County, doctors confront opioid abuse: Physicians urged to be cautious with how they prescribe medication

There’s only theories as to why that may be — whether it’s because of the county’s affluence, well-educated population or even higher numbers of people born in countries who don’t consume as many opioids.

But what is known is that people are dying from drug overdoses in San Mateo County and last year more than 24 million opioid pills were prescribed to local residents, said county Health Officer Dr. Scott Morrow. That means physicians wrote enough prescriptions for every adult in the county to receive 43 pills, he said.

“We created this problem, unintentionally, we created this opioid crisis in the country. We had the best intentions,” Morrow said, noting in the 1990s doctors were taught to recognize pain as one of the main vital signs. “But we are now killing more people than motor vehicle accidents. It’s iatrogenic, a physician-caused problem.”

Morrow said they’re now focused on prevention by educating doctors and patients. In February, the county’s Health System sent out a public health alert about local opioid dependency statistics and science-based guidelines developed by the Centers for Disease Control, which physicians are urged to follow.

The extent of the problem

Morrow estimates there are 7,800 people in the county dependent on opioids. These drugs are so addictive, some people can become hooked after just three days, he said.

In 2015, there were 60 drug-induced deaths, although last year he noted less than 20 were related to opiates. But even the data may not reflect to true extent of the problem, he said.

For example, there may be multiple causes of death, there isn’t a consistent labeling system used amongst doctors and toxicology reports are not always issued. Plus, those who die from an overdose oftentimes have multiple drugs in their systems, Morrow said.

One positive indication is that heroin use appears to be low and less than four people died from it last year. Morrow said he also hasn’t seen a local prevalence of fentanyl or the highly-toxic carfentanil, the extremely strong opioids on which hundreds of deaths are blamed.

But while the number of opioid-induced deaths may be relatively low, addiction seems to be on the rise, said Jim Stansberry, executive director of Project 90 who has worked at the substance abuse treatment center for 28 years.

“In the last year, year and a half, there has been a upswing of opioid users,” Stansberry said. “It’s one of those things where San Mateo looks good by comparison to a lot of other places in the country and their numbers and their ability to take care of people, but it’s still got the problem.”

He estimated at least 20 percent of the nearly 500 clients Project 90 treats a year have opioid dependency issues. He also wouldn’t be surprised if more people start turning to heroin as those who start out on pills, often move into using the street drug.

Exactly why San Mateo County has lower rates of overdoses or deaths as compared to surrounding communities and the Central Valley is hard to qualify. But Dr. Sameer Awsare has a few theories.

“I think the income level and education level here is higher on this side of the Bay. I think we have a lot of immigrants from other countries, Asia and India, and the rest of the world doesn’t use [opioids] as much,” Awsare said, noting the United States makes up less than 5 percent of the world’s population but consumes 80 percent of the global opioid supply.

An internal medicine doctor practicing out of Kaiser Permanente’s Campbell office, Awsare has spent years working to develop a training program for physicians on how to combat the opioid epidemic.

Like Morrow, Awsare said preventing deaths and addiction must include education for doctors who inadvertently contributed to the crisis.

“All of these drugs are derivatives of opium, which we’ve had for 5,000 years,” Awsare said, noting it wasn’t until recently that there was the proliferation of prescription drug addiction. “They became available because of the education that was provided to the physicians — to treat pain at any cost.”

Bolstering the doctor-patient relationship

Setting achievable and realistic goals with patients is key, Morrow and Awsare said.

“Our goal is not to eliminate pain, our goal is to make you functional so you can live your life. We’re trying to get them off this idea that pain free is the state we’re trying to get to,” Morrow said.

Neither of the physicians are advocating the medical community do away with opioids. Instead, it’s about how and when they’re used.

Morrow noted short-term prescriptions for acute pain or end of life treatments is an appropriate use of opioids; however defaulting to opioids for chronic pain is problematic. Instead, he suggests other alternatives, such as non-opioid pharmacological therapy, physical therapy or “rewiring” the brain with cognitive behavioral therapy.

Doctors are also advised to not begin prescribing opioids unless there’s a plan for how the patient will stop, and to give the lowest doses for the shortest amount of time, according to the guidelines.

In 2015, nearly 350,000 opioid prescriptions were filled in the county, with the average doctor writing 100 prescriptions. The top prescriber wrote more than 3,900, according to Morrow.

Officials are also looking to crack down on “doctor shoppers,” or those receiving drugs from multiple prescribers. Thanks to a new state law, California doctors are now required to register and check the “CURES 2.0” system to monitor patients receiving controlled medications.

Previously, it was hard to track because the patient data was “de-identified.” The new state program makes it easier for doctors to monitor who’s getting what, Morrow said.

Awsare said Kaiser also implemented an internal system to check what patients are receiving. Other efforts include educational seminars for doctors and working to discourage drugs from being diverted onto the streets. Since beginning their training in Kaiser’s Northern California region, opioid prescriptions have been reduced 43 percent, Awsare said.

“Prescribe them safely, appropriately and if our patients are on them, monitor them to make sure they’re not dumping them in the community,” Awsare said.

To address diversion, or the drugs ending up in the hands of those to whom they weren’t prescribed, Kaiser drug tests patients. In one case, Awsare said he was shocked to find out an unassuming elderly man with a prescription didn’t have any opioids in his system. The man turned out to be diverting his drugs because he’d “fallen on hard times” financially, Awsare said.

Morrow noted it’s also important to educate the public on how to properly dispose of unused medication and to safeguard medicine cabinets to keep them out of the hands of youth.

Aside from working to prevent people from developing opioid addictions, the medical community must also address those who are already hooked. Morrow noted he’s pleased to see an increase in the number of doctors becoming certified to prescribe suboxone, a drug used to treat narcotic addiction. Other statewide efforts include making naloxone, a drug that can help reverse opioid poisoning, more widely available at pharmacies. Awsare noted there could be drawbacks to making naloxone widely available while not addressing the root problem.

“Opioid addiction is a disease and if people survive on their first overdose, they die on their second or third; they live to die again,” Awsare said. “If we don’t get you afraid of your addiction, you’re still going to die.”

But the doctors and Stansberry agreed preventing premature deaths and drug overdoses needs a multi-faceted approach. Still, with public awareness growing across the nation and the medical community stepping up, Morrow said he’s hopeful.

“No, I don’t think the full extent of the nationwide epidemic is known,” he said, adding “I think we’re definitely at the tipping point in this topic.”

samantha@smdailyjournal.com

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