When Congress passed legislation earlier this month making $1 billion available to states for opioid abuse prevention and treatment programs, Elisha Figueroa started thinking about all the ways that money could help Idaho.
Last week, President Barack Obama signed the 21st Century Cures Act after a bi-partisan Congress approved legislation to set aside $4 billion in funding for cancer research, drug addiction recovery and mental health services. Of that sum, lawmakers agreed to make $1 billion available to states in the form of grants over the next two years specifically for the prevention and treatment of abuse of heroin, opioids and addictive drugs.
Figueroa, administrator of Idaho's Office of Drug Policy, will be among those getting in line to get some of that money for prevention, the top mission of the office. But like many others in Idaho's world of public health, Figueroa understands the battle against opioid addiction also needs more resources devoted to treatment.
"Our state seems to be woefully lacking in resources and programs to adequately provide treatment," said Idaho Medical Association Chief Executive Officer Susie Pouliot. "We lack any sort of significant infrastructure relative to the needs in Idaho."
Last year, more than 50,000 Americans died from drug overdoses, the most in any year on record and 15,000 more than the number of people killed in car crashes, according to the Centers for Disease Control and Prevention. The increase in 2015 compared to previous years is being blamed in part on the growing abuse of heroin and prescription painkillers, a class of drugs known as opioids. Abuse of drugs like Oxycontin and Vicodin killed more than 17,500 people nationwide last year.
Idaho is hardly immune from the struggles and consequences of abuse of opioids and heroin. In 2014, 63 people in Idaho died of drug overdose, with 60 percent of those deaths attributed specifically to opioid abuse, according to state and federal data. In recent years, Idaho has managed to improve compared to other states painkiller abuse.
In 2010-11, Idaho was ranked fourth in the nation for prescription drug abuse, but in 2014-15 fell to 35th in the nation, according to the Office of Drug Policy. Still, policy makers and treatment professionals acknowledge there is plenty of work to be done to in dealing with the misuse of prescription opioids or use of illicit opioids.
Even with more federal money in the prevention and treatment pipeline, Figueroa says the challenge now is identifying how best to use the money available to states.
“Sometimes we get so passionate about our work, and we want to just do something,” she said. “But we have to take a time to really look at the data and then put strategies in place.”
To get that process started, the state is using a portion of a recent federal grant, $576,000 from the CDC, to create a statewide strategic planning committee. The group is expected to convene next year to identify professionals with expertise on opioid abuse and develop a more refined plan of action for the state on the prevention and training side, Figueroa said.
But as Pouliot and others point out, prevention is just one way to attack an abuse problem that's impacting hospitals and law enforcement, stressing treatment centers and prompting some changes in the state database designed to track prescriptions.
When the 2017 Idaho Legislature convenes next month, state policy makers will have another opportunity to address opioid abuse, specifically with how painkillers are tracked and dispensed.
The Idaho Board of Pharmacy intends to introduce legislation that would require every pharmacist to register with the so-called state prescription monitoring program, which collects data on prescribed controlled substances, including painkillers like oxycodone and hydrocodone. Idaho already requires those licensed to prescribe drugs, like physicians, to register with the monitoring system. Recently, rules were modified to allow prescribers to have delegates register. Coroners have been given access to the monitoring program as a way to help them validate a potential overdose death.
The monitoring system also help law enforcement track and identify opioid users who may be gaming the system to feed an addiction. It's not uncommon, officials say, for people misusing painkillers to get prescriptions from multiple providers for the same illness, faking an illness, or avoiding recognition by using multiple pharmacies.
But to Alex Adams, Board of Pharmacy executive director, a weakness in the monitoring system is the 24-hour lag in time that exists when information is entered into the database. For example, he said if a patient goes to multiple pharmacies within a 24-hour period, the central database may not show that the patient already had the prescription filled elsewhere.
The strength of the database, however, is in its ability to track repeat offenders.
"It's designed to help people identify red flags for abuse, because if you're an individual prescriber, you don't necessarily know if a patient went to multiple other prescribers to get opioids," Adams said. "If you're a pharmacy, you don't necessarily know if that patient went to multiple other pharmacies in that time period. Those are things that could suggest red flags."
From January through September, the monitoring program helped identify 376 patients who were found to have gone to five or more prescribers in one month to receive a controlled substance, according to Adams.
Lawmakers from across the state acknowledge Idaho faces a challenge in dealing with opioid abuse. But, they say, it's important to strike a balance between imposing new rules or laws and encouraging the public and private sector to educate and respond to demands.
Senate President Pro Tem Brent Hill, R-Rexburg, said he met with the Idaho Medical Association to discuss opioids earlier year, but remains uncertain if legislation is appropriate at this point. Hill said criminal laws are already on the books for abusers and medical professionals who prescribe opioids illegally.
"I don't know that there needs to be legislation," Hill said. "The laws are there and the penalties are there for prescribers and abusers. But I think we need to do a better job of getting people aware."
On the House side, Rep. Luke Malek, R-Couer d'Alene and vice chairman of the Judiciary, Rules and Administration Committee, said slowing opioid abuse is one of his priorities. But he said it's also important to find a way to do that without adding too many more burdens on physicians.
"It's making sure they have legitimate balance prescribing," Malek said. "And also making sure legislators like me, that don't understand medicine, ... don't interfere with it," he said.
Pouliot said the Idaho Medical Association has no plans to introduce legislation next year, but she said the emphasis remains on educating physicians about the guidelines and recommendations for painkillers from the CDC.
The recent CDC grant to the Department of Health and Welfare will award about $200,000 to the Public Health Districts for education and training of those with authority to prescribe painkillers. Another $120,000 will be given to the Board of Pharmacy to implement its own program for pharmacists.
The Office of Drug Policy will receive $80,000 for assessing needs and ongoing training around opioids. The remaining $140,000 will be used by Health and Welfare for training coronors on how to report overdose deaths and methods to track overdose deaths in vital statistics.
None of the funding will be used for substance abuse treatment.
To Jason Coombs, executive director of Renaissance Ranch, an addiction treatment center in Meridian, the state at some point will have to address the needs and demand for treatment.
Part of the problem, Coombs said, is fully understanding abuse and addition to a drug so easily available and found in medicine cabinets in millions of homes all across the nation. From Coombs' perspective in the treatment sector, there is plenty of demand for new resources and professionals trained to deal with an addiction that impacts rich and poor, young and old.
"I am consistently baffled at how this disease is infiltrating families of all levels and demographics, (families) who will be and are being effected," said Coombs.
THE FIGHT ELSEWHERE
Lawmakers, public health experts and treatment professionals in other states are experimenting with different programs and approaches.
Last month, Virginia Gov. Terry McAuliffe declared a public health emergency, which among other things legalized the use and sale of naloxone in the state without a prescription. Naloxone is a medication used to counteract the effects of opioids and is especially effective in dealing with overdose.
In 2015, Rep. Christy Perry, R-Nampa, sponsored a bill to legalize the use and possession of naloxone in Idaho. The bill unanimously passed through the House and Senate and is now available in pharmacies in Idaho without a prescription. It's also being used by some law enforcement agencies across the state, including the Nampa Police Department, which is providing training and doses that officers can use in responding to overdose cases.
Next door in Oregon, where deaths from overdoses for the first time exceeded motor vehicle fatalities, a state task force has recently recommended evaluations, consultation and more documentation for patients who are taking higher doses of prescribed painkillers, among other things.
In Minnesota, the state attorney general issued a sweeping report last month looking at the impact of opioid abuse in that state. The report also offered a series of policy recommendations, including requiring doctors to review patients' drug histories before prescribing painkillers and expanding access to drug treatment programs.