Episode 1 Scope of the problem

In 2005, we have roughly 650 admissions
for treatment for individuals with the primary SUD of opioid use disorder. That
number has increased to about 2200 in 2017. So over the last decade, again going
back to about 2005, we had 59 opioid involved deaths in the state of Iowa. In
2017, that number had increased to the all-time high, so far that we know of, 206
opioid involved deaths. If we don’t have opportunities for those individuals that
experience a non-fatal overdose to change some of those behaviors or make
some healthy choices, then the likelihood of them experiencing a fatal overdose in
the next 12 months is significantly higher. And so that’s where medication
assisted treatment, OTP programs, buprenorphine waiver prescribers, really
come into play. If we don’t have opportunities for those individuals, then
we’re not really doing much of a service other than keeping those individuals
alive to experience possibly another overdose later. In 2015, we received a
grant called medication assisted treatment prescription drug and opioid
addiction, or Matt Padua, and we received that from Samhsa. A couple of things
that we were asked to do as a result, or as part of that; one was to expand
medication assisted treatment, and two was to look at recruitment of additional
buprenorphine waiver prescribers. And so at that time we had thirty-one
buprenorphine waiver prescribers in the state, and when you think about a
population of roughly 3.1 million you know that’s one prescriber per 100,000
Iowans. We were the lowest per capita in the country. Last week we ran numbers
again because Samhsa has a website called the buprenorphine physician locator and
as part of our efforts, as part of the medical society’s efforts, as part of
other state entities, we’re now up to 129 buprenorphine waiver prescribers in
the state. Just generally with a substance use disorder, addiction,
dependency, there’s stigma. Then when you look at the issue of an opioid use
disorder I think some people tend to think about opioids and they think about
heroin you know, and they think that that could never be me, that could never be my
family. The problem is 80% of the individuals
that we have come into treatment with heroin as their primary drug of choice
started off with the prescription opioid. People don’t see that transition. Now a
clarification, you know we talked about 80% of those individuals that started
with the prescription opioid, they started with the prescription opioid but
in most cases it wasn’t something that was prescribed to them, it was something
that was left over from somebody else’s supply. And so that is the relationship
to the overprescribing concern. People think you know my doctor prescribed it,
it must be safe, it must be okay. Or some people get a prescription, they only take
a few but then they keep them in a medicine cabinet or in a drawer, and
that really you know creates an opportunity for more problems to occur.
But when we start thinking about the general public and their views on stigma,
or their views on opioid use disorder, I think we’re seeing an increased
understanding. There’s still a ways to go. But I think we’re seeing more people
that have been affected by opioids, they know somebody, they know somebody whose
child you know had an issue with opioids, they know somebody that may have
experienced an overdose. I think it’s getting better, but I think we all have a
role to play and one of the things that we’re doing at public health is trying
to help address that stigma. For some, they think just by saying the word
stigma you’re creating an issue or you’re creating problems, that you’re
somehow isolating this as a separate issue. But I think stigma kills people.
Because if I’m afraid to ask for help, if I’m afraid to go to a pharmacy and get a
prescription of narcan because I’m worried about a family member, because
I’m worried that my name is gonna show up on a prescription monitoring program,
or my insurance is going to be aware that I purchased this, or you know I try
to get somebody help for opioids, or I go to another doctor to-
you know, there’s a lot of different reasons that interfere with people
getting help. But people need to realize that this is an issue, that unless you
address it, unless you whether it’s medication assisted treatment, whether
it’s you know just discontinuing the opioids, whether it’s looking at
alternative forms of dealing with pain you know in therapy, that’s a reason that
we’re seeing you know such an increase in the overdose deaths or the opioid
involved deaths. In 2017 we reached an all-time high of over 72,000 overdose
deaths in the U.S. 62 percent, roughly, of those were opioid related. That’s huge. I
mean you look at about 49,000 individuals that died because of opioid
involved usage. For the first time since I think 1962 and 1963, we’ve had a
decline and the average life expectancy for two continuous years. That’s directly
contributed to the opioid crisis that we’re experiencing in our country. The
United States accounts for 80% of the oxycodone prescribed in the world and a
hundred percent, nearly, of the hydrocodone you know prescribed in the
world. Yet, there’s been no change in you know pain or pain tolerance that’s being
experienced in our country. We have a society that has, they’ve got faith in
our medical prescribers, and they should. The problem is our medical prescribers
though, our medical professionals have been trained in a way to think
more is better, they had different types of groups that were
supporting them, prescribing more opioids. The American Pain Society,
the AMA was involved, the Joint Commission on Accreditation, CMS all
played a role in “prescribe more opioids”, “listen to the individual”, “pain as the
fifth vital sign”, and that’s helped get us into the situation that we’re in now.
We need to realize that one of the outdated methods that we measure
pain is a scale of one to ten. The problem with that is it’s so
subjective. What might be a two for me might be a six for somebody else, and to
expect that where everybody’s gonna get to zero, that’s not realistic. If I can go
from a six to a two, that’s great you know. And then what else can I do? Maybe I walk, maybe I swim, maybe I practice yoga or
participate in acupuncture. But we need to look at what are some others
safer alternatives, and that’s one of the things that we’ve tried to do at public
health. Last year we hosted an approaches to pain management symposium
to try and look at a lot of those different areas. The Joint Commission on
Accreditation you know they oversee all of these hospitals, and you know regulate,
and you know license, and you know to conduct site visits, and inspect. At one
time you know they issued guidance to hospitals and said there’s no concern
regarding you know opioid addiction. They’ve since reversed that view as most
other you know groups have you know the American Pain Society, the American
Dental Association, the American Medical Association, they’ve all changed you know
direction and believe that yes, we are in an epidemic, we need to be doing
something different, and I think prescribers need to hear that.
Maybe there’s training that they need to experience as far as motivational
interviewing or trying to address those. Having those conversations, those crucial
conversations, but telling that patient or sharing with that patient, “I’m
concerned about your health, I could prescribe you an opioid but I’m
only gonna give it to you for two or three days based on your injury,” and that
goes along with or aligns with what the CDC has said in their prescribing
guidelines for prescription opioids. So three goals are, the three things that
kind of drive all of our efforts are reduce opioid misuse, prevent opioid
overdose, and expand medication assisted treatment. Prevention works, treatment is
effective, and people do recover. When we look back to 2015, just not that
long ago when we had received our Matt Padilla grant, we had roughly
eight opioid treatment program locations in the state.
And they tended to kind of fall right along the I-80 corridor so any
individual that lived in Ringgold County, or lived in Cerro Gordo
County, or anywhere off of the main path had to travel
two to three hours to receive medication assisted treatment. We
now have because of medication units, or will have by the end of the spring,
approximately twenty different locations where an individual can receive
medication assisted treatment, methadone to address an opioid use disorder.
Especially in the case of UCS health care, the fact that they’re a Medicaid
eligible provider is huge because we only have one other agency,
maybe two, in the near future that are able to accept Medicaid for
reimbursement for medication assisted treatment, specifically methadone. So the
fact that UCS is expanding offering these medication units in other
underserved areas of the state is very significant, because otherwise these
individuals because of transportation, because of distance, and because of cost
wouldn’t have received services. So that’s why I think medication units save