The opioid epidemic was barely a blip on the horizon when Dan Schmidt saw his first overdose death in the early 1990s.
Schmidt, a Moscow family physician and former state lawmaker, served as Latah County coroner from 1991 to 2006. He was a couple of years into the job when he received a call about an unattended death.
He remembers walking into the home and seeing the deceased sitting in a chair with a bottle of pain pills still in his hand.
“I counted the pills and they didn’t add up,” he recalled.
From what he could determine, the man had run out of pills a week or two before his 30-day prescription was up; then, after a new prescription was filled, he took a few too many.
It was a pattern Schmidt saw repeated over time: People running out of pills, losing some of the tolerance they’d built up, then taking more drugs than their bodies could handle.
“Either that or they’d (be prescribed) a different medication that affected them in a different way,” he said. “It contributed to their susceptibility to an overdose.”
Schmidt didn’t see a lot of overdose deaths during his time as coroner, but it was enough to cause concern.
“In a small county, it’s really hard to pick up trends,” he said. “You might see one accidental overdose death, then go a year and a half before you see another. But by 2006, as I was leaving office, I thought there was a growing problem. I could sense I didn’t have a real clear picture, but from the small window I was looking through, things didn’t look good.”
Overdose deaths remain relatively rare in north central Idaho and southeastern Washington. However, opioid prescription rate data offers a clearer view of the extent of the problem.
According to the latest figures from the Centers for Disease Control, Nez Perce County or Lewis County had the highest or second highest per-capita prescription rate of any county in Idaho every year from 2006 through 2017 (see table).
Lewis County, with a population of less than 3,900, stands out regionally as well: It had the highest per-capita rate of any county in the Western United States five times during that period, topping out at 227 prescriptions filled for every 100 people.
In Washington, Asotin County ranked among the Top 5 counties in the state 10 times, including six years at No. 1. In 2016 and ’17, it ranked third in the entire West (see table).
Such florid numbers suggest that, if there’s an epicenter to the opioid crisis in Idaho and Washington, this area may be it.
‘We dropped the ball’
Several factors contribute to the high prescription rates, including economic conditions and demographics.
Schmidt, for example, fills in as an emergency room doctor in hospitals across north central Idaho. He notes that many of the patients he sees are on disability.
“That’s a trap to poverty,” he said. “They’re not supposed to have gainful employment, but they get a monthly check and health care. They get pills, which they can sell to add to their income.”
Market factors also play a role in the prescription rates. The figures are based on where prescriptions are filled, not where the patients live. That means if someone from out of the area fills a prescription while shopping at the Clarkston Costco, it bumps up Asotin County’s number.
“And we know it’s a market area, with the Costco being there,” said Spokane County Health officer Robert Lutz, who also serves as the contract health officer for the Asotin County Public Health District.
To get a better sense of the local conditions, Lutz recently reviewed the state opioid database. It provides a quarterly view of how many county residents had at least one opioid prescription filled during the period.
“Unfortunately, when we do that, Asotin is still up there,” he said.
In the fourth quarter of 2018, the rate in Asotin County was 102.8 per 1,000 residents, or about 10 percent of the population — still the highest rate of any county in the state. The number ranged from 58.6 per 1,000 for 18- to 24-year-olds, up to 152.1 per 1,000 for those between the ages of 35 and 44.
“My interpretation of the numbers is that there is an issue in Asotin County,” Lutz said. “Certainly there’s a prescription issue.”
For Schmidt, a 12-year stretch of high prescription rates raises questions about the medical community’s willingness to regulate itself. The opioid crisis itself appears to be a test of its ability to self-govern.
“That’s how I saw it,” he said. “And I saw it as a failure. I saw that we, as a medical profession, dropped the ball.”
Misled and deceived?
The role of health care providers in fostering the opioid crisis has largely been ignored in the recent spate of lawsuits against drug manufacturers and distributors.
Idaho’s lawsuit against OxyContin maker Purdue Pharma, for example, suggests the company duped the entire medical profession by downplaying the risks associated with opioids.
“This marketing campaign misled and deceived doctors into prescribing more Purdue opioids, in increasingly dangerous doses, for longer periods of time,” the state alleges.
Similarly, Washington’s 2017 lawsuit against Purdue maintains that the company “used sophisticated and highly targeted marketing to deceive and mislead Washington health care providers into expanded and ongoing opioid prescribing, in spite of massive and sustained public harms.”
As a practicing physician, Schmidt remembers drug company sales representatives showing up at his clinic with free food, three times a week. They’d make their pitch, telling doctors that modern pain pill formulations are less addictive and can help with long-term, chronic conditions.
“That didn’t make sense to me, so I didn’t prescribe their drugs and they stopped chatting me up,” he said. “Doctors want to help patients with chronic pain, (but) what I was taught in medical school is that opioids don’t do that.”
Opioids are central nervous system depressants. They block pain signals by attaching to receptors in the brain, spinal cord and other parts of the body. Over time, though, patients build up a tolerance, so higher or more frequent doses are needed to yield the same level of relief.
Nationally, per-capita opioid prescription rates climbed 18 percent between 2006 and 2012, to a rate of 81.3 per 100 people. By 2017, that figure had declined nearly 28 percent, to 58.7, according to the Centers for Disease Control.
The number of overdose deaths, however, continues to rise. Unintentional poisoning, a category that primarily reflects drug overdoses, is now the leading cause of accidental death in the United States. In 2017, 47,600 Americans died from legal and illegal opioid overdoses — more than the number of combat deaths during the Vietnam War, according to the Centers for Disease Control.
Like Schmidt, Lutz is unwilling to give his profession a free pass for such devastation.
“There probably hasn’t been enough holding the hands to the fire,” he said.
Various studies suggest 80 percent of heroin users first become addicted to prescription opioids. While manufacturers surely misled the medical community regarding the dangers of their drugs, Lutz said, the entire history of opioids has been a story of addiction and misuse.
“We (medical professionals) have known that opioids are drugs of addiction,” Lutz said. “So why would we think oxycodone or hydrocodone are any different? That’s not taking responsibility. If the regulatory bodies aren’t willing to regulate, they do everyone a disservice.”
“We have taken steps”
The Washington Post recently reported that drugmakers and distributors shipped more than 76 billion oxycodone and hydrocodone pain pills to pharmacies around the country between 2006 and 2012.
The information came from a federal Drug Enforcement Agency database that tracks opioid shipments. The Post, together with HD Media, which publishes the Charleston Gazette-Mail in West Virginia, gained access to the information following a yearlong legal battle.
The data indicates that 53.35 million pills flowed into north central Idaho and southeastern Washington during that seven-year period — an average of 381 pills per person, based on the area’s 2010 population.
The per-capita distribution ranged from a high of 87 pills per person in Lewis County to a low 26 in Whitman County.
Despite such evidence of local hot spots, the professional licensing boards — the boards of medicine, dentistry, nursing and pharmacy — say they’re not set up to investigate entire counties.
For example, Anne Lawler, executive director of the Idaho Board of Medicine, noted that her board lacks the financial resources to handle such work, and likely wouldn’t have the legal authority to do so.
“Everything the board does is based on state statute,” she said. “Its mission is to protect public health. We do that by investigating (complaints) that come to us. The board looks at cases one by one. They’re all unique.”
The regulatory boards are funded exclusively through licensing and exam fees, as well as fines and other miscellaneous revenue. They receive no state general fund support, and collectively operate on a budget of less than $6.5 million per year.
“We do as much education as we can, but our principle role is licensing and renewals,” Lawler said.
While the boards investigate and discipline medical professionals on an individual basis, that’s the extent of their regulatory role. That doesn’t mean they’ve ignored the opioid issue.
The Board of Medicine, for example, has adopted a formal policy regarding the use of opioids in managing chronic pain.
Lawler said the policy is based on the 2017 Federation of State Medical Board guidelines. Among other provisions, it supports the use of “pain contracts” for chronic pain patients. The documents typically highlight the risks of using opioids and outline steps the doctor and patient will take to manage the condition. The contracts may allow for random drug tests as well, to discourage misuse.
Another provision within the board policy encourages doctors to check the state Prescription Drug Monitoring Program database before prescribing opioids to any patient.
The database tracks every prescription filled in Idaho, on a daily basis. It allows hospitals, pharmacies and physicians to track the number and type of prescription a patient receives, helping to crack down on attempts to score multiple prescriptions from multiple sources.
“Before, a patient could go from doctor to doctor to doctor, and the doctors would never know it,” said Alex Adams, former executive director of the Idaho Board of Pharmacy, which runs the database.
During his three years as executive director, Adams focused on making the database more useful by incorporating it into electronic medical records. That way, doctors and pharmacists can just click on a link, rather than having to log into the database separately.
“That was a game-changer,” he said. “I think the number of searches went from about 300,000 per year to 7 million.”
Nicki Chopski, who recently replaced Adams after he left to become Idaho Gov. Brad Little’s budget director, said the number of searches has now topped 15 million, just in the first eight months of 2019.
The database also includes analytical tools that automatically provide risk scores for patients, based on the number of physicians they see and combination of drugs they’re prescribed.
Other efforts to address the opioid crisis include new quarterly “report cards” that show doctors how their prescribing practices compare with their peers, as well as recent legislation expanding access to naloxone, commonly known by the brand name Narcan, which can save lives by countering the effects of an opioid overdose. Public health districts have also received funding for regional education efforts, to alert practitioners to new pain management guidelines.
“So I would disagree that the boards are unable to self-govern,” Chopski said. “I feel like we have taken steps and that we are cooperating. Overall, prescription levels are down.”
“That really knocked things on the head”
To date, Idaho regulators have relied on voluntary measures to achieve that reduction.
Washington, by contrast, requires greater regulation. For example, it was one of the first states to adopt rules requiring physicians to consult with a pain specialist before prescribing high doses of opioids. Doctors also must take educational courses if they exceed a certain dosage limit per month.
Perhaps as a consequence, the state’s per-capita prescription rate is nearly 20 percent below Idaho’s. It has been below the national average for the past six years, while Idaho now ranks second-highest in the West, behind Nevada.
Nevertheless, there is reason to think the combination of governmental and private efforts are having an impact — as evidenced by the turnaround in Lewis County.
In its ongoing opioid coverage, the Washington Post noted that the county’s only pharmacy, Arnzen’s Kamiah Drug, received 2.298 million pain pills between 2006 and 2012. On a per-capita basis, that was the third-highest distribution in the United States.
What the story didn’t show is how those numbers have tanked in recent years.
According to the Centers for Disease Control, Lewis County prescription rates went from 227 per 100 population in 2012 to 133 by 2015. Then they fell off the map, dropping to 8.9 per 100 in 2016 and 7.4 in 2017.
Rod Arnzen, the pharmacist and owner of Arnzen’s Kamiah Drug and two other pharmacies in the area, said the figures match what he saw at the store.
“Yeah, that’s when the DEA came through the area and docs got more scared of them than of getting sued by their patients,” he said. “And Medicaid finally put a limit on the (monthly dosages) they could prescribe. That was genius; it really put a stranglehold on things.”
Insurance companies also have begun requiring prior authorization before opioids are prescribed. And many now pay only for seven-day prescriptions, to cut down on the number of pills being diverted and resold.
“Another thing Medicaid did was prohibit patients from paying cash,” Arnzen said, which keeps them from filling the same prescription multiple times.
“That really knocked things on the head,” he said. “The insurance companies and Medicaid have done a better job (reducing opioid rates) than just about anyone.”
The state board of pharmacy, by contrast, wants pharmacists to talk to doctors who might be over-prescribing.
“I’ve had them tell me that,” Arnzen said. “That’s kind of an unfair position to put us in.”
On his own, Arnzen has stopped filling most prescriptions from out-of-state physicians. His pharmacy also has partnered with the local Upriver Youth Leadership Council and state agencies to provide thousands of free medication lockboxes and drug disposal bags to community members.
Having been a pharmacist for more than 40 years, Arnzen has seen the perception of opioids come full circle, from a wonder drug doctors were encouraged to prescribe to now the demon seed.
Although the declining prescription rates affect his bottom line, he’s not sorry to see them go.
“I’m not pro-opioids,” he said. “I got into this business to heal people. My true belief is that people will feel better if they get off them (and) use exercise or physical therapy to control pain. I think there’s a better way.”
Note: The Washington Post pain pill shipment numbers referred to in the story can be found online at https://www.washingtonpost.com/graphics/2019/investigations/dea-pain-pill-database/
Spence may be contacted at email@example.com or (208) 791-9168.
A LOOK AT AMERICA’S PRESCRIPTION DRUG CRISIS
This is the second installment in a series of stories about the opioid epidemic that will run periodically over the next few months in the Lewiston Tribune. The first story can be found at lmtribune.com. Readers who would like to share how this issue has affected them can contact reporter William L. Spence at firstname.lastname@example.org or (208) 791-9168.