Douglas W. Coleman, special agent in charge for the U.S. Drug Enforcement Administration (DEA) Phoenix Field Division, took an unusual tact in welcoming attendees to the Arizona Opioid Summit at the Summit for Clinical Excellence event Thursday in Tempe, Ariz. He put the responsibility for the opioid crisis at the feet of everyone in the room.
“We need to all accept we have a role in this. None of us is blame-free,” Coleman said.
In his opening remarks, Coleman also outlined challenges being faced by all stakeholders in attendance—from local law enforcement facing an influx of fentanyl through the southern border, to physicians wanting to satisfy patients who want pain medications.
“Let’s quit blaming each other and come together to find solutions,” he said.
The DEA’s fight
Coleman noted that the Centers for Disease Control and Prevention (CDC) is recording record numbers of overdose deaths in the United States. Heroin use is on the rise: In 2010, the DEA seized 370 pounds of heroin. By 2016, the total climbed to 1,488 pounds. Last year, it skyrocketed to 2,444 pounds.
Fentanyl saw a similar rise, as agents seized over 219 pounds in 2017, compared to less than 50 pounds the previous year. Coleman told attendees that this is a result of cartels creating fentanyl in a pill form that closely resembles oxycontin—a form appealing more to users who do not want to inject.
The role of trauma
Shana Malone, clinical initiatives project manager for the Arizona Health Care Cost Containment System, said the single largest factor in the opioid crisis that clinicians have failed to address is the role of shame, anxiety and trauma—particularly childhood trauma.
Malone noted that of Arizona youth who had misused opioids within the past 30 days:
- Two out of three said they used to cope with stress or feelings of sadness;
- Nine out of 10 said they had one or more adverse childhood experiences (ACEs), as defined by CDC;
- One-third had experienced four or ACEs; and
- Half have lived with someone who has a substance use disorder.
Bennet Davis, MD, pain program director at Sierra Tucson, built on Malone’s presentation during a later session, noting that an American with depression or anxiety is four times as likely to be prescribed an opioid pain medication than someone without. He then explained how trauma changes brain function, leading to symptoms that respond to opioids and patients having their pain misdiagnosed as tissue injuries and ending up on high-risk medications.
Lisa Villarroel, MD, MPH, medical director, Public Health Preparedness and Opioid Epidemic Response, Arizona Department of Health Services, shared updates found in the 2018 edition of the state’s opioid prescribing guidelines. The new guidelines stress avoiding the use of judgmental terminology, as well as prescribing opioids at the lowest possible dose for the shortest amount of time. The guidelines also cover how to:
- Implement the guidelines into a clinical flow;
- Manage an “inherited pain patient;”
- Evaluate patients for opioid use disorder;
- Connect patients with medication-assisted treatment;
- Approach an exit strategy from long-term opioid therapy;
- Manage pain and opioid use in special populations; and
- Connect with local and national resources.
Doug Skvarla, director of the Controlled Substance Prescription Drug Monitoring Program (PDMP), Arizona Board of Pharmacy, shared key changes for the PDMP in 2018 and 2019.
As of April 26, pharmacists must dispense schedule II opioids with a red cap and warning label about the potential addiction. Skvarla said that because of a shortage of red caps, the state board of pharmacy is recommending pharmacists use red stickers temporarily.
Electronic prescribing will be mandatory for schedule II opioids in 2019. Prescribers in large counties will be required to be compliant by Jan. 1, while small counties will have until July 1. Pharmacists will also be required to be able to accept electronic prescriptions by the same dates in large and small Arizona counties.
The National Rx Drug Abuse & Heroin Summit is the largest national collaboration of professionals from local, state, and federal agencies, business, academia, clinicians, treatment providers, counselors, educators, state and national leaders, and advocates impacted by prescription drug abuse and heroin use.