by Scott Richter and Dr. Patrick Jones
Every indicator on the Trends site tells a story about what is happening locally. When possible, it is accompanied by a state and U.S. benchmarks, primarily offered to provide context to local data. Benchmarks can also show issues of concern, as well as areas where we might be doing better than the benchmarks. At their core, benchmarks show we are all connected, to some degree, and local actions and achievements are not isolated.
While the opioid crisis in Spokane County is unique to us, the same is true for other communities all across the nation. Problem outcomes unique to communities across the U.S. scale up to the national opioid crisis.
Opioids are now the national focus perhaps shifting from methamphetamines in recent years. Yet, overdose deaths involving cocaine and psychostimulants are also increasing. Methamphetamine (a psychostimulant, not an opioid) was responsible for more overdose deaths in Spokane County from 2015 to 2017, at almost a 2-to-1 ratio compared to opioid-related deaths (see: page 25).
Why mention overdose deaths when this article is focusing on opioid prescriptions per 1,000 residents? Simply to point out that opioids are not the only drug killing people in Spokane County (and across the U.S.), but also to show the increase in opioid-related drug overdose deaths has been the unintended consequence of a dramatic increase in opioid prescriptions.
From the American Society of Addiction Medicine: “From 1999 to 2008, overdose death rates, sales and substance use disorder treatment admissions related to prescription pain relievers increased in parallel. The overdose death rate in 2008 was nearly four times the 1999 rate; sales of prescription pain relievers in 2010 were four times those in 1999; and the substance use disorder treatment admission rate in 2009 was six times the 1999 rate.”
According to the U.S. Centers for Disease Control and Prevention (CDC), the “rise in opioid overdose deaths can be outlined in three distinct waves” with the first being “increased opioid prescribing during the 1990’s”.
The CDC reports, “From 1999 to 2017, almost 218,000 people died in the U.S. from overdoses related to prescription opioids.”
According to the National Institute on Drug Abuse (NIDA), during 2017 in Washington State, opioid-involved overdose deaths per 100,000 residents was 9.6. Of the 742 total opioid-involved overdose deaths in the state during 2017, 343, or 46.2%, involved prescription opioids.
As new treatments are developed with a much lower risk for addition or abuse, legitimately prescribed opioids are still very much a necessity. Opioids are sometimes still the best treatment for people with chronic or intractable pain. Opioids also help in the initial stages of recovery from serious injuries or surgeries.
While receiving a legitimate opioid prescription is far from a direct connection to an addiction, an opioid disorder, or even heroin use, there is still a risk. As a result, laws and recommendations for safe prescribing are constantly being updated.
NIDA says of all legitimate recipients of a physician-prescribed opioid, nearly 30% misuse them and between 8%-12% will develop an opioid use disorder. Further, as many as 80% of heroin users misused prescription opioids first. Therefore, it is helpful in understanding the problem and potential solutions of prescribed opioids.
Nationally, both the total number of opioid prescriptions and the rate per 100 persons have decreased since 2006, according to the CDC. During 2016 in the U.S., the total number of opioid prescriptions written was 191,218,272, decreasing from 215,917,663, or by 11% since 2006. The prescribing rate per 100 persons was 58.7 during 2016, decreasing from 72.4 in 2006.
Looking at the Recipients of Opioid Prescriptions per 1,000 Residents indicator on the Trends website, we see during the fourth quarter of 2018 (18Q4), the recipients of an opioid prescription per 1,000 residents of Spokane County was 88.2, decreasing from 118.9 in 12Q1. Across Washington State, the rate was 68.7, decreasing from 98.2 in 12Q1.
Further, the trend line has been decreasing in both the county and state. Additionally, Spokane County has been consistently above the state benchmark. It’s also interesting how the trend lines for the state and county have a very similar path – they both seem to have similar ebbs and flows.
Where the actual prescription was written doesn’t matter in this series, whether outside of the county, or even the state. To be counted, the prescription must have been filled in Spokane County. Filling an opioid prescription anywhere in Washington State triggers the Prescription Monitoring Program (PMP). PMP tracks all prescribed medications designated as controlled substances, which are pharmaceuticals classified as Schedule II-V. PMP will record the details of the person receiving the prescription. This indicator includes opioid prescriptions for all age groups.
The PMP provides information for prescribers and pharmacies so they know in real-time if someone is receiving multiple prescriptions from different doctors, which would increase the ability to misuse and abuse the medication.
PMP does not count prescriptions opioid medications:
- dispensed outside of WA state,
- with quantities lasting 24-hours or less,
- given to patients in hospitals,
- dispensed by a pharmacy inside a jail or prison,
- dispensed by an Opioid Treatment Program,
- some federally operated pharmacies, such as Indian Health Services.
Prescribers face increased scrutiny, regulatory responses, and in some cases criminal liability for how they prescribe opioids. People who might have received an opioid prescription 10- or 20-years ago, but under the same circumstances would not today.
One of the unintended consequences is some people with severe pain are finding it difficult to get an opioid prescription. The CDC Guideline for Prescribing Opioids for Chronic Pain are non-mandatory and increasingly stringent prior authorization requirements for opioid prescriptions are having a negative impact on both doctors and patients.
While opioids will have a role in dealing with chronic and severe pain in the foreseeable future, pharmaceutical technologies are developing new pain medications with a much less likelihood of potential for misuse and abuse. Since opioid pharmaceuticals are one of the driving forces behind the opioid crisis, it is likely this indicator will continue its downward trend.
Keeping an eye on this indicator towards the future, the big question for Spokane County is will we eventually begin to see rates closer to those of the state? Or, will the county continue to be 15 to 20 opioid prescriptions per 1,000 residents? If the Spokane County opioid overdose death rate is still consistently above the state benchmark, it might indicate we need to change how we are responding to our local opioid crisis.