STASH Vol. 11(7) – Just what the doctor ordered: Washington State’s comprehensive approach to opioid epidemic sees results.

Globally, countries such as Australia, Canada, the US, and much of Western Europe have experienced large increases in the rates of per capita opioid usage. Increased prescribing of opioids provides relief to those who suffer from chronic pain, but not without an unintentional increase in the morbidity and mortality associated with opioid abuse. According to the latest national figures during 2013, 1.9 million people in the US were abusing prescription opioids and 16,235 people died from an opioid overdose. Recently, states such as Massachusetts have announced comprehensive plans to address opioid abuse.  This week’s STASH describes a recent review of Washington State’s collaborative effort to address opioid abuse (Franklin et al., 2015).

Methods

• During the late 1990’s as medical and advocacy groups were pushing for better chronic pain treatment, new prescription opioids were approved by the FDA and marketed to prescribers for the treatment of chronic pain.
• In responses, many states including Washington in 1999 enacted more permissive laws and regulations for prescribing opioids to patients with chronic, noncancer pain (CNCP).
• Then, starting around 2005, the state began efforts to reduce prescription opioid morbidity and mortality (Table 1).

  Collaborate across relevant state agencies

  Develop best-practice guidelines for prescription opioid use (e.g., dosing).

  Pass strong pain management laws.

  Implement effective prescription drug monitoring programs.

  Institute surveillance to track opioid prescribing and use practices and health outcomes.

  Incentivize the use of best practices (e.g., pay more for documenting best practice in medical records, free CMEs).

  Educate those already using opioids to prevent overdose.

  Increase access to medication-assisted treatment.

  Evaluate impact of interventions.

Figure. Washington State’s comprehensive approach to address opioid abuse. Adapted from Franklin et al., (2015).

• The authors used publicly available data from the Washington State Department of Health to measure the impact of the state’s efforts to curb opioid abuse.
• Measures included the age-adjusted prescription opioid death and overdose hospitalization rate per 100,000 from 1995 to 2012.

Results

• As Figure 1 shows, the age-adjusted rate of opioid involved overdose deaths grew significantly from the late 1990s through 2006. The rate then stabilized through 2009 before declining from 2009 to 2012.
• The age adjusted rate of opioid involved hospitalizations followed a similar trajectory as deaths, but instead of stabilizing in 2006, hospitalizations continued to grow, albeit more slowly, until 2011 and then decreasing in 2012.

Figure. Prescription opioid overdose hospitalizations and deaths and implementation dates for prevention policy and programming in Washington State, 1995-2012. Adapted from Franklin et al. (2015). Click image to enlarge.

Limitations

• The analysis is an ecological study of the experiences of one US State.
  • The results might not be generalizable to other states or countries.
  • The results might be the result of the ecological fallacy. Relying on state level data is helpful for identifying associations and potential cause/effect relationships. But because there is no measure of exposure or outcome of individuals, it cannot be used to determine cause and effect.

Conclusions

The results of this review suggest that Washington State has begun to stem the tide in its effort to address opioid overdoses. As more jurisdictions begin addressing opioid abuse in their region, it is important to look to the success and barriers that other areas have experienced. This review of the experiences in Washington is an important step in developing a comprehensive evidence based approach to addressing opioid abuse. Future efforts should look at how individuals abusing opioids are being impacted by the efforts recommended here and how successful they are in recovery.

— John Kleschinsky

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Reference

Franklin, Gary, Sabel, Jennifer, Jones, Christopher M, Mai, Jaymie, Baumgartner, Chris, Banta-Green, Caleb J, . . . Tauben, David J. (2015). A comprehensive approach to address the prescription opioid epidemic in Washington State: milestones and lessons learned. American Journal of Public Health, 105(3), 463-469.