Wednesday, December 12, 2018

Sonoma Medicine

The magazine of the Sonoma County Medical Association

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PUBLIC HEALTH
The Opioid Epidemic in Sonoma County

Sarah Katz, MPH, Arielle Kubu-Jones, Karen Milman, MD, MPH, Melissa Struzzo, MPH, Terese Voge, MPA

The misuse and abuse of drugs, particularly prescription opioids, is a growing prob-lem in Sonoma County, the state of California and the United States. Overdose deaths from drugs obtained both legally and illegally now exceed all other causes of injury-related deaths both locally and nationally, and they take more lives than traffic accidents.

Nationally, more than 47,000 drug overdose deaths occurred during 2014—higher than any previous year on record. Since 2000, the age-adjusted drug overdose death rate has more than doubled (from 6.2 to 14.7 per 100,000 residents), and the rate for deaths from prescription opioids has nearly quadrupled (from 1.4 to 5.1 per 100,000 residents).1

In California, more than 12,500 residents died from drug overdoses from 2011 to 2013. The crude rate of overdose deaths from drugs obtained both legally and illegally, and all intents, was 11.0 per 100,000 residents.2 During the same time period, prescription opioid overuse and overdose led to 4,200 deaths, with a crude death rate of 3.7 per 100,000 residents.3 The age-adjusted rate of deaths related to prescription opioids increased by 16% from 2006 to 2013; the rate of deaths related to heroin increased by 67%. In 2013, the death rate for overdose due to heroin was 1.3 per 100,000 residents.2,3

Sonoma County Data
Opioid-related data in Sonoma County range from near real-time electronic death-certificate surveillance to less timely injury data from the California Department of Public Health. These differences in release time mean that 2015 Sonoma County data is available, but not comparable data for California. Every effort has been made to obtain the most current and relevant data, but direct comparisons between Sonoma County and California are not always possible.

More than 900 Sonoma County residents died from a drug overdose in the past 15 years. In 2011–2013, the crude rate of overdose deaths from drugs obtained both legally and illegally, and from all intents, was 10.3 per 100,000 residents.2,3 The most recent local data (2013–2015) indicate that, on average, one Sonoma County resident dies every week from a drug overdose.4 From 2000–2002 to 2010–2012, the age-adjusted drug overdose death rate increased significantly for both Sonoma County and California. In 2010–2012, the rate in Sonoma County (12.0 per 100,000 residents) was higher than in California (10.1 per 100,000 residents).

In 2011–2013, drug overdose was the leading cause of injury death in Sonoma County, with overdoses causing more than twice the number of deaths as motor vehicle accidents. More than 80% of Sonoma County’s drug overdose deaths were unintentional. Almost half of these deaths were among people 45–59 years of age, and the vast majority were among white, non-Hispanic residents. At least one in three drug overdose deaths was due to prescription opioids; the crude rate of these deaths was 3.5 per 100,000 residents.5 (These data likely underestimate the true number of prescription opioid deaths; the type of drugs involved in drug overdose deaths are not always known or reported on death certificates.)

Sonoma County has also seen increasing morbidity as a result of drug overdose. From 2011–2014, there were at least 660 non-fatal opioid-related emergency department visits.6 (As with prescription opioid deaths, these data likely underestimate the true number of opioid-related ED visits; the drugs involved in ED visits are not always known or reported.) From 2009–11 to 2012–14, the rate of nonfatal treat-and-release ED visits for unintentional drug poisoning due to opiates increased by 73%, from 10.0 per 100,000 residents in 2009–11 to 17.3 per 100,000 residents in 2012–14 (Figure 1). The age-adjusted rate for this type of ED visit was statistically higher in Sonoma County (15.8 per 100,000 residents) than in California (9.8 per 100,000 residents).

Pharmaceutical opioids were the principal cause for about three-quarters of these ED visits; heroin was the principal cause for about one-quarter. Notably, the ED visit rate for heroin increased 267% from 2009–11 to 2012–14.7 Though the abuse of illicit opioids like heroin is outside the scope of this article, the Sonoma County Department of Health Services (DHS) is monitoring heroin trends and is committed to reducing the use of heroin county-wide.



 CURES Data
In 2015, the Committee for Health Care Improvement, part of Health Action, the county-wide coalition of stakeholders working to improve health across the county, formed the Sonoma County Opioid Prescribing Work Group to guide policy and systems changes. The group’s first task was to analyze 2014 data on Sonoma County opioid prescribing patterns from California’s controlled substance utilization review and evaluation system (CURES). The group’s finding s included:

  • Approximately 459,000 opioid prescriptions were prescribed to about 126,000 unique Sonoma County residents during 2014, or 25% of all county residents.
  • The prevalence of prescription opioid use decreased with age, as shown by the percentage of each age group that received at least one opioid prescription in 2014. For residents 65 years or older the prevalence was 41%, followed by 55–64 (34%), 45–54 (31%), 35–44 (26%), 25–34 (25%) and 18–24 (19%). Only 4% of residents under 18 years received at least one opioid prescription.
  • Fifty-eight percent of Sonoma County residents with an opioid prescription were female.
  • Hydrocodone (57%), oxycodone (18%) and morphine (7%) were the most frequently prescribed opioids.8

Meanwhile, the California Health Care Foundation (CHCF), using 2010–13 data from CURES, found that Sonoma County consistently had a higher rate of opioid prescriptions than the state average during that time period. (Buprenorphine was excluded because its use for pain is trivial statistically, compared to its use for addiction.) In 2013, Sonoma County’s rate was 885 opioid prescriptions per 1,000 residents, compared to 563 prescriptions per 1,000 residents in California. The rates were not age-adjusted, however, so the higher median age in Sonoma County may account for some of the difference between the two rates.

CURES tracks whether an individual patient has been on a daily dosage of 100 MME (morphine milligram equivalents) for 30 or more days, and whether the patient has been on a combination opioid and benzodiazepine prescription for 30 or more days. CHCF also analyzed 2010–13 data from these two measures. (In the forthcoming CURES 2.0, providers will receive alerts for these two measures and three others.) CHCF found that:

  • From 2010 to 2013, the rate of Sonoma County residents on a 100 MME daily dosage for 30 or more days was almost double California’s rate; in 2013, the Sonoma County rate was 15 per 1,000 residents and the California rate was 8 per 1,000 residents. 
  • In 2013, about 13 per 1,000 residents in Sonoma County were on combination opioid and benzodiazepine prescriptions for 30 or more days, compared to 9 per 1,000 California residents.

These various analyses of CURES data represent a first effort to contextualize opioid prescription users in Sonoma County. DHS will continue monitoring opioid prescribing and drug overdose data to better understand and describe the local factors associated with the county’s growing opioid epidemic. The data will guide local work on the epidemic, track local changes in prescribing patterns, and evaluate the impact of existing and future efforts.

Increasing Opioid Safety
In Sonoma County, various coalitions, health care providers, and work groups are using specific interventions to increase opioid safety and prevent and treat the misuse of opioids. These interventions include:

Prescribing Guidelines. The Opioid Prescribing Work Group described above is a partnership of health care organizations, providers, government agencies and community groups who came together to coordinate a unified plan for medical management of opioid use and abuse in Sonoma County. The work group is endeavoring to create and adopt standardized guidelines for primary care providers and hospital emergency departments across the county. The guidelines will serve as a vital clinical tool to reduce opioid morbidity and mortality. Implementation of the guidelines is expected to start in early fall 2016, with the goal of having at least 60% of the county’s primary care providers and all its hospital emergency departments fully participating by May 2017.

Regional Opioid Safety Coalition Grant. The Redwood Community Health Coalition (RCHC) received a grant from the California HealthCare Foundation in 2015 to increase opioid safety through a collaboration of community partners, including Partnership HealthPlan, community health centers, hospitals and Sonoma County DHS. The project features three main interventions:

  • Partnering with the Opioid Prescribing Work Group to support safe prescribing practices by developing and implementing common opioid prescribing guidelines among primary care providers and hospital emergency departments in Sonoma County.
  • Expanding access to buprenorphine (Subutex) and buprenorphine/naloxone (Suboxone) for RCHC patients. These drugs are approved by the FDA for treating opiate addiction.
  • Developing policies, procedures and funding options to ensure access to naloxone (an opiate antagonist) for opioid overdose prevention in Partnership HealthPlan managed care Medi-Cal patients.

CURES 2.0. By law, all prescribing clinicians are required to register for CURES 2.0 by July 1, 2016. The current draft of the Opioid Prescribing Work Group’s guidelines recommends using CURES 2.0 as a monitoring tool for identifying potential misuse. As mentioned before, a new feature of CURES 2.0 is an alert system that can send automatic notifications to prescribers for their patients who fit certain scenarios, such as taking 100 MMEs daily or using a combination of opioids and benzodiazepine.

Drug Medi-Cal Expansion. California plans to test a pilot program for expanding services to Medi-Cal patients with substance use disorders. Sonoma County has applied to be included in the pilot, and if its request is approved, implementation is anticipated to begin by 2017. The expanded services would be provided by Sonoma County Behavioral Health and contracted providers. In addition, residential treatment facilities with more than 16 beds that are currently ineligible for Medi-Cal funding would become eligible for reimbursement.

Safe Medicine Disposal. Disposing of personal medications is a recognized strategy for preventing opioid abuse. Research shows that 21% of the people who use medications for non-medical reasons obtain them from a doctor, and 64% obtain them from a friend or relative.9 These statistics underline the importance of safe disposal options for keeping medications out of the wrong hands. Fortunately, Sonoma County has an active disposal program for expired, unused and unwanted prescriptions and over-the-counter medications. The program uses mailbox-style bins at hospitals, law enforcement offices, senior centers and medical clinics in certain Sonoma County locations. (For a list of locations, visit www.safemedicinedisposal.org.) Not all bin locations are able to accept controlled substances, but program partners are working to ensure greater access to bins that can accept those substances.

A Long Road Ahead
No single approach can solve the opioid epidemic; it is a public health problem that must be tackled from every angle. Sonoma County is using a multifaceted, public health-based approach, which includes working with health care providers to adopt uniform prescribing practices, advocating for medication-assisted treatment, getting unwanted opioids out of the home, and increasing access to treatment for people with substance use disorders. People involved with health care in Sonoma County need to strengthen and expand these efforts, and to look for new ways to address the leading cause of injury-related deaths in our county, state and country. ::

The authors work for the Sonoma County Department of Health Services. Ms. Katz and Ms. Voge are health program managers; Ms. Kubu-Jones is administrative support; Dr. Milman is the public health officer; Ms. Struzzo is a health information specialist.
Email: sarah.katz@sonoma-county.org

Resources
For more information on opioid prescribing in Sonoma County, visit:
Unintentional drug poisoning in Sonoma County,
www.sonoma-county.org/health/publications
Understanding the epidemic through data,
www.chcf.org/oscn/data

References
1. Chen LH, et al, “Rates of deaths from drug poisoning and drug poisoning involving opioid analgesics,” MMWR, (Jan. 16, 2015).
2. California Healthcare Foundation, “Bringing communities together to prevent overdose deaths,” www.chcf.org (2015).
3. California Healthcare Foundation, “California deaths related to drug overdose and nonfatal ED visits related to opioids,” www.chcf.org/oscn/data (2016).
4. Sonoma County DHS, “Analysis of 2013-2015 drug poisoning deaths in the Death Statistical Masterfile Plus,” unpublished analysis (2016).
5. California Dept. of Public Health, “2011-13 CDPH vital statistics DSMF and multiple cause of death file,” unpublished analysis (2016).
6. California Office of Statewide Health Planning and Development, “Emergency department data,” www.chcf.org/oscn/data (2016).
7. Katz S, “Unintentional drug poisoning in Sonoma County,” Sonoma County DHS, www.sonoma-county.org/health/publications (2016).
8. Katz S, “Opioid prescribing patterns among Sonoma County residents,” Sonoma County DHS, unpublished analysis (2015).
9. Substance Abuse and Mental Health Services Administration, “Results from the 2013 National survey on drug use and health,”www.samhsa.gov (2014).
 

SONOMA MEDICINE  |  Summer 2016  |  Sonoma County Medical Association

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