Oregon Opioid Treatment Access Ranks Near the National Bottom
The Oregon Medical Association has released a report in conjunction with its national umbrella organization, detailing steps doctors have made to move way from prescribing addictive opioids for chronic pain. Doctors have also more frequently reported the prescription of controlled substances to state databases.
Nationally, opioid prescriptions declined 22 percent between 2013 and 2017, and their numbers were reduced 25.5 percent in Oregon. Meanwhile, the number of queries to the Oregon Prescription Drug Monitoring Program increased from 1.2 million in 2016 to almost 1.4 million in 2017, according to the OMA.
But the American Medical Association’s own report showed that Oregon was one of the worst states for people needing treatment, with more than 91 percent of those with a substance use disorder not receiving help.
“There is still much we need to do,” said Dr. Amy Kerfoot, an OMA trustee and the association’s representative to the governor’s Opioid Epidemic Task Force. “We have to ensure that all patients, no matter their level of insurance coverage, have access to medication-assisted treatment and addiction services. There should be as few hurdles as possible to get someone the treatment needed to overcome an addiction to any drug.”
While the national media keeps the public focused on the day-to-day mischief of the president, his presumed ties to Russia, and the insults traded by celebrities, the opioid epidemic kills more people in a year than the number of Americans who died in the entirety of the Vietnam War.
The number of drug overdose deaths in the United States has doubled since 2009 and tripled since 2002 and shows few signs of abating. More than 64,000 Americans died from drug overdoses in 2016, the leading cause of death for people under 50.
By contrast, 40,000 Americans died in car accidents and 38,000 were killed by firearms. At the height of the AIDS epidemic in 1995, 40,000 people died as a result of the immune disorder before fatalities fell dramatically due to development of life-saving medications.
Despite trailing most of the nation in access to treatment, Oregon has seemed to reverse the annual number of opioid deaths — which continue to climb nationally. Overdose deaths in Oregon have been below the national average per capita, and fell from 338 deaths in 2011 to 271 in 2015.
Kerfoot blamed Oregon’s laggart access to treatment in part on poor access in rural areas, but 70 percent of Oregonians live in the nine counties between Portland and Eugene, not in the state’s far-flung rural areas. Other western states that are more rural than Oregon -- such as Wyoming, Oklahoma and New Mexico, have gotten a considerably higher percentage of people with substance use disorder into treatment, according to the AMA.
The University of New Mexico launched Project ECHO, which provides free training to healthcare professionals in opioid addiction treatment. Maryland eased access by barring insurers from requiring prior authorization for medication-assisted treatment.
A bigger reason for a lack of access may be that primary care providers have been slow to seek waivers to prescribe medications like buprenorphine. Methadone must be administered in a clinical setting, but providers can prescribe buprenorphine or naltrexone for the patient to administer at home.
Until recently, nurse practitioners were barred under federal law from prescribing buprenorphine. That recently changed, but both they and physicians need to seek a waiver if they wish to prescribe these drugs, and this requires a fee and an eight-hour class. Prescribing narcotic painkillers requires no such waiver.
In the 1990s, France cut heroin overdoses by 79 percent in four years by allowing any physician to prescribe buprenorphine without special licensing or training. Soon, the majority of French prescribers were primary-care doctors as opposed to addiction specialists or psychiatrists. As a result, 10 times as many drug users were receiving treatment, up to half of the people addicted, according to an April article in The Atlantic.
Kerfoot said patients with addiction issues need more than just someone to prescribe medications, they need wraparound care, including social workers and behavioral health workers -- all of which is included in the state’s patient-centered primary care home.
Oregon frequently touts its patient-centered primary care home model for Medicaid, yet less progressive states like Ohio, Indiana and Pennsylvania -- the epicenter of the epidemic -- all report higher percentages of people in treatment.
Health policy officials often blame the stigma of drug addiction as a barrier to seeking treatment. “People treat it as a moral problem rather than a medical disorder,” Kerfoot said.
The moralizing approach to kicking heroin by legal authorities has in some cases led directly led to overdose deaths. In 2015, a Long Island judge ordered a man to stop his methadone treatment, because in the judge’s opinion only abstinence could fully end his addiction. The man had held down a job on methadone, but soon after the judge’s order he went back on heroin, overdosed, and died.
“We’re trying to reduce stigma overall and we want to bring this out of the shadows,” said Jeff Rhoades, a policy advisor to Brown. “People are suffering from addiction, and they’re trying to get better.”
Kerfoot conceded that healthcare providers themselves might contribute to these negative attitudes. “There’s a stigma of having these people in your waiting room.”
Dr. Andrew Kolodny, a psychiatrist at Brandeis University, told The Atlantic that many primary-care providers are worried about getting inundated with patients addicted to heroin, given the small percentage of physicians who prescribe medication-assisted treatment.
“Doctors also want to take care of kids with colds, and adults with bad backs and cancer patients and the panoply of humanity that they know how to take care of,” he said. Kolodny suggests requiring any physician who wishes to prescribe opioids to also seek the waiver to prescribe buprenorphine to treat those who get addicted.
Overuse of prescription opioids has only been part of the problem, as people hooked on prescriptions who get cut off may turn to illicit drugs like heroin and fentanyl of murky origin, with questionable purity and unknown concentrations.
“Once we start someone on Vicodin, and they get addicted, it opens the door to illicit drugs,” Kerfoot said.
While progress on increasing access has been slow in Oregon, the governor has authorized a task force of behavioral health providers, county agencies and insurers, as well as the Oregon Medical Association to discuss possible solutions to the crisis.
In 2017, the Legislature passed a bill from the governor requiring prescribing practitioners to register with the Oregon Prescription Drug Monitoring Program, just as dispensing pharmacists must do.
The bill also provided limited, targeted funding to fight the opioid epidemic in four counties -- Multnomah, Marion, Jackson and Coos. Those counties are allowed to improvise on the best approaches to lowering opioid overdoses, such as the use of peer behavioral specialists. Successful approaches may be adapted statewide with additional funding next year.
Reach Chris Gray at [email protected].