At The Oklahoman’s addiction summit. Kelly Fry is giving the introduction. She had everyone flip an hourglass to remind people how many die of overdoses.
Fry: ‘it’s 8 people an hour. That’s unacceptable’
Andrew Kolodny from the Opioid Policy Research Collaborative is speaking first. He’s starting with what opioids are.
Kolodny: opioids have a role in end of life care and for acute pain after surgery/injury. Most US prescribing isn’t for that.
Kolodny: ‘every year for the last 20 years we’ve set a new record for drug overdose deaths’
Kolodny: every county has had at least an 8% increase in overdoses since 1980. Some had far more.
Kolodny: prescription opioids drove the increase until 2010. Then heroin and fentanyl started taking off.
Kolodny: people assumed pill users switched to heroin because of a crackdown. ‘The switching happened much earlier’
Kolodny: young people started using heroin early in the epidemic, didn’t start dying until fentanyl arrived ‘the heroin supply got so dangerous’
Kolodny: fortunately, fentanyl isn’t widespread in Oklahoma
Kolodny: some people became addicted while using recreationally, others when prescribed ‘once you become addicted, you’re not doing it for fun’
Kolodny: secondary problems are children going into foster care, babies born dependent, workforce issues
Kolodny: opioid sales and deaths tracked closely from 1999 to 2007 ‘as the prescribing went up, the deaths went up’
Kolodny: Admissions for treatment also tracked up at the same time. CDC suggests overdoses won’t go down until prescribing does
Kolodny: opioid manufacturers spent $880M to block efforts to reduce prescribing over 10 years. 8 times as much as gun industry lobbying
Kolodny: opioid prescribing hasn’t fallen as much in Oklahoma ‘we’ve got a way to go before we get to more rational levels in Oklahoma’
Kolodny: oxycodone and hydrocodone prescribing started to take off in ‘96. Some is new drugs on the market, but not all
Kolodny: Purdue Pharma tried to change the culture of prescribing for opioids. Moving toward using it for more common conditions than end of life cancer pain
Kolodny: ‘in the early 90s, we knew better. We knew these drugs were too dangerous to treat low back pain, for example’
Kolodny: pain management physicians and state medical boards started pushing doctors to prescribe more
Kolodny: The Joint Commission had a financial relationship with Purdue Pharma and pushed messages that opioids were safe
Kolodny: ‘we know from worker’s compensation data that if you treat patients with opioids for long-term pain, that patient is much less likely to go back to work’
Kolodny: doctors were told less than 1% of patients would get addicted. That was based on a chart review of patients who got a few doses in a hospital
Kolodny: there isn’t enough evidence to be sure that long-term opioid use helps patients, but there is evidence for harm
Kolodny: patients who got a 30-day of opioids had a 40% chance of still using it a year later
Kolodny: need to reduce prescribing, expand access to treatment, use law enforcement to shut down pill mills and cut off fentanyl supply
Kolodny: it’s been difficult because of a false frame that the problem was about recreational/non-medical use
Kolodny: ‘the problem wasn’t kids getting into grandma’s medicine chest. The problem is every grandma having opioids in her medicine chest’ about 40% of people prescribed develop signs of addiction
Kolodny: example of AIDS epidemic ending when patients got access to treatment. Access to buprenorphine could help reduce opioid deaths
Kolodny: it isn’t perfect because you can misuse buprenorphine, but deaths go down. Also a role for psychosocial treatment and 12 steps
Kolodny: it looks like overdose deaths could have peaked, but too early to be sure. ‘They’re still at an extraordinarily high level’ deaths have started to trend down in Oklahoma
Kolodny: ‘there is good work being done here’ to expand medication-assisted treatment
Terri White from ODMHSAS is up next.
White: four addiction issues in Oklahoma. ‘It’s the biggest public health problem facing our state’
White: about 300k Oklahomans 12 and older need addiction treatment, drives foster care rates, early deaths, incarceration
White: attitudes about risk drive use. People tend not to use things they see as risky. 64% of teens see little risk in have 5+ drinks at a time
White: ‘what have we been telling Oklahoma kids and not just Oklahoma kids but kids across the nation? Marijuana is medicine’
White: part of the brain that handles decision making isn’t finished developing until mid 20s, addiction risk is much higher before then
White: ‘we have to figure out how to stop kids from becoming addicted’ to make an impact of addiction overall
White: Oklahoma kids start drinking, on average, at 13. More than 85% of those seeking alcohol treatment in Oklahoma started before 18
White: Oklahoma men die at 75.9 on average. People with untreated mental illness and addiction die 30 years earlier
White: Oklahoma has one of the highest death rates from overdose, suicide and cirrhosis
White: 153k people misused pain drugs last year. Young people ages 18-25 were more likely to misuse
South and Southeast counties have the highest death rates. White: it used to be Tulsa was the highest, but that’s gone down with concentrated attention
White: in Tulsa, they equipped all first responders with naloxone and increase access to medication assisted treatment
White: ‘we are getting ready in Oklahoma to ensure 4000 more locations can sell high-content alcohol,’ greater access to alcohol for kids
White: more Oklahomans died from results of excessive drinking than opioids
White: ‘kids drink differently than adults, because 90% of the time, they binge drink’
White: about three-quarters of people drink, so we’re not as comfortable thinking of it as a threat, have to talk to kids about risk
White: When Oklahomans binge drink, they drink 8.4 drinks at a time, higher than national average. 1 in 5 adults and 2 in 5 kids binge drink.
White: marijuana was behind only alcohol for people seeking treatment. It looks like meth is surpassing that.
White: Oklahoma isn’t preventing medical marijuana recommendations to kids. Shouldn’t use it before brain development ends.
White taking issue with reporters publishing the names of doctors recommending marijuana.
White: in 2016 and 2017 meth became the most common drug of choice for people seeking treatment
White: after about 2 years without using meth, the brain recovers if you’ve had treatment
White: number of doctors with waivers to prescribe medication-assisted treatment has gone up
White: most people who die by suicide have some substances in their body at that time
White: OKImReady.org is replacing the Take as Prescribed website
White: ‘when we don’t do this, we go broke as a state,’ treatment costs about $2k v $15k for hospitalization, $19k for prison, $21k for foster care
Reggie Whitten is up next. Whitten’s son died at 25 after years battling addiction.
Whitten: ‘it is a disease that masquerades as bad behavior, but it’s not’
Whitten is introducing Gary Mendell, a businessman whose son also died of addiction.
Mendell created a nonprofit called Shatterproof.
Mendell’s son Brian’s friend Mikey had cancer, got proven treatment and lots of support. They didn’t have that when Brian was dealing with addiction.
Mendell: ‘Brian just found silence’
Mendell: Brian started with alcohol and marijuana as a teen and escalated to harder drugs. None of the treatment he went to was evidence based, had to fight stigma
Mendell: Brian had gone 13 months without using drugs when he died by suicide seven years ago. ‘My son died of a disease that is preventable and we don’t prevent. That is treatable and we don’t treat’
Mendell: after his son died, he relied on the serenity prayer. He came up with the idea of a small nonprofit, but it grew as he learned more
Mendell said he had no idea how common addiction was. ‘Think what would happen if 375 cattle dropped dead. It would be on the nightly news. These are our sons and daughters, and no one was talking about it’
Mendell: we’ve dramatically cut smoking and drunk driving, but stigma prevents the same on addiction. ‘How could we have something so big, that’s mostly about our children, there’s information that could save lives tomorrow and it’s being stigmatized and not used’
Mendell: no national organization existed to advance addiction treatment. ‘American Cancer Society for addiction’ made possible because ACA and parity act moved into medical realm
Mendell: worked with CDC and to advance state and federal legislation
Mendell: also having public events like the Rise Above Addiction run to fight stigma
Mendell: lack of information available on which treatment programs were following evidence-based practices, going to insurers to get them to agree on a national standard of care
Mendell: The standard will be used to create a provider scorecard for families and to make sure insurers pay for the right things
Mendell: OK still has a high rate of drug deaths and opioid prescribing
Mendell: contain the problem by reducing prescribing, treat with medication and effective therapy, make naloxone as available as fire extinguishers
Mendell: naloxone would cost $5-10B nationwide. ‘We would give that to hurricane victims in a heartbeat’
Mendell: 12-step groups can inadvertently give up misinformation, making a curriculum for them
My phone died, but now I'm back online for the panel discussion. Looks like it's White, Mendell, Kolodny, and AG Mike Hunter. Not sure who the 5th person is.
That's Dr. Kasey Shrum from OSU Med School.
Hunter is giving an update on the opioid lawsuit. Says it was a "difficult decision" to sue manufacturers making important drugs and employing thousands of people. "Sometimes, businesses do bad things."
Hunter: wasn't "somebody deciding to be evil," but responding to a business opportunity to address pain
Everything I've heard suggests that the development of the product preceded the idea that pain was a "fifth vital sign," but Hunter's got those flipped.
Hunter: "These entities need to be held accountable for what they've done to the state" with inaccurate marketing that opioids weren't addictive, damages could be in billions
Hunter calls criticism of the lawsuit "disgraceful"
Shrum is next to talk about what OSU College of Medicine is doing.
Shrum: important that doctors hear personal stories of patients' and families' experiences with addiction
Shrum: "This is how the pendulum swings back in the right direction" after going too far in prescribing, they now have 3 addiction medicine specialists teaching and require students to do a rotation with them
Shrum: doctors are having to unlearn what they were taught about what's good practice
Shrum: they received a grant to train students to prescribe buprenorphine
Kolodny is next. Question for him was why prescribing habits take a while to change. "I think that many doctors have in their mind is that addiction happens to a subset of our population"
Kolodny: "I think they make the mistake of assuming that it's not that addiction makes people behave badly, it's that bad people get addiction"
Kolodny: also the belief that pill mills are driving the epidemic, not doctors prescribing for legitimate patients "What they're missing is that the bigger part of the problem along has been the well-meaning doctors"
Kolodny: a legitimate prescription can set someone up to be a pill mill customer in the future
Mendell: doctors in Oklahoma only are required to check the prescription database every six months when a patient gets opioids or benzodiazepines "It should be every time"
Mendell: "The things we're doing are not the biggest movers," for example insurers could identify problematic patterns
Mendell: doctors in CA who were notified when their patients overdosed reduced their prescribing, also issue of pills being easier and cheaper to get than physical therapy for example
White: prescription database works in real time, so that's one good thing, but it needs to be better used
Mendell: database also can tell if people are getting both an opioid and a benzodiazepine because taking both increases the risk of dying
Question about 12-steps and medication-assisted treatment. White: AA and NA are helpful to many people, but they're not evidence-based treatment we should pay for.
White: Oklahoma pays $100 a day for residential treatment. Probably should be $300-$500 to get full evidence-based services
White: the state will have to make investments to get savings later from treatment, some in Legislature struggle to plan beyond one year
Mendell: "Medicaid expansion would help a lot" to pay for treatment
Mendell: ideally the state would only license treatment programs that offer medication-assisted treatment to patients who want it. Buprenorphine costs about $500/month outpatient.
Mendell: Massachusetts got rid of prior authorization for addiction medications. Oklahoma could do that
Kolodny giving the analogy that people with Type 2 diabetes can sometimes get off insulin and oral medications with diet and exercise. We don't take away medications because not everyone can do it, but do that with addiction drugs.
Kolodny: "For most people with opioid addiction, the abstinence-based approaches don't work"
Shrum: have to have treatment available when a person seeks help or the prescription database shows they need it
That's a wrap here. I'll try to find out the answer to Jay's question before heading back to write the story.
