Editor’s note: This is the fourth in a five-part series by West Hawaii Today focusing on opioid addiction on Hawaii Island. It begins with how a heroin overdose played a vital role in the shuttering of a well-known Kailua-Kona homeless camp and finishes on what more needs to be done to fight painkiller abuse. Eye-opening stats will be presented along the way: Hawaii County’s prescription rate doubles every other county in the state, while a vast majority of overdose calls are in homes and condos, not in homeless sites.
KAILUA-KONA — So far, lessons have been learned.
The knowledge gained from them has helped health care experts implement tighter safeguards and heightened awareness, both key components in moving the fight against drug misuse and addiction down the field.
Because as crucial as resources are for treating opioid use disorder and getting people onto a path toward recovery, so, too, will be the efforts health professionals and policymakers take to prevent the misuse of drugs.
In 2016, Hawaii County led the state in the rate of opioid prescriptions with 66.4 prescriptions per 100 people, twice the state rate.
“With this opioid crisis, one of the biggest ways to address it and the most effective is going to be obviously prevention and education,” said Dr. Megan Arbles, pharmacy manager at KTA Super Stores’ Puainako location.
For years, Arbles said, there was an upward trend, when the mindset was closer to “if something’s not working, we give them more,” but that’s an attitude that has changed as the opioid epidemic has grabbed the nation’s attention.
“I think a lot of the prescribers are more aware of it, the pharmacies are definitely more aware of it,” she said.
Last July, Gov. David Ige signed into law a bill that limits the prescription of an opioid along with a benzodiazepine, a class of drugs that includes Valium and Xanax, to a seven-day supply except for the treatment of certain conditions.
And since July 2016, state law has restricted any Schedule II controlled substance, which includes opioids, from being prescribed or dispensed for more than a 30-day supply except in specific circumstances.
At KTA Super Stores, Arbles said, they also place quantity limitations for filling opioid prescriptions depending on the diagnosis and its intended use.
“I think the pharmacists play a vital role in this whole thing,” she said. “We’re the last person the patient sees before they’re handed that opioid prescription.”
Pharmacists then have a responsibility to ensure every prescription’s legitimacy, she said, and look out for the safety of both the patient and community in regards to not only how much of a given drug is being dispensed and if it’s appropriate for the diagnosis, but also whether there are other, potentially safer options.
“So I think the pharmacists are definitely going to be playing a bigger role and I hope they will be playing a bigger role in the future with this whole thing,” she added.
For their part, Arbles said, she thinks pharmacies “are definitely more aware of it” and taking steps to question the validity of large quantities and ensuring the drugs are for a legitimate purpose.
Other initiatives at the pharmacy level include counseling patients, Arbles said, especially those who are new to opioids about the potential for overdose and dependence as well as counseling for those who have been using opioids.
State law requires anybody who dispenses controlled substances in the state to register with the Prescription Drug Monitoring Program, and file data about what is being dispensed. That database also allows pharmacy staff to see if patients have filled prescriptions at other pharmacies in recent months, which can raise a flag about any prescriptions being duplicated.
And part of a pharmacist’s job as the expert on pharmaceuticals is the responsibility of staying on top of the latest recommendations for managing pain, including what medications are best at what doses.
“And if what the doctor’s doing is not what’s recommended currently or what is therapeutically appropriate, I think it’s our responsibility to question that,” she said, “and to bring it to their attention and say, ‘Hey look, maybe there’s a better option for this patient,’ versus the whole attitude that if it’s not working, we’re just going to give them more.”
There’s also the component of preventing pills from going unused, leaving them available to be picked up later for potential misuse.
The response then, said Dr. Diane Logan, clinical psychologist and substance use coordinator at West Hawaii Community Center, is to prescribe the pills as needed, as well as taking a more measured approach for how long a patient’s acute pain is expected to last.
Using those and other practices at the clinic has meant West Hawaii Community Health Center has seen a “huge reduction” in how many controlled substances are coming out of the clinic.
When it comes to opioids, it’s meant about 125,000 fewer doses in 2017 than just one year before. The number of opioid prescriptions also dropped in that same time frame by about 14,000.
THE NEXT STEP IN FIGHTING ADDICTION
Dr. Michael McGrath of the Recovery Enhanced Medicine Institute, said one of his goals is to create screening instruments and tools that can be used to help doctors apprehensive about treating chronic pain patients who might be at high-risk of developing problems with opioids because of factors such as a personal history involving trauma.
Those tools would give him the ability to screen the patients, he said, and develop alternative plans for those high-risk patients.
Telemedicine, he said, offers an excellent avenue for providing those screenings and evaluations, but in his opinion, it hasn’t yet been put to its full potential.
“It’s underused for this problem,” he said. “And with our island, with a lot of rural areas, it’s really the way to go because I can reach individual patients, I can set up groups and I can outreach to clinicians.”
He’s also reaching out to other clinics to help them with those high-risk patients as well as get doctors comfortable with prescribing buprenorphine — a drug doctors can prescribe as part of a treatment plan to reduce a person’s reliance on opioids.
Currently, a list maintained by the Substance Abuse and Mental Health Administration includes just over a dozen physicians who are authorized to treat opioid dependency with buprenorphine in West Hawaii.
“Any prescriber can learn to competently use this drug,” he said. “If any prescriber can prescribe hydrocodone, it’s tragic and shameful that they are unable or unwilling to prescribe buprenorphine.”
GETTING MORE DOCTORS USING RESOURCES
The hesitation, McGrath said, can often be the result of a doctor’s discomfort with treating addiction or a lack of understanding about buprenorphine.
Here in Kona, he said, he’s gotten a “fair amount” of doctors comfortable with prescribing buprenorphine, expressing a desire to reach out to doctors and offer his expertise.
That goal aligns with a state action plan’s objective to, by the end of 2018, increase by 25 percent the number of prescribers licensed to prescribe and administer medication-assisted treatment including treatment plans that use buprenorphine.
There are currently 108 such prescribers licensed in the state of Hawaii, according to the Substance Abuse and Mental Health Services Administration.
The state action plan said the goal to increase the number of buprenorphine prescribers was “pending” when published, indicating that the Alcohol and Drug Abuse Division within the state Department of Health was to develop training this year.
While health professionals continue to bring local residents along the path of recovery, many in the community — from first responders to social services to pharmacies — are making strides to maximize their impact with the opportunities they have.
At the Hawaii Island HIV/AIDS Foundation and Hawaii Health and Harm Reduction Center, community health outreach worker Bud Luth said they hope to be able to offer trainings in naloxone, a medication that can block the effects of opioids and reverse an opioid overdose. Those trainings would be aimed at family members and friends of people using opioids, noting how important it is for them to have access to something that could save a loved one’s life.
“Especially on a big island like this,” said Teri Hollowell, director of programs at the Hawaii Island HIV/AIDS Foundation. “Because it has to be administered right away or as soon as possible. So you can’t wait several hours.”
Last week the governor signed a bill into law that authorizes pharmacists to prescribe and dispense an opioid antagonist, such as naloxone, to someone considered “at risk for an opioid overdose” or a family member or caregiver of such a person.
The prescribing pharmacist is also required to give the recipient information about risk factors of opioid overdose, signs of an overdose and how to respond to one as well as how to use the opioid antagonist.
At Hawaii Fire Department Emergency Medical Services, the standing orders under which paramedics operate have protocol for overdoses, which include the administration of naloxone, said Bureau Capt. Chris Honda.
Going forward, Honda said their goal is to develop a team effort from community members, organizations and businesses along with treatment and recovery providers to let the community know what resources are available and how people can connect with help.
“Because it’s real. It affects everybody,” Honda said. “And recovery doesn’t happen overnight.”
There’s still work to be done, which will hopefully better empower the community and people first responders serve.
“We’re still learning a lot about this,” Honda said. “The more we can learn, the more we can pass on to the community to assist families.”