In a recent report the following information was released about opioid abuse:

1. In Montgomery County, Ohio with a population of 500,000 the coroner had to lease space in a funeral home because he ran out of space to store bodies of people who died of opioid overdose.
2. In 2015, 2/3rds of the 52,000 deaths due to drug overdose was due to opioid drug overdose.
3. In 2015, there were 91 deaths a day due to opioid drug overdose, which is twice the number of deaths per day during the Vietnam War.
4. In 12 Midwest and Southern states the number of opioid prescriptions exceeds the number of people who live there.
5. In New Hampshire, a state of 1.2 million people,13,000,000 doses of opioids were dispensed  in a three-month period.
6. Four out of five heroin addicts started with prescription opioids.
7. Dayton, Ohio is the heroin capital of the nation.
8. Americans consume 81% of the world supply of oxycodone and 100% of the supply of hydrocodone.
9. Beginning in 1990, big pharma began lobbing for the use of pain medicines arguing that pain is a fifth vital sign.
10. In 1996 oxycontin was brought out and made big pharma a fortune.  The owners of Purdue Pharma have become the 14th richest family in America on the basis of their sales of opioid pain medicine.
11. When oxycontin was brought out it was advertised not to be so dangerous because it released slowly but addicts quickly learned how to release it instantly.
12. Fentanyl has become a big issue because it is smuggled in from China and Mexico and is fifty times stronger than heroin. 
13. Only 27% of the opioids are used by the person for whom they are prescribed.

In America there are tens of thousands of pharmacies, all of which can dispense opioids unlike other countries where opioids can only be prescribed by hospitals.  In Clay County, Kentucky, the city of Manchester has only 1,500 people but has eleven pharmacies.  Opioids are covered by Medicaid.  With this easy access, Medicaid recipients take twice as many opioids as others and are 3-6 time more like to overdose.

Clay County, Kentucky has only 20,000 people but in a three-month period pharmacies dispensed 617,000 units of   oxycodone and over 2.2 million hydrocodone which represents over 140 does synthetic heroin per person.  Yet, this level of usage attracted no attention from the eleven Federal enforcement agencies responsible for drug enforcement.

Under the last Presidential administration, Big Pharma was allowed to continue to promote opioid usage.  12,000,000 Americans are on opioids chronically.  They should be used only for a few days after surgery, an accident or for end-of-life pain control.  Common chronic conditions

In additional to law enforcement efforts, the most significant improvement in drug addition would be cautious prescribing by healthcare providers. Also, FDA commissioners should be leading the

The permanent solution to this epidemic is going to include a collaboration between:

• Healthcare providers including dentists, physicians, nurse practitioners, physician assistance, and pharmacists.
• Patient education about the dangers of opioid addiction and effective ways to treat and to endure pain without “pain killers.”
• Federal and State government regulation of all of the above.0
• Limitations on advertisements of opioids for pain control and/or cautions about their addictive potential.
• Federal interdiction of opioid smuggling.

In the United States, there are 147,000 dentists, 662,000 physicians, 56,000 nurse practitioners and 30,000 physician assistants.  Approximately 12% of opioid addicts begin with prescriptions from dentists.  Dentists represent about 16.4% of healthcare providers, not including pharmacists.

SETMA and the Solution

For over fifteen years, SETMA has systematized pain-medication management with a tool which can be reviewed at:  EPM Tools - Pain Management Tutorial.   Included in this tool is “SETMA’s refill policy” which states:

“This represents SETMA's refill policy. This policy will print on the pain management document that will be given to the patient at the end of the visit. This policy states:

“Under no circumstances will the medication be refilled:

1. Prior to the renewal date at the prescribed dosage and frequency of use.
2. Without the patient being seen in the office
3. Without evidence of continuing need for medication
4. On the weekend, evenings after hours, holidays or other times when your regular doctor is not available.

“The following reasons will not be accepted by any SETMA provider for an early refill of pain medication and/or medication with a significant potential for habituation:

1. My medications were stolen.
2. I only got half of the prescription filled.
3. I dropped my medications into the sink, the sewer, the swimming pool or other watery body.
4. I left my medication in my hotel on my trip.
5. I missed my appointment.
6. The neurosurgeon and/or the surgeon cancelled my appointment.

“Pain Medication Should Last - the date will automatically appear here which is a calculation of the number of pills given including refills and the maximum daily dose. This date will be the minimum time for a refill but does not indicate that the prescription should be refilled on this date. See explanation in number five below.”

27% of Controlled Substances and Opioids Are Not Taken by the Person for whom they were Prescribed

Since the development of this tool, the above described State Medical Board regulations have been strengthen and SETMA has responded to the changes by adding another tool which recommends the frequency of drug screening for “Drugs of Abuse” and/or “Drugs which require a Drug of Abuse Screening for Interaction.”   

When I began practicing medicine in 1973, urine drug screens were done to discover people who were taking illicit drugs.  While that is still the case, no urine drug screens are use principally to make sure that the person for whom an opioid or controlled substances is prescribed is actually the one taking the medication. 
The steps of action with this tool are:

1. When the patient’s electronic medical record is opened and the patient is taking drugs in either of these categories, an alert appears which states, “Urine Drug Screen Suggested.”
2. Next to this suggestion is a button entitled “click here.”  When this button is clicked, the following appears.
3. Any drugs which have been prescribed for the patient and which should be periodically screen will appear in the appropriate box.

See the template below with the alert outlined in green. This does not mean that you must do a urine drug screen but that you should think about it and document why if you opted not to do one.

When the Urine-Drug-Screening tool is deployed, there are several reasons why a “suggested” drug screen alert might not be done, although many of those reasons are being shown to be invalid as we find that when we do the screen it proves the patient is not taking the medication.

If you opt not to do a drug screen, you can document your reason for not doing by click in the space which is outlined in green below and then selecting the appropriate reason in the second box below, also outlined in green. 

SETMA is committed to complying with all State Board of Medicine requirements and to making sure that we use narcotics appropriately.  These tools help us do that more efficiently.

In the subsequent parts of this series, we will discuss methods and tools for helping healthcare providers monitor their use of opioids and controlled substances.  Later in this series we will discuss non-provider based means of addressing the opioid epidemic.