Nevada is applying a new get-tough approach to the state’s opioid-abuse problem, enacting tighter restrictions on prescriptions.
Meanwhile, North Las Vegas, Reno and Clark County in Southern Nevada are threatening to sue pharmaceutical companies to recover some of the millions of dollars spent on law enforcement and emergency aid and other public services in response to opioid overdoses.
On Jan. 1, the state’s Controlled Substance Abuse Prevention Act went into effect, taking direct aim at one of Nevada’s biggest issues related to opioid abuse: prescriptions. The prescription rate for opioids in Nevada is 87.5 per 100 residents, significantly higher than the national average of 66.5 per 100, according to the Centers for Disease Control and Prevention.
The new law restricts the prescribing of highly addictive opioids such as oxycodone; tightens reporting requirements on patient information, prescription rates and overdoses; and requires physicians to conduct a physical examination, assess a patient’s abuse risk, establish a pain management plan, and review treatment after 30 days and 90 days.
All information will be kept in the state's drug-monitoring database. The bill also enacts the Prescribe 365 program, preventing physicians from prescribing a controlled substance to a patient who has already received 365 days' worth of that substance.
State and local medical professionals and addiction experts welcome the recent focus on the problem but caution that it requires many approaches. Dr. Mel Pohl, the chief medical officer of the Las Vegas Recovery Center, doesn't think stricter legislation alone is the answer, but he says it's a start.
"I don't think legislating prescribing practices is optimum behavior, but people weren't changing any other way," Pohl said. "The benefit of these policy efforts is that people are taking these potent medications way more seriously and physicians are more aware that getting people started on these medicines is a bad idea."
The downside, unfortunately, is that making prescription opioids harder to get could potentially lead to a surge in illicit opioid use, including heroin and the extremely lethal fentanyl. Additionally, limiting the prescription of opioids presumes that all those abusing prescription opioids themselves have a legal prescription, which is not necessarily the case.
"People are getting prescription opioids from people they know. [Young people] will steal their friends' parents' opioids out of their medicine cabinets," said Mark Disselkoen, project manager for the Center for the Application of Substance Abuse Technologies (CASAT) at the University of Nevada, Reno. Yet the oft-quoted opioid statistics don't parse out the differences between overdose deaths by users legally prescribed opioids and those accessing opioids through someone else's prescription.
According to National Center for Health Statistics data from 2016, the most recent year for which data is available, 42,249 people died from overdosing on opioids, with 17,087 of those deaths attributed to commonly prescribed opioids.
In Nevada, the number of opioid overdose deaths was 665 in 2016, equating to 21.7 deaths per 100,000 residents – above the national average of 19.8 per 100,000, according to the Center for Disease Control and Prevention.
Disselkoen says CASAT focuses on treatment for those with opioid use disorder, regardless of how they came about it. The center provides face-to-face and web-based training in the fields of substance abuse and mental health for those who are providing treatment, and certify all the substance abuse prevention centers and treatment programs that receive funding through the state or federal government and private practices required to do so by insurers.
Last year, Nevada received a $5.6 million federal Opioid State Targeted Response grant to combat opioid abuse. The grant has funded three opioid use treatment facilities: the Center for Behavioral Health in Las Vegas and Reno; the Life Change Center in Reno and Carson City; and Vitality Unlimited in Elko.
The facilities use medication-assisted treatment, meaning they administer methadone, suboxone, buprenorphine, and naloxone.
While some argue that treating an opioid use disorder with more opioids is just trading one kind of addiction for another, Disselkoen, whose office oversees the grant funding in Nevada, says that medication-assisted therapy is closely monitored and more effective than treatments that do not include medication.
"Outcomes are very poor with just behavioral therapy," he said, and that is largely due to the severity of withdrawal symptoms and the extent to which opioids hijack the brain.
The federal funding will allow the centers to increase their impact with additional treatment and support services, mobile recovery teams, and increased rural outreach.
Meanwhile, there’s an additional treatment variable in play in Nevada: a fully legalized medicinal and recreational marijuana industry.
Legalization advocates have argued for years that marijuana can be used as an effective alternative to opioids for chronic pain treatment, but the data does not yet exist and won't until restrictions around research are reduced.
Marijuana is classified by the DEA as a Schedule I drug – in the same category as heroin, LSD and ecstasy. For comparison, Schedule II drugs include the bulk of all opioids save for heroin: methadone, oxycodone, morphine, codeine and fentanyl. This Schedule I classification has long made it extremely difficult for researchers to conduct clinical trials examining the therapeutic effects of marijuana, even in states where the drug is entirely legal because clinical research is conducted under federal oversight.
A double-blind, placebo-controlled crossover study at the University of Colorado Denver is currently underway comparing cannabis with an opioid painkiller. It began in June 2017 and will conclude in June 2019, with a total of 100 participants enrolled.
"I'm very discouraged about the nature of the marijuana industry right now," Pohl said. The push towards legalization has led to the development of a rapidly growing industry worth $10 billion in North America alone in 2017, according to some estimates. With that kind of money on the table and a medical community still stifled from doing any kind of meaningful research, the lack of information on marijuana’s physical, psychological and social effects should be cause for concern, Pohl says.
Disselkoen also cautions against viewing marijuana as a consequence-free magic bullet.
"There are a lot of things people need to consider related to marijuana,” Disselkoen said. “It's legal now so we're going to have to live with it, but we're also going to have to deal with it."
Neither policy nor pot alone will prove to be adequate solutions, but they may be effective as part of a mix that also includes education and prevention efforts for both healthcare providers and the general public, a greater focus on non-medicinal alternatives to pain management, and increased access to mental health and substance abuse treatment services, other experts say.
The Las Vegas Recovery Center has been open for 15 years and specializes in treating opioid dependence with what Pohl calls a "functional restoration" program. It offers both inpatient and outpatient programs that treat addiction with co-occurring chronic pain and mental disorders, taking a holistic approach to treatment and helping patients discover ways to recover from chronic pain without the use of prescription pain medications through education, counseling, strength training and meditation instruction.
The nature of the epidemic is a multi-pronged problem, Pohl says. First, there is a patient with a pain condition and a desire to be out of pain.
The patient goes to a provider who doesn't necessarily have the skillset to help him or her explore non-drug-based treatments, so the provider tackles the problem with a prescription pad without considering what happens beyond the next year or two.
The problem is once a person has taken opioids for a while they develop a tolerance and need a stronger dose.
"They [pharmaceutical companies] sent the message, 'If you've got pain, opioids are the solution forever,' and that's just simply not the truth, as we know now," Pohl said.