In Oregon in 2013, more drug overdose deaths involved prescription opioids than any other type of drug, including methamphetamines, heroin, cocaine, and alcohol. Since the 1990’s, , there has been a dramatic increase in prescription controlled substance sales, use, misuse, dependency, and overdose due to opioids in Oregon. New data from Oregon’s Prescription Drug Monitoring Program (PDMP) shows that prescribed opioid use is pervasive among Oregonians. In 2013, almost 1 in 4 Oregonians received a prescription for opioid medications1, and in a recent national survey2, Oregon ranked 2nd among all states in non-medical use of pain relievers (i.e. prescription pain medication).
Reducing prescription drug poisonings (“overdoses”) is a complex problem that will require coordinated implementation of a comprehensive set of solutions. The following strategies are part of the framework to reduce prescription opioid overdose, misuse and dependency:
Reduce problematic prescribing practices:
o Develop and implement Opioid Prescribing Guidelines for Pain Management that address treatment of acute pain, chronic pain, and co-prescribing in various provider settings (e.g. primary care, emergency departments, dental offices, prenatal care, tribal clinics, Federally Qualified Health Centers, etc.)
o Use the Prescription Drug Monitoring Program (PDMP) to assess high risk behavior, prescribing thresholds, and dangerous co-prescribing, and use of multiple prescribers and pharmacies. Develop the PDMP to allow for notifications to providers regarding at-risk patients (e.g. four or more providers providing painkiller prescriptions, > 120 mg Morphine Equivalent Dose (MED), etc.). Explore statutory change needed to integrate PDMP access into existing electronic health record systems (e.g. EDIE in Emergency Departments).
o Provide reimbursement for non-opioid pain treatment therapies for chronic pain and increase access to the Chronic Pain Management Center model, including services such as nutrition, PT, chiropracty, massage, acupuncture, Cognitive Behavioral Therapy, graded exercise; as well as Medication Assisted Treatment and substance use disorder treatment.
o Implement pharmacy opioid management strategies including: prior authorization for opioids, including clinical assessment of comorbidity, risk factors; preferred/non-preferred drug lists; dispensing limits for MED, quantity of pills, number of refills, and early refills; implement lock-in programs through pharmacy management-programs
Improve safe drug storage and unused medication disposal
o Explore statutory changes needed to require routine drug take-back at pharmacies.
Increase and improve the infrastructure for naloxone rescue, and naloxone co-prescribing
o Co-prescribe naloxone when prescribing opioids for at-risk patients
o Allow naloxone prescribing and dispensing to third parties of patient (e.g. spouse, parent, partner, etc.)
o Explore statutory changes needed to allow for naloxone to be prescribed and dispensed by directly by pharmacists.
o Improve infrastructure for law enforcement and EMTs to administer naloxone to patients who have overdosed on opiates
o Promote knowledge of the “Good Samaritan law” to the general public
o Promote access to naloxone trainings for the public, at pharmacies, etc.
Provide medication assisted treatment (MAT) for opioid use disorder
o Ensure that Coordinated Care Organizations (CCOs) provide (MAT) for opioid use disorder.
o Improve access to MAT services for patients throughout the state, including tribal populations (both urban and on reservations)
o Increase the number of buprenorphine waivered physicians in practice in Oregon
Implement routine collection, analysis and reporting of opioid overdose, misuse, and dependency data.
o Evaluate the public health impact of implementation of the opioid prevention plan
o Report data on overdose deaths, hospitalizations, percent of population with prescriptions for daily MED >120 mg, opioid use disorder treatment by: demographic characteristics and geographic location in the state, with a focus on disparities, including by socio-economic status, homelessness, veteran status, race-ethnicity.
Provide education and training of the public, providers, health systems, policy-makers on the issues related to opioid overdose, misuse and dependency
o Promote education of the public, providers, health systems regarding risks of opioid medications and reasonable expectations of chronic pain treatment and availability of non-pharmacologic pain treatment
o Provide training to providers for challenging situations such as drug tapering, MAT, Substance Use Disorder treatment, pregnancy, and neonatal abstinence syndrome.
Collaborate with federal and state entities to support the work of the initiative – including the Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS), the Medicaid Medical Directors Network, and states such as Washington, New York, and Massachusetts who have implemented effective strategies.
A variety of state and local initiatives are under way to support the implementation of the strategies in this plan. Coordinated Care Organizations (CCOs) began work on an opioid prescribing Performance Improvement Project (PIP); the Public Health Division (PHD) received a grant from CDC to implement several of the strategies outlined in this plan in five regions of Oregon over four years; the Oregon Coalition for the Responsible Use of Meds (OrCRM) received a grant from the Oregon Department of Justice that will support local implementation of the strategies in this plan. Oregon will participate in a National Association of Medicaid Directors project to reduce misuse of, overdose and death from prescription opioids. Several regions in Oregon have developed opioid prescribing guidelines, and Jackson County CCOs and Western Oregon Health CCO have pioneered work to change prescribing practices of their providers.
To guide the coordination of this work, the Oregon Health Authority has chartered an Opioid Initiative Task Force that will meet monthly to monitor progress and plan ongoing work across the Authority and among state agencies.