WASHINGTON — When a recent CDC report noted that deaths from prescription painkillers have reached epidemic levels in the past decade in the United States, the news hit especially close to home for American Indians and Alaska Natives.
|Prescription drug abuse was discussed at the White House Tribal Nations Conference shown here. – Official White House Photo by Pete Souza|
That data, published in a recent issue of the agency’s Vital Signs, revealed that American Indian or Alaska Natives, along with whites, are at a greater risk for overdosing on prescription painkillers than other groups. In addition, about 1 in 10 American Indian or Alaska Natives age 12 or older used prescription painkillers for nonmedical reasons in the past year, compared with 1 in 20 white Americans and 1 in 30 black Americans.
In fact, the CDC data on prescription drug painkillers may underestimate the problem, IHS acknowledged.
“The mortality review was done using the public-use multiple cause of death database, which NCHS often uses to describe differences in mortality in the U.S.,” IHS officials told U.S. Medicine in a written statement. “Our experience using these data is that there may be varying degrees of racial misclassification leading to artificially lower rates through the misidentification of AI/AN as non-AI/AN. It is possible, therefore, that the reported rates are actually even higher among AI/AN and that the disparity with white populations is greater. Other than the possibility of misclassification, however, the methods are sound and the data set is a reasonable one to use for this study.”
Addressing Prescription Drug Abuse
In general, prescription drug abuse and misuse has been a problem that has concerned tribal communities. At the White House Tribal Nations Conference held last month, representatives of the 565 tribal nations gathered with administration officials to highlight various issues in private sessions.
Drug problems were one of those issues, according to Tom Perrelli, Department of Justice associate attorney general.
“One of the things that we heard this year very clearly was that there was an enormous range of drug problems on different reservations,” Perrelli said at the conference, summarizing what his group discussed. Some reservations were reporting problems with methamphetamine use, others were reporting marijuana use and still others reported prescription drug abuse, he said.
As with the rest of the country, pain management is one way that American Indians and Alaska Natives may eventually get addicted to prescription drugs, according to Walter Lamar, president and executive director of Lamar Associates. Lamar previously served as deputy director of the Indian Affairs Office of Law Enforcement and senior adviser to the Department of the Interior’s Office of Law Enforcement and Security.
His company, Lamar Associates, has partnered with the National Association of Drug Diversion Investigators (NADDI) to create a prescription abuse drug prevention training program for tribes. In 2011, the Department of Justice awarded Lamar Associates a grant to offer 22 additional training opportunities in partnership with NADDI and the National Indian Child Welfare Association.
Lamar, who is a member of the Blackfeet Nation of Montana, said that IHS also has the added challenge of inadequate levels of funding. That means beneficiaries sometimes have to use pain medication longer while they are awaiting surgery and have more opportunities to develop addiction.
There also is the problem of “doctor shopping” that takes place when “people go from one clinic or doctor to the next and go to a neighboring reservation and get another prescription,” Lamar told U.S. Medicine. “There are a host of ways that these drugs are being provided to folks.”
In addition, research suggests a link between alcohol use disorders and using prescription drugs nonmedically. Two studies by University of Michigan researchers published in 2006 suggested that men and women with alcohol-use disorders are more likely to report nonmedical use of prescription drugs than people who do not drink.
One of the studies noted that Native Americans appeared to be at increased risk for nonmedical use of prescription drugs and that this should be the focus of future research.
“Prescription-drug abuse is a growing issue in Indian country,” IHS officials told U.S. Medicine. National studies indicate that prescription-drug abuse appears to strongly correlate with alcohol-use disorders and found AI/ANs to be at particular risk for this combination of conditions.”IHS Grapples with Pervasive Prescription Opioid Misuse in Tribal Areas Cont.
Addressing Prescription Drug Abuse
Christopher M. Jones, PharmD, MPH, LCDR, USPHS, a subject-matter expert on prescription-drug overdose in the CDC Injury Center’s Division of Unintentional Injury Prevention explained in a CDC blog posting that CDC believes that improving the way drugs are prescribed can help reduce the number of people who are abusing and overdosing on prescription painkillers.
Prescription drug monitoring programs and patient review and restriction programs also are measures that can address prescription drug abuse in the U.S., he said.
“Prescription drug monitoring programs — which track controlled substance medications in a state — are a tool used by healthcare providers to identify patients who may be at risk for an overdose. Patient review and restriction programs require patients who are inappropriately using controlled substances to receive them only from one physician and one pharmacy,” he wrote. “Both of these programs can improve patient care while also helping to reduce abuse and overdose.”
The Indian Health Care Improvement Act, enacted in 2010, requires the creation of a prescription drug monitoring program for IHS, tribal and urban healthcare facilities. IHS is working on implementing the monitoring program, the agency told U.S. Medicine.
According to the IHS, the agency “has set in motion a plan that will establish electronic connectivity between IHS facilities and the Prescription Monitoring Program database of the state in which the facility resides,” IHS officials said in a statement. “Connectivity will be completed for all IHS and urban Indian programs and will be offered to tribal programs by January 1, 2013. So far, connectivity has been established for all IHS facilities in North Dakota, South Dakota and Minnesota. Test sites are being selected for all other states containing an IHS, urban Indian or tribal program. Work is ongoing.”
Other efforts also are in place, according to IHS. From 2002 through 2011, the IHS reports it has provided 29 training sessions for Office-Based Opioid Therapy. IHS also has trained 200 physicians and 200 midlevel practitioners in the use of buprenorphine, which is employed to manage drug addiction.
IHS officials also said the agency has increased surveillance of in-house controlled-substance utilization at the facility, area and headquarters levels.
“IHS Service Units are required to perform perpetual inventories of all CII drugs, and monthly or more frequent verification of the validity of all controlled-substance prescriptions. All controlled substances are ordered electronically. These orders are now monitored by the National Supply Service Center, the Prime Vendor and individual Area Offices. Area pharmacy consultants are required to review Service Unit control systems annually.”
The agency also charged a multidisciplinary Pain Management Taskforce with studying the problem and developing a national pain management policy. That policy now is going through an approval process, according to officials.
“The policy details system controls that should be in place at the area and service unit levels, requires the signing of a pain agreement between the prescriber and the patient, defines what should be done if the agreement is broken, requires urine drug testing, requires medication counts, requires a local Chronic Pain Management Review Committee and generally empowers the prescriber to enforce the agreements,” IHS officials said. “In addition, the policy encourages facilities to join state run controlled substance reporting systems that monitor patients going to multiple providers.”