overprescribing continues to play a significant role in fueling the opioid epidemic. The most common drugs involved in prescription opioid overdose deaths include methadone, oxycodone, and hydrocodone with the highest rates among people between 25 and 54 years. Men have been more likely to die from overdoses, but the mortality gap between men and women is closing. Mississippi physicians have traditionally been high prescribers of opioids, as have those in many other Southern states. Tennessee, Alabama, and West Virginia often lead nationwide in per capita prescriptions of opioids as well as benzodiazepines, the combination which so often is seen utilized in overdoses. There is a wide variation among states with the prescribing rate in Alabama in 2012 being 2.7 times the rate in Hawaii. U.S. prescribers wrote 82.5 prescriptions for opioids per 100 persons in 2012, enough for every adult in the United States to have their own bottle of pills! Annual CME for prescribers, drug screening, use of the state PDMPs (prescription drug monitoring programs), pain agreements, and pill counting have all been admirable exercises and of some benefit, but have not seemed to eliminate the persisting epidemic of narcotic overuse and overdosing. In March, 2016, the CDC sent U.S. doctors their excellent and helpful Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. It was posted online as an MMWR (Morbidity and Mortality Weekly Report) early release. The information appears well researched and pragmatic, and, if followed by prescribers, it would abruptly bring relief to America’s opioid epidemic. I have not heard of any large documented reductions in opioid prescribing, however, and do not expect to. For, despite the millions of dollars expended in the preparation of the report, I expect that very few doctors (other than those involved in its preparation) read the 49 pages.

In contrast, my brief proposal, which follows, is guaranteed to reduce narcotic overprescribing and overuse. With the current state of online communications, I believe it is reasonable and will not be overly expensive. Despite the accurate data obtained and recorded by the state on individual physicians with the PDMPs, because of the many variables it is impossible to say exactly how many prescriptions the “average” physician in Mississippi prescribes. Everyone believes it to be excessive but “how many is too many?” (We consume twice as many opioids per capita as the second ranking nation, Canada.) There is, of course, a wide variation among reasonable physicians and a much greater range when physicians who prescribe more freely are included. Some doctors and practitioners care for an older population or one consisting of more disabled individuals, and a variation in practices will have to be taken into account. (Physicians who serve their communities as Hospice and/ or Suboxone providers should be carved out from this plan.) But, with the information already being obtained by the PDMP, it should not be overly difficult to obtain the total and average narcotic prescription rate in the state and calculate reasonable allotments at the 80 percentile for the average Mississippi practitioner who is not serving a outlier population. If the average is approximately 2,500 narcotic prescriptions per doctor per year, the total allowed could be reduced to 2,000. Each doctor would receive his or her allotment and would be responsible for and allowed to prescribe only that amount. Only those physicians with significant narcotic prescription use would be affected by the program. Dermatologists, pediatricians, and those belonging to some of the other specialties might not need to participate. According to the CDC, primary care providers account for prescribing about half of the opioid pain relievers dispensed, and it is probably higher in a rural state like Mississippi. Prescribing rates are generally highest among pain medicine specialists, surgeons, and physical medicine/ rehabilitation doctors. Many other factors and problems will arise such as prescribing across state lines, how to deal with physicians overseeing nurse practitioners or covering for other physicians, which narcotics and dosages will be counted, hospital, hospice or nursing home use where out-of-state pharmacies might be used, etc. None of these potential problems are insurmountable, and all can all be worked out. In my opinion, it is safe to say that more than 20% of the total prescribed narcotic tablets are not strictly medically indicated, but no one but the prescribing physician or nurse practitioner is in the position to make the individual decisions that add up to the 80%. It is an easy call to hand out a prescription, but often a difficult one to refuse to do so. But, substituting a non-narcotic or offering a lesser number of opioid tablets would definitely be easier for a practitioner if only a finite number of dosages were available to be prescribed. Reducing the flow of these narcotics by this plan should directly reduce the overdose problem. Most of those who abuse prescription opioids get them from a relative or a friend, but those who are at the highest risk of overdose (those using prescription opioids non-medically 200 or more

JOURNAL MSMA

days a year) get them with their own prescriptions (27%), from friends or relatives for free (26%), buying from friends or relatives (23%), or buying from a drug dealer (15%). Those at highest risk of overdose are about four times more likely than the average user to buy the drugs from a dealer or other stranger. This suggested coordinated effort will be somewhat taxing for narcotic control officials, doctors, patients, and pharmacists; but the guaranteed reduction in prescription narcotic abuse and overdoses will be worth the effort. Expect sufficient complaining from all groups involved. Doctors will, by necessity, become more conservative in their prescribing habits as they ensure that a larger percentage of their narcotic prescriptions go to accommodate those with genuine severe pain. Physicians unwilling to change their liberal prescribing habits might discover that their allotment of prescriptions has been expended before year’s end and may have to refer their ailing patient to another doctor who has practiced more conservatively. Each month all practicing physicians could review the PDMP website to review his or her total yearly allotment, the amount used that month, and how much remains (so that prescribing behavior could be altered, if needed). An annual trial run of this 20% plan for narcotic reduction, I believe, is workable, worthwhile, and within the range of the types of programs that the CDC has been so strongly recommending the past couple of years. Their program, Prescription Drug Overdose: Prevention for States was developed to help states combat the ongoing prescription drug overdose epidemic. The purpose of Prevention for States is to provide state health departments with resources and support needed to advance interventions for preventing prescription drug overdoses. Sixteen states were selected through a competitive application process to receive funds in September 2015 and an additional 13 states were funded later, allowing the CDC to reach 29 states with programs and strategies to improve safe prescribing practices and help prevent prescription drug overdose and abuse. Mississippi is not on the map of states that were approved for funding! Through 2019, the CDC plans to give selected states annual awards between $750,000 and $1 million to advance prevention in four key areas: 1. 2. 3. 4.

Maximizing prescription drug monitoring programs Community or insurer/health systems interventions State policy evaluations Rapid response projects

The Prevention for States program includes evaluation of awarded states’ program activities to monitor performance, demonstrate effectiveness, and capture success stories. It seems to me that my proposal may be exactly the type of innovative pilot program that the CDC wishes to fund! Apparently the $750,000 to 1 million is dangling there just waiting for Mississippi officials to make an application. The CDC lists four states as having reportable successes under the funded programs. Both New York and Tennessee began requiring prescribers to check the state’s PDMP before prescribing opioids (apparently Tennessee specified “painkillers”). Tennessee reported a

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36% decline in patients seeing multiple prescribers for the same drugs and New York reported a 75% decrease. Oregon’s anti-drug program consisted of establishment of a PDMP, requiring prior authorization for methadone doses, educating lay persons on using naloxone for suspected overdose, and physician and allied health care training. This resulted in a 38% decrease in the rate of poisoning due to prescription opioid overdoses and a reduction of the death rate associated with methadone poisoning of 58% between 2006 and 2013. Florida seems to have had the most success of all the participating states thus far and may have shown the first documented substantial decline in drug overdose mortality in any state in recent years. They used their money to establish a PDMP and began to regulate pain clinics, stopping health care providers from dispensing prescription opioid pain relievers from their offices. Their 2012 result was a 50% decrease in oxycodone overdose deaths! Why don’t we take the dangling CDC money like Florida and the other states did if we can get it? Regardless, let’s not let this opportunity slip by. We can prevail, with or without the Federal government, if we have to. We can all work together toward making Mississippi the state with the 20% reduction in narcotic prescriptions in 2018! n Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1. Erratum in: MMWR Recomm Rep. 2016;65(11):295. PMID: 26987082.

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The Heart of Hospice Difference At Heart of Hospice our mission is to serve all hospice eligible patients the way they desire to be served. We work with each patient to develop a plan of care that is unique to their specific situation. Physical therapy, IV therapies, radiation and other comforting treatments approved by the physician may be included in the patient’s plan of care. As always, the Heart of Hospice team will be working 24/7 to admit eligible patients who need our care. HEARTOFHOSPICE.NET * Counties shaded blue represent Heart of Hospice’s service area

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E D I T O R I A L

The Other Side of the Opiate Crisis: Why Increasing Opiate Hurdles May Negatively Impact End of Life Patient Care KURT MERKELZ, MD CHIEF MEDICAL OFFICER FOR HOSPICE COMPASSUS • SPECIAL TO THE JMSMA

As a major contributor to opiate utilization, hospice has both a responsibility and requirement to ensure opiates are used timely and appropriately.

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The hospice nurse arrived shortly before Jane. Having previously confirmed that the opiate medications were delivered, the nurse was ready to sweep in and provide the needed opiates Jane would require to stifle the excruciating pain being inflicted by her bony metastasis. Jane received a final bolus of pain medications at the hospital just an hour before being transported home where she would spend her final days surrounded by family and friends. Now, shifting concerns around opiate use is threatening the ability of hospice to provide this crucial component of end of life care. As a major contributor to opiate utilization, hospice has both a responsibility and requirement to ensure opiates are used timely and appropriately. During the 1990s, as opiate manufacturers heavily marketed new, and increasingly expensive, opiate medications, a fifth vital sign was being promoted within the care community. Alongside the usual vital signs of blood pressure, pulse, and temperature, pain level was being asked to be recorded on every patient. Communication around the use of opiates generally reported that patients do not become addicted when accepted guidelines were followed and that opiates had a better safety record than aspirin. No longer was pain a symptom that a patient had to tolerate; pain was a condition that could be controlled. A new era of pain management utilizing synthetic opioid medicines had arrived. It was not enough to treat the underlying condition, patients expected to be pain-free. The aggressive approach to control pain became paramount as pain treatment became an expected outcome of every doctor visit: in offices, in hospitals, in nursing homes. By 2010, the United States, with about 5 percent of the world’s population, was consuming 99 percent of the world’s hydrocodone, along with 80 percent of the oxycodone, and 65 percent of the hydromorphone. But then, the abuses began to over-shadow the benefits. Pharmaceutical companies heavily lobbied for less restrictive regulation. Patients demanded more. Doctors wanted their patients to be happy. Prescriptions were written. And the national opioid crisis was born. State registries as well as on going physician education has already shown benefits with prescriptions of opiate medications already seeing a downward trend. Unfortunately, sharp increases in deaths have been reported during this same timeframe. The CDC has documented a quadrupling of overdose deaths from opioid prescriptions, including deaths from patients taking opiates as prescribed. Stricter opioid prescribing rules are being put into place across the country in reaction to this national opioid epidemic. These rule changes are focused on regulating the most significant source contributing to the flow of opiates – the physician prescriber. And, although putting more hurdles in the way of a physician’s ability to prescribe opioids may make sense (most certainly resulting in fewer unnecessary opioid prescriptions written), the full impact of such an approach needs to be carefully considered from the position of patient care, and especially from the standpoint of hospice. Considered the model for quality compassionate care for people facing a life-limiting illness, hospice provides expert symptom and pain management to over 1.6 million patients each year in the United States. Under this model, physicians aggressively treat patients’ pain, usually

author information: Kurt Merkelz, MD, Chief Medical Officer for Hospice Compassus, is a nationally recognized Hospice physician. The recipient of the R. Sean Morrison, M. D. Award for Outstanding Achievement in Hospice Physician Leadership, he has published articles and chapters on hospice care in both journals and textbooks. He is triple board certified in Hospice and Palliative Care Medicine, Family Medicine, and Geriatrics. He currently resides in Brentwood, Tennessee. Contact him at kurt.merkelz@compassus.com. following the World Health Organizations (WHO) Step Ladder to pain management. The WHO Ladder represents the standard approach to pain assessment and treatment. The pain relief ladder begins with nonopioid (ibuprofen and acetaminophen) and adjuvant (additional drugs that have additive benefit for pain relief) medications as the first line towards effective pain treatment. Medications of increasing strength, including opioids, are prescribed as necessary. The current model of pain management also includes the idea that, in addition to being the appropriate drug at the correct dose, drugs should be given “by the clock” on a set schedule, rather than “on demand” as so often these medications are prescribed. Followed correctly, it is estimated that upwards of 90 percent of a patient’s terminal pain can be effectively treated. Notably, central to this pain management goal is the maxim that no ceiling exists when prescribing opioids for intractable pain. Mechanisms do, however, need to be in place to ensure patients at the end of life receive appropriate and safe medications. The first question that should be addressed is: what level of prescription medication does a patient require to control pain at end of life? Clearly, pain may be a significant problem for persons who are seriously ill. Studies have shown that among those with cancer, significant pain occurs in 30 to 40 percent, and up to 90 percent in patients with advanced cancer.1 Half of seriously ill children suffer pain, and 20 percent of them have pain reported as moderate to severe. Among elderly living in the community, up to half suffer pain problems, and up to 80 percent of elders living in institutions suffer from significant pain. So, we have a problem. Yes, there is a national opioid abuse epidemic. But, also, there is a significant portion of our community that need this very useful, very effective pain treatment. Despite the downward trend in the number of prescriptions being written by physicians, efforts to curb the national overdose crisis have resulted in stricter enforcement. Most recently, Mississippi has placed harder limits on opioid prescribing. In addition to requiring physicians to check with a state registry before writing a prescription for a controlled substance and limiting the amount of narcotics being dispensed to 7 days, is a new requirement under review that physicians must complete a history and physical exam prior to providing the written prescription. On the surface, such a request makes complete sense. Why wouldn’t one expect a physician to complete a detailed history and physical prior to the

JOURNAL MSMA

prescription of a dangerous and deadly medication? Clinical observation has been a part of Egyptian, Babylonian, Chinese and Indian physician practice for thousands of years. As a first year resident, my supervising physician handed me a small booklet called, The Care of the Patient by Dr. Francis Peabody. This essay taught …”the practice of medicine requires continuous study and prolonged experience in close contact with the sick.” The reality is hospice frequently does not receive a referral for a patient until very late in the disease process, and often the patient is imminently dying. In 2015, 28% of all Medicare beneficiaries enrolled into hospice programs died within 7 days of admission.2 Physicians who work as hospice medical directors are often well versed in pain management. Most, however, serve as part-time hospice employees, maintaining busy medical practices of their own in their respective communities. Practically speaking, a requirement forcing terminally ill patients to have a completed history and physical by the new prescribing hospice physician before receiving medications to manage pain at the end of life is unconscionable and cruel. What can the hospice clinician do? As the bulk of caregiving that is provided to a patient on hospice service is provided by a family caregiver, it is imperative to ensure that patients and families have received the necessary education to respond to changes in condition. Disease courses often change throughout the time that a patient receives hospice care. Patients and their caregivers should be instructed on appropriate steps to take in responding to pain or changes in pain level. This first step can and should be initiated with step one medications such as ibuprofen and acetaminophen. Other treatment approaches should also be considered, including relaxation, massage, biofeedback, and other non-traditional approaches that are often overlooked but effective. Sometimes, however, a much stronger medication may be necessary to control pain. Concurrently, patients should also be free from the troublesome side effects such as nausea, sedation, anorexia, and constipation that frequently occur with opiate medications. Patients and family caregivers need to be well-informed of these detrimental side-effects and need to understand that pain-free might not be a desirable option. Hospice physicians need to continuously ensure that the three-step approach of administering the right drug, at the right dose, at the right time is put into place at every opportunity. With any job, it is easy to succumb to habit and routine. As care providers, routine may cause us to treat every patient as if they are the same. In pain management, this oftentimes means that opiates represent the initial and only treatment response to a pain situation. What is lacking is simply asking the question, “what does the patient need?” and “What does the patient want?” Shared decision-making, a process in which clinicians and patients/families work together to make decisions, select treatments based on a balance of risks and expected outcomes, and and put patients’ values and preferences first, is an approach which has the potential to help deflect our routine tendencies to prescribe “the usual”. The medical community does have a responsibility to address the opiate crisis that exists in our nation. However, burdensome regulations can and likely will result in harm to the very patients they purport to protect. It is unfortunate that the only solutions that are being pursued at this

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time are tighter regulations and requirements that only serve to impede the ability of responsible physicians to prescribe necessary and appropriate medications to their patients. Requiring hospice physicians to see home-bound patients, who often have only hours to days left to life, before they can receive pain medications and other controlled substances is simply wrong. Yes, there need to be restrictions on opioids, but these restrictions need to be reasonable, timely, and not compromise the availability of this crucial class of medications to those in need. What is needed is a change in the climate, a change in the interaction between the patient and physician. Involving the hospice patient and their family in the decision-making process as well as helping them to understand even some of the myriad implications and effects of these decisions is a daunting task. But the benefits of such a change in the clinical interaction are worth the effort. Shared decision-making is a step towards restoring a more personal relationship between patient and physician. We will make our patients happy by keeping them informed, by making them feel included, and by giving them back some control over their own care. An informed public will be less afraid of the opioid epidemic and more understanding of the need for this class of prescription medication and others like it. n Zhukovsky DS, Gorowski E, Hausdorff J, Napolitano B, Lesser M. Unmet analgesic needs in cancer patients. J Pain Symptom Manage. 1995;10:113–9. 2 NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA: National Hospice and Palliative Care Organization, September 2017. 1

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Pain.

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Harvard Medical School has stated that “chiropractic spinal manipulation may be helpful for back pain, migraine, neck pain, and whiplash.” The Journal of the American Medical Association (JAMA) recently found that in “patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function.” Every day, more voices join in the call to address pain with a conservative, non-invasive, non-addicting approach. We stand ready to contribute in overcoming the opioid crisis that is affecting millions of Americans. Let’s do this. Together.

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Special

Report

GOVERNOR'S OP IOID AND HERO I N STUDY TASK FO RCE GOVERNOR PHI

L BRYANT

JOURNAL MSMA

Dear Colleagues and Members of the Mississippi State Medical Association, As physicians practicing in the state of Mississippi, we are all keenly aware of the growing epidemic of opioid and heroin addiction and death that has a grip on our great state and nation. In response to this tragic public health problem, Governor Phil Bryant appointed the Governor’s Opioid and Heroin Task Force. I was honored to serve as vice chair of the task force. It is with pleasure that I set forth to membership the study group’s recommendations. As Chairman Dowdy and I sat down over a year ago, it was our intent to recommend to the Governor a task force with representation from all of the stakeholders. I am comfortable that we have accomplished such. The task force has representation from medicine, nursing, dentistry, lawenforcement, pharmacy, mental health, and the judiciary. The medical community was well represented by former MSMA President Dr. Claude Brunson, MPHP Director Dr. Scott Hambleton, Dr. Carol McLeod, and me. Your Medical Association should take particular pride in the fact that MSMA’s own task force on opioid and heroin addiction was the standard by which the Governor’s task force was measured. While I understand that the proposed recommendations will require a change in practice patterns for many of us, I am confident that our membership will step up to the plate and join hands with the governor to fight this growing epidemic. MSMA has always taken the lead in establishing quality healthcare for our citizens, and I am confident such measures will continue. Sincerely,

Randy Easterling, MD, FAAFP Vice Chair, Governor’s Opioid and Heroin Task Force MSMA Past President Member, Mississippi State Board of Medical Licensure

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Recommendations to Address the Healthcare Provider Community RECOMMENDATION NO. 1: The University of Mississippi Medical Center facilities should work with the Pharmacy Board and the MPMP to make sure all prescriptions for scheduled medications are reported daily to the MPMP. The MPMP should reflect the name and location of the provider who wrote the prescriptions. All physicians in training in the state of Mississippi, regardless of PGY level, should have their own DEA number. Each faculty member at the school of medicine and in every training program should have their own DEA number. RECOMMENDATION NO. 2: All VA facilities in the state of Mississippi should work with the Pharmacy Board and the MPMP to make sure all prescriptions for scheduled medications are reported daily to the MPMP. The MPMP should reflect the name and location of the provider who wrote the prescription. RECOMMENDATION NO. 3: There needs to be improvement in the reporting mechanism and the ability to investigate and report drug overdoses throughout the state of Mississippi. Coroners should have adequate training and support in order to facilitate the recognition of reporting any drug overdose in a timely manner. All coroners should be members of the State Coroner’s Association. RECOMMENDATION NO. 4: Providers should be discouraged from writing more than a 3 day supply of opioids for acute non-cancer pain, and shall not provide greater than a 7 day supply for acute non- cancer pain. Providers may issue an additional 7 day supply if clinically necessary, but must be issued in accordance with Title 21 CFR § 1306.12 Refilling prescriptions; issuance of multiple prescriptions (i.e., the prescription must be dated on the date of issuance with ‘do not fill until’ noting the date the prescription may be filled), and such need for an additional 7 day supply must be documented in the chart.

RECOMMENDATION NO. 5: Benzodiazepine prescriptions should be limited to 1 month with no more than 2 refills. MPMP should be checked each time a prescription for benzodiazepines is written. RECOMMENDATION NO. 6: Point of service drug testing should be done each time a Schedule 2 medication is written for the treatment of chronic non-cancer pain. Point of service drug testing should be done at least every 90 days for patients on benzodiazepines for chronic medical and/or psychiatric conditions. RECOMMENDATION NO. 7: Pharmacists shall work closely with the providers and should be more vigilant when filling prescriptions for excessive amounts of Schedule 2 medications and/or benzodiazepines. The provider should be contacted when the pharmacist suspects “doctor shopping” is in play or when the patient is getting large quantities of opioids and/or benzodiazepines (either per prescription and/or over a prolonged period of time). Providers and pharmacists should respect each other’s professional boundaries. RECOMMENDATION NO. 8: The Mississippi State Board of Dental Examiners should work with the task force in order to engage Mississippi dentists in an effort to decrease opioid prescribing, addiction, and death. All dentists with a license should be required to register with the MPMP and all dentists should be required to receive at least 5 hours of continuing dental education every 2 years on prescribing opioids and/or benzodiazepines. RECOMMENDATION NO. 9: Any healthcare provider licensed by a regulatory board in the state of Mississippi should register with the MPMP. Any medical, nursing, and/ or dental provider in the state of Mississippi, who has an active DEA number, should receive a minimum of 5 hours continuing education every 2 years on prescribing opioids and/or benzodiazepines.

JOURNAL MSMA

Chairman John Dowdy Director, Mississippi Bureau of Narcotics

Vice-Chair Dr. Randy Easterling Mississippi State Board Medical Licensure

Dr. Claude Brunson Senior Advisor to the Vice Chancellor, UMMC

Patricia Burchell District Attorney, Forrest and Perry Counties

Larry Calvert, R.Ph. President, Mississippi Board of Pharmacy

Dr. Frank Conaway, Jr. State Board of Dental Examiners

Joey East Chief, Oxford Police Department

Dr. Scott Hambleton Medical Director, Mississippi Physician’s Health Program

Joshua Horton Ole Miss Law Student, Southern Recovery Advocacy

Phyllis Johnson Executive Director, Mississippi Board of Nursing

Ken Magee Retired Deputy Administrator, Mississippi Department of Public Safety

Dr. Carroll McLeod Jackson Anesthesia Pain Center

Melody Winston Bureau Director, Mississippi Department of Mental Health

TASK FORCE

MEMBERS

RECOMMENDATION NO. 10: MPMP should be run at each patient encounter in which a Schedule 2 opioid and/or benzodiazepine is written. Benzodiazepines may be written with 2 refills, which would mean that the MPMP should be checked every 90 days for benzodiazepines. RECOMMENDATION NO. 11: There should be increased access to and funding for treatment facilities, programs, and medically assisted treatments for opioid and/ or benzodiazepine addiction. Explore all options for federal funding, grants, etc. and engage the Department of Mental Health in this endeavor. RECOMMENDATION NO. 12: The Mississippi Legislature should consider a surcharge on each pharmaceutical company who sells and/or provides Schedule 2 and/or Schedule 3 medications to the state of Mississippi. This could be a flat surcharge or could be volume driven. Funds collected should be dedicated to the diagnosis, education, and/or treatment of addiction to prescription medications. RECOMMENDATION NO. 13: Methadone should rarely, if ever, be written to treat chronic and/or acute non-cancer pain. Encourage all regulatory boards to investigate providers who treat chronic and/or acute non-cancer pain with methadone. RECOMMENDATION NO. 14: The use of long-acting opioids for the treatment of acute non-cancer pain should be discouraged. RECOMMENDATION NO. 15: Require all Hospice services to have a standardized program for the collection and disposal of all medications at the time of a patient’s death. Hospice providers should also have a standard mechanism to track and record all Scheduled medications written for the patients (involve the Mississippi State Department of Health in this endeavor). RECOMMENDATION NO. 16: Strongly discourage the use of opioids and benzodiazepines concomitantly. RECOMMENDATION NO. 17: Dosages larger than 50 morphine mEq per day increases risk without adding benefits for pain control or function. Clinicians should avoid increasing dosages to greater than 90 morphine mEq per day. RECOMMENDATION NO. 18: All wholesalers permitted by the Mississippi Board of Pharmacy shipping Schedule 2 through 5 medications within or into Mississippi shall report data to the Mississippi Prescription Monitoring Program. Specific data fields and format are to be determined.

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II.

Recommendations for Improved Law Enforcement and Prosecutorial Functions RECOMMENDATION NO. 1: Miss. Code Ann. § 41-29-139 should be amended to provide an increased punishment for persons who sell, or possess with the intent to sell, heroin and/or fentanyl and/or fentanyl derivatives. Additionally, Miss. Code Ann. § 41-29-139 should be amended to include an enhanced sentence of 40 years to life for persons illegally selling or transferring controlled substances that result in death (or serious bodily injury). RECOMMENDATION NO. 2: Miss. Code Ann. § 9-23-15 should be amended to exclude persons from entering Drug Court who are before the court on a pending sale of controlled substance charge. RECOMMENDATION NO. 3: Miss. Code Ann. § 41-29-159, which provides that health-care providers, coroners and law enforcement officers shall notify MBN of any death caused by a drug overdose, must be enforced. This statute should be amended to provide an enforcement provision, such as the imposition of a fine for not reporting. RECOMMENDATION NO. 4: Training should be provided to all Law Enforcement Officers and Emergency Medical Technicians regarding the dangers of contact with Fentanyl and the use of Naloxone (Narcan) to prevent death from overdose.

RECOMMENDATION NO. 6: Because of the failure of many Coroners to report overdose deaths, legislation should be passed mandating that all coroners/medical examiners utilize the Mississippi Crime Lab. Additionally, the legislation should mandate that all coroners/medical examiners be members of the MSS Coroners/Medical Examiner Association. RECOMMENDATION NO. 7: When responding to a death, authorization needs to be granted to coroners and medical examiners for the retrieval and delivery of pharmaceuticals to law enforcement for disposal. RECOMMENDATION NO. 8: Due to inadequate staffing within the Mississippi Crime Lab, and the 1,000+ pending laboratory cases that are currently greater than 30-days old, additional staffing is paramount. The Crime Lab should be bolstered with the following: n

Toxicology – 2 forensic scientist trainees Drug Chemistry – 2 forensic scientist trainees n Medical Examiner – 2 PINS n

RECOMMENDATION NO. 5: In some areas of the state, dropboxes are readily available. However, even in those areas, it is generally agreed that the availability of dropboxes for excess controlled substance medications is not well known by the general public. We recommend that the dropbox program be expanded and that a public service campaign be initiated to inform the public.

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III.

Recommendations for Enhanced Education, Prevention and Treatment RECOMMENDATION NO. 1: Design an integrated data collection and reporting platform that interfaces with primary data sources to ensure accuracy and speed while eliminating redundant reporting among multiple agencies.

RECOMMENDATION NO. 4: Create a comprehensive MS Opioid Resource website with separate modules to provide information as follows:

RECOMMENDATION NO. 2: Encourage multi-agency coordination to implement a state-wide media campaign raising awareness of the negative effects of opioid and heroin by utilizing: 1) Public Service Announcements; 2) Billboards; 3) Town hall meetings; 4) State agency websites; and 5) School presentations. The media campaign should include the following components:

n n n

n n

n n n

Signs and symptoms of addiction Education for individuals that addiction is a public health issue Information on the risks of sharing prescription medication Warning on how easily addiction can develop including addiction through prescribed use Signs to recognize and respond to an overdose and the administration of naloxone Best practices for prescribing opioids for pain management Clear and concise guidance on the safe home storage and appropriate disposal of prescription opioid medication Mississippi’s Good Samaritan Law Information on accessing treatment and recovery support services state-wide Methods to reduce the stigma of addiction Expand Civil Commitment Procedures and Compelled Treatment

RECOMMENDATION NO. 3: Make system-level improvements to increase availability and use of naloxone. n

State-level standing order to make naloxone available to all pharmacies Purchase Naloxone for law enforcement n Provide training on proper administration of naloxone n Track data to capture circumstances, location and outcomes of naloxone administration n

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n n

Link to multi-agency data platform described above Prevention module to educate about the risks of opioid use and signs and symptoms of addiction Instruction on proper disposal of prescription medication including list of drop-box locations Resource guide for individuals to access treatment providers (including inpatient, outpatient, MAT, recovery support, and prevention specialists) Instructions on how to purchase and administer naloxone, including a list of pharmacies with available supply Link to complete prescribing guidelines for emergency room, medical, and dental professionals (including specialty populations such as OB/GYNs, geriatric, and sports medicine) Link to Prescription Monitoring Program for medical, pharmacy, dental, and veterinary professionals

RECOMMENDATION NO. 5: Increase funding to expand statewide treatment bed capacity (stateoperated alcohol and drug treatment facility, and community primary drug treatment) through grants, legislation, appropriations, etc. RECOMMENDATION NO. 6: Expand access to medication-assisted treatment (MAT): n

Educate treatment workforce on opioid use disorder and advantages of MAT n Expand treatment services for pregnant women/parenting women n Improve evidence-based programs within treatment facilities to reduce recidivism rate

RECOMMENDATION NO. 7: Implement strategies to reduce barriers to opioid treatment: n

Educate primary care providers to utilize Screening, Brief Intervention, and Referral to Treatment (SBIRT) for individuals who may present with a substance use disorder n Facilitate training collaborative efforts among emergency departments, first responder, law enforcement, and Community Mental Health Center mobile crisis teams to develop multi-agency overdose response teams n Collaborate with Department of Medicaid and third party insurance providers to expand coverage for MAT medications RECOMMENDATION NO. 8: Enhance and support the provision of peer and other recovery support services designed to increase treatment engagement and retention, and promote long-term recovery. RECOMMENDATION NO. 9: Evaluate current Drug Court and Re-entry programs to enhance systems with expansion of best practices specifically designed for these justiceinvolved individuals. RECOMMENDATION NO. 10: Establish or Partner with Recovery Community Organizations (RCOâ&#x20AC;&#x2122;s), entities that work with law enforcement and medical personnel to assist in employment, education, housing, life skills, and recovery (Pilot Programs Already Being Established by the Re- Entry Council). RECOMMENDATION NO. 11: Tax Incentives for employers willing to hire those actively working a program of recovery. RECOMMENDATION NO. 12: Implement Recovery Support Services and Peer Support within Department of Corrections. RECOMMENDATION NO. 13: Establish Crisis Intervention Centers. RECOMMENDATION NO. 14: Provide for an increased revenue stream for treatment by taxing pharmaceuticals. RECOMMENDATION NO. 15: Collaborate with the Insurance Commissioner to mandate more coverage be provided for treatment by the companies providing insurance in Mississippi.

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A Safer Approach to Pain Exists SHERRY MCALLISTER, DC, MS (ED), CCSP

Treating a patient who has an addiction requires the medical profession to consider other potential treatment options for recovering opioid addicts such as practicing mindfulness, physical therapy, yoga, massage therapy, dry needling, and acupuncture. – Ed.

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Drug overdoses have now been identified as the leading cause of death among Americans under the age of 50. Overdose deaths involving prescription opioids have quadrupled since 1999 and data continues to rapidly accumulate on opioid-related deaths in the United States.1,2 The rise in prescription drug overdoses gives us pause as to what options exist for those that prescribe opiates to help alleviate pain. In response to this public health crisis, many organizations have created guidelines and recommendations for treating pain. Some states are mandating a non-pharmacological option as a first-line pain treatment before opioids. It is time to seriously consider safer alternatives to opioids to manage pain. One such alternative, especially for back pain, is spinal manipulation. This was endorsed more than 25 years ago in what was then the Federal Agency for Health Care and Policy Research, which noted spinal manipulation as one of the leading and best documented strategies. Spinal manipulation lacked the side effects of NSAIDS (the other leading strategy). 3 Chiropractic is noted as performing over 90 percent of the spinal manipulations in the United States. 4 According to recent guidelines developed by the American College of Physicians, conservative non-drug treatments should be favored over drugs for most back pain. The guidelines are an update that includes a review of more than 150 recent studies and conclude that, “for acute and subacute pain, the guidelines recommend non-drug therapies first, such as applying heat, massage, acupuncture, or spinal manipulation, which is often done by a chiropractor.” 5

ACCORDING TO RECENT GUIDELINES DEVELOPED BY THE AMERICAN COLLEGE OF PHYSICIANS, CONSERVATIVE NON-DRUG TREATMENTS SHOULD BE FAVORED OVER DRUGS FOR MOST BACK PAIN.

The Foundation for Chiropractic Progress is a not-for-profit organization and the leading voice of the chiropractic profession, the Foundation for Chiropractic Progress (F4CP) informs and educates the general public about the value of chiropractic care. Visit www.f4cp.com or call 866-901-F4CP (3427).

Joint Commission identifies non-pharmacologic strategies to include: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy. 7 Health plans are also playing a leading role in combating this crisis. America’s Health Insurance Plans (AHIP), the national association whose members provide coverage for health care and related services, encourages integrative, non-opioid approaches to help patients access effective treatments for pain. In a recent blog from the Executive Vice President of AHIP, Carmella Bocchino states, “Because the risk of addiction is so great and the consequences so profound, our members encourage physicians and patients to jointly develop pain treatment plans that consider non-narcotic treatment options, such as physical or occupational therapy, chiropractic care, or acupuncture. Many plans support the CDC’s opioid prescribing guidelines that state opioids should not be first-line or routine therapy for chronic pain.” 8 Additionally, the Senior Advisor for Government Relations at the Society for Human Resource Management (SHRM), Chatrane Birbal, recently voiced her support of the role of chiropractic treatment in dealing with the opioid epidemic: “Most employer-sponsored health benefit plan offerings have already been solidified for 2018, however, looking ahead, it is possible that advisers would recommend adding alternative therapies including acupuncture, chiropractic treatment, yoga and more to plan offerings.”9

Guidelines published May 2017 in the Canadian Medical Association Journal strongly recommend non-pharmacologic therapy, including chiropractic, before using opioid therapy for chronic non-cancer pain. Guideline Recommendation 10 provides for “…a coordinated multidisciplinary collaboration that includes several health professionals whom physicians can access according to their availability (possibilities include, but are not limited to, a primary care physician, a nurse, a pharmacist, a physical therapist, a chiropractor, a kinesiologist, an occupational therapist, an addiction medicine specialist, a psychiatrist and a psychologist). 6

The Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA) and Institute of Medicine (IOM) have all called for the early use of non-pharmacologic approaches to pain and pain management. Unfortunately, beyond asserting the need to move in this direction, little, if any, guidance has been offered to providers, patients and payers on how to accomplish this important transition in the healthcare model. It is a fact that a chasm exists between the worlds of pharmacologic-based management of pain, and the nonpharmacologic-based management of pain. Medical physicians are encouraged to integrate their training, knowledge and understanding of non-pharmacological options into their daily clinical recommendation to patients.

The Joint Commission, an independent organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States, published revisions to pain management Standard PC.01.12.17, stating that, effective January 1, 2015, for ambulatory care, critical access hospital, home care, hospital, nursing care center, and office-based surgery accredited programs, both pharmacologic and nonpharmacologic strategies have a role in management of pain. Further, the

The first step is to provide resources to prescribers that will detail the indications, effectiveness, efficiency and safety of non-pharmacologic approaches. In particular, the chiropractic profession is a first-line approach to manage spine, joint and neuro-musculoskeletal pain. Through its 70,000 practitioners in the United States, the profession represents a significant and proven non-pharmacologic approach for reducing the need for opioids, opioid-related products and non-opioid pain medications.

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As longtime advocates of drug-free management of acute, subacute and chronic back, neck and neuro-musculoskeletal pain, the chiropractic profession is committed to actively participate in solving the prescription opioid addiction crisis. A profession dedicated to health and well-being, Doctors of Chiropractic (DCs) are educated, trained and positioned to deliver non-pharmacologic pain management and play a leading role in “America’s Opioid Exit Strategy”10 on several levels: Perform first-line assessment and care for neck, back and neuromusculoskeletal pain to avoid opiate prescribing from the first onset of pain. Provide education on self-care approaches to manage pain throughout treatment to mitigate the introduction of pharmacological agents. Help addicts as they reduce their opioid usage by offering an effective approach to acute, subacute and chronic pain management to achieve a wellness focused, pain-free plan. It’s also a compelling opportunity for our health system, commercial and government payers, employers -- and most importantly patients -- to resolve the issues surrounding pain at lower costs, with improved outcomes and without drugs or surgery. The opioid crisis has provided a wake-up call for regulators, policy experts, clinicians and payers nationwide. As the support for integrative healthcare builds, interdisciplinary approaches to chronic pain management is considered best practice.

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Chiropractic care has earned a leading role as a pain-relief option and is regarded as an important element of the nation’s Opioid Exit Strategy: a drug-free, non-invasive and cost-effective alternative for acute or chronic neck, back, and neuro-musculoskeletal pain management. n CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov. 2 Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep. ePub: 16 December 2016. DOI: http://dx.doi.org/10.15585/mmwr.mm6550e1. 3 Bigos S, Bowyer O, Braen G, et al. Acute low back pain in adults. Clinical practice guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. December 1994. 4 Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH (1992). Spinal manipulation for low-back pain. Ann Intern Med. 117 (7): 590–598. 5 Reddy, S. (2017, February 13). No Drugs for Back Pain, New Guidelines Say. Available at https://www.wsj.com/articles/no-drugs-for-back-pain-new-guidelinessay-1487024168. 6 Busse, J, et al, Guideline for opioid therapy and chronic noncancer pain, CMAJ 2017 May 8;189:E659-66. 7 The Joint Commission (www.jointcommission.org) revised its Pain Management Standard PC.01.02.07, Joint Commission Perspectives®, November 2014;34(11). 8 Bochino, Carmello, Fighting opioid abuse with solutions that work, AHIP Oct 11 2017 Available at https://www.ahip.org/fighting-opioid-abuse-with-solutions-that-work/. 9 Albinu, Phil. How employer and advisors can address the opioid crisis.Oct 30 2017. Available at https://www.employeebenefitadviser.com/news/how-employers-andadvisers-can-address-the-opioid-crisis. 10 Carabello L, Clum G, Meeker W. Chiropractic – A Key to America’s Opioid Exit Strategy. Georgetown, CA: Foundation for Chiropractic Progress, 2017. 1

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E D I T O R I A L

Opioid Summit: A Slippery Slope? D. STANLEY HARTNESS, MD ASSOCIATE EDITOR Talk about an attention-getter at the recent MPHP Opioid Summit: the projection on two gigantic screens of a single handwritten prescription for 3,000-plus tablets of a controlled substance with directions to “take 9-11 every 2 hours as needed for pain.” I kid you not! For me personally, another eye-opener was that out of some 200 healthcare providers in the cavernous Muse Center auditorium, I could count on one hand the number of attendees I knew. Who are these people? Considering my years of involvement in MSMA and MAFP, it was not only humbling but also telling since I could’ve been most of ‘ems grandfather! Keynote speaker Dr. Paul H. Early, medical director of the Georgia Professionals Health Program, Inc., (with his presentation on The Neurobiology of Addiction: A Disease of Learning and Memory) had our neurons firing (and reeling!). As impressive as that information was, the simple reminder that family history is the single most important factor in assessing a person’s propensity for addiction made an indelible impression. In Epidemiology of Opioid Prescribing in Mississippi, Dr. Thomas Dobbs reported that during 2014, 7,287,299 prescriptions were written for controlled substances, of which 3,356,455 (46%) were for opoid analgesics…enough for every man, woman, boy, and girl in Mississippi to have a 30-day supply of Lortab! If there’s any consolation in these disturbing

statistics, it was pointed out that the Pareto principle (named for economist Vilfredo Pareto) specifies that 80% of the effects come from 20% of the causes. In this case, statewide 17% of all prescribers issued 500 or more prescriptions during 2014 with 12 prescribers responsible for more than an astounding 10,000 prescriptions each. Talk about bad apples! Also significant was the fact that opioid-related hospital discharges (dependence, abuse, overdose, adverse effects) increased from 2010 to 2014 by 33% while hospital charges for opioid-related hospital stays almost doubled during this time from $97,804,656 to $186,727,420. Proposed changes by the Mississippi Board of Medical Licensure to curtail opioid misuse generated considerable controversy and consternation. In addition to cost and time issues associated with the Prescription Monitoring Program and point-of-service drug screening, concerns were voiced regarding the limitation to 7 days the prescribing of opioids for acute pain. When recommendations from the Governor’s Opioid and Heroin Study Task Force, MSMA, MAFP, and Blue Cross/ Blue Shield are thrown into the skiing metaphor, the summit becomes a black slope challenging even the most seasoned provider. As with any mountaintop experience, we can’t remain on the summit forever but must make our way back down into the real world. Regardless of the ultimate rules and regulations related to our prescribing of opioids, hopefully this conference will make us think twice as we consider pain control so that we can become part of the solution rather than part of the problem. n

Just like the river, you are strong and unstoppable. Find your strength at the river. If you or someone you know is struggling with addiction, call today. (877) 654-9761

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At The River www.JourneyPureRiver.com

E D I T O R I A L

The Rural Difference TIMOTHY ARNOLD, MD CHIEF MEDICAL OFFICER, ALLIANCE HEALTH CENTER, MERIDIAN A study published recently by one of American’s biggest insurance providers found that “the number of Americans being diagnosed with opioid addiction continues to skyrocket, but still very few receive any treatment,” according to CNN reporter Nadia Kounang in June of this year. What the study doesn’t highlight is the challenge we – as psychiatry and addiction specialists in rural areas – face in getting patients into treatment programs and the challenges those patients face once they leave our programs to find continuing community resources. Over the years in my practice, I have seen the number of people diagnosed with addiction problems steadily rise and have seen a sharp increase in the level of addiction severity. However, going hand-in-hand with this upswing in addiction and severity, insurance companies and the government have increased their scrutiny to a point that it takes a new level of clinical expertise to determine which patient is appropriate for in-patient medical detoxification services – and if those services will be covered.

AS WE CONTINUE TO SEE AN INCREASE IN THE NEED FOR ADDICTION TREATMENT AND LIMITED OR RESTRICTIVE RESOURCES TO MATCH THIS GROWING NEED, IT FALLS TO WE MEDICAL PROFESSIONALS ON THE FRONT LINES IN RURAL AREAS TO CREATE INNOVATIVE PROGRAMS THAT ACTUALLY HELP PATIENTS – AND PROGRAMS THESE PATIENTS CAN ACTUALLY AFFORD. In the past, once patients were medically detoxified, they could enter a 60- to 90-day treatment program. Now, patients who can get into a 30day treatment program are very fortunate, due to restrictive insurance regulations. In large metropolitan areas, travel to and from the 30day programs is available. However, in rural areas surrounding many treatment centers in Mississippi and Alabama, the financial and travel barriers prevent many patients from much-needed after care, even if their insurance would pay for it.

A solution that has found traction is to create a hybrid of the 30-day program that qualifies for partial-hospitalization level of care but is tailored in a setting that provides a more residential level of care. Adding a boarding component to a partial hospitalization program solves many of the challenges rural residents face in being able to participate. The success of this type of program is enhanced because the majority of patients are in a 24-hour-a-day therapeutic program as opposed to the 6-8 hours they would receive in a traditional partial hospitalization program.

NOW, PATIENTS WHO CAN GET INTO A 30-DAY TREATMENT PROGRAM ARE VERY FORTUNATE, DUE TO RESTRICTIVE INSURANCE REGULATIONS. Using this unique approach, patients can work toward recovery in a more secure therapeutic environment but can still be encouraged to use community resources to transition to full out-patient status. The trick is to have both components of the program – residential and partial hospitalization – cover the entire spectrum and meet the needs of patients as they move forward. In our rural areas, the transition to out-patient status presents another challenge. The services available for the next level of care in an outpatient setting in urban areas is extensive. In the East Mississippi and West Alabama area, these services are not optimal. Therefore, it is incumbent for physicians and facilities in our area to provide a better level of care before the patient transitions. As we continue to see an increase in the need for addiction treatment and limited or restrictive resources to match this growing need, it falls to us medical professionals on the front lines in rural areas to create innovative programs that actually help patients – and programs these patients can actually afford. n

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Opioid Addiction from an Emergency Room Physician’s Perspective PHILIP L. LEVIN, MD EMERGENCY PHYSICIAN • PRESIDENT-ELECT, MISSISSIPPI/ACEP • GULFPORT

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The nurses passed around the obituary of Sarah M, a 42-year-old housewife whose life we’d saved the week before. The rescue squad had been called to her home by a friend who reported that Mrs. M had stopped breathing. A dose of naloxone, the opiate reversing drug, had brought her back to life, and once in our E.R. she sneered at my recommendations for addiction rehabilitation. “Who do you think I am, Lindsay Lohan?” she asked. “Those places won’t take people without insurance.” She pulled off her leads, ripped out her IV, and strolled out of the E.R. It was the last time our hospital would see her alive. Sadly, this is a common scenario. According to the American College of Emergency Physicians (ACEP), 10% of all patients treated with Naloxone for drug overdose will die within a year, half of them within a month (Weiner, Scott G., et al. Abstract 402). While naloxone can interrupt the acute emergency, it can’t change a person’s lifestyle. Thus, opioid overdose deaths continue among those who continue to use leading to a national emergency, the highly publicized opioid epidemic. According to the New York Times, “The current opioid epidemic is the deadliest drug crisis in American history. Overdoses, fueled by opioids, are the leading cause of death for Americans under 50 years old – killing roughly 64,000 people last year, more than guns or car accidents, and doing so at a pace faster than the H.I.V. epidemic did at its peak.” New York Times 10/26/2017. HHS.gov states, “Opioid abuse is a serious public health issue. Drug overdose deaths are the leading cause of injury death in the United States.” The National Institute of Health reports, “Every day, more than 90 Americans die after overdosing on opioids,” June 2017. In a recent poll by ACEP surveying over 1200 active emergency room physicians, over 42% of the physicians reported treating patients coming to their emergency rooms for opioid overdoses at least daily, including 29% reporting treating these patients several times a day (Figure). Over half of the physicians reported treating the same overdose patients with naloxone over 75 times a year. Talk about recidivism! Sadly, only 3% of all E.R. physicians surveyed said they’d never had to declare a patient dead due to a narcotic overdose. Where do all these overdoses come from? Is it the physicians’ faults for overprescribing? Not according to National Survey on Drug Use and Health who reported, “At least three quarters of opioid-pill abusers and almost all heroin addicts got hooked without ever having been prescribed pain medication for an injury or illness.” According to SAMHSA, who conducts the NSDUH survey, 79.5% of recent heroin initiates report previous abuse of prescription opioids. So, roughly 80% of recent heroin users are receiving diverted medication, mostly from family and friends. Ultimately, too much is being prescribed. JAMA stated, “Emergency-room records show only a fraction (13% ) of opioid-overdose victims began taking drugs because of pain.” Rather, addiction more commonly begins because of people experimenting with drugs.

Personally, at Memorial Hospital of Gulfport, we have daily patients seeking “pain medicines.” We don’t have a specified policy, and some physicians are more willing to prescribe opiates than others. I tell my patients that the E.R. doesn’t prescribe chronic pain medicines and they’ll have to get their opiate drugs from their attending physicians. Even for those in acute pain, such as burns or kidney stones, I limit prescriptions to three days’ worth. Besides the deaths and disabilities, opioid addiction comes with a high economic cost. The Centers for Disease Control and Prevention estimates that the total “economic burden” of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement. The AMA has stepped in with an Opioid Task Force. “The AMA Opioid Task Force recognizes the need for increased physician leadership, a greater emphasis on overdose prevention and treatment, and the need to coordinate and amplify the efforts and best practices already occurring across the country.” The AMA Opioid Task Force encourages physicians to take 6 actions: Register and use state prescription drug monitoring programs Enhance education and training Support comprehensive treatment for pain and substance use disorders Help end the stigma of opioid addiction Co-prescribe naloxone to patients at risk of overdose Encourage safe storage and disposal of opioids and all medications Another possible political solution is ensuring that naloxone, the opioid reversal agent, is available to EMS workers, and even in the household. Narcan® (Naloxone) Nasal Spray is a prefilled, needle-free device that requires no assembly and is sprayed into one nostril while patients lay on their back. It’s partner, Evzio®, is a prefilled auto-injection device that makes it easy for families or emergency personnel to inject naloxone quickly into the outer thigh. Once activated, the device provides verbal instruction to the user describing how to deliver the medication, similar to automated defibrillators. Both Narcan® Nasal Spray and Evzio® are packaged in a carton containing two doses to allow for repeat dosing if needed. Unfortunately, this 2-pack costs $4,500! [Gupta R, Shah ND, Ross JS. “Perspective: the rising price of naloxone — Risks to efforts to stem overdose deaths”. N Engl J Med. 2016;375(23): 2213–2215. doi:10.1056/NEJMp1609578.] They are relatively easy to use and suitable for home use in emergency situations. Although some states require a prescription for naloxone, many pharmacies offer naloxone for use in an outpatient setting without bringing in a prescription from a physician. For example, CVS stores offer naloxone products without a prescription in Ohio, Arkansas, California, Minnesota, Mississippi, Montana, New Jersey, North Dakota, Pennsylvania, South Carolina, Tennessee, Utah, and Wisconsin. Another attempt to reduce the opioid overdose death rate is to offer “Safe Injection Stations.” CNN (12/17/15) featured an article about one such station in Vancouver, Canada, with thirteen booths, servicing up to a thousand customers a day. Supervised with closed circuit cameras,

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persons with opioid addiction inject themselves safely with illicit drugs, preventing accidental deaths by overdose. Also available at many such stations are free needle exchange, instructions on how to safely inject, and information on rehabilitation programs. When the patient with opioid use disorder is discharged from the emergency department, follow-up referral to a rehabilitation program is desirable. At MHG, we have counselors who provide a list of locally available programs. Many of these have considerable costs, and some insurance programs don’t offer this kind of coverage. Yet many free or low-cost programs exist across our state, such as the Abundant Grace Emergency Center in Moss Point, the Salvation Army in Jackson, and Teen Challenge in Poplarville. Most of these types of programs rely on donations and volunteers and might have long waiting times. The ACEP survey reports that nearly 6 in 10 of emergency physicians find that detox or rehab facilities were rare or inaccessible. Opioid addiction devastates the individual and the family, an escalating crisis affecting all socio-economic classes. Emergency medicine physicians report a startling increase in the number and intensity of patients presenting with opioid overdose, and statistics confirm the epidemic nature of opioid related deaths. Physicians must be proactive in identifying their patients at risk and perhaps suggest that family members have access to naloxone, instructing them on when and how to use it, and to help their patients become involved in detox and rehabilitation programs. Perhaps Sarah M’s death can inspire physicians to step up our intervention attempts. n

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For information, contact 601.824.0342 or www.region8mhs.org

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2 0 1 7 ACE P E ME RGE NC Y PH Y S I CI A N POLL

OPIOID PATIENTS IN THE EMERGENCY DEPARTMENT Poll Methodology: This survey was conducted online between Sept. 21 and Oct. 2, 2017, with 1,261 emergency physicians. There was a response rate of 5.3 percent and a margin of error of 2.7.

Q1. HOW OFTEN DO PATIENTS WHO ARE OVERDOSING ON OPIOIDS COME TO YOUR EMERGENCY DEPARTMENT? SELECT ONE. QUESTION

Don't know/No opinion More than 2-3 times a day Multiple times a week (4 or more) Multiple times each month (4 or more) Never Once a day Once a month Once a week Several times a day (2-3) Several times a month (2-3) Several times a week (2-3)

NO. SURVEYED: 1261

NO. RESPONSES: 1254

Did not respond

19 156 105 16 13 170 65 85 364 75 186

1.52% 12.44% 8.37% 1.28% 1.04% 13.56% 5.18% 6.78% 29.03% 5.98% 14.83%

Q2. HOW OFTEN DO OVERDOSE PATIENTS, WHO COME TO YOUR EMERGENCY DEPARTMENT, RECEIVE NALOXONE, EITHER IN THE EMERGENCY DEPARTMENT OR BY EMS? SELECT ONE. QUESTION

1-10 times per year 11-25 times per year 26-50 times per year 51-75 times per year Don't know/No opinion More than 75 times per year Never administered

NO. SURVEYED: 1261

NO. RESPONSES: 1249

Did not respond

100 110 146 113 67 705 8

8.01% 8.81% 11.69% 9.05% 5.36% 56.45% 0.64%

Continued on next page.

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Q3. IN THE PAST YEAR, HAVE YOU SEEN AN INCREASE IN THE NUMBER OF PATIENTS SEEKING OPIOIDS? SELECT ONE. QUESTION

Don't know/No opinion No, a decrease No, a significant decrease Stayed the same Yes, a significant increase Yes, an increase

NO. SURVEYED: 1261

NO. RESPONSES: 1250

Did not respond

32 97 35 440 272 374

2.56% 7.76% 2.80% 35.20% 21.76% 29.92%

Q4. HOW OFTEN ARE YOU INVOLVED IN THE CARE OF PATIENTS WHO DIE OF A PRESUMED OVERDOSE, EITHER BY CARING FOR THEM IN YOUR EMERGENCY DEPARTMENT OR BY GIVING THE ORDER OVER THE PHONE TO DECLARE THEM DEAD? SELECT ONE. QUESTION

1 – 10 times per year 11-25 times per year 26-50 times per year 51-75 times per year Daily Don’t know/No opinion More than 75 times per year Never

NO. SURVEYED: 1261

NO. RESPONSES: 1256

Did not respond

755 183 71 9 24 145 26 43

60.11% 14.57% 5.65% 0.72% 1.91% 11.54% 2.07% 3.42%

Q5. HOW ACCESSIBLE ARE DETOX/REHAB TREATMENT CENTERS FOR OPIOID-ADDICTED PATIENTS WHO COME TO YOUR EMERGENCY DEPARTMENT? SELECT ONE. QUESTION

Always accessible Don’t know/No opinion Never accessible Rarely accessible Somewhat accessible

NO. SURVEYED: 1261

NO. RESPONSES: 1254

Did not respond

43 26 100 613 472

3.43% 2.07% 7.97% 48.88% 37.64%

Q6. DOES YOUR EMERGENCY DEPARTMENT PROVIDE MAT (MEDICATION ASSISTED TREATMENT)/ BUPRENORPHINE OR METHADONE? SELECT ONE. QUESTION

Don’t know/No opinion No Yes Continued on next page.

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NO. SURVEYED: 1261

NO. RESPONSES: 1255

Did not respond

31 1,158 66

2.47% 92.27% 5.26%

Emergency Care and the Nation's Opioid Crisis

Nearly 9 in 10 emergency physicians reported the number of patients seeking opioids has increased or remained the same during the past year.

Nearly 6 in 10

reported the detox or rehab facilities were rare or not accessible.

Of all patients who were treated with Naloxone: 10% of patients treated with Naloxone died within one year. Of those, HALF died within one month. “Virtually every emergency physician has seen firsthand the tragedy of opioid addiction,” said Paul Kivela, MD, FACEP, president of ACEP. “The consequences of this epidemic are playing out in the nation’s emergency departments." This survey was conducted online between Sept. 21 and Oct. 2, 2017, with 1,261 emergency physicians. There was a response rate of 5.3 percent and a margin of error of 2.7.

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Q7. IN WHAT STATE DO YOU PRACTICE? SELECT ONE. QUESTION

Alabama Alaska Arizona Arkansas California Colorado

Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma

64 VOL. 59 • NO. 1 • 2018

NO. SURVEYED: 1261

NO. RESPONSES: 1254

Did not respond

18 14 25 12 78 32 21 11 6 56 35 6 5 46 38 4 6 19 18 5

1.44% 1.12% 1.99% 0.96% 6.22% 2.55% 1.67% 0.88% 0.48% 4.47% 2.79% 0.48% 0.40% 3.67% 3.03% 0.32% 0.48% 1.52% 1.44% 0.40%

35 22 54 24 7 28 5 8 9 7 28 14 83 52 3 71 8

2.79% 1.75% 4.31% 1.91% 0.56% 2.23% 0.40% 0.64% 0.72% 0.56% 2.23% 1.12% 6.62% 4.15% 0.24% 5.66% 0.64%

Q7. IN WHAT STATE DO YOU PRACTICE? SELECT ONE. (CONTINUED) QUESTION

Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee

Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

NO. SURVEYED: 1261

NO. RESPONSES: 1254

23 69 8 17 4 15 76 12 3 42 39 11 18 4

1.83% 5.50% 0.64% 1.36% 0.32% 1.20% 6.06% 0.96% 0.24% 3.35% 3.11% 0.88% 1.44% 0.32%

Q8. WHAT IS THE EMERGENCY DEPARTMENT VOLUME WHERE YOU WORK THE MAJORITY OF YOUR TIME? SELECT ONE. QUESTION

Don’t know/No opinion Up to 10,000 10,001-20,000 20,001-30,000 30,001-40,000 40,001-50,000 50,001-75,000 75,001-100,000 100,001-200,000 200,001-300,000

More than 300,000

NO. SURVEYED: 1261

NO. RESPONSES: 1255

Did not respond

10 35 66 97 150 143 329 256 153 9 7

0.80% 2.79% 5.26% 7.73% 11.95% 11.39% 26.22% 20.40% 12.19% 0.72% 0.56%

Q9. AS AN EMERGENCY PHYSICIAN, DO YOU WORK DIRECTLY FOR YOUR HOSPITAL OR FOR A PRIVATE GROUP CONTRACTING WITH YOUR HOSPITAL? SELECT ONE. QUESTION

An emergency medicine group Directly for my hospital Don’t know/No opinion Neither

NO. SURVEYED: 1261

NO. RESPONSES: 1246

Did not respond

729 420 8 89

58.51% 33.71% 0.64% 7.14%

JOURNAL MSMA

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P O E T R Y

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M E D I C I N E

This month, we print another poem by John D. McEachin, MD, FAAP, a Meridian pediatrician and the Journal’s unofficial poet laureate. This poem, entitled “Paean to My Poets,” pays tribute to the poets who have shaped his life and his own poetry. I encourage you to seek out the brilliant poems and talented poets to whom he refers. Dr. McEachin writes: “Luke’s sharing the poetry of Edgar Lee Masters in recent issues reminded me of this tribute to just a few of the poets I have come to appreciate through the years. I share this brief testimony with physicians hoping they will avail themselves of the opportunity and privilege of sitting at the feet of these masters. Their works are experiential and yield thoughts on subjects familiar to us and to our patients. In these few references, we are exposed to the sea, children at play with their father, a happy barefoot boy, an older man coming to grips with his blindness, a Canadian physician and a New Englander, both of whom as soldiers in World War I died soon after their writings, a Scottish poem of romantic love, a soothing preparation for the coming of death, and an excerpt from an essay dealing with the slippery slope of personal ethics.” For those seeking an accessible poetry anthology, Dr. McEachin recommends “a slender little book,” the classic ‘One Hundred and One Famous Poems’ by Roy Cook, published first in 1916 and still in print. For more of Dr. McEachin’s poetry, see past and future JMSMAs. Any physician is invited to submit poems by slow mail for publication in the Journal, attention: Dr. Lampton or email me at lukelampton@cableone.net. —ED.

68 VOL. 59 • NO. 1 • 2018

Paean to My Poets To my favorite poets, I send regards! To John Masefield for his “Sea Fever”, I revere it now as in yesteryear. Yes, I can yet quote it with no aid or cue! To H. W. Longfellow and “The Children’s Hour”, For that Mouse-Tower on the Rhine. And too, the sinewy, masculine “Village Blacksmith”! To John Greenleaf Whittier’s “Barefoot Boy”— Exactly eighty-two lines, and forty-one rhymes, Perfect lines, each with seven syllables! To John Milton for “Sonnet on His Blindness”, For a non-Shakespearean, but Italian style sonnet, “They also serve who only stand and wait”! To Lieut. Colonel John McCrae, “In Flanders Field”, After four years on the Western Front, You joined your friends—they gave their all! To Sgt. Joyce Kilmer, and his sensitive “Trees”, Twelve beautiful long metered lines, You, too, fell in France in World War I! To Robert Burns, “My Love Is Like a Red, Red Rose”! “…And I will luve thee still, my dear, Till a’ the seas gang dry”! To William Cullen Bryant, your “Thanatopsis” Gives aid and comfort in life’s final days, Though you penned these thoughts at age seventeen! To Alexander Pope, for “An Essay on Man”, And your insightful quatrain on vice, closing, “…We first endure, then pity, then embrace.”! – John D. McEachin, MD Meridian

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The Painkiller Panic: From Pandemic to Pandemonium DWALIA S. SOUTH, MD MSMA PAST PRESIDENT AND COMMITTEE ON PUBLICATIONS CHAIR Unless you have been living on another planet recently, it is very apparent that physicians of all stripes are now engaged in a great “uncivil war.”

available on the “manner” of these deaths, whether they were accidental or intentional suicidal overdoses, and how illicit street drugs and alcohol played a role in these tragedies.) There is no denying that there is real diversion of Schedule II narcotics from manufacturers, foreign countries, unethical pharmacies to the black market, and then to the street.

Along with a variety of other healthcare professionals, doctors are facing unprecedented scrutiny and government suspicion from federal and state law-enforcement agencies, placing our calling as South healers in a distasteful defensive posture. The medical profession has now become the sacrificial lamb and given the burden of blame due to the government’s impotence at solving America’s growing drug problem. There has been longstanding unwillingness to fund more addiction treatment facilities (other than jails) and scant community based prevention and drug education strategies for our ‘at risk’ youth.

Nevertheless, the knee-jerk connection that law enforcement agencies have drawn between these reprehensible illegal activities and the everyday legitimate prescribing practices of medical professionals has never been and never will be established. The great majority of America’s healthcare providers are ethical, law abiding, God-fearing creatures who have their patients’ best interests at heart. The faulty inference made that physicians are “drug-pushers disguised in white coats” is sensationalized pseudo-news designed to shock the public, intimidate doctors, and put a feather in someone’s cap. Yes, when officers threaten us in a televised news conference blatantly shaking their fingers at the television cameras and using threatening phrases about coming to get doctors then we should realize that, however misguided and unfathomable it may be, there is indeed a “War on Doctors.”

Physicians today are enduring the brunt of incredibly reckless and injurious law enforcement activity. Drug enforcement agencies have failed to stop the influx of illicit drugs from other countries and seem powerless to prevent diversion from crooked pharmacies and pharmaceutical manufacturers. Thus far, the bureaucracies of narcotics control militiamen have been ineffectual at curtailing crystal meth labs from sprouting up in rural trailer parks or to shut down crack houses in urban areas. These days doctors’ offices, medical clinics, and pharmacies are being raided, and healthcare professionals are being maligned and targeted by gun-wielding uniformed officers because they are the ‘low hanging fruit’ and easy pickings. Also, as a general rule, we spook easily and almost never shoot back.

What are some factors that have put our profession in this regrettable state of affairs? Let’s name a few:

There is no doubt in anyone’s mind that there are some really bad doctors out there. Our profession has its share of sociopaths greedily running “pill mills.” There is no question that death rates due to prescription drug overdoses have been on the increase. (However, there is no real data

70 VOL. 59 • NO. 1 • 2018

1. BIG PHARMA About 20 years ago someone (who likely was on “the Big Pharma” dole) promoted the concept that “PAIN IS THE 5th VITAL SIGN.” Critically, the Joint Commission issued the edict in 1999 that “Pain is whatever the patient says it is.”1,2 This then led Congress to proclaim the decade commencing January 1, 2001, as the “Decade of Pain Control and Research.”3 Thus, everyone who comes to your office, for whatever complaint they may have, is asked to rate their pain on a tenpoint scale, or circle smiley/frowny emoji faces if they cannot quantify it. They may have come simply to get their blood pressure medicine refilled. Planted in the patient’s mind is the idea that every person on your schedule is suffering from some sort of pain. It was literally interpreted to mean that practically every patient, with a few miles left on his or her bodily odometer, qualified for an opiate prescription. Imagine asking a patient to rate his blood pressure, temperature, or weight and

documenting this guess on the chart as a vital sign! It is exactly the same thing, and it is far removed from scientific or evidence based medicine. 2. JCAHO From that juncture, we were then told, by JCAHO (Joint Commission on the Accreditation of Healthcare Organizations) who arguably bears a good deal of blame in America’s current painkiller fiasco, that not to treat the patient’s pain adequately was verboten. We were also informed that we might be sued for malpractice if we didn’t do so. In the past couple of years, we have also been informed that our reimbursement rates would at be least partially based on patient satisfaction scores. Saying “no” to their controlled drug requests does not make patients happy campers. A few get violent. 3. PAIN MANAGEMENT PRESCRIBING GUIDEBOOK Purdue Pharmaceuticals™ launched a very successful but very wrongful and dangerous introduction and promotion of OxyContin® as a “completely safe therapy for chronic pain.” According to the information Purdue promulgated to physicians in their 2003 Pain Management Prescribing Guidebook, “More than 50 million Americans suffer from chronic nonmalignant pain. Unremitting pain is associated with anxiety, depression, loss of independence, and interference with relationships…pain that is widely undertreated; one study reports that more than 40% of patients in routine practice settings fail to receive adequate relief.” Although this safety claim is sadly quite laughable now, physicians totally bought into the concept. The buzz-phrase on the book’s opening page was “Together, let’s treat the pain.” (For a fascinating read, check out an investigative article by Patrick Radden Keefe entitled “Empire of Pain” in the October 30, 2017 issue of The New Yorker magazine. Read the expose′ on Purdue Pharmaceuticals’™ owners, the Sackler physician family. It outlines the “ruthless promotion of opioids which generated billions of dollars and millions of addicts.”) Drug companies should never have been allowed to market their wares to physicians or patients in the cavalier manner that occurred around 15 years ago. 4. SICK SOCIETY During the interval of the increase in the prescribing and use of more pain medicines, our country has undergone “The Great Recession of 2007-2009,” the tsunami effect on our economy still being felt. So many jobs and homes have been lost with the tanking of Wall Street at that time that the mental and emotional health of our entire society has been at risk. Even though the Dow and our 401(k)’s are looking better, the outlook we see from the media about our leaders in government is demoralizing. The diagnosis of major depression has increased, and along with our patients’ depression comes a decreased tolerance to pain and an increase in suicidal ideation. We have the great misfortune to live in a very sick and somatizing society. 5. NEW SAFE DRUGS (or lack thereof) There is a paucity of “safe noncontrolled prescription drugs” on the market and none in the pipeline, it seems. The price of what are touted to be safer formulations of pain medications is cost prohibitive to the majority of our patients. They are also not covered by most prescription insurance plans because there are so many cheaper (though riskier) options available for pain relief. The only new prescription drugs that seem to be coming to the pharmacy near you

are laughably for the recently invented diagnostic malady called “OPIOID INDUCED CONSTIPATION.” Watch television for one night and chances are you will see a commercial advertising this horrible new disease! 6. AGING We live in a society of aging baby boomers with multiple chronic illnesses who know there are treatment options out there for their aging-related aches and pains. They want nothing less than the best available medicine to keep them “pain free.” Family physicians as a specialty are increasingly getting timeworn right along with their patients. We understand their creaks and groans of physical decline all too well. As our patient populations become more and more geriatric heavy, the ravages and discomforts of aging and the numbers of frail elderly increase exponentially. It becomes quite easy to empathize with them! Also, it is very common that as we physicians age our practice patterns become stale and antiquated; prescribing the easy and usual fix can become rote. Physician burnout is rife in all ages and stripes of healthcare providers, but is rampant in those of us who qualify for senior discounts. This makes learning new practice patterns and keeping up with rapidly changing rules and regulations more difficult to achieve. It has always been thus. (Do you remember laughing at the old doc who gave out B-12 shots to all comers? Now we want to give ourselves one, too!) 7. SPECIALISTS The great majority of specialist physicians have refused to get involved in the treatment of the chronic pain, which should be totally within the purview of their specialty practice. Practitioners of neurology, neurosurgery, orthopedics, and rheumatology routinely advise their patients that they are “not going to manage your chronic pain” and instruct then in writing that “you should go back and see your family doctor to get treatment for your pain issues.” The buck is officially passed to the patient’s primary care provider who must deal with their very real pain problems in perpetuity and who are now unable to adequately do so without being branded as a criminal “Dr. Feelgood.”

THE MEDICAL PROFESSION HAS NOW BECOME THE SACRIFICIAL LAMB AND GIVEN THE BURDEN OF BLAME DUE TO THE GOVERNMENT’S IMPOTENCE AT SOLVING AMERICA’S GROWING DRUG PROBLEM. 8. PRIMARY CARE OVERLOAD Cardiologists and nephrologists who have received our referrals now routinely discontinue the non-steroidal anti-inflammatory meds we have been advised to prescribe to our patients to reduce their somatic pains. They offer the patient no alternatives and basically tell them, “If you keep taking what your family doctor is prescribing it will kill you… and if you need pain relief, go back to them to get a clinically safer prescription of a narcotic drug because we are not going to prescribe it for you.” The buck once again has been passed back to the primary care provider. It all sounds like a game of “hot potato” with the patient ending up the loser. 9. PAIN MANAGEMENT CLINICS The elderly, uninsured, and the working low-income patients all have extreme difficulty getting to pain

JOURNAL MSMA

management venues monthly. In rural Mississippi, these are overbooked and are routinely only to be found one hour or more away from the patient’s home. Many are physically unable to drive at all; many cannot actually afford the gas to do so monthly. If they have a job, the patient must miss a day’s work each month. The uninsured will not ever be granted an appointment to begin with. Therefore, who will be left to care for them but their primary care physicians? For the primary care clinic staff nurses, simply getting a patient successfully connected with a pain management practice is a time consuming and onerous task. Once they are seen, many patients are almost criminalized, and there is no real connection or interpersonal relationship ever sought or formed in most cases. The attrition ratio is fairly dreadful. 10. REIMBURSEMENT ISSUES Insurance companies, Medicare, and other third party payers seem to be reluctant to pay for physical therapy for more than a paltry number of visits. Alternative pain management options (physiotherapy, wellness/exercise centers, acupuncture, chiropractic, etc.) are given the short shrift or a flat refusal also. Then, what if the patient is identified as requiring drug treatment for a narcotic addiction? Other than a rapid inpatient detox, they are either back on the street, back on drugs, or back in jail. For the most part, they are kicked to the curb and flat out of luck if they are uninsured or a member of the growing sector of “the working poor.” 11. EMPLOYED PHYSICIANS Today more and more physicians are no longer the masters of their practice universe and are being given the mandate to see a certain minimum number of patients per day, in 10 to 15 minute time increments. An employed physician is informed that the front desk people make the decisions about whom, how many and when you will see patients. Autonomy is rapidly going out the window. This scenario cultivates what Sir William Osler called a “nickel-in-the-slot” practice. It becomes much easier to acquiesce to patient demands than it is to spend time explaining why you really should say “no.” Physician salaries and bonuses are now determined many times based on patient numbers seen and patient satisfaction surveys, as those are very easy to calculate and seemingly more paramount goals to the bean counters, versus quality and real outcomes of care. 12. POLICING ROLE It is seemingly trendy, media attention getting, and all too easy for multi-agency law enforcement officials to now put the burden of blame for society’s drug addiction problems on physicians. Folks with Glocks and badges and no medical training are telling us how to treat our sick patients. We are then forced into the policing role, doing background checks, prescription drug investigations, and drug testing every patient at every visit. If we don’t, then we become “bad doctors” and are held criminally liable. John Dowdy, Jr., the new director of the Mississippi Bureau of Narcotics, posed in a statewide televised press conference this past May and threateningly addressed the healthcare community thusly: “If we find out that your prescription habits are causing addiction problems, we’ll come find you. If we have overdose deaths related to your prescribing habits, let this serve as notice to the healthcare professionals in this state, we’re not playing around anymore.”

72 VOL. 59 • NO. 1 • 2018

If that statement does not constitute a declaration of war against physicians, then I’ll eat my stethoscope! n To be continued: In future issues, we will address “The War on Doctors is a War on Patients” and “The War on Doctors: Personal Physician Stories From Ground Zero.”

Baker DW. The Joint Commission’s Pain Standards: Origins and Evolution. Oakbrook Terrace, IL: The Joint Commission; 2017. 2 Baker DW. History of The Joint Commission’s Pain Standards: Lessons for Today’s Prescription Opioid Epidemic. JAMA 2017; 317(11):1117-1118. 3 Brennan F. The US congressional “Decade on Pain Control and Research” 20012011: A review. J Pain Palliat Care Pharmacother. 2015 Sep;29(3):212-27. doi: 10.3109/15360288.2015.1047553. 1

Articles and editorials expressed in the Journal are those of the indicated author. Comments and opinions are not expressions of the views or official policies of the Mississippi State Medical Association. We encourage our membership to submit comments for publication regarding any opinion expressed or information contained in the Journal. Email to KEvers@ MSMAonline.com or mail to Lucius Lampton, MD, Editor, 111 Magnolia St., Magnolia, MS 39652-2825. We encourage your comments.

August 17-18, 2018 The Westin Jackson

Defining Events in the Evolution of Mississippi Medicine 74 VOL. 59 â&#x20AC;˘ NO. 1 â&#x20AC;˘ 2018