Meeting Agenda – September 2018

Caldwell, ID

Hosted by Canyon County

Date:
September 17, 2018
11:00 am – 1:00 pm

Location:
2805 Blaine St, Caldwell

11:00 am – 11:05 am
Welcome and Introductions
Commissioner Tom Dale
11:05 am – 12:10 pm
Open Discussion
12:10 pm – 12:30 pm
Update – Idaho Board of Pharmacy
 – Prescription Monitoring Program and Other
Alex Adams – Director, Idaho Board of Pharmacy
12:30 pm – 12:55 pm
Opioid Efforts and the Coroner’s Office
  Dotty Owens – Ada County Coroner
12:55 pm – 1:00 pm
Director’s Report
 – Minutes and Financial Statement
Bill Larsen

Treasure Valley Partnership

Meeting Minutes – September 17, 2018

Attendees
Alicia Almazan
Dave Bieter
Gheen Christoffersen
Tom Dale
John Evans
Brad Holton
Debbie Kling
Nathan Leigh
Garret Nancolas
Guests and Staff
Alex Adams – Director, Idaho Board of Pharmacy
Dotti Owens – Ada County Coroner
Bill Larsen – TVP

Open Discussion

Canyon County Commissioner Tom Dale and welcomed everyone to the Treasure Valley Partnership meeting.

Tom said the biggest thing that is looming in Canyon County is how they get the new jail going. They have managed to authorize a temporary set up. They have been working with the City of Caldwell and are putting up temporary facilities. They will be in the parking lot of the jail and will have sewer and electricity. They will house 122 female inmates in these new facilities.

Garret said the conversations between Canyon County and the City of Caldwell have been progressing on the event center/fairgrounds. There will be some major investment in the next two to three years. Tom said the partnerships that are happening in this regard are great. The City paid for paint and the County paid for electrical upgrades on a barn facility that is near where we are meeting today.

Tom said we talk continually about property tax relief and the local option sales tax. He thinks that one issue that might be an easier lift with the legislature is to change the prohibition on school districts from having impact fees. Why should school districts not be able to have impact fees? There is a direct relationship between the need for new schools and how many new houses are being built. Right now, the school districts must go out to get a bond to build new schools.

He feels we need to appeal to the legislature on this issue.

Prescription Monitoring Program

Bill introduced Alex Adams the Director if the Idaho Board of Pharmacy. He introduced Fred Collings his Opioid/Controlled Substance Investigator.

Alex said, regarding the Prescription Monitoring Program, any opioid that gets dispensed, gets reported to them by the end of the next business day. They have virtually real time data on where opioids are being dispensed, where/when they are being prescribed and their quantities.

He indicated the number of opioids that are being dispensed in Idaho through legitimate channels is actually declining. In FY 16 we went from 1.56 million prescriptions to 1.38 million in FY 18. The data base tracks whether the prescription occurred from an Idaho Pharmacy or an out of state pharmacy. He wanted to point out that this decline in prescriptions is even occurring in the face of a growing population.

The natural question you might ask is if the number of prescriptions are going down, are they being compensated by issuing prescriptions with larger or stronger doses? They have a statistic they call the MME which is the Morphine Milligram Equivalence. And this is also declining in the same time period.

The next question they always get, is this a Boise phenomenon? They have had a decrease in MME’s in every County in the State since 2016.

What scares him in his role as the Director of the Board of Pharmacy is highlighted by a recent article in the Washington Post. Often what States find is, as you see a decrease in prescribing and dispensing opioids through legitimate channels, paradoxically, the opioid related death rate increases in the short term. This is because of a fraction of patients that were addicted will switch over to street drugs such as heroin or synthetics. It seems like we have done a good job on the medical provider end in Idaho and he worries about what the death rates will do.

Dave said if people don’t get addicted because of the prescription end, they wont switch to the illegals. So, wouldn’t this effect show up in these statistics. Alex said that the Centers of Disease control provides information that indicates few people start with the street drugs.

The long-term benefit on our downward trends is that fewer people starting opioids will result in fewer deaths over time. But in the short term the opposite has been true in other states.

Alex said that the trend we are on speaks volumes about what the long-term effect will be, but in the short term, how do we connect patients to treatment, recovery and support so we don’t see the increase in overdose deaths in the short term?

They administer the Prescription Monitoring Program. As he indicated earlier, any prescription gets reported by the next business day. This information is available to physicians and pharmacists to help identify potential abuse. Some of the potential uses that physicians and pharmacists look for is; identifying patients that are receiving opioids from multiple prescribers, identifying patients that are on high MME doses, patients that are receiving dangerous combinations, etc.

Alex said the traditional way to access their data base is, if you, as a doctor are going to prescribe an opioid for a patient. You to the PMP website and run a search for the patient’s name and this takes about three minutes. This has proven to be a hinderance as these three minutes eat up a chunk of time for a typical office visit. As of August 2017, they now have the capacity to integrate their data base with electronic micro-records. So, both St. Luke’s and St. Al’s integrate with electronic micro-records and have access to the PMP in real-time and it takes about three seconds to access data for a patient. This capability has increased the use of the PMP tremendously.

Providers not affiliated with either of these two organizations, still must search and identify through the PMP system. Very few health systems throughout the State have integrated to their system and one of their goals is to get all health systems to integrate.

However, the growth of use of their data base is tremendous. The number of searches has gone from 500,000 in a year to over 7,000,000. The use has grown, largely as a result of the integration of records but there is an increase of other physicians utilizing the program as well.

Alex said that physicians can also have a delegate access the system. So, nurses and administrators are using the PMP, obtaining reports and printing a copy for the file. As of the previous week, fewer than 10% of physicians in the State have registered to use the PMP.

In terms of potential uses of the PMP, they say their data base shouldn’t be used to dismiss patients from care. They say the data base is to be used for a physician and patient to start that conversation. “It looks, from looking at the PMP reports, that you might have a problem with opioids, how can we get you into a treatment and recovery program?”

Their goals for the future for the PMP.

1. Streamline access. Make the program as easy to use as possible.
2. Enhance the usability of the data.
3. Ensure that data is secured and is not being used for malicious activities. For example, they work to ensure that all access is in accordance with privacy laws.

In an effort to increase usability, they are doing several things. They are now sharing data with 44 other States. They have closed the gap with all our border states with the exception of Washington. The State of Washington just bid for a new vender for PMP services and they selected the same vendor as ours. Alex is optimistic they will be closing the Washington gap real soon.

They also have some decision support tools. If you log onto our website, you will see linear data of every opioid prescription has been filled by a patient including both the physician and the pharmacist after.

They have just recently instituted a program called Narxcare which will analyze the data for the provider and will segment patients into percentiles of risk. It will look at patterns of; going to multiple prescribers or multiple pharmacists, are they paying cash, or are patients doing early refills. It calculates percentiles based on risk. This gives physicians kind of a heads up on when they need to address this issue.

Garret asked if insurance carriers restrict the number times a prescription can be refilled? Alex said this is the reason behind patient’s using cash. More often or not, when patient’s start abusing, they start paying with cash. They circumvent early refill warnings and other warnings that insurers have flagged in real time.

Tom asked regarding the “unsolicited reports threshold,” a report is sent if a patient gets prescriptions from five or more providers in a month, shouldn’t this threshold be like 2? Alex said you might have a primary physician treating for something, you could have an injury treated by someone else, and you could have a psychological problem. They have analyzed this threshold and over the years, through experience they have set the threshold at five.

Alex said this five prescriptions from 5 or more providers in a month threshold, would seem like a large number to trigger an unsolicited report. Given that, in 1017 they still sent out 1,200-1,300 reports on patients going over that 5-provider threshold.

One of the things they started doing in February of 2018 they started sending a report card to every physician in the state on a quarterly basis. This report gives averages per patients on a variety of indicators and provides an average of what other doctors were doing. They got 63 calls or emails when they first sent this report out from doctor’s indicating there was no way they were prescribing such a large quantity of opioids. This has made physicians pause about their prescription practices. They have sent out three reports now. It is premature to know if it is working. However, they have triggered enough calls that he feels it is working.

Regarding legislative changes, he had mentioned earlier about some people switching over to non-prescribed alternatives. One of the ways to prevent this is to connect patients to Data-waived providers. These prescribers are ones that can use a drug called suboxone. This is a drug that helps wean people off opioid addictions.

Idaho has struggled to have access to data waived prescribers. As of 2016, Nurse Practitioners and Physician Assistants can now become data waived providers. That has increased the numbers and will continue to raise the number of data waived providers in the state.

Naloxone is a drug that reverses the effects of overdoses. In Idaho, you can obtain this at any pharmacy without a prescription. They require naloxone prescriptions be reported as of July 1. The results show that naloxone is unsubscribed in our State. About 40% of naloxone prescriptions were obtained at a pharmacy without a physician’s script. Overall, Alex was pretty disappointed with the naloxone numbers.

They changed their laws in 2016 to make it easier to dispose of opioids. They have take-back days at police offices and other locations and these have been well attended. There is some survey work that shows people are less apt to go to a police station to dispose of drugs. The more we can get these drop boxes in lower pressure settings the better.

They have 30 take back boxes in pharmacies in the State. Bill had produced a report indicating the drop box locations in the valley and there were a few private pharmacies that were participating.

Alex said pharmacies must follow a lot more the federal restrictions associated with drug disposal than a police office. This has been a hinderance in getting private pharmacies to participate. They have grant funds to pay for 60 drop boxes around the State and only 30 pharmacies have taken advantage.

Tom asked where the drugs go once they are in a drop box. Alex said the ones in a pharmacy have to be retrieved by a DEA registered reverse distributor who takes to a secured site. There is a charge for this service.

Dave asked, given the data we have just seen, does Alex have any idea if we have crested in regard to the opioid abuse problem as we reduced prescriptions. Alex said he doesn’t think we have. Dotti Owens, stated that she felt Idaho was a couple years behind the national trend. On her end, they have been seeing the effect of fentanyl from china and believes we are not on the peak of that. And this follows suit nationally as the number of prescriptions gets reduced.

Opioid Efforts and the Coroner’s Office

Dotti said she is in her first term as Ada County Coroner and has been in the field since 2006. In the last three years they have been nationally accredited. They have 28 employees. They review about 3,500 cases per year and perform over 600 autopsies. The Ada County Coroner’s office is operating as a regional facility and they have contracts with 33 counties and 3 reservations they do forensics for including toxicology and autopsies.

They have seen a huge influx of overdose deaths. They do an overdose chart on everyone on their caseload and analyze the data they develop.

What they are seeing is the number one cause of deaths is an opioid, methamphetamine and heroin mix. Their number two cause is methamphetamine and it is making a comeback. Last year they saw 6 methamphetamine deaths, they had that many in the month of August 2018.

They only had 1 death from cocaine this last year and it was in combination with fentanyl.

This year they have ad an increase in Imodium deaths. Imodium is diarrhea medicine. People are taking 60 plus pills of Imodium and it is giving them a cocaine type high. Upon autopsy, Imodium is blowing up people’s hearts.

For the year in Ada County, they are at 80 overdoses. This is not just an opioid overdose and the reason for calling them just overdoses is they are seeing multiple drugs involved in 90 percent of the cases.

Compared to the previous year, we are right on track and their doesn’t appear to any appreciable difference.

Dotti said that the numbers that are being reported are not necessarily accurate and she knows that Canyon County struggles with the same thing. Dotti said that many times a person will go into a hospital for what is suspected as an overdose and they may be in there for 6-7 days. However, the hospital destroys the tests within 72 hours. This has always been a problem. But still the number of cases they must call undetermined, has increased.

The other thing they are seeing on those numbers is we are tracking with national statistics. Age wise we are talking 42-50 year old white men. 67% of her overdoses occur in this demographic.

Dotti said she has recently been named president of the State’s Coroner Assn. She has been working with coroners around the state to get them to gather data for the purpose of being able produce reports for elected officials and others. This has been a hard thing to do.

The Ada County Coroner’s office does extensive research on any overdose that comes in. For example, they pull pharmacy information, medical and health records to identify if there has been doctor shopping or any indicators of abuse or other problems that the client was having. They look for trends on how the addiction happens.

Debbie asked what they are seeing on the mental health side. Dotti said they are seeing a lot in their CSI. She hates to say it, but the suicide rate is 1 ½ quarter ahead where we should be on the calendar year. They surpassed the last years 12-month numbers by the first part of September.

Dotti encouraged each member to be in touch with their coroner because they do have a wealth of information.

Dotti said they do a full autopsy on all the potential overdoses. The reason they do this, is by chance the tox comes back clean, she still has to be able to provide a cause and manner of death.

On each case, they also do interviews with family and friends. They have found out that a lot of the time, family members are not going to know about the addiction. Especially if it is a husband or wife situation.

As a community service, the Ada County Coroner’s office is trying to educate the public. She feels like we can slow the growth of overdoses. They are working with law enforcement agencies to identify new trends to know the kinds of things they need to test for. They are involved with both the State Strategic Plan and the Treasure Valley Opioid Strategic plan.

Under the State Plan, they are running awareness ads and are publishing drop off literature.

They have teamed up with the Office of Drug Policy to write a grant for Coroners around the State. They are offering supplemental toxicology funds. Running a toxicology is a very expensive process and a lot of the coroner offices have limited budgets. She ran an informal survey with every coroner in the State and found out that there would be at least 15 more toxicology’s done on cases around the State if the funding were available.

The other thing they are offering with this grant is training to coroner’s around the State. What they discovered is that a lot of coroners don’t understand what a potential overdose “on-scene” is going to look like. Ada County is offering a-3 day training. The participants do one day at her morgue. Then they do two days of shadowing the investigation team. The training is at no cost to the counties or the coroners.

On a national level, she sits on four committees with the National Association of Counties. They are currently writing a resolution on the opioid crisis to address the funding shortage for coroners in rural areas.

She said they are not seeing as many incidences of overdoses on prescriptions anymore. What they are seeing is an influx of fentanyl, analogs and the illegal stuff bought off the street. She recently presented in Las Vegas with a gal whose son bought schedule 2 drugs from Pakistan. The drugs came in an Amazon looking box. The point is, they are that accessible.

Alex said they play this never-ending game with Chinese synthetics that somehow fall through Federal controlled substance laws. They have had to schedule them faster in the State than the federal government.

Another thing they are seeing a trend is basically “spice” that can be bought at some of the smoke shops. Dave said he has heard a lot about this and is concerned that the mentality is that it is not addictive.

Debbie asked what it would take to change the status of spice. Alex said the legislature would have to change the controlled substances act.

Garret moved, and Brad seconded to approve the minutes and financial statement. Motion carried.