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2017-01-27 / News

The Pain of Addiction

A Q&A with Pennsylvania’s Physician General, Dr. Rachel Levine
By r. brock pronko
Regional Business Analyst


Levine Levine In 2015, Pennsylvania ranked ninth in the nation in drug overdose deaths, with heroin most often being responsible for the fatal overdoses. Pennsylvania’s physician general, Dr. Rachel Levine, calls drug overdoses “the biggest health crisis in Pennsylvania.”

She estimates that in 2014, about 2,500 Pennsylvanians died from heroin. Over 3,400 died from overdoses in 2015, with heroin or opioid painkillers found in 81 percent of the victims. When tallied, Levine expects deaths from overdoses in 2016 to be even higher, but she is optimistic that we are now turning the corner, thanks to wider access to Naloxone, a drug that counteracts heroin overdoses, new drug education and prevention programs in schools, and expanded treatment programs in rural counties.

PBC: What role did opioids play in the drug epidemic, and what is the connection between opioid addiction and heroin use?

Levine: The origins of this epidemic are complex - it’s the perfect storm of several factors. The roots go back 20 years when federal regulatory authorities such as CMS and the Joint Commission, which regulate hospitals, asked physicians and other medical providers to do a much more robust job assessing and treating acute and chronic pain. That’s when pain became the fifth vital sign. I remember in my adolescent eating disorder clinic at Penn State Hershey, we had to assess acute or chronic pain, and unfortunately, the expectation was not only would we treat it, but that we would somehow eradicate pain.

At the same time, drug companies developed some extremely powerful opioid pain medications that were marketed as not being addictive, but that ultimately proved to be very false. Over the course of 15 years, the rate of opioid prescriptions for pain increased 400 percent.

The third piece of the puzzle was the influx of cheap, powerful and plentiful heroin from Central and South America and Asia into the U.S. The initial overdoses were primarily from prescription opioids, but in the last five years, heroin overdoses have spiked. Patients became dependent on prescription opioids, but then they couldn’t get more from their doctors, so they began buying them illegally. However, as opioids became more expensive, addicts have turned to heroin, which is much cheaper or more readily available.

PBC: How has Naloxone helped stem the epidemic of overdoses? Did you get pushback for allowing residents to buy the drug without a doctor’s prescription?

Levine: Naloxone has been available for physicians for decades, but community use of the drug is new. Under the auspices of Act 139 of 2014 or David’s Law, I signed two standing order prescriptions the following year. The first was for first responders to have access to Naloxone, which includes state police, municipal police and fire departments. Over the last two years, the police have saved over 2, 200 lives throughout Pennsylvania using Naloxone to reverse an overdose.

In October 2015, I signed a standing order prescription to the public so anyone can go into a pharmacy in Pennsylvania and obtain Naloxone, either the intranasal form or the autoinjector, which looks like an EpiPen. Based on the prescription of the physician general, they don’t need a prescription from their doctor. We want the public to have access to Naloxone in case they have a loved one who is at risk of overdosing. If they administer Naloxone, they don’t just give it and go back to bed. They are told to call 911 so that the patient can be brought to the emergency department for further medical treatment, as well as what we call a warm handoff, which is a facilitated referral for treatment.

I reject completely that doing this is controversial. All Naloxone does is save a life and everyone deserves a chance at life and a full recovery.

PBC: In September 2016, Governor Wolf addressed a joint session of the General Assembly asking them to push through reforms to help the state fight the growing opioid and heroin epidemic in the state. Can you summarize the plan?

Levine: If we look at our response, I would put them into three buckets. The first ‘bucket’ is ‘rescue’ using Naloxone, which I already talked about.

The next is ‘prevention.’ From a community point of view, in terms of young people, the Dept. of Drug and Alcohol Programs is working with the Dept. of Education on prevention efforts in schools. The Dept. of Health has been working on opioid stewardship, which means that physicians and other medical providers need to do a much better job in prescribing opioids more carefully and judiciously.

We are also working with the deans of all the medical schools in the state and providing them clinical competencies for all graduating medical students. We will be working with other health professional schools, too, and have been providing these guidelines for continuing medical education in collaboration with the Pennsylvania Medical Society and other professional societies.

We have also been working on a set of nine prescribing guidelines, which we have brought to the respective professional boards, such as the Board of Medicine, for their affirmation and acceptance. For example, explaining how doctors can determine if their patients are doctor shopping and might need an intervention. That’s a critical program that’s been running for about six months now.

The third bucket is treatment. To expand treatment, the governor has worked with the Dept. of Human Services to create centers of excellence to expand treatment to rural areas. Until recently, it was impossible to access treatment in rural areas. Treatment was mainly in urban and suburban areas. With these new centers of excellence, which are throughout the state, patients with Medicaid can access quality treatment either with or without medication- assisted treatment.

I’m a positive and optimistic person, and I think that with all of us working together, we will gain a handle on this problem, although there’s no quick fix. We’re in it for the long haul and the governor and I are committed to addressing this crisis. .

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