After a decade that has seen a dramatic increase in the per-capita distribution and prescription of opioids and a nearly four-fold increase in opioid poisoning deaths, Ohio legislators last year passed HB 93, a measure which established a range of rules, guidelines, and license requirements to crack down on the operation of “pill mills,” restrict the dispensing of illegal opiate pain medications, and require specific medical education for physicians engaged in the treatment of chronic pain.
Among the key provisions, the measure expands the reach of the state’s prescription reporting system to include all opiate prescription and dispensing, including that in hospital ERs and pharmacies, caps the amount of opiates that can be prescribed or furnished by physicians, and steps up scrutiny of clinics where the majority of patients are being seen for pain-related treatment.
The offshoot of the recent legislation has been a six-month crackdown on so-called “pill mills,” clinics where unscrupulous or careless prescribers offer opiates with little or no medical assessment. In southern Ohio’s rural Scioto County, where 9.7 million opioid doses were dispensed in 2010—some 123 doses per county resident—this has meant closure of 13 “pill mills” since the legislation’s passage in the five months since HB 93 passed.
Ohio’s most significant problems with illegal opiates—so called “hillbilly heroin—occur in the counties that border West Virginia to the east and southeast, and Kentucky to the south along the Ohio River. Here, in counties like Scioto, opiates have poured in to meet local demand or move further north. To help stem the tide, Ohio has joined an interstate Opiate Task force with Kentucky, West Virginia, and Tennessee and engaged in a multi-year effort to interdict the flow (law enforcement), identify abusers, and foster treatment alternatives.
Low-dose treatment could stretch limited budget
In Ohio, treatment alternatives will soon include a new protocol that recommends medication-assisted opiate treatment (MAT). Ohio’s proposed MAT protocol recommends that trained prescribers use smaller doses of buprenorphine and suboxone, and other medications like naltrexone where indicated.
According to Orman Hall, director of the Ohio Department of Alcohol and Drug Addiction Services (ODADAS), this treatment approach was developed in part through the research of Ted Parran MD, a professor of medicine at Case Western Reserve University and a principal of GMA Consultants, an addiction treatment education provider, both based in Cleveland, Ohio.
According to Hall, the proposed MAT protocol, combined with behavioral therapy, improves the rate of long-term recovery to about 50 percent, far exceeding the 80 percent relapse rate for unmedicated patients. But the low-dose approach, combined with the state’s plan to make the protocol available in cooperation with federally qualified health centers (FQHCs), offers other advantages.
Hall says that by working with lower doses and purchasing advantages available to FQHCs, FQHC look-alikes, and other designated healthcare providers, the now-limited funding available to the program, just $1 million provided by the Appalachian Regional Commission, can be stretched. The result, says Hall, is that “we can treat people longer with the medications and see a lower incidence of relapse.”
To launch the program and gauge its effectiveness, a pilot program is now being established at an FQHC in Jackson, Ohio. This pilot will report results to the Ohio Valley node of the NIDA-funded Clinical Trials Network.
At this point, Hall says that the goal is “to concentrate on proving that this protocol works, that it will provide a clinically effective result.” If the low-dosage protocol produces the results seen in earlier study, Hall says that there is a potential to open two additional sites in 2013.