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By Taylor Knopf
Likely the most prominent piece of opioid overdose prevention legislation this year, House Bill 243, known as the STOP Act (Strengthen Opioid Misuse Prevention Act), sailed through the House Health committee last week.
The bill, heavily backed by Attorney General Josh Stein, Health and Human Services Sec. Mandy Cohen, Gov. Roy Cooper and bipartisan House and Senate leaders, focuses on decreasing the number of narcotics in the state and adding substance abuse treatment services.
The legislation is seen as a response to the increasing number of overdose deaths in North Carolina, which have climbed from 1,215 in 2013 to 1,306 in 2014 to 1,498 in 2015.
The STOP Act has the support of the medical community, which has tacitly acknowledged the need for tightening the way legal opioids are doled out to patients. And addiction professionals have expressed optimism that the bill will help reduce the number of deaths and increase the number of people in treatment.
Big problem, big answers
Four people in North Carolina die each day from drug overdose and an additional 16 are hospitalized each day resulting in $1.8 billion per year in medical expenses and lost work, said Attorney General Josh Stein at a press conference last week at the North Carolina Department of Justice.
Stein said teens see opioids as a safer alternative to other drugs, and 20 percent of 11th graders in the state have taken them without a prescription.
“When someone is prescribed 30 or 60 or 90 pilled and uses only four, the rest go on a shelf in the bathroom, the majority of which get into the wrong hands,” Stein told reporters.
Stein said only one out of 10 people abusing drugs receive treatment in North Carolina.
“Jail time is usually not the best way to treat addiction,” he said. “At four times the cost, prison is certainly less cost effective than treatment.”
Data, map courtesy NC Dept. of Health and Human Services
Last year was the first time there were more overdose reversals than deaths from opioids due to naloxone (also known as the brand name Narcan), Stein added.
“Even as we mourn the approximately 1,500 accidental overdose deaths of last year, let’s celebrate the lives saved,” he said.
Enough for treatment?
The STOP Act seeks to combat the overprescribing of opioids and the problem of too many extra pills. In 2016, North Carolina health providers prescribed about 664 million opioid pills, according to the NC Department of Health and Human Services.
If passed, the bill would set a five-day limit on initial prescriptions for acute pain. Providers would also be required to consult the North Carolina Controlled Substance Reporting System — a database of all prescriptions for opioids and other drugs that can be abused — before prescribing opioids in an effort to cut down on “doctor shopping” and ensure patients aren’t receiving opioids elsewhere.
It would also phase in e-prescribing and help phase out prescription pads in hopes of decreasing prescription forgeries.
The legislation initially provided $20 million over two years for community-based substance abuse treatment and recovery. But in the House Health committee last week, lawmakers removed the funding portion, saying it would be dealt with separately during the budget process.
Rep. Nelson Dollar, House appropriations chairman, offered assurances that this is a high priority for the House.
“We know what the cost will be, and although we cannot appropriate ahead of the budget, we will have to account for that when the budget comes through the House,” Dollar told the House Health committee last week.
“We usually only have about two or three bills that we handle in this fashion, things that are very important and we want to move the policy ahead of the budget. Then the budget will have to account for that, which we will do,” he added.
This is something that supporters of the bill like such as Mark Ezzell, executive director of Addiction Professionals of North Carolina, will watch carefully.
“[We] must be vigilant to make sure the money ends up in the budget,” he said.
Ezzell said he’s not particularly concerned that the money was taken out of the bill, saying it would have slowed it down in the appropriations committee. Ezzell said he’s holding on to the verbal commitment Dollar made, and that he takes legislators at their word and believes it will be funded.
He also has confidence in the STOP Act.
“This bill will work as intended,” Ezzell said. “It will drive people to seek more treatment. But as a result, we must bulk up our treatment centers and services.”
Ezzell said it’s a “relative rarity” to get state funds for addiction treatment. North Carolina receives federal money in the form of a “substance abuse prevention and treatment” block grant, which totals about $40 million per year.
“$20 million is certainly not enough, but it’s an important step,” Ezzell said. “It gets us on a path to where we want to be.”
Fewer opioid prescriptions
Meanwhile, the North Carolina Medical Board has started a Safe Opioid Prescribing Initiative, which means it’s cracking down over-prescribing and adding classes for the people who write prescriptions.
Plus, the board is more aggressively investigating providers with high opioid prescribing numbers and those who have had two or more patients die while taking prescription opioids.
In 2016, residents in 20 counties were prescribed more than 100 pills per person. Five years ago, there was only one county at that prescribing level.
The medical board investigated 62 opioid prescribers last year in North Carolina.
To put that in perspective, there are about 26,000 physicians and 5,800 physician assistants licensed to prescribe in the state.
Of the 62 providers, a quarter were investigated due to high prescribing numbers, and the rest got reviewed because they had two or more patient deaths.
In the end, 46 percent of the providers investigated received no formal disciplinary action, and 24 percent received a private action. For example, the medical board sent letters telling providers that while the investigation showed no breach of care, there’s some concern about over-prescribing.
The remaining 30 percent investigated were publicly disciplined via letters posted to the medical board website.
In addition to investigations, the Medical Board will begin requiring controlled substance prescribing courses as part of its license renewal, according to Evelyn Contre, spokeswoman for the board.
“We are offering this because we think it’s the right thing to do,” she said. “It’s important.”
It’s also a law, added in the 2015 state budget.
To renew their medical licenses, physicians must take 60 continued education hours every three years. Physician Assistants must take 50 hours every two years. Physicians must now dedicate at least three hours to controlled substance prescribing, PAs need two hours.
The requirement goes into effect July 1, and some physicians and PAs will need to fulfill the course hours immediately. So the medical board is making webinars available.
Brooke Chidgey, pain physician and anesthesiologist at UNC Health Care, is part of the webinar faculty.
She said when it comes to pain management, there are many methods besides opioids.
For example, there is a machine that creates sensations to muscles called a TENS unit which is great for treating back or leg pain, Chidgey said.
There are other classes of medications to treat pain, such as anti-inflammatory drugs, muscle relaxants, antidepressants and topical agents such as lidocaine. Chidgey said she might prescribe a combination over-the-counter drugs like Tylenol and ibuprofen to target pain in different ways.
While Chidgey said she would prefer that physicians keep opioids as a last resort, some patients just need them. And many physicians end up prescribing opioids because insurance companies will not always cover alternative options, she said.
For example, Medicaid will not cover a TENS unit for back pain, but it will cover the treatment for leg pain, she said.
“We have to fight with insurance constantly to get these covered,” she said. “We also have a lot of patients on Medicaid and sometimes other options are expensive.”