Pennsylvania Initiatives to Address Opioid Use Disorder

February 2018 Issue

  1. Sarah Boateng Executive Deputy Secretary of Health, Commonwealth of Pennsylvania Co-author
  2. Rachel L. Levine, MD Acting Secretary of Health, Physician General, Commonwealth of Pennsylvania Co-author
  3. Michael A. Ashburn, MD, MPH Professor, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania Co-author


Drug overdose death rates are in the news almost daily, and the data demonstrate that the situation continues to get worse. Although 2016 data document that deaths attributable to prescription drugs has leveled off, deaths attributed to heroin and fentanyl continue to rise. Indeed, more Americans died from drug overdose in 2016 than during the Vietnam War.

In this article, we report on ongoing efforts to address opioid overdose deaths in Pennsylvania. This Pennsylvania story has been one of partnership among state government leadership, health professionals, and patient advocacy organizations. Several states have taken action to address this public health emergency. In Pennsylvania, legislation was passed in 2015 and 2016 that created a prescription drug monitoring program, established physician education requirements, and required changes to medical school education.

Pennsylvania has been working on improving the use of opioids for the treatment of pain for several years. Convened by the Department of Health and the Department of Drug and Alcohol Programs, the Safe and Effective Prescribing Practices and Pain Management Task Force was established by the state in 2015. The task force includes representatives from state and federal government, professional societies, individual physicians, and patient advocates. It developed 10 evidence-based specialty or location-specific state-based clinical practice guidelines to provide clinicians with best practices related to the use of opioids for treatment of non-cancer pain (Figure 1). The guidelines ultimately were reviewed and endorsed by several state regulatory boards, including boards representing physicians, nurses, and pharmacists.

 

Pennsylvania task force members have recognized that changes in the patient care process do not occur simply through publication of guidelines. Therefore, the task force advocated for the creation of continuing education on topics related to pain, the use of opioids, addiction screening, and referral for treatment. In partnership with the Pennsylvania Medical Society and other professional organizations, the task force made continuing medical education on the above topics free and available to all providers within the state.

Pennsylvania state leadership created a task force consisting of leadership from all Pennsylvania medical schools in 2016 to discuss possible changes to medical student education related to prescribing opioids. The task force developed core competencies for education on pain, opioids, and addiction (Figure 2). Ultimately, the Pennsylvania state legislature passed legislation that required Pennsylvania health education programs to provide instruction on pain management, addiction, prescribing, and dispensing practices for opioids as part of their training. In addition, the Pennsylvania state legislature passed legislation that required continuing medical education for all providers on these same topics.

Pennsylvania leadership recognized the need to establish a prescription drug monitoring program (PDMP) that providers could use to guide clinical decision-making related to prescribing controlled substances. The Pennsylvania PDMP went live for licensed prescribers and dispensers in 2016; those sources are now required to register with the program. Additional state legislation quickly led to adoption of a requirement that all providers query the PDMP before prescribing any opioids and benzodiazepines. As a result, more than 94,000 providers registered with the Pennsylvania PDMP in the first 12 months of operation, and an average of 52,000 queries are completed during a typical workday. In 2017, the Pennsylvania PDMP became capable of providing data from 15 other states and Washington, DC.


“This Pennsylvania story has been one of partnership among state government leadership with health professionals and patient advocacy organizations.”


The system will soon integrate with electronic health records to facilitate the availability of PDMP data in guiding clinical decision-making. Initial data indicate that the availability of the PDMP is impacting provider prescribing. In fact, the number of people receiving schedule II medications from more than 10 physicians and pharmacies has essentially been eliminated, and the number of people receiving schedule II medications from more than 5 providers and pharmacies has decreased by more than 80%. PDMP data demonstrate a decrease in opioid prescribing of 12.6% since the third quarter of 2016.

Concern is growing about the impact of physicians overprescribing opioids for the treatment of acute pain. Between the duration of opioid therapy and the risk of migration from acute to chronic opioid use, the association has recognized that 80% of individuals who use heroin report having started opioid use through use of prescription opioids.

In addition, several published reports have documented that physicians routinely overprescribe opioids for acute pain, resulting in large numbers of unused opioids being left in the home, often unsecured, and thus readily available for nonmedical use. To decrease the availability of unused opioids and other medications in the home, Pennsylvania created the Pennsylvania Prescription Drug Take-Back Program. Under the leadership of the Department of Drug and Alcohol Programs, the commonwealth has collected and destroyed 301,388 pounds of drugs since 2015.

Pennsylvania has also made progress in expanding naloxone availability for the treatment of opioid overdose. This included the physician general signing a standing order to make naloxone available to first responders (as well as the general public), allocating several million dollars to provide naloxone for first responders. Since the start of the program, increased availability has led to 3,988 reversals of opioid overdoses by Pennsylvania law enforcement using naloxone.

Pennsylvania is working on the expanded availability of medication-assisted treatment for opioid use disorders through a series of grants offered to providers to explore transformative methods of providing expanded addiction treatment throughout the state. This program, the Pennsylvania Coordinated Medication Assisted Treatment, expands medication-assisted treatment through a hub-and-spoke model with an addiction-medicine physician as the hub, networking with primary care providers as the spokes.

Although considerable more work needs to be done, the experience in Pennsylvania and other states demonstrates that progress can be made when state government leadership effectively partners with health care professional leadership and others to develop and implement sound policy to address a pressing public health need.

Tags: opioids, overdose, leadership, public health

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