By Sandra Adamson Fryhofer M.D., MACP, FRCP Member, MAA Board of Directors and MAA Opioid Task Force
Each day, more than 90 Americans overdose and die from opioids.1 more than quadrupled from 1999 to 2015.2 And the amount of opioids prescribed tripled since 1999.3 These are deadly, disturbing statistics.
Recent stats from the National Survey on Drug Use and Health (2015)2 further emphasize the magnitude of the problem:
• More than one third (38 percent) of all US adults (nearly 92 million) used prescription opioids.2
• 5 percent (more than 11 million adults) misused them (taking them without a prescription, or longer, more often or in greater amounts than recommended by their physician).2
• 1 percent (nearly 2 million adults) had opioid use disorder.2
Fact versus Myth
This is mainly a rural problem. False. Opioid use and misuse is just as common in urban and suburban areas as in rural areas.2 As highlighted recently in The Washington Post, rural areas do have additional challenges: fewer healthcare professionals to treat addicted patients and longer travel distances for first responders.4
Socioeconomic factors play a role. True. Adults with low incomes, as well as those without a job, were not only more likely to misuse opioids but also more likely to have an opioid use disorder. The same goes for those with behavioral health problems. Adults without health insurance were twice as likely to misuse opioids.2 An accompanying editorial in Annals suggests that having health insurance should provide ways – other than opioids – to deal with pain.5 But even those with health insurance, higher income and higher education are still at risk.5 No strata of society has been spared.5
Most people misuse opioids to get high. False. Most people (64 percent) who misuse opioids do so to relieve physical pain.2 About 22 percent use them to relax (11 percent) or to get high (11 percent).2
The longer you take opioids, the greater the risk of use disorder, overdose and death. True. Taking even low doses of opioids for more than 90 days increases odds of opioid use disorder by a factor of 153.
Reducing opioid prescribing leads to increases in heroin use. False. In a recent JAMA viewpoint, Drs. Schuchat, Houry and Guy dispel this myth by citing evidence that state policies aimed at reducing amounts of opioids prescribed reduce both opioid-involved deaths and heroin overdose deaths by reducing initial opioid exposure, thus reducing addiction risk.3
Physician prescriptions are the source of the majority of opioids that are misused. Half true. Although family and friends were the source of free drugs for more than 40 percent of opioid misusers, 86 percent of those misused opioids were diverted to the misuser from prescriptions prescribed (to the misuser’s friends and family) by physicians.2 This means that many of our patients are giving away pain meds, not realizing the dangers and long-term consequences.
“The cycle of prescribing opioids begins with clinicians.”3 Our Georgia state legislature and composite state medical board seem to think so. On May 4, 2017, Gov. Nathan Deal signed into law HB 249 to address the opioid problem in the State of Georgia.6
This new law moved the Prescription Drug Monitoring Program (PDMP) from the Georgia Drugs and Narcotics Agency to the Department of Public Health. It also contains several requirements that directly affect Georgia physicians. To address this issue, the Medical Association of Atlanta’s (MAA) Board of Directors assigned a Task Force to create an Opioid Resources webpage: End the Opioid Epidemic on the MAA website at maa-assn.org.7 It includes the new requirements, deadline dates and links to resources to help physicians comply. The three new requirements are:
1. PDMP Requirement
New state requirements include PDMP sign up (mandatory as of
January 1, 2018), PDMP check and every 90 day re-check (mandatory as of July 1, 2018):
• The PDMP check requirement applies to prescriptions for all benzodiazepines but only to those opioids listed in in paragraphs 1 and 2 of § 16-13-26 Schedule II list.8 The list includes commonly prescribed opioids such as hydrocodone (Vicodin, Lortab, Zohydro), oxycodone (OxyContin and Percocet) and morphine.12 10
• The PDMP check requirement does NOT apply to non- benzodiazepines including non-benzodiazepine sleeping pills: Zolpidem (Ambien, Intermezzo, Zolpimist), Eszopiclone (Lunesta), Zaleplon (Sonata) – since they are NOT benzodiazepines.9 The PDMP check requirement does apply to all benzodiazepines 9 Since Estazolam (Prosom), Flurazepam (Dalmane), Temazepam (Restoril), Alprazolam (Xanax), Chlordiazepoxide (Librium), Clonazepam (Klonopin), Diazepam (Valium), Lorazepam (Ativan) and Oxazepam (Serax) are benzodiazepines,9 they are included on the PDMP required checklist.
• Although checking the PDMP may be delegated to two members of your staff (registration by Georgia Board of Pharmacy required for unlicensed staff), any unauthorized use of PDMP data by a delegate can result in civil or criminal penalty for you, “the prescriber.”6
• PDMP checks must be documented in the patient’s chart.6
2. Patient Education Requirement
In addition, HB 249’s provision for mandatory (oral or written) patient education on opioid addictive risks and safe disposal when prescribing opioids became effective as of July 1, 20176 Links to free patient educational materials (in English and Spanish) are also on the new MAA Opioid Resource webpage.7
3. CME Requirement
The Composite State Medical Board now requires at least 3 hours of safe opioid prescribing CME prior to obtaining or renewing your medical license (effective January 1, 2018). Our MAA webpage has a link to a free CME course that will fulfill the Board’s CME requirement.11
Although these new requirements present an additional administrative burden for physicians, they are now law, and we must comply. Although the requirement cannot “cure” the problem, they do shine a spotlight on the issue of opioid prescribing, use and misuse and increase awareness of the problem.
MAA’s Opioid Resource webpage7 also contains links to the Medical Association of Georgia’s Think About It and Project DAN-Deaths Avoided by Naloxone initiatives, AMA’s End the Epidemic website, the Surgeon General’s Turn the Tide website, additional opioid resources from the CDC, as well as a bibliography of recent references and scholarly articles addressing opioid use and misuse.7
Already, we are beginning to see some encouraging prescribing trends as revealed in a new AMA report: “Between 2012 and 2016, the number of opioid prescriptions decreased by more than 43 million – a 16.9 percent decrease nationally. Every state saw a decrease in opioid prescriptions during this period.”12
Helping those already afflicted with opioid use disorder is also important. Gov. Deal also signed into law SB 88,13 the Narcotic Treatment Programs Enforcement Act, requiring the Department of Community Health to specify minimum standards and quality of services for narcotic treatment programs seeking licensure in Georgia.
Going forward, more research and resources are needed as we respond to this national emergency. Physician involvement is and must remain a critical part of the solution. On that, the Medical Association of Atlanta can be a vital resource for you and for the health of your patients.
1. Volkow ND, Collins FS. The Role of Science in Addressing the Opioid Crisis. New England Journal of Medicine July 27, 2017: 391- 94.
2. Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health. Ann Intern Med. [Epub ahead of print 1 August 2017] doi: 10.7326/M17-0865
3. Schuchat A, Houry D, Guy GP. New Data on Opioid Use and Prescribing in the United States. JAMA.2017;318(5):425–426. doi:10.1001/jama.2017.8913
4. Humphreys K. Opioid abuse started as a rural epidemic. It’s now a national. Washington Post, accessed on September 3, 2017. Available at: https://www.washington- post.com/news/wonk/wp/2017/07/31/opioid-abuse-started-as-a-rural-epidemic-its- now-a-national-one/?utm_term=.c9eb36351499
5. Lasser KE. Prescription Opioid Use Among U.S. Adults: Our Brave New World. Ann Intern Med. [Epub ahead of print 1 August 2017]doi: 10.7326/M17-1559
6. 2017-2018 Regular Session – HB 249: Controlled substances; collect more information regarding dispensing and use; provisions, Available at http://www.legis. ga.gov/Legislation/en-US/display/20172018/HB/249 Accessed on Sept 3, 2017.
7. Medical Association of Atlanta website, Opioid Resources Webpage: End the Opioid Epidemic, Available at http://www.maa-assn.org/?page=OpioidEpidemic Accessed on September 3, 3017
8. Link to § 16-13-26 Schedule II list of controlled substances: Please note that HB 249 applies to drugs listed in Paragraphs 1 and 2 of this schedule : http://law.justia. com/codes/georgia/2010/title-16/chapter-13/article-2/16-13-26
9. List of Sedative-Hypnotic Drugs (Sleeping Pills) eMed Expert website. Available at http://www.emedexpert.com/lists/sedative-hypnotics.shtml Accessed on September 3, 2017.
10. Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults. Ann Intern Med. [Epub ahead of print 1 August 2017] doi: 10.7326/P17-9042
11. Notice of Intent to Amend and Adopt Rules. Georgia Composite Medical Board website (Rule 360-15-.01. Requirements for Physicians). Available at https://medi- calboard.georgia.gov/sites/medicalboard.georgia.gov/ les/intent%20360-15-01.pdf Accessed on September 3, 2017.
12. Physicians’ progress to reverse the nation’s opioid epidemic. Available on the Medical Association of Georgia website at http://www.mag.org/sites/default/ les/ downloads/AMAOpioidTaskForce2017progressreportMay2017.pdf Assessed on September 7, 2017.
13. Deal signs opioid legislation. State of Georgia website. Available at https://gov. georgia.gov/press-releases/2017-05-04/deal-signs-opioid-legislation Accessed on September 3, 2017.