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About Smoke signals. (Grand Ronde, Or.) 19??-current | View Entire Issue (Dec. 1, 2017)
S moke S ignals DECEMBER 1, 2017 13 'A lot of this was driven by big pharma' OPIOID continued from front page “This reduction will result in changes of availability and cause shifting of brands to try and accom- modate fills for patients,” Grand Ronde Pharmacy Director Leatha Lynch says. “I also see things like this causing increasing demands of other medications to help cover pain, which then causes those to go into a shortage as well.” Given recent statistics from the Centers for Disease Control and Prevention, the crackdown on opi- oid use is no surprise. Since 1999, there have been more than 165,000 deaths from overdoses related to prescription opioids, which breaks down to 40 people per day. Additionally, a national survey from 2014 indicated that 4.3 mil- lion Americans used prescription opioids recreationally in the last month. However, although the amount of opioids prescribed and sold in the United States quadrupled since 1999, the overall amount of pain reported by Americans hasn’t changed. The question on the minds of local doctors, clinic managers, pharmacists, addiction counselors and others is: Will cutting off the legal supply help curb the opioid crisis or will users turn to street drugs, such as heroin and synthetic opioids, to avoid painful medication withdrawals? Just how far the pendulum has swung since OxyContin was first approved in late 1995 to how it has now become a focal point for opioid abuse issues was illustrated by Grand Ronde Medical Director Lance Loberg. “A lot of problems originated due to treatments such as massage, physical therapy and acupuncture not being covered by the Oregon Health Plan,” he says. “Providers were pressured to prescribe opi- oids. Now, OHP is realizing it and approving other modalities. But now we have patients here who depend on these medications for back pain. Taking those away will be a big desatisfier … but there is a lot of research that shows the risks of opioids outweigh the benefits.” The other issue that arises is that, over time, people build up a tolerance to opioids and larger doses must be taken to achieve the same effect. “People end up being in more pain, and they think they need more medication,” Loberg says. “A lot of this was driven by big pharma.” According to an Oct. 30, 2017, article in The New Yorker, after na- tional studies showed inadequate treatment of chronic non-cancer pain by physicians, demands were made to address the issue. Seeing the trend for doctors to take pain more seriously, drug companies pitched products such as OxyCon- tin, which was marketed as less addicting because its formulation allowed for dosing every 12 hours instead of four to six hours. Tribal physician Dr. Marion Hull “We want to keep our patients safe and provide a healthy lifestyle. It’s just one of those things, as the rules get stricter and stricter, we need to help patients manage the best we can.” ~ Health Services Executive Director Kelly Rowe Tribal Police want to stay ahead of synthetic opioids By Danielle Frost Smoke Signals staff writer Synthetic drugs such as fen- tanyl are making it dangerous for police officers to perform their jobs as traditional field testing of these substances can be deadly if it comes into contact with the officer’s skin or lungs. The Drug Enforcement Admin- istration issued a memo recently urging police to use caution from the beginning of a traffic stop. It also discouraged field testing of drugs, saying these materials should be sent straight to the respective state crime lab. Grand Ronde Tribal Police Chief Jake McKnight says that although the problem is “min- imal” locally, outside sources may bring drugs to nearby Spirit Mountain Casino. “We typically find more meth than anything else,” he says. “It’s not a big issue here, but when you bring in outside players, it said that in the 1990s, the Oregon Medical Board required all Oregon physicians to take a class on pain management. At the time, there were some physicians who were sanctioned for not prescribing ade- quate amounts of narcotics. “Notably, this coincided closely with the Oregon euthanasia legis- lation,” she says. Now, the pendulum has swung in the opposite direction of very limited opioid prescriptions. “This is hard for us because our goal in life is to help people,” Hull says. “It is difficult when people come in and have an agenda about what they want to take when we know it may not be the best thing for them. It puts us in an adversar- ial position with our patients and we don’t like it.” The Tribal Health & Wellness Center is working toward imple- menting new procedures, using treatments such as physical ther- apy, chiropractic, acupuncture and opioid alternatives like an- ti-inflammatories and nerve pain medications. Health Services Executive Direc- tor Kelly Rowe says that the clinic’s policy changes are being driven by nationwide substance abuse issues, as well as recommendations from the CDC and Indian Health Ser- vice. Also, having a pharmacy direc- tor in place after the position was vacant for a few years has helped can become a problem. We need to look at getting in front of it.” McKnight says his officers car- ry Narcan, an overdose antidote, and he is also researching the purchase of a handheld narcotics analyzer TruNarc. The $23,000 device enables officers to safely scan for more than 414 suspected illicit substances in a single test. According to the TruNarc website, the device also allows the scanning to be conducted through a plastic container for most samples to minimize con- tamination, reduce exposure and preserve evidence. Currently, the Tribal Police Department sends suspect sam- ples to the state crime lab. “I am hoping different de- partments will help chip in for this,” McKnight says. “Fentanyl is here, but it hasn’t become an epidemic yet. It is better to stay ahead of it and keep officers safe though.” in the effort to streamline policies. “We want to keep our patients safe and provide a healthy life- style,” Rowe says. “It’s just one of those things, as the rules get strict- er and stricter, we need to help patients manage the best we can.” After being hired as pharmacy director last year, Lynch joined the Tribe’s Controlled Substance Management Committee. “Since the pharmacy is the one dispensing, I wanted to bring us into the conversation,” she says. Lynch says that although the pharmacy had a pain agreement, it wasn’t used consistently with patients. “That leaves a lot open for in- terpretation,” Lynch says. “As pain clinics are being closed down, people are scrambling trying to manage their pain. We decided to have something more streamlined. It is still in process.” The group, which includes Health & Wellness Center employees, spent time during the past year comparing guidelines, policies and procedures at local, state and fed- eral levels. “With the changes to the Oregon Health Plan, it will impact how we process coordination of bene- fits,” Rowe says. “It’s a huge shift and there are other guidelines for CDC. We are constantly shifting and adjusting where they need to be. For our patients (on pain med- ication), their worst fears are that the pain is going to come back and get worse.” The new rules put doctors in a tough spot, too. “They are under scrutiny as well from the Oregon Health Board,” Lynch says. Loberg agrees. “I think sorting things out with OHP is going to be the big challenge,” he says. “Ul- timately, it would be nice to offer acupuncture and physical therapy at the clinic, and other alternatives beyond just saying, ‘No.’ ” Currently, massage and chiro- practic services are offered onsite. When opioids must be used, the CDC is recommending starting with the lowest possible dose, pre- scribing immediate release vs. ex- tended release tablets and limiting acute pain prescriptions to three days or less since long-term opioid use often begins with short-term prescriptions. “It is definitely going to be more difficult to get them for acute use,” Lynch says. Rowe says that the restrictions may unwittingly make it more dif- ficult for doctors to treat patients. “With smaller amounts (of med- ication), prior authorization and having to show that you aren’t abusing it, everything slows down,” Rowe says. “It puts up roadblocks for people who don’t abuse their medication and the providers … but it is the climate we are in. We are still committed to helping people manage pain.” Lynch says that the ultimate goal is to still provide pain relief, but without risking lives in the process. “We have to go along with the regulatory bodies,” she says. A ‘profit-driven, public health crisis’ At the time of OxyContin ap- proval in 1995, the Food and Drug Administration believed the con- trolled-release formula would re- sult in less abuse potential since the drug would be absorbed slowly. However, the FDA’s labeling of the product unwittingly resulted in widespread abuse. It noted that crushing the controlled release capsule and using it could result in abuse and that injecting it could be lethal because the controlled release properties would no longer be effective, giving users a “high” all at once. Purdue Pharma, manufactur- er of OxyContin, was issued a warning letter from the FDA in January 2003 for misleading ad- vertisements, among them ads that omitted and minimized the safety risks associated with the drug and promoted it for uses beyond severe pain. In 2007, Purdue Pharma ul- timately plead guilty in federal court of misbranding its product and agreed to pay $600 million in fines, one of the largest amounts ever paid at the time by a drug company. According to an Oct. 30, 2017, article in The New Yorker, See OPIOID continued on page 14