Tribes reach out to legislature to combat prescription abuse
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HELENA – In the past month the Confederated Salish and Kootenai Tribes launched an aggressive initiative to curb drug abuse, but last week Tribal Director of Health and Human Services Kevin Howlett implored the state legislature to take additional steps that might help combat the problem of prescription abuse.
In an interim Children, Families, Health and Human Services Committee hearing, Howlett told legislators that lack of funding for Indian Health Services has led to a devastating cycle of physicians over-prescribing painkillers in an effort to band-aid health problems when there aren’t adequate resources to deal with them appropriately.
“It is an epidemic now, and it has been an epidemic for a number of years. That in part is because of the situation that most tribal members are placed in terms of access to health care … meaning Indian Health Services is woefully underfunded,” Howlett said. “Not having the ability to take care of medical situations, people are given a prescription for pain pills to mitigate pain and … after three months we’ve got people who are hooked, and that have been hooked for 20 or 30 years.”
Data analyzed by the Montana Department of Health and Human Services and presented to legislators in the same hearing where Howlett spoke showed that Lake County led the state in rate of deaths caused by opioid painkillers per 100,000 people. That data was compiled from death records from 2000 until 2012. The state averaged 4.2 opioid-related deaths per 100,000 people during that time frame. The Lake County rate was more than double the state number, at 10.2 deaths per 100,000 people.
“Toxicology screens are not conducted on all deaths, so it’s likely these estimates provided are underestimates and that there are probably more cases that were missed,” Montana Public Health Representative Todd Harwell told the legislators.
On the Flathead Reservation, tribal pharmacies dole out about $8 million worth of drugs each year, of which about 60 percent are narcotics, according to Howlett.
“That’s an unconscionable amount of drugs,” Howlett said.
Last month tribal pharmacies put in place restrictions meant to limit the number of narcotics on the street, but because most tribal healthcare is provided through the private sector, the Tribes’ efforts can only go so far as state law allows on some fronts.
Howlett gave an example of two tribal doctors who noticed a non-tribal practitioner in the Flathead Reservation community doling out an inordinate amount of hydrocodone to pregnant women.
“My medical staff was aghast at the volume and the frequency of those drugs,” Howlett said. A complaint was filed with the state medical board examiner’s office, but the case was dismissed due to lack of state regulations that set guidelines for the matter.
In the past few years most states have had to grapple with establishing guidelines of some sort for the dispensing of opioids and painkillers, according to Dr. Gary Franklin, director of the Washington State Department of Labor and Industries. Franklin spoke at the hearing about how Washington has reformed the law in his state to combat prescription abuse.
“We have a pretty good story to tell here in Washington,” Franklin said. “We feel pretty proud of beginning to reverse this whole problem of prescription opioid epidemic related to chronic pain.”
Washington, like many other states, fell prey in the late 1990s to scientifically unsound medical advice that encouraged doctors to prescribe opioids to people with chronic pain. Doctors were told that tolerance to the drug wasn’t a problem and that if patients did develop tolerance, they should be given a higher dosage of the drug, Franklin said. Drug company advocates lobbied state legislators to make the painkillers more available.
“By about 1990 or so, at least 20 states, probably more than that, passed new laws and regulations and policies that moved each state from a near prohibition of opioid for chronic pain to really dosing without any guidance whatsoever,” Franklin said.
Washington’s regulation, which is similar to Montana rules written in 2002, was worded in a way that no disciplinary action could be taken against a physician based on the number of opioids dispensed.
“Your disciplinary board would have a hard time doing something about a doctor who was even handing out bags of opioids because of this language,” Franklin said.
In 2009, Montana updated its guidance for physicians, but still included a passage that explicitly stated doctors should not fear prosecution for prescribing the painkillers.
In the meantime, drug companies coined the phrase “pseudo-addiction,” as they continued to pedal their product, Franklin said. But evidence mounted that not only were the opioids addicting, they were also deadly.
Data shows 100 percent of people on opioids for at least three months have some degree of dependency, Franklin said. About 50 percent of those people will still be on opioids five years later. That percentage increases to 85 percent for people who have substantial mental health problems.
“Over 100,000 people in this country have died from this epidemic of
over-prescription of opioids in the past 15 years, compared to 58,000 people who died in Vietnam,” Franklin said. “This is probably the worst man-made epidemic in history.”
In April 2007 Washington became the very first state to advise against increasing the dosage of opioids prescribed to patients who developed tolerance to the medicine. A plethora of online resources for physicians were also released, Franklin said.
In 2010, specific dosing guidances and regulations were passed in the Washington state legislature. By 2012, the number of prescription opioids prescribed to people in the worker’s compensation program had gone down, and the number of people hospitalized because of overdoses also decreased.
The number of painkiller related deaths decreased by half in that two-year period.
Since 2012, the state of Washington has continued to roll out stricter regulations and specific guidance for physicians on how opioids should be used.
Franklin gave many suggestions on how Montana could improve its system, but at the crux of all of them was the idea of a top-down, multi-agency approach where all entities are working collaboratively on the same page.
Howlett said the Tribes are willing to work with the state on the issue.
Senator Johnathan Windy Boy said he would like to see he and Howlett chair a subcommittee to gather additional information about prescription abuse in Indian country.
“It’s kind of like we’re on Mars and the tribes are on Venus,” Windy Boy said of cooperation between the state and its seven tribes in combating opioids.
On all but the Flathead and Rocky Boys Reservations, it may be more difficult to bring about change in policy because mental health and substance abuse services are administered by a broken Indian Health Service system, Howlett said. Local government often has little say in the priorities of those Indian Health Service programs, although they want to, Howlett said.
“I think there are people at the tribal level who desperately want to
address these problems,” Howlett said.
The committee has a few more months to gather information, before it makes recommendations for the next legislative session.
For Howlett, who has lost three immediate family members to the epidemic, moving forward is a personal victory.
“From a personal perspective this has been a 50-year quest of mine, to see the day come where we would begin to look at the laws in this state and the prescribing habits, and the unlimited accessibility to these drugs.”
The stakes are high, he noted.
“If we don’t do something about it, we’re going to lose a generation of people,” Howlett said.
