Prescriber Guidance Letter
California Department of Public Health Director and State Health Officer, Dr. Karen Smith, in conjunction with the Statewide Opioid Safety (SOS) Workgroup, has developed an opioid resource letter for providers who see patients and write prescriptions for pain management. The letter specifically offers resources for health care providers to assist them with patients who may need special medical guidance due to opioid addiction. This letter is issued in the hope that it benefits prescribers with patients needing assistance around opioid use. Efforts to prevent opioid addiction and overdose in California are appreciated.
Award Announcement (February 28, 2017)
The California Department of Public Health/Safe and Active Communities Branch is pleased to announce the twelve awarded recipients for the Request for Applications - Local Coalitions to Address Opioid Misuse and Abuse. These awardees will be implementing comprehensive local opioid safety coalition activities beginning June 2017 through February 2019.
Prescription medication misuse and overdose is a national epidemic, according to the Centers for Disease Control and Prevention (CDC). The long-term health consequences are severe and can lead to limitations in daily activity, impaired driving, mental health problems, addiction, overdose and death. When it comes to unintentional injury deaths in the U.S., more people die from prescription medication overdoses than in motor vehicle crashes. In 2014, more than 28,000 people died from opioid overdose, with 14,000 of those deaths involving prescription opioids.
In the past, prescription opioids (such as hydrocodone, oxycodone, morphine and codeine) were prescribed for relieving short-term (acute) pain. Today, they are increasingly being used to treat chronic, non-cancer pain, such as back pain or osteoarthritis, despite serious risks and the lack of evidence about their long-term effectiveness. Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014, but there was not an overall change in the amount of pain Americans reported during that same time period.
In California, opioid related poisoning/overdose deaths appear to have leveled off since 2009; however, they remain high with 2,024 deaths in 2014, (a rate of 3.5 per 100,000). Additionally, all opioid-related poisoning/overdose emergency department admissions have continued to increase steadily, with over 4,100 admissions in 2014. The majority of these visits, from 2006 to 2014, involved opioid pharmaceuticals. Furthermore, some California counties have opioid prescription death rates that are two to three times higher than the national average.
One of the unintended consequences of this prescription drug epidemic has been the increase in heroin addiction and overdoses, in part due to the transition from prescription opioids to less expensive heroin street drugs. Heroin is the one exception to the statewide leveling trend among opioid related deaths. Heroin deaths have continued to increase steadily by 67% since 2006 (with a 2014 rate of 1.4 per 100,000) and account for a growing share of the total opioid related deaths.
As the most populous state in the country (38.8 million residents as of 2015) the raw number of individuals affected by improper prescribing and misuse is substantial, with rates varying significantly across counties, and even within counties. California’s highest opioid overdose rates are in several northern California rural counties. For example, Lake and Shasta Counties have prescription opioid related death rates that are two to three times higher than the national average. Additionally, there are several large urban counties (San Francisco, Orange, and San Diego) with higher than state average rates, accounting for a greater total number of deaths.
For state and local data on opioid mortality, morbidity and prescribing rates, visit the California Opioid Overdose Surveillance Dashboard.
What is the California Department of Public Health Doing?
Statewide Opioid Safety (SOS) Workgroup
In response to this national epidemic, the California Department of Public Health (CDPH), and its state partners, convened a Statewide Opioid Safety Workgroup in spring 2014.
This workgroup is exploring opportunities to improve collaboration and expand joint efforts among state agencies working to address this epidemic. The goals for the Workgroup are:
- Promote safe and effective prescribing and dispensing policies and practices.
- Guide appropriate patient use, storage and disposal of prescription drugs.
- Support proper pain management methods.
- Minimize the unintended consequence of increased heroin use.
- Promote the expansion of medically assisted treatment opportunities.
Workgroup Membership is representative of many agencies and disciplines, bringing diverse perspectives and valued content expertise.
As the action arm of the Workgroup, four Taskforces have been convened to address specific aspects of the problem. These Taskforces represent different disciplines and focus on: Communications and Outreach, Data Gathering and Sharing, Integrated Health Care and Policy, and Treatment.
Prescription Drug Overdose Prevention Initiative
In 2015, the California Department of Public Health was awarded a four year grant from the Centers for Disease Control and Prevention (CDC) to implement a comprehensive program addressing opioid misuse and abuse in California’s counties most impacted by the opioid epidemic. The Prescription Drug Overdose Prevention Initiative (PDOP) focuses on three primary interventions:
1) promotion and increased use of the Controlled Utilization Review and Evaluation System (CURES), which tracks and monitors all opioid prescriptions within California;
2) engagement of health insurance plans and health care systems to implement safe prescribing policies, expand Medication Assisted Treatment, promote increased use of naloxone, and conduct physician and pharmacist educational outreach; and,
3) local health department and community coalition capacity building through dissemination of local prescribing and health consequences data, outreach and education, and other community-based interventions.
PDOP also develops and maintains a data dashboard which provides statewide and local data on opioid mortality, morbidity and prescribing rates.
Together, CDPH and the California HealthCare Foundation (CHCF) also support several local opioid safety coalitions. These coalitions are responsible for much of the innovative efforts taking place at the local level and can serve as models for implementing evidence-based practices at the local level addressing health care systems, providers, consumers and the general public.
What Can You Do?
Opioid misuse and overdose prevention and safety is a shared responsibility. Everyone has a role. While the information provided here highlights key points, more detailed descriptions, graphics, guidelines, and downloadable materials can be found on the CDC website.
- Ask your physician about other ways to manage your pain that do not involve prescription opioids.
- Understand the risks and side effects of taking prescription opioids.
- Ask your physician to prescribe naloxone if you will be taking opioids at home (to prevent overdose).
- Tell your physician about any mental health, addiction, or dependency issues you may have or had in the past.
- Help prevent misuse and abuse by keeping medications securely stored. Never share or sell prescription opioids.
- Make sure medications are used in the manner in which they are prescribed.
Physicians and Dentists
- Follow recommended prescribing guidelines from the CDC and the California Medical Board when writing opioid prescriptions.
- Recommend the use of non-pharmacologic therapies (such as exercise and cognitive behavioral therapy) and non-opioid pharmacologic therapies (such as anti-inflammatories) for patients with chronic pain.
- Do not prescribe opioids routinely for chronic pain.
- Check the Controlled Substance Utilization Review and Evaluation System (CURES) to ensure prescription regimen is appropriate for the patient and to avoid concurrent prescribing.
- Make sure patients understand the risks of opioid medications.
- Screen patients for mental health, drug abuse, and addiction problems.
- “Start low and go slow” when prescribing opioids.
- Regularly monitor patients to make sure opioids are improving pain and function, without causing harm.
- Prescribe an opioid antagonist (Narcan/naloxone) for patients taking long-term or high-dose opioids, which can be administered in the event of an overdose.
- Learn how to provide Medication Assisted Treatment (MAT) for patients with addiction or make a referral for opioid use disorder to a treatment specialist or treatment program. Do not “fire” a patient who needs your assistance recovering from addiction.
- Understand the patient’s treatment plan and condition, and ensure that the prescription is for a legitimate medical purpose.
- During consultation, ensure patients understand the proper dosage and directions for use.
- Educate patients about side effects and risks.
- Explain the importance of monitoring, safeguarding and properly disposing of unused pain medications.
- Explain the importance and benefit of having Narcan/naloxone available for overdose prevention.
Additional Resources and Information