The magazine of the UW School of Public Health

Download full issue PDF. Spring/Summer 2016
Volume 33, Number 1

Inside this issue

Winner, 2017 APEX Awards for Publication Excellence


Tracking and Treating Opioid Addiction in Washington State

Washington was the first state to recognize and respond to the nation’s epidemic of prescription painkiller overdose deaths.

By Michael McCarthy

Washington was the first state to recognize and respond to the nation’s epidemic of prescription painkiller overdose deaths.

The Centers for Disease Control and Prevention has prioritized prescription opioid overdose as one of the nation’s top health concerns, recently announcing national guidelines for prescribing opioids—a landmark move for the agency. While the move marks a nationwide call to action for reducing death rates related to this epidemic, Washington State pain experts and public health professionals have been at the forefront in recognizing this problem and developing solutions to address it.

“For good or ill, Washington State is about two years ahead of the rest of the country,” said Caleb Banta-Green, PhD, MPH, MSW, Senior Research Scientist with the Alcohol and Drug Abuse Institute and Associate Professor at the University of Washington School of Public Health. “Washington was the first state to recognize the rise in prescription opioid use and do something about it, and we’re the first state to see use level off and begin to decline.”

The declining use is a victory for public health professionals, won by a hard-fought battle where data was the first weapon. Over a decade ago, Gary M. Franklin, MD, MPH, Research Professor in the departments of Environmental & Occupational Health and Health Services, and his colleagues reported a marked jump in opioid-related overdose deaths among workers covered by the state workers’ compensation system. They discovered people were getting hurt on the job and seeking pain medication from their doctors. Too frequently, these workers would overdose. Researchers linked the increases in medication access and death with the relaxing of prescribing laws in the late 1990s.

Eased regulations and heavy marketing from pharmaceutical companies enabled physicians to prescribe more pain medication, such as hydrocodone and oxycodone, to more patients, especially those with less life-threatening conditions. Unfortunately, the effort to relieve suffering ended up causing more harm than good. It created what Franklin called the “worst man-made epidemic in medical history,” a prescription-opioid epidemic that has left more than 175,000 Americans dead, and millions more addicted.

In response to the prescription opioid epidemic, Washington State’s Agency Medical Directors’ Group (AMDG), a collaboration of state agencies, convened an advisory group of clinical and academic pain experts to draft new prescribing guidelines. The guidelines, issued in 2007 and updated in 2010, encourage physicians to use opioids more conservatively and at lower doses. They also recommended that providers consult with a pain specialist when a patient’s daily dose reaches a threshold level known for substantial increased risk of overdose. In 2012, the state also set up an online prescription monitoring program to help track controlled substances.

For patients who do require opioids, the guidelines recommend early follow-up evaluations to assess whether both pain and function have improved. The newest iteration of the guidelines released in 2015 say opioid regimens that do not improve the patients’ function by at least 30 percent are not clinically meaningful, and they encourage other strategies, such as graded exercise and cognitive-behavioral therapy. “This is huge,” said Franklin. “If a patient is not improving in both pain and function, you shouldn’t keep them on opioids.”

Thus far, the prescribing guidelines have made a positive impact in the prescription-opioid epidemic fight. “After the guidelines were put into practice, there was a 40 percent decline in prescription opioid overdose deaths statewide, from 512 deaths in 2008, to 319 in 2014,” said Franklin, who is also the Co-Chair of AMDG.

However, when an upstream approach is implemented after a problem surfaces, many people can get caught in the prevention gap. In this case, it’s those who became addicted before the prescribing regulations were tightened, many of whom remain at risk for continued misuse and overdose. In some cases, tightening prescription regulations can reroute the addiction pathway to alternatives such as heroin, which is both cheaper and easier to access. So while Washington State celebrates substantial success in lowering the rate of prescription opioid related deaths, a different number is rising. “Heroin-involved deaths have doubled from 146 to 293 during the time frame we saw a decline in prescription-opioid deaths,” explained Banta-Green.

Once opioid addiction manifests, it can only be managed, not permanently eliminated. Access to treatment services is heavily influenced by a patient’s resources and social circumstances. Further, those using prescription opioids illegally or using illegal opioids such as heroin, face differential legal consequences due to race and class. “Not only are we seeing adverse health consequences due to the use of drugs themselves, but also due to the legal consequences of drug use which are strongly influenced by race, class and geography,” said Banta-Green. “The societal consequences are huge.”

The opioid epidemic is far from over. Strides have been made to stem the tidal wave of addiction and overdose by creating a more thoughtful prescribing culture and offering new intervention options. However, for Banta-Green and his colleagues, public health must also address the roots of addiction. “If you listen to these patients, it isn’t just about pain; it’s about pain, anxiety, and depression,” he said. “Pain is a very human experience, and it shouldn’t be ignored.”