By Annette M. Boyle
ROCKVILLE, MD—This summer, the Indian Health Service (IHS) instituted new rules for pharmacists and providers designed to reduce abuse and overuse of opioids, making it one of the first agencies to directly address the burgeoning rates of addiction and death associated with narcotic medications.
Pharmacists now must check state Prescription Drug Monitoring Program (PDMP) databases whenever they dispense a prescription for opioids for more than seven days and periodically throughout chronic pain treatment.
“Checking a PDMP database before prescribing an opioid helps to improve appropriate pain management care, identify patients who may have an opioid misuse problem, and prevent diversion of drugs,” explained Leonda Levchuk, an IHS spokesperson.
The rate of drug-related deaths among American Indians and Alaska Natives has increased dramatically in recent decades, rising from five per 100,000 population in 1989-1991 to 22.7 per 100,000 in 2007-2009, Mary Smith, IHS principal deputy director, said in announcing the new policy. That puts drug-related deaths among American Indians and Alaska Natives at nearly twice the rate of the general U.S. population, which was 12.6 per 100,000 population among all races in 2007-2009.
Deaths from prescription opioid overdose have risen nearly 400% among American Indian and Alaska Natives in the past 14 years. In 1999 the rate was 1.3 per 100,000. By 2013, it had reached 5.1 per 100,000, according to the national Centers for Disease Control and Prevention.
The IHS program is one of several initiatives announced by the U.S. Department of Health and Human Services (HHS). Deaths nationwide from drug overdoses now exceed the number of fatalities from car crashes, said HHS Secretary Sylvia Burwell in program materials. In 2013, 16,000 Americans died from prescription opioid overdoses and another 8,000 from heroin-related overdoses.
The HIS has developed mandatory training on effective opioid prescribing for all of its pharmacists, as well as the agency’s 1,200 prescribers, Levchuk said.
The new rules require IHS pharmacists to access state PDMP data prior to processing any non-HIS prescription for a controlled substance and at least every three months when reissuing or refilling an IHS prescription, as well as when filling any opioid prescription written for more than seven days. Of the states, only Missouri currently lacks a PDMP.
To ensure appropriate care as well as communication of potential issues, IHS pharmacists also are required to discuss any potential abuse or diversion with prescribers, Levchuk said.
In addition, IHS pharmacists have taken the lead in distribution of naloxone, an opioid overdose-reversing drug. “Pharmacists and providers across IHS widely co-prescribe nasal naloxone to patients at risk of opioid overdose,” Levchuk said. “Co-prescribing is the process of evaluating risk as patients are receiving a prescription for opioids. If patients are deemed at risk, they are provided nasal naloxone and, along with family members, educated on overdose symptoms and administration of the naloxone.”
Intranasal naloxone was approved by the U.S. Food and Drug Administration in November, offering an easier-to-use alternative to the injectable form of naloxone that was previously available.
Because of concerns about contaminated needle sticks and injections, some first responders and primary caregivers had been using “unapproved naloxone kits that combine an injectable formulation of naloxone with an atomizer that can deliver naloxone nasally,” according to the FDA, which said the new formulation addresses these concerns. Naloxone can counter the effects of an overdose within two minutes.
Research published this summer in the Annals of Internal Medicine found that co-prescribing naloxone in a primary care setting for patients taking opioids for long-term chronic pain reduces opioid-related emergency department visits by 63% annually, compared with those who do not receive prescriptions for naloxone.1
In the study, providers were more likely to co-prescribe naloxone to patients prescribed higher dosages of opioids and those who had had an opioid-related ED visits within the previous year. Patients who received a prescription for naloxone also had 47% fewer opioid-related ED visits per month in the following six months than those who did not receive a naloxone prescription.
The study authors said they did not know how many patients actually filled their naloxone prescriptions, but their analyses indicated that co-prescribing might have a behavioral effect simply by increasing patients’ awareness of the risks associated with opioid use.
More than 90 IHS pharmacies also have partnered with the Bureau of Indian Affairs (BIA) to provide BIA law enforcement officers with naloxone for responding to drug overdoses. “To date, HIS has trained and provided naloxone to over 240 BIA law enforcement officers,” Levchuk pointed out.
The partnership aims to dispense the overdose-reversal agent to about 500 officers this year and to train them to administer emergency treatment to individuals experiencing an overdose. By putting naloxone in the hands of first responders, IHS pharmacists enable members of tribal communities to receive the fastest possible access to potentially life-saving medication when every second matters, she added.
“We know that naloxone is one of those tools that can help save the lives of overdose victims so they can get the treatment they need for their opioid use disorder,” said Michael Botticelli, director of National Drug Control Policy. The “commitment by IHS and BIA is an important example of public health and public safety partnerships to address this epidemic.”
1 Coffin PO, Behar E, Rowe C, Santos GM, Coffa D, Bald M, Vittinghoff E. Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain. Ann Intern Med. 2016 Jun 28.