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Top doctor proposes regulations to combat opioid abuse, deaths

The state’s top health official wants to limit how many pills with opiates patients can get at once, outlaw paper prescriptions for those drugs and outlaw doctors from giving out the drugs themselves.

And Dr. Cara Christ even wants opioid bottles to have a red cap to help educate patients that this isn’t just another drug.

Christ said Wednesday those steps are needed to combat a rising death rate from overdoses of the drug, both legal and otherwise. The director said she believes broad-based action is necessary, saying the problem has reached epidemic proportions.

She acknowledged under questioning that more people actually die each year in Arizona from other preventable causes, including automobile accidents and smoking-related diseases.

“We actually take all of those issues very seriously,” she said, with her agency also trying to address many of those. But she said it is the sharp rise in the number of opioid-related deaths that, in her opinion, requires the label of an “epidemic.”

Dr. Cara Christ, director of the Arizona Department of Health Services (Photo by Gary Grado, Arizona Capitol Times)

Dr. Cara Christ, director of the Arizona Department of Health Services (Photo by Gary Grado, Arizona Capitol Times)

“It’s at its highest point ever,” Christ said.

Opioid deaths hit 790 last year, up from 638 the year before. That includes 482 people who died from prescription misuse and another 308 who overdosed on heroin.

And there’s another reason she thinks the epidemic label will help.

“It also is a preventable issue that we feel by putting in certain recommendations and providing resources that public health can have the ability to impact and turn this epidemic around,” Christ said. Her target is to drop the overall death rate to 592 by 2020.

Daniel Scarpinato, press aide to Gov. Doug Ducey, also said there is a greater awareness of the problem now than even a year ago, albeit some of that generated by Ducey himself with his emergency declaration earlier this year and the publicity that generated.

Anyway, Scarpinato said, it’s not like focusing on this problem means less attention for everything else. He pointed to the governor’s directive to the state Department of Transportation to do more to keep motorists from driving the wrong way on freeways.

One of the biggest changes Christ wants is to limit prescriptions for what she calls “opioid naive” patients – those who have not been taking opiates in the past three to six months — to a pill supply of no more than five days.

“We’re eliminating the risk of people becoming opioid-use dependent while not taking the medication away from those who are currently on them and truly need them,” she said.

There is some basis for what she wants lawmakers to enact.

Using his power of executive order, Ducey earlier this year limited doctors in both the state’s Medicaid program and the state employee health plan to giving out no more than a seven-day supply of drugs. But Christ said Wednesday more recent research by the Centers for Disease Control suggests even that may be too much.

“The CDC released a paper that showed that the risk of long-term opioid use significantly increases after Day 5 of taking this medication,” she said. “So on Day 6, you have a significant increase of still being on an opioid a year later.”

Christ said that should be enough.

“Most people, according to the CDC and Arizona prescribing guidelines usually need about three days after an acute injury or surgery,” she said. “This gives an additional couple of days, with the opportunity for people to go back.”

That limit also could result in fewer pills on the black market as patients won’t have as much left over.

Christ is also proposing some limits on exactly how doctors could prescribe drugs to patients who need them.

As she sees it, Arizona law should have a limit on dosages to less than 90 “morphine milligram equivalents.” The CDC reports that the risk of overdose doubles above 50 MME.

Christ acknowledged there are probably some patients who already are getting a higher dosage. Her proposal would require that to be tapered off to that 90 MME figure, albeit over a period of years, with the law allowing for certain as-of-yet-to-be-specified exceptions.

The question of illegal opioid sales also fits into Christ’s recommendation to allow only electronic prescriptions for the drug.

“Patients wouldn’t be able to take a paper prescription off of a prescription pad to a pharmacy,” she said. “That has high risk for abuse as well as fraudulent prescriptions.”

And Christ said it should not interfere with the ability for patients to get the drugs they need, saying there’s no reason an electronically written prescription could not be ready by the time someone gets to the pharmacy.

Along the same lines, Christ wants to overturn laws that now allow doctors to distribute opioids themselves.

“What you don’t want is the same person who is prescribing to be the same person who gives you the pills,” she said. If nothing else, Christ said opioids should be distributed by pharmacies who can check electronic databases to see if patients are taking other drugs that might interact badly and create health problems.

Doctors also would have to have at least three hours a year of continuing medical education courses on the use of opiates.

She also wants to remove laws that now preclude the state pharmacy board, which keeps track of prescriptions for narcotics, from informing medical boards when it appears a doctor may be overprescribing. It would then be up to that medical board to review the doctor’s records and determine if proper medical standards are not being followed and discipline is appropriate.

Another change would be to amend the state’s “Good Samaritan” laws to cover those who report apparent drug overdoses. Christ said situations arise where two people are both doing illegal drugs and one goes into convulsions.

“They’re afraid of when law enforcement and first responders show up they’ll be arrested for illegal activity,” she said. Christ said granting them immunity for their own acts in these situations ensures that the other person can get prompt medical attention.

 

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