KAILUA-KONA — Rep. Nicole Lowen of Kona’s 6th District has introduced a bill this session that would cap initial prescriptions for highly addictive opioids and benzodiazepines at seven consecutive days.
House Bill 666, for which Lowen is a co-sponsor, is one of several bills put forth by Hawaii legislators in 2017 to tackle what a number of doctors, pharmacists and politicians have described as a national epidemic.
“We’ve seen an increase in the use of opioids in general,” Lowen said. “There has been new types of drugs introduced to the market and maybe not as much oversight, or maybe they’re more addictive than others.”
The National Institute on Drug Abuse estimates that opioid-related substance abuse issues plague 2.1 million people in the United States, and deaths by opioid overdose have increased in the country fourfold since 1999.
Dr. Scott Miscovich — a family physician and chairman of the Hawaii Opioid and Overdose Leadership Action Work Group (HO’OLA), which is comprised of doctors, pharmacists, academics, nonprofit and addiction community leadership, judges and drug enforcement officers — said Hawaii has actually controlled the problem better than most states.
Miscovich said Hawaii ranks 49th in the U.S. when it comes to deaths per capita, meaning only one state deals with fewer. In terms of the percent of opiates prescribed per capita, Hawaii is in the bottom third.
But that doesn’t mean the medical community shouldn’t get ahead of the problem before it worsens to the point seen in Appalachian states like West Virginia and New Hampshire.
There will be individual counties in those states, Miscovich said, that will report more opioid-related deaths in 2017 than Hawaii will register throughout the entire state.
“We’ve had overdose deaths pass traffic accident deaths, which was a real sentinel marker for us when this occurred three years ago,” he said. “We don’t want there to be a rampant takeoff of heroin use, which has started across those states and really caused spikes in their death (tolls). And that usually follows opiates because heroin is a synthetic opiate.”
Miscovich added everyone at HO’OLA is in agreement — the issue must be addressed. Viewpoints diverge, however, when it comes to how exactly that should be done.
“The bill does make sense,” said Greg Formanack, a pharmacist at the Kmart in Kona. “Opiates are used for acute pain that is not controlled by NSAID, such as Ibuprofen. You don’t want to give somebody more than they need. The longer they are on it, they can develop a dependency. Seven days seems reasonable.”
Sen. Josh Green, who represents Kona and Ka’u, disagreed. He said he’s behind the intention of Lowen’s legislation, but that a seven-day prescription is “a non-starter for the medical community.”
Green, who also sits on the HO’OLA panel, added that the group of experts would uniformly oppose it.
“A lot of people need more than seven days of pain medication for serious injuries or other ailments,” Green said. “Plus we have better ideas than that.”
Miscovich said HB666 could work, and that five other states have passed similar legislation. Furthermore, the Centers for Disease Control last year incorporated initial opioid prescription limits as a guideline for primary care physicians dealing with moderate, painful injuries.
But for HO’OLA to support the plan in Hawaii, the legislation would require a number of caveats.
“There’s no one answer, and you can’t have a blanket, hard, one-line sentence,” Miscovich explained. “For example, post-operative pain. If someone has major spine surgery, to think you can pull someone back in after seven days when they are just recovering doesn’t make sense. Or a new hospice patient, there would have to be some type of exemption for that.”
Green said one of the ideas superior to an initial prescription limit that has been floated involves informed consent, a process in which the prescribing doctor sits down with a patient and outlines the risk of taking too many opioids.
Senate Bill 505 — a competing measure with HB666, on which Green is a co-introducer — addresses informed consent.
However, Green said the best solution to rising opioid abuse and subsequent deaths in Hawaii is the Prescription Drug Monitoring Program (PDMP), which was actually created by legislation passed two years ago.
The system combats “doctor shopping,” where patients visit numerous doctors and get prescriptions sent to different pharmacies so as to collect as much of the drug as possible. This is done by addicts for personal use and dealers for purposes of profit, Green said.
He added that he’d heard of one instance in which a person obtained around 20 opioid prescriptions in a single month.
“In states where everybody uses (PDMP), the number of pain pills in circulation has dropped 50 percent,” Green said.
Miscovich said 49 states currently have PDMPs and 39 have recently upgraded regulations on how to use them. He added 14 states have made it mandatory for all doctors and pharmacists, including New York, which did so three years ago.
Since then, the state estimates a 64 percent reduction in doctor shopping.
Green said similar regulations are the next step for Hawaii.
“Right now, we need to get the percentages up,” he said. “Not everyone is using it. Over time we should consider making it mandatory.”
Green added pharmacists are “using (PDMP) like crazy” and are catching abusers. But doctors are another story.
Miscovich said based on the most recent numbers available — out of roughly 3,000 physicians throughout the state, only around 140 use the PDMP.