County health officials fighting an epidemic of prescription drug abuse in Marin declared a small victory earlier this month, when Health and Human Services announced a 41 percent drop in the average dose of opioid drugs prescribed to county Medi-Cal patients since 2013.
The news left health providers and advocates cautiously optimistic that progress is being made to reverse a flood of prescription drugs in the county, where opioid abuse contributed to 27 accidental overdose deaths in both 2012 and 2013.
And, according to the county, there were just 10 overdose deaths in 2014. That data, from the coroner’s office, depends on toxicology reports that may not be complete, however. Nor does it account for deaths that occurred outside Marin.
“We’re not there yet by a long shot,” said Dr. Matt Willis, the county’s public health officer, at a recent Board of Supervisors meeting. “But we’re making progress. Every accidental drug overdose is preventable, and each event signals the tip of an iceberg signaling hundreds of others who may be struggling with abuse or dependence.”
The county’s announcement follows news of a medical malpractice lawsuit filed by the mother of 32-year-old Forest Knolls resident Adam Emmott—who died last year from a prescription drug overdose—against Dr. Wendi Joiner. An investigation by the state medical board found that Dr. Joiner had written 33 false prescriptions to a fictitious name later traced to her fiancé.
The announcement also preceded new voluntary guidelines issued by the Centers for Disease Control that recommend doctors first treat chronic-pain patients with non-opioid therapies and, when prescribing painkillers, to do so only in low doses. The first such recommendations from the C.D.C., the guidelines apply only to primary care physicians treating patients with chronic pain not associated with cancer treatment, palliative care or end-of-life care.
Curtailing prescriptions
Since 2013, the average dose of painkillers prescribed to Marin’s roughly 37,000 Medi-Cal patients has dipped from 151 morphine milligram equivalents to 86 equivalents per patient. Morphine milligram equivalents, or M.M.E., is a scale used by epidemiologists to compare a wide range of drugs—including hydrocodone and oxycodone—to the opioid content of morphine, “so we’re comparing apples to apples,” Dr. Willis said.
The county attributed the drop both to the educational efforts of its prescription drug advocacy arm, RxSafe Marin, and a rule instituted about six months ago by the state’s Medi-Cal provider that requires physicians to ask permission from the provider before prescribing painkillers in excess of 100 M.M.E.
Keeping the average opioid dose down for a sizable percentage of Marin’s users, Dr. Willis said, should help decrease overall access to abusive avenues.
“We know that the mortality rate increases dramatically for people who are taking more than 100 M.M.E. per day,” Dr. Willis said. “We’re learning as we go. But one of the things we’ve learned over the last 15 years is that prescription narcotics—especially in high doses—are much less safe than we thought before.”
Data on drugs prescribed by providers, including emergency room doctors, is contained in the state’s Controlled Substance Utilization Review and Evaluation System—or CURES—report, which tracks and catalogues the total amount of controlled substances prescribed in California. Dr. Willis expects an updated CURES report that contains data since 2013 to be issued sometime over the
summer.
Many involved in the prescription drug fight see the Medi-Cal dose drop as only one piece of a very large puzzle. April Rovero, a San Ramon resident and founder of the National Coalition Against Prescription Drug Abuse, said Medi-Cal patients represent a small segment of the whole prescription drug user population.
She is particularly concerned that the county does not have a way of tracking how many Marin kids in colleges outside the county abuse and overdose on
painkillers.
“We know the numbers are still there,” said Ms. Rovero, whose son, Joey, died from a deadly combination of alcohol and painkillers while away at college in 2009. “There’s not enough education in schools to ensure that children going off to college would be making sound decisions regarding prescription drugs.”
Other advocates point to the absence of data for opiates given to patients admitted to emergency rooms. Since 2013, Marin General Hospital has admitted an average 35,000 patients annually to its emergency room, while Sutter Health’s emergency department in Novato admitted an average of about 15,000.
Speaking at the board meeting earlier this month, Supervisor Katie Rice acknowledged that dosage rates for Medi-Cal patients do not tell the full story of painkiller abuse in Marin. “We have many, many visits to the hospital,” she said. “We have folks getting addicted probably on a daily basis.”
According to Dr. Willis, all of the county’s emergency department directors agreed to follow voluntary guidelines for prescribing painkillers to emergency room patients that limit prescriptions to “a small amount.” Per the guidelines, emergency room doctors should not prescribe long-acting pain medications and should not prescribe anything to a patient already receiving painkillers from another provider. (A spokesperson for Marin General said its emergency department is following the guidelines.)
Still, Dr. Willis said it is primary care physicians, not emergency room doctors, who prescribe the majority of painkillers, which go to patients seeking help with chronic pain. But he agreed that emergency rooms can become breeding grounds for cultivating abusive tendencies, particularly among younger patients. “We’re learning that some of those ‘one-time’ prescriptions for an acute event can and do lead to dependence more frequently than we thought,” he said.
Yet many advocates warn that a decrease in prescriptions can bring unintended consequences. Many communities nationwide are suffering from heroin abuse as addicts switch over to the street drug once opioid painkillers become less available through prescriptions and more expensive to obtain on the street.
Though Dr. Willis said Marin has not seen the same increases in heroin use that other communities have, he said the county is on the lookout for any rise.
“Certainly that’s a concern,” he said. “And there’s some evidence from back East that when there’s an aggressive reduction in the amount of prescription narcs in a community, if not paired with help, [addicts] may seek more harmful substances to use, like heroin.”
Dr. Willis said county health officials are working with health providers to trim down the number of opioid prescriptions in a “sequential decrease over time.” He pointed to medication-assisted therapies like buprenorphine as other ways to phase out an addict’s substance dependence.