Stopping the flow of opioids in Delaware

DOVER — So many opioid pain medications pour into Delaware each year that every person could hold a small mountain in the palm of their hand.

According to a Drug Enforcement Agency database obtained by the Washington Post, the First State received 276,177,276 prescription pain pills from 2006 to 2012, or nearly 39.5 million annually.

That’s about 40 pills each year for every person in Kent County.

In Sussex, it’s higher: about 62 pain pills per person annually.

Those statistics aren’t lost on Delaware’s health officials and policy makers, who have taken steps to stem the crisis in Delaware.

And it’s certainly not lost on the families who have buried their loved ones, dead from overdoses, or for those individuals who have spiraled into addiction and battle each day to stay sober.

The abuse of prescription pain medicines contributed to just over a third of the First State’s 400 overdose deaths in 2018.

In addition, the state currently has the highest national rate of high dose and long-acting prescriptions written to patients. While opioid prescribing rates decreased 25 percent from 2013 to 2017, Delaware is still ranked 18th nationally.

According to Lt. Gov. Bethany Hall-Long, the state has taken numerous steps to combat the opioid epidemic and has succeeded in slowing but not stopping the crisis.

Delaware has invested more in substance abuse and mental health and adopted an approach that views addiction as a disease to be treated rather than a crime to be punished. With that new approach comes more emphasis on treating addiction and laws loosening or even eliminating punishments for drug-related offenses.

Groups like the Addiction Action Committee and the Behavioral Health Consortium help coordinate efforts and provide recommendations to state agencies. Some of those suggestions are passed on to legislators and turned into law.

The state now has an overdose system of care, meaning a plan to get victims into treatment as soon as first responders arrive. Other laws include requirements on substance abuse and mental health coverage for health care providers, access to a medication that can counteract the effects of an overdose and the establishment of a committee to study drug deaths.

Another big part of what the state is doing is a little more abstract: informing and changing public opinion on addiction and the stigma it carries.

“It’s OK to not be OK,” Lt. Gov. Hall-Long said. “You don’t have to struggle alone.”

Increased outreach by the Department of Health and Social Services and other state entities has made a difference, she said.

But despite that increased focus, the number of deaths continues to climb.

Four hundred Delawareans fatally overdosed last year, up from 343 in 2017.
Per an analysis of the 2017 deaths conducted by the Division of Public Health, 67 percent of the overdose victims were male, 76 percent were between the ages of 25 and 34, 79 percent were white, 59 percent were never married and 24 percent had an opioid prescription in the year before their death.

With the study and other tools, officials have said they hope to be able to pinpoint and stop potential overdoses.

Asked if what the state is doing is making a difference, given that the number of deaths keeps rising, officials note it’s impossible to know what the impact of the epidemic would be without Delaware’s investment.

And Lt. Gov. Hall Long points to current public health statistics to show that tangible proof could be coming that efforts are paying off in Delaware. According to DPH, as of Sept. 3, there were 194 suspected overdose deaths in Delaware this year.

Messages in Georgetown to those who lost the battle against drug use.

While there’s still about 30 percent of the year left, including the holidays, which Lt. Gov. Hall-Long noted sometimes see a spike in overdoses, that figure means Delaware is on pace to fall short of 2018’s total.

The last time Delaware’s overdose total fell? 2012.

Tracking the problem
The state has taken action in the past five years to stem the flow of pain pills to patients, through legislation that limits the number of pills prescribed and that changes treatment approaches.
Delaware also has joined other states in filing lawsuits against pharmaceutical companies in an effort to hold them accountable for their practices in the past decade.

The Washington Post’s DEA report found that from 2006 to 2012, at least 276 million pain pills arrived in Delaware.
Of that, 106,132,970 of the pills were distributed by Walgreen Co. and 106,293,320 were manufactured by Actavis Pharma, Inc. Manor Pharmacy in New Castle got the most pills.

But large amounts, the report showed, flowed to Downstate Delaware.
In Kent County, there were 44,551,410 prescription pain pills supplied, enough for 40 per person per year.

Dozens of pharmacies dispensed those drugs, but according to the DEA report, leading the list were:

• Two Walgreens (formerly Happy Harry’s) locations in Dover that dispensed 5.65 million pills
• A pair of Rite Aid stores dispensed 5.06 million, and
• Atlantic Apothecary in Smyrna dispensed 2.34 million.
An attempt to reach Atlantic Apothecary for comment was unsuccessful.

Overall, Walgreen distributed 17.3 million pills in Kent County and 17.9 million were manufactured by Actavis Pharma. In Sussex County, those numbers were 33.3 million and 32.1 million, respectively.

As for distribution in Sussex, the DEA report found that the 82,872,450 prescription pain pills — enough for 62 pills per person per year there — were supplied primarily by these pharmacies:

• The Pill Box Pharmacy in Milford led with 7.13 million
• Four Walgreens (noted as the former Happy Harry’s in the report) pharmacies in Lewes, Seaford, Milford and Millsboro got a combined 13.77 million pills.

Pill Box Pharmacy Head Pharmacist Edward Asare said at one point the drugstore was filling about 500 prescriptions a day.

“It was very busy for a small pharmacy and there was a lot of pressure for those seeking them for medical reasons such as insulin for diabetes,” he said. “We’ve seen a great reduction in controlled medicines presented since then.”

In late April, Delaware Attorney General Kathy Jennings joined a nationwide push to sue pharmaceutical companies for allegedly sparking an addiction epidemic through marketing efforts that misled and concealed the dangers of treating chronic pain with opioids.

At that time, she said, “The seeds of this epidemic were sown by opioid manufacturers and distributors who put profits above human life. These companies knew exactly how addictive their products were and nevertheless aggressively pushed them into our state, selling more than 276 million prescription pills in Delaware from 2006 to 2012 alone. We are fighting to hold them responsible for their role in the epidemic and are doing everything in our power to remediate the damage they have caused, including advocating for law enforcement assisted diversion programs, supporting the provision of Narcan to first responders, and working to get people into treatment and away from jail cells when it’s safe to do so.”

“Although manufacturers are prohibited from marketing opioids through misstatements or omissions of material facts, (the defendants) nonetheless disseminated misstatements through multiple channels. This campaign includes websites, promotional materials, conferences, guidelines for doctors, and other vehicles,” she said.

An Oklahoma judge recently rendered a $572 million decision against drug company Johnson & Johnson, and according to the Associated Press, 48 states plus around 2,000 local and tribal governments have sued companies in the drug industry, arguing that those that make, distribute and sell the drugs are partly responsible for a crisis that the CDC reports has killed more than 400,000 people across the country since 2000.

Just this week, AG Jennings filed suit against seven members of the Sackler family, owners of Purdue Pharma. “The Sacklers have blood on their hands,” she said. “More than 1,400 Delawareans suffered fatal drug overdoes from 2014 to 2018, and nearly 200 lives have been claimed by addiction this year alone.

“We cannot bring back the loved ones, friends and neighbors who have been taken by the opioid crisis — but we can and must seek justice and accountability for the victims of the Sacklers’ avarice, callousness and fraud.”

Stemming the tide
Among the efforts on the prevention side is a DPH campaign that’s nearing its launch. Delaware’s “Stem the Tide” campaign will be aimed at prescribers, asking them to closely monitor and improve prescribing habits.
That will join the state’s existing Prescription Monitoring Program and the online website

Partnering with the Department of Professional Regulation, DPH has been providing educational sessions to prescribers on how to use the monitoring program and to better identify and assist patients at-risk for substance use disorder, Director Dr. Karyl Rattay said.

Bayhealth has followed new guidelines and evidence, resulting in physicians reducing prescribed opiates by half in the past year.

“We know from the medical literature that many of the pills that were prescribed weren’t being used by the patients, so our first step was dialing back the number of pills prescribed to an appropriate number,” Bayhealth Chief Medical Information Officer Dr. Jonathan Kaufmann said. “We also work more closely with patients to communicate what the pain expectation will be post procedure and advocate for a holistic approach when appropriate. We also are using tried-and-true evidenced based methods such as Tylenol or Ibuprofen and even ice when appropriate.”

Abuse habits have shifted fatally to illicit fentanyl and other synthetic opioids, according to the DPH. In 2009, prescription drugs were responsible for nearly all overdose deaths. Only 72 percent of last year’s fatalities were spurred by opioids.

“We must continue to focus on preventing and identifying addiction and connecting people to evidence-based, comprehensive treatment and recovery services, as well as reducing harm,” Dr. Rattay said.

Opioid laws
As the number of opioid deaths skyrockets, Delaware has passed several laws relating to opioids in the past five years. Included are some of the most notable.

Opioid fee: Legislation approved earlier this year adds a tax of 1 cent per morphine milligram equivalent for brand-name opioid medications and one-quarter cent per mme for generics. A 10mg pill of oxycodone will cost an extra 15 cents for a brand-name or 4 cents for generic medication. The state estimates the surcharge would take in about $2.8 million in the upcoming fiscal year, money lawmakers say could be used for various addiction-related services.

Expanded health care coverage: Under a bill passed in 2017, health insurance providers must offer coverage for “medically necessary” addiction treatment.

Naloxone: A 2014 bill allows law enforcement to carry naloxone, a medication that can reverse the effects of an overdose. Another bill from the same year lets members of the public obtain the medication.
Immunity: Several bills grant immunity to pharmacists who dispense naloxon and individuals who administer it to someone who has overdosed.
Non-opioid methods of treating back pain: This measure, which became law in 2018, requires health insurance plans to cover physical therapy and seeks alternatives to opioids for patients with back pain.

Data collection: A 2017 measure expands the collection and sharing of data relating to overdoses.
Drug overdose committee: Legislators in 2016 established the Drug Overdose Fatality Review Commission to review opioid deaths.
Drug dealing resulting in death: In this 2016 bill, the General Assembly created a specific crime for drug dealing that causes the death of an individual.

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