American Crisis

Opioid overdoses have claimed the lives of millions of Americans but the epidemic is much more than an addiction problem on the streets.

HOW THE KAWEAH DELTA PHARMACY DEPARTMENT, IN COLLABORATION WITH PHYSICIANS, IS HELPING GUIDE TULARE COUNTY THROUGH A NATIONWIDE PROBLEM WITH PAIN MEDICATION

The opioid crisis in America. Words heard often in news stories but not often understood by the majority of non-affected Americans. For many, the image of the opioid crisis looks like drug addicts living on the streets; however, this singular depiction of the issue does not address the complicated path that has led millions of Americans to opioid addiction. To begin to comprehend the issue, it’s important to understand which drugs are considered legal and illicit opioids, how the under-treatment of chronic pain contributed to the opioid epidemic, and what healthcare providers like Kaweah Delta are doing to combat rising rates of addiction and overdose.

WHAT IS AN OPIOID?

Opioids are a class of drugs that includes BOTH prescription pain medications and illicit drugs. This class of drugs includes legally prescribed pain relievers such as oxycodone (OxyContin), hydrocodone (Vicodin), codeine, tramadol, and morphine, and synthetic opioids like fentanyl, as well as illegal drugs such as heroin.

According to the Centers for Disease Control and Prevention (CDC), over 50 million people suffer from chronic pain in America. Prescribing opioids for the treatment of severe pain has been common practice for more than two decades; however, recent studies have shown how quickly prescription drugs, legally administered to manage pain, can become challenging for patients to manage safely. In fact, in some cases, physical dependence on prescription pain medication can happen within one week and can take the form of physical and psychological dependence. The latter may be triggered by an individual’s history or family history of substance abuse, sexual abuse, and psychological diagnoses. Furthermore, data supporting the effectiveness of long-term chronic opioid use is lackluster and in some cases has shown to increase patient risk without increasing overall benefit.

HISTORICAL BACKGROUND

Between 1997 and 2007, opioid prescriptions in the United States increased by 700%. The exponential increase in prescribing opioids has correlated with an increased rise in opioid-associated deaths. In 2007, the CDC reported 27,658 opioid-related deaths. In 2016, the annual number of deaths had risen to 63,600. Although opioid abuse is a nationwide problem, California is actually faring better than many states when it comes to opioid overdose deaths with a death rate of 4.9 per 100,000 people. In Tulare County the rate of death is two per 100,000 people, with a total of 35 opioid-related overdose hospitalizations in 2017 and 43 heroin overdose visits to the Emergency Department. Every day, more than 130 people in the United States die after overdosing on opioids, making death by drug overdose the leading cause of injury-related death in the United States – higher than deaths caused by motor vehicle accidents.

HOW THIS HAPPENED

1990s: The First Wave

In the mid- to late 1990s, pharmaceutical companies – including Purdue Pharma, the maker of OxyContin – aggressively marketed opioid pain relievers and reassured the medical community that patients would not become addicted to the drugs, claiming that the risk of addiction was very low. Consequently, prescriptions for opioid pain relievers sharply increased for the treatment of pain and these actions led to pervasive diversion (the illegal transfer of opioids from the individual for whom they were prescribed, to others) and increased opioid abuse. Unsurprisingly, the rates of opioid overdose began to rise.

2010: The Second Wave

By this time, the extremely addictive qualities of opioid pain medication had become clear. In an effort to mitigate the problem, medical providers decreased prescribing opioids, making the addictive pain relievers harder to get. With limited options, desperate opioid users turned to heroin, a cheap, easily accessible, illegal opioid with high potency, and as a result, the country witnessed a rapid increase in deaths from heroin abuse. The CDC reported that heroin-related overdose increased by 286% from 2002-2013. Four in five heroin users report their addictions started after getting “hooked” on prescription pain medications they were legally prescribed but later abused.

2013: The Third Wave

In 2013, synthetic opioids came into focus as deaths related to these substances, such as fentanyl, increased. Prescribed fentanyl comes in the form of skin patches, lozenges, or nasal sprays but it can also be illegally made and is often incorporated into counterfeit pills. Commonly, illicitly manufactured fentanyl is mixed with other drugs like heroin or cocaine, with or without the user’s knowledge. The sharpest rise in deaths occurred in 2016 when 20,000 deaths from fentanyl and related drugs were reported. According to the National Institute on Drug Abuse, nearly 50,000 Americans died as a result of an opioid overdose, including prescription opioids, heroin, and illicitly manufactured fentanyl. In the same year, roughly 1.7 million people in the country suffered from substance abuse disorders related to prescription opioid pain relievers, including 652,000 suffering from a heroin use disorder.

Present Day

The CDC has issued comprehensive guidelines for prescribing opioids to treat chronic pain in an effort to reduce the risk of addiction and maximize the benefits for patients needing pain treatment options. Non-opioid treatments are the preferred first step in the CDC’s prescribing recommendations, which also state that opioid medications should only be added to a patient’s treatment plan after careful assessment of pain control. If opioids for pain management are deemed necessary and prescribed, regular evaluations of each patient’s continued need are imperative to reducing their risk of developing an opioid addiction. Kaweah Delta leads by example in this endeavor.

WHAT KAWEAH DELTA IS DOING

In the Hospital
In light of this public health problem, the Kaweah Delta Pharmacy Department took action to address the issues here at home in Tulare County. With guidance and support from medical staff, the Kaweah Delta Executive Team, and the Kaweah Delta Board of Directors, the Pharmacy Department initiated the Inpatient Pharmacy Pain Management Service in 2013.

Through this consultation-based, opioid stewardship program, pharmacists who are specially trained in pain management are available daily to work with medical providers and help make recommendations about which medications would be best to give to patients to efficiently manage their pain. The team also evaluates medication orders to identify patients who may be at a higher risk of suffering adverse side effects from the pain medications prescribed and works proactively with providers to develop pain regimens that will minimize the side effect risk while optimizing their pain control and satisfaction.

Thanks to this new approach of managing pain in the acute care setting, the Kaweah Delta Pharmacy team was one of six national recipients honored with a 2014 American Society of Health System Pharmacists (ASHP) Best Practice Award. The Inpatient Pharmacy Pain Management Service effectively decreased opioid usage by 45% between 2014 and 2017 with patients reporting improved pain scores and satisfaction despite a decrease in opioid use. The award-winning Pharmacy team, in partnership with medical staff, recognized the urgent need to be responsible stewards of opioid use and developed a program that is successfully altering the effects of the opioid epidemic in Tulare County.

“We are fortunate to have a great team of pharmacists and pharmacy technicians that function at the top of their licensure and have advanced specialty training and certifications,” shared James McNulty, PharmD, Director of Pharmacy Services at Kaweah Delta. “Their educational diversity enables us to develop and implement programs capable of caring for a wide population of patients, helping them manage their pain successfully and lead more full lives.”

In the Community

The Kaweah Delta Pharmacy team plays an important role in pain management as patients transition from inpatient care to outpatient care, and for those living with chronic pain. Despite the nationwide rise in opioid misuse, abuse, diversion, and overdose, many patients continue to suffer from chronic pain control issues. Inadequate pain control can result in longer hospital stays, increased readmission rates, and a decreased ability to function normally in everyday life. Besides the physical and emotional burden, patients may also face financial stress due to missed work and healthcare costs related to pain management.

To better serve this population of patients, the Pharmacy team expanded the Inpatient Pharmacy Pain Service in March 2018 to include pain services for outpatients. As part of the referral-based Outpatient Pharmacy Pain Service, two specialty trained pharmacists, under the direct supervision of an anesthesiologist acting as medical director, create personal and comprehensive treatment plans to improve patient function and increase their access to pain treatments in the Central Valley. Patients can be referred to the pharmacy pain service by their primary doctor and the team works to optimize their regimen to meet the unique pain needs of each individual patient, reduce the risk of adverse events, and reduce their opioid burden where feasible.

To date, this team has seen over 100 unique patients and has reduced the amount of opioids they are taking by an average of 58%. In one particular case, the team reduced a patient’s opioid burden by 83% (roughly equivalent to eliminating over 19,000 10mg Vicodin tablets a year), while improving the patient’s functional abilities and quality of life.

“Patients who get referred to us have likely been dealing with pain for a very long time,” stated Bradlee Rea, PharmD, Clinical Pharmacist – Pain Management at Kaweah Delta. “Many of these patients have been on pain pills for 10-20 years and have so little trust in methods of pain management that involve them taking less medication. They want what they know works. Our goal is to explore other options and find new ways to relieve their pain. We build their trust and find the right treatment plan that fits.”

Education for patients and providers, as well as community partnerships, are vital to the success of the outpatient program. Besides treating pain with medication, the Pharmacy team accesses its large network within the community to make referrals when patients need special care. These services may include counseling, physical therapy, mental health services, and special procedures to help control pain and reduce the amount of medicine a patient needs to take.

Clint Brown, PharmD, Outpatient Pharmacy Manager at Kaweah Delta has witnessed firsthand how this collaborative effort leads to excellence in patient care. “Patients have pain that needs to be treated,” he said. “Our goal is to maximize their pain regimens to provide superior pain control while minimizing any potential risk from the medications being taken. When we do this in a team based approach, the patient being the most important team member, we are able to empower them to take an active role in their pain management and together we experience great outcomes.”

Life Saving Medication

In addition to the outpatient service, the Kaweah Delta Pharmacy team has endeavored to promote the use of Naloxone, a medication used to treat opioid overdose and prevent death. The goal of the Naloxone Community Education Project is to educate community members about drugs that can cause overdose, familiarize them with the signs and symptoms of opioid overdose, and inform them of the effects of Naloxone, a medication being carried by first responders and saving lives across the nation. Naloxone is available in injectable and nasal spray form and can be purchased at pharmacies without a prescription – a fact many illicit drug users, opioid using patients, and medical providers are unaware of. The Pharmacy team provides patients with step-by-step guides on how to administer the medication and encourages them to obtain Naloxone at their local pharmacy. In the event of an accidental overdose, having Naloxone on hand can make the difference between life and death.

HOW COMMUNITIES CAN HELP

The opioid crisis is still an unfortunate reality in the United States but with grit, education, and support from medical providers like the Kaweah Delta Pharmacy team, local residents can minimize the impact of the epidemic in Tulare County neighborhoods. If you or someone you know is battling chronic pain, abusing opioids, or battling substance abuse, contact a healthcare professional for help and consider a referral to a specialty pain provider. Also, be sure to visit the Kaweah Delta Retail Pharmacy located at 202 W. Willow Ave., Suite 102 in Visalia to pick up a supply of Naloxone in case of an accidental overdose.

LEARN MORE

Visit kaweahdelta.org/pharmacy for more information about the work of the Kaweah Delta Pharmacy Department. To learn more about Naloxone and the Kaweah Delta Retail Pharmacy, visit kaweahdeltapharmacy.org or call (559) 624-4880.