Questions, notes, and discussion from the Opiate Summit - October 2016, Firekeeper’s Casino, Battle Creek MI
Breakout session - Jim Middleton, moderator
1. Akron, Ohio had a sudden emergence of carfentanil - how do we prepare for such an emergency in this area? - increased monitoring of nalaoxone use in treating overdoses - if it takes more than a few milligrams to resurrect the patient, chances are strong that the product in question contains carfentanil. At present, fentanyl and carfentanil are not part of routine screening; current law enforcement personnel is able to focus on marihuana possession with greater interest because the product itself is so very visible. Carfentanil can be lethal at a dose of 1mg.
2. When can we see improvements to the current MAPS program? - the new server is set to roll out in January 2017, with clinicians being able to review their own MAPS usage data (to check for unauthorized use of their DEA information) in April 2017. The internal flags within the MAPS program are set pretty high - reportedly, it takes the use of many multiple unique clinicians in a 30 day period to flag a patient as being suspicious, placing a lot of the interpretive burden for abuse at the level of the pharmacist. Clinicians are still underutilizing the MAPS program, not helped by its “voluntary” participation. (The Lieutenant Governor, during his opening remarks, openly acknowledged the challenge of the narcotic problem in Michigan, but seemed reluctant to increase any regulatory burden by Michigan upon the clinicians.)
3. How do you perceive the 25% reduction in opioid production affecting the current heroin crisis? - the lack of access to legally prescribed and manufactured opioids will result in an increase in illicit use. While the DEA is taking steps to reduce the total amount of opioid products available for use, with the tools they have at their disposal, the overall impact of this restriction is being regarded as misguided: pharmacies with the wherewithal will begin stockpiling product in anticipation of the shortage by year’s end, which will only further contribute to the shortage.
4. What responsibility do drug companies have in this opioid abuse problem? - the concensus in the group was that it laid a lot of blame on the drug manufacturers, both for creating the problem and for apparent price gouging for the treatment - naloxone prices have escalated 400% in just the past few years. LARA (Michigan’s Licensing and Regulatory Affairs) was also taken to task for their perceived lack of oversight, giving Michigan the reputation of being the “new Florida” (one peninsula switched to another) for “bad prescribers.”
5. Family medical providers are the most common over-prescribers. Any studies on the causes of this or the actions being taken to reign in this practice? - It takes 30 seconds to say yes, 30 minutes to say no. Independent physicians have been placed in group practices in order to maintain reimbursement through their insurance contracts. Blue Cross began cutting reimbursement by 25% to independent clinicians while linking reimbursement to community health improvement. In January 2017, Blue Cross, through its pharmacy benefits provider (PBM) Express Scripts, is also restricting controlled substance analgesics to a 30 day supply, along with a maximum daily “morphine equivalent” for pain therapy before triggering a prior authorization process. Caremark, the nation’s other primary PBM is implementing similar restrictions in 2017. Both PBMs are implementing these new controls in a rapid manner, often with only a few weeks’ (or days) notice.
6. What is “Pink”? An Upjohn test drug with about 7 and ½ times the potency of morphine, it was not considered useful enough to go beyond initial studies, but was assigned an ID of U-47700. The patent has apparently expired, and its manufacturing information has been circulating. Pink, carfentanil, “bath salts” all seem to be originating from labs in China and are being distributed to the United States by way of Mexico.
7. What can hospital administrators do to help or support providers/clinicians? Hospital emergency departments in Grand Rapids have created a network to identify and move opioid “frequent fliers” into rehabilitation programs, while strictly limiting outpatient prescriptions for controlled substance analgesics. Cross-platform EMR databases also help to identify patients with similar health-risk behaviors.
8. Heroin addicts - criminals or victims? - The original view that the overdosed heroin user was a victim was embraced by law enforcement in March of 2016. However, by year’s end, the repeated revisits to overdosing are taking their toll on law enforcement attitudes. One weekend, police rescued the same patient 6 times in a 48 hour period, and the patient refused further treatment. Such rescues are becoming a challenge with pressures to work staffing more “efficiently” and with other police services still requiring attention.
8. What is the status of naloxone and pharmacy distribution in Michigan? - still adrift in the Michigan legislature (October 2016), Kent and Kalamazoo counties have proactively partnered with Spartan-Nash stores and Dr. Sandra Dettman of Grand Rapids to provide naloxone kits with a prescription umbrella from Dr. Dettman. The kits are 2-packs of naloxone in nasal spray format, with 4mg naloxone per dose. The public is still completely misinformed about the effects of naloxone being a “cure” for the overdose - it is only effective for minutes before requiring re-administration, and carfentanil requires a substantial increase in dose for effectiveness (and is effective for an even-briefer period of time).
9. Has Adderall been a problem? - Adderall and other ADHD stimulants in the DEA C-II category are routinely abused or sold by students, prescribed with very brief physician interactions, and are coming under increased DEA scrutiny once it feels adequate processes are in place for opioid review. “Helicopter” parents are pressing clinicians to prescribe stimulants, not for ADHD, but for performance enhancement in academics and athletics. Stimulants used in such a manner may increase attentiveness and short-term memory retention, but may actually diminish long-term retention of information.
|(cc) Jim Middleton, The Animating Apothecary|