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
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.
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.
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
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
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.
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.