West Virginia: Influencing Policy and Legislation Towards Improving Opioid-Related Deaths Background

The opioid overdose crisis has hit the state of West Virginia hard, with the highest incidence of drug-related deaths in the United States (United Health Foundation [UHF], 2017). In fact, West Virginia ranks 50th of the 50 states in drug-related deaths, with the rate of these deaths increasing significantly by 25.3% in 2015-2016 (UHF, 2017; CDC Injury Center, 2016). A 2013 CDC study found that West Virginia providers were two times more likely to prescribe opioids for acute pain than stimulants or benzodiazepines alone, with West Virginia more likely than seven other states to prescribe opioids in conjunction with benzodiazepines (Paulozzi et al., 2015). This leads to a higher risk of CNS and respiratory depression, leading to death.

West Virginia, specifically, has risk factors which influence its vulnerability to the opioid overdose crisis. For example, high rates of uninsured, low-income, and rural residents with limited access to primary care and high rates of chronic illness and obesity. But there is a positive side to this situation. Protective factors such as high per capita of public health spending and an increase in health and social service jobs provide a rich opportunity for broad interventions across the spectrum of treatment and prevention (West Virginia Department of Health and Human Resources, 2018; Bump, 2017; Colburn, 2017; Kaiser Family Foundation, 2017; UHF, 2017; United States Census Bureau, 2017; Wing, 2017; Bureau of Labor Statistics, 2016).

Policy Option # 1: Create policy requiring the use of a Prescription Drug Monitoring Program (PMDP) prior to prescribing an opioid analgesic

Prescription Drug Monitoring Programs (PDMP) are currently being used in thirty-seven states as a means of combatting over-prescribing of opioid analgesics, which may lead to abuse and overdose("State Prescription Drug Monitoring Programs," 2016). Colorado, North Carolina, Ohio and Oregon have partnered with the Centers for Disease Control (CDC) to enact policies which focus on use of a PDMP to decrease over-prescribing, and methods which allow for ease of access to opioid overdose reversal resources (Deokar et al., 2018, p. S28). There has also been a study in a large healthcare organization in Pennsylvania, which used fifteen hospital emergency departments to collect data on the use of a PDMP to decrease the rates of opioid prescribing for acute pain visits. They looked at trends in opioid prescribing over twenty months for all providers with prescribing privileges and saw an overall decrease of 17.7% in the prescribing of opioid analgesics, with consecutive decreases of 0.5% each month after implementation of a PDMP (Suffoletto, Lynch, Pacella, Yealy, & Callaway, 2017, p. 6). In addition to a goal of an overall decrease in opioid prescribing, another study found that providers who used PDMPs consistently showed lower incidence of inappropriate prescribing, or prescriptions “for which a second prescription with the same drug name, from a different prescriber, was filled within 7 days of a first prescription that contained ≥30 pills.” (Deyo et al., 2018, p. 172) The goal with the implementation of a state or nationwide PDMP is to create a pause for providers between an assessment and possible over-treatment. By making a provider aware of the how much of a particular prescription a patient may have already received they are better equipped to either try a different pain management strategy or have a discussion with the patient on the dangers of opioid misuse.

Policy Proposal # 2: Enact legislation which limits the prescribing of opioids for acute pain to no more than 7 days

By placing a limitation on the number of opioids that can be prescribed at one time for an acute pain visit, the goal is to limit the risks of opioid addiction and dependence. In 2012, the state of Ohio enacted an action team, which came up with three prescribing guidelines to give providers structure on decreasing overprescribing. After enacting these guidelines Ohio saw a 14.7% decrease in the number of opioids prescribed in larger numbers (i.e. more than 80mg of morphine equivalent per day) (Deokar et al., 2018, p. S27). New York state has also adopted a law to limit initial opioid prescriptions to no more than seven days and ranks 13th in the nation for drug related deaths, compared to West Virginia’s 50th. ("State Summaries New York | 2017 Annual Report | AHR," 2017). By limiting how much of an opioid medication a person can initially receive the goal is to decrease the risks of opioid dependence leading to overdose and death.

Policy Proposal # 3: Enact a requirement of a physician education course for opioid prescribing

Many states who have had successes (Deyo et al., 2018) in lowering their opioid overdose rates have mentioned the importance of healthcare provider education. West Virginia held a public comment board town hall at the beginning of 2018 where many citizens voiced their desires for healthcare providers to have more education in opioid prescribing risks. A study in Florida highlighted the importance of newer generations of emergency medicine providers in receiving education on opioid abuse. In fact, only 30% of emergency medicine providers in the study had ever received training specific to opioid misuse disorder signs (Young, Tyndall, & Cottler, 2017, p. 4). With greater education for providers on safe prescribing and recognition of opioid misuse disorder the goal is reduce risky prescribing, and therefore opioid overdose deaths. Additionally, when providers are more educated they have the ability to educate their patients more effectively on the dangers of opioid misuse and dependence. This will lead providers to understand the risks of long term or high dose opioid use and help them find ways they can impart this information to patients leading to better patient-centered and informed care.

References

Deokar, A. J., Dellapenna, A., DeFiore-Hyrmer, J., Laidler, M., Millet, L., Morman, S., & Myers, L. (2018). State Injury Programs' Response to the Opioid Epidemic: The Role of CDC's Core Violence and Injury Prevention Program. J Public Health Manag Pract, 24 Suppl 1 Supplement, Injury and Violence Prevention, S23-S31. doi:10.1097/PHH.0000000000000704

Deyo, R. A., Hallvik, S. E., Hildebran, C., Marino, M., Springer, R., Irvine, J. M., . . .

McCarty, D. (2018). Association of Prescription Drug Monitoring Program Use With Opioid Prescribing and Health Outcomes: A Comparison of Program Users and Nonusers. J Pain, 19(2), 166-177. doi:10.1016/j.jpain.2017.10.001

Paulozzi, L. J., Strickler, G. K., Kreiner, P. W., Koris, C. M., Centers for Disease, C., & Prevention. (2015). Controlled Substance Prescribing Patterns--Prescription Behavior Surveillance System, Eight States, 2013. MMWR Surveill Summ, 64(9), 1-14. doi:10.15585/mmwr.ss6409a1

State Prescription Drug Monitoring Programs. (2016). Retrieved from https://www.deadiversion.usdoj.gov/faq/rx_monitor.htm

State Summaries New York | 2017 Annual Report | AHR. (2017). America’s Health Rankings. Retrieved from https://www.americashealthrankings.org/learn/reports/2017-annual-report/state-summaries-new-york

Suffoletto, B., Lynch, M., Pacella, C. B., Yealy, D. M., & Callaway, C. W. (2017). The Effect of a Statewide Mandatory Prescription Drug Monitoring Program on Opioid Prescribing by Emergency Medicine Providers Across 15 Hospitals in a Single Health System. J Pain. doi:10.1016/j.jpain.2017.11.010

Young, H. W., 2nd, Tyndall, J. A., & Cottler, L. B. (2017). The current utilization and perceptions of prescription drug monitoring programs among emergency medicine providers in Florida. Int J Emerg Med, 10(1), 16. doi:10.1186/s12245-017-0140-0