HealthChangers Podcast: Tackling the Opioid Epidemic

April 25, 2019

Opioid misuse and addiction continue to be a nationwide epidemic. Every day in the United States more than 130 people die from an opioid overdose. In fact, the crisis is so great that today more people in the U.S. die from overdoses than car accidents.

In this episode of HealthChangers, we talk with Dr. Jim Polo, the behavioral health medical director for Regence health plans, and Phil Caruso from Walgreens to take a closer look at the opioid crisis and what is being done to help address this epidemic in our own communities.

Susan Gage: Today, we're joined by Dr. Jim Polo, behavioral health medical director for Regence health plans and Phil Caruso from Walgreens. Thank you both for being here today.

Dr. Jim Polo: Thank you for having us.

The Ripple Effect: The Impact of the Opioid Epidemic on Families 

SG: Let's start with the big picture. The opioid epidemic has become one of the largest public health crises we face today. How did we get here?

JP: The opioid crisis is actually the unintended consequence of trying to address pain. In the 1990s, the medical profession focused heavily on addressing the complaint of pain. Pain for many years has been the number one thing that people will go to see their doctors for, whether it's in a primary care clinic or the emergency room. In the 1990s, we focused on trying to really alleviate pain and address pain. We even developed in the industry what's called the "fifth vital sign," which was asking people about pain. In response, the pharmaceutical industry developed many new medications to address pain, largely the opioid class and medications, like Vicodin, Percocet, Dilaudid, common medications that most of us know about.

“The opioid crisis is actually the unintended consequence of trying to address pain.”

Then, at the same time, the insurance industry responded by making it easy for folks to be able to get these medications through their health plan, so not one part was solely at fault, but what ended up happening is we had high level of prescription of opiates, easy access, inexpensive access, and we also created a generation or two of folks that have an expectation that all pain should be treatable and that living pain-free regardless of the reason of getting pain or having pain or what caused it, became an expectation. The result is by 2015, we had enough opioid prescriptions that were being issued on a daily basis where you could medicate every single American 24/7 for three weeks.

We ended up with a huge crisis, and, unfortunately, opiates are highly addictive. In some cases, it leads to addiction, which can lead to all kinds of medical problems. In the long run, it really hasn't helped us really address the underlying pain problems, so that's how we got here to the current crisis.

Partnership Strives to Promote a Dose of Reality

SG: As the health plan and others have done a lot to lean into helping resolve this crisis, and one of the things that Regence has done was, in 2018, begin a partnership with Walgreens to sponsor safe medication disposal kiosks in Walgreens stores in Oregon, Washington, Idaho, and Utah. Can you both talk about the Walgreens' program and how the partnership works to reduce opioid misuse in our communities?

“This partnership with Walgreens gave us the opportunity to go the next step further, getting medications out of circulation and disposed of in a way that is safe and helpful.”

Phil Caruso: You have all these medications that were being dispatched, and when taken properly or treated very good in legitimate medical uses, and one of the things we've always noticed as a pharmacy, and we get this all the time from patients, is, "What do I do with medications that are sitting in my medicine cabinet that I'm no longer taking?" or "They are expired" or, "I don't want them anymore." Up until we started this program with our kiosks, we really didn't have a great answer.

There have been twice annual prescription drug take-back days, which are great programs that allow folks to clean up their medicine cabinet and bring them to facilities that collect them. One of the drawbacks is they happen twice a year and they're usually on a Saturday and people are busy, so Walgreens had this idea to install a permanent safe medication disposal kiosk in our stores, in our pharmacies throughout the country, and we've been working with several partners including Regence to do so, and these kiosks are a great opportunity to dispose of unwanted opioids and other prescription drugs and controlled substances, including over-the-counter medications like pet medications or liquids at no cost to the customer, and it's available every day.

“Walgreens has installed permanent, safe medication disposal kiosks in our stores, working with partners like Regence to ensure unwanted opioids and other prescriptions can be disposed of safely, every day, at no cost to the consumer.”

JP: When we first heard about the Walgreens program, we were very excited. We've put a lot of effort into decreasing the numbers of prescriptions that are being given to our members for opiates. It doesn't change the fact that people have had these medications storing up in their medicine cabinets, as Phil mentioned, and I'll highlight that the take-back program is for all medications. It's not just for opiates, but, obviously, the opiates pose a significant danger because they're high risk for addiction, they're high risk for misuse, and medications that are sometimes available in a cabinet can be also misused by either adolescents or friends that are already having difficulties, and so we were excited because this gave us an opportunity to go the next step further, which is how do we get these medications out of circulation, how do we get them disposed of in a way that is safe and helpful to folks that are wanting to get rid of them.

Understanding & Responding to the Effects of the Opioid Epidemic 

SG: What makes partnerships like this particularly important?

JP: I think what makes partnerships like this really important is that it emphasizes that, in health care, we have to all be working together. The opiate crisis is a complex problem that was created over time by many different parts of our health care system, and to really adequately address it, I think we have to work in partnership together. This is precisely the kind of partnership where we work in tandem with other organizations that have the same thing in mind. They want to make sure that their customers, our members are healthy and doing well.

“The opioid crisis is complex and to adequately address it, we need to work in partnership together.”

PC: Partnerships are one of the best ways we can all work to address the opioid epidemic. Working together across the health care chain is the job of insurers, as pharmacies, as the providers, everybody. Our goal is to help the patient and working together on an issue like this just makes. It's common sense, and we're really excited about the work we've done to expand our safe medication disposal program through our partners by installing additional safe medication disposal kiosks in Oregon, Washington, Idaho, and Utah. We have truly made it more accessible and convenient for our patients to have access to these programs at no cost to them every day.

The exciting note, Walgreens started this program back in 2016. Before we expanded the program, it was just Walgreens, and we installed an initial 500 or so kiosks around the country, and we wanted to see if there would be a demand or would a patient or customer utilize this service. What we saw from that was truly tremendous and inspired us to reach out across the health care chain to bring in these partnerships together so that we can work on this program and make it more accessible for people, so I'm really pleased and excited to share with everyone today that, since this program began in March of 2016, Walgreens has collected and safely disposed of more than 1.2 million pounds of unwanted medications.

SG: That's incredible. Congratulations on the program overall, and Regence is, I know, very happy to be part of that. Phil, you mentioned before the DEA's National Drug Take-Back Day, and the next one is coming up on April 27th. Twice each year, that event offers safe and convenient collection sites for people to dispose of unwanted medications often at law enforcement sites, and it also raises awareness about the potential for medication misuse. Dr. Polo and Phil, what makes opioids particularly relevant to this conversation?

“Since the Safe Medication Disposal Kiosk program began in March of 2016, Walgreens has collected and safely disposed of more than 1.2 million pounds of unwanted medications.”

JP: Let me highlight that, I think, as has been mentioned, Walgreens' effort is really to help members, or their customers dispose of all medications, and, misused, many medications actually are harmful. What makes opiates a little bit more unique to many of the other medications that they will accept back is that opiates are highly addictive, and not only are they highly addictive, there are a lot of people that know that they're addicted and there are a lot of people that are already struggling with addiction, so, when opiates are not disposed of and left on the shelf in the medicine cabinet, they're there essentially for the taking for somebody that may want to misuse them. As I highlighted before, adolescents frequently will scour their parent’s medicine cabinet looking for drugs or medications, thinking that somehow this will make them feel good, and opiates really exposes them to the possibility of addiction.

Opiates are highly addictive. The most commonly abused opiate is Oxycodone, which is also OxyContin, or Percocet, and, unfortunately, there are some folks that respond and are so sensitive that, literally, after just taking a few doses, they could become addicted, and when you think of addiction as a potential lifelong problem, this is a significant thing that we want to try to avoid, so, getting rid of these medications is really a huge need for us to do to make sure that we keep people safe.

PC: Jim, I would just add on to that that the DEA does a fantastic program twice a year with Drug Take-Back Day, and Walgreens for years has been proud to work with local law enforcement around the country to serve as a host location for police to come hang on in our parking lot and collect the unwanted medications. It's a great program.

“The best thing you can do is safely discard of controlled substances, like opioids, by participating in DEA Drug Take Back Day, visiting a Walgreens kiosk or finding another permanent take back solution in your community.”

PC: We at Walgreens, came to the conclusion that it needs to be more accessible, and that's why we've installed kiosks in our stores so, that way, if you can't make it to Drug Take-Back Day on Saturday, this gives you an opportunity to visit a Walgreens or the kiosks at a time that's just more convenient for you, and that's our goal here, but, getting back to Jim's point, the real goal is to have a conscious mind that, when you're done taking your medication and these medications are sitting in your medicine cabinet or cabinet in the cupboard in the kitchen, you have a plan and you know that there's a way to safely get rid of them.

The best thing you can do with controlled substances, for example opioids, is to safely discard them either by participating in Drug Take Back Day or visiting a Walgreens kiosk or finding another permanent take-back solution that's in your community.

Safe Drug Disposal: Communities Seek Solutions

SG: In addition to safe medication disposal, what are some other things that we all can do to address the opioid crisis in our communities?

JP: I think it's important, as I mentioned earlier, to address it from multiple different angles. As a health plan, we've actually addressed it in a variety of different ways. As has already been highlighted, we spent a number of years working to just decrease the number of prescriptions that are actually being written, and that comes in a variety of different forms, first of all, implementing CDC guidelines in terms of how opiates are prescribed.

A very simple example, we've all been to the dentist for a tooth extraction or maybe a tooth filling or something that we know is going to be painful, and it used to be very common, very typical for the doctor maybe to write a prescription for 30 pain pills, and you would take those home, and you might only use two or three of them, so one of the guidelines is limiting the numbers of pills that are actually dispensed to basically one week's worth of medication, which very often is already more than folks are going to need for those acute pain issues, and then also thinking about decreasing the actual dose, the strength of the opiate in the sense that we want to get folks getting a lower dose that actually addresses whatever their acute pain is in a way without exposing to higher doses which can lead to addiction as well.

“We’re working with the community and making sure we get awareness out into the schools and with legislators. We want to make sure we create awareness and as many different possible ways to combat the problem.”

We've worked with our providers to make sure that they're educated, that they understand that we're working with them to keep their patients healthy by making sure that we're not exposing them to the possibility of addiction. We're also working with our providers to emphasize what are ways that we can treat pain that are alternative and different, what are the other things that might help people, whether it's acupuncture or massage therapy or cognitive behavioral therapy. Then, finally, for the people that already have difficulties with addiction to opiates: how do we help identify those folks now, get them into treatment to help them get past their addiction in a way that's respectful, in a way that doesn't make them feel like somehow, they're a drug user? Rather that they're somebody that is suffering from an addiction to a medication that, unfortunately, occurred as a consequence of having been given to them at some point as part of their medical treatment.

I think working with the community at large though and making sure that we get awareness out into the schools, into our county legislators that all the different parts of the community need to come together, understanding that this opiate crisis is affecting so many people across all different kinds of settings. Whether it's in a school setting or a work setting, a hospital setting, the opiate crisis is touching families everywhere, and so we want to make sure that we create as much awareness and as many different possible ways to combat the problem.

PC: Jim, to add on to what you said there, having the community involvement in combating opioid [abuse], I think is great, in addition to the kiosk program, Walgreens has been working really hard to make naloxone, which is a medication that if administered in time can reverse the effect of an overdose, available in our pharmacies and more accessible. We're really proud of the fact that we can now dispense that medication without requiring a prescription in almost all of our pharmacies. We're in about 46 states.

“We’ve been in schools, trying to get the next generation to understand that when you’re finished with medication, you take it to a Walgreens or permanent drug disposal place to make sure it gets out of the home.”

What that does and what we encourage folks is, if you do have a loved one or someone who may be at risk, who's taking a high amount of controlled substances or some other illicit medication to get educated on what they can do to have naloxone, to have that medication on hand in case it's needed because, when it comes to an overdose, that can count, and having that medication on hand could make the difference and could be that first step toward getting to recovery. If you don't survive the overdose, it's hard to move on to those next steps that you were describing on recovery and treatment.

The other thing, just to build on your awareness, we've taken a lot of steps to educate the public about, again, drug take-back and safe medication disposal practices. We've been in schools and talking to high school kids around the country, trying to get the next generation and instill it in their mind that, when you're finished with medication, it doesn't go in the cabinet. You take it to a Walgreens or you take it to a permanent drug disposal place and make sure it gets out of the home because you don't need it anymore and there's no reason for it to be there.

JP: Phil, I really appreciate your bringing up naloxone. I think that's an important part. We know that there are ways to help people that are either at risk for an overdose or have already overdosed, and naloxone has really become important to be able to help those folks. At the health plan, we encourage the use of naloxone, and we've removed all barriers for folks to be able to get that medication, so, in partnership with you, where you're already able to give it out, I think that's another part of our combined effort that's really focused on trying to help folks in our communities.

Collaboration for Safe Medication Disposal Takes Practical Steps with Kiosks

SG: It seems that this crisis today touches nearly everyone, so I wonder, Phil and Jim, what is your personal experience with this issue?

JP: I'll share my experience. I'm now at the stage of my life where my two parents, who are both alive, in their mid-80's, are both struggling with dementia, and they live very nearby, and so I actually care for them and take a lot of effort to make sure that all of their needs are being met. My parents grew up in a generation where medications were not as prescribed as much. When they were prescribed, you generally put them in the medicine cabinet. You never got rid of them. You didn't get rid of any medications.

This program came along and, a couple of things, first of all, I was able to help my parents rid their cabinets of all kinds of medications that had been lingering around and clearly been in their cabinet for many years, and what I came to realize is that my parents were actually misusing many of their medications, taking medications that were no longer prescribed, taking medications that were actually expired. Actually, by going through the cabinet to take away the medications they didn't need is how I actually learned that they weren't really taking their medications as prescribed, and so, to me, this has really been a huge program that's been eye-opening.

I've got two Walgreens, one on my way to work and one on my way to my parent’s assisted living facility, that both have kiosks that allow me to make sure that I keep my parents safe.

PC: I had an aunt who, 10 years or so ago, lost her fight to cancer, and she had a brave, great fight, and I remember, when she passed, we were left with so many decisions and questions and things to do at the moment, but one of the things that came in was we looked in the medicine cabinet, and there were so many medications, controlled substances, liquids, stuff I've never heard of, stuff I didn't know, but it looked heavy and serious.

She had three young children, so, the question was: "What am I supposed to do with these?" Fortunately, we had a neighbor on the block, she was a nurse, and she told me what to do with it. Otherwise, I honestly had no idea. I was going to throw them in the trash or flush them down the toilet, which I think, having been part of this program now for a couple of years, are one of the two worst things I could have done at that moment because I didn't know any better.

Fast forward a couple of years now, I get phone calls once a week from people in similar situations like this, and I am able to now get on the phone and say, "Hey, I'm so sorry about your loss. The nearest Walgreens to you that has this is right here in this town, and it's free, and when you get a chance to drop it off, we'll take care of the rest," and it's a pretty gratifying solution.

“Seeking safe medication disposal kiosks or finding a permanent drug take back solution gives you the opportunity to ensure these medications are not intentionally or accidently misused and prevents them from ending up in the landfill or inadvertently harming the water supply.”

SG: Let's talk a little bit about the safest methods of disposal because, often, people don't know what to do, and talk about why the kiosks are the best option for safe disposal.

PC: Sure. Happy to. There's a number of reasons to consider. One, you don't want a medication sitting around. It's pretty obvious, right? You don't want it to be intentionally or accidentally misused by somebody else, but there are a number of other factors that oftentimes are almost side-benefits to it. For example, if you look at the FDA's guidance on how to safely dispose medications, it tells us that we're really not supposed to throw them in the trash. We could, but they also recommend we mix them with coffee grinds or cat litter and, quite frankly, a lot of people get put aside by that. "That's messy. That's dirty. That's ugly. I don't want to touch that."

Some people think that we should flush them down the toilet. For the most part, that's really not recommended. There are some medications, depending on if you look at the EPA or the FDA's website on guidance for that, but seeking a safe medication disposal kiosk or finding a permanent drug take-back solution, like participating in Drug Take Back Day on Saturday, April 27, it gives you an opportunity to ensure that these medications are not intentionally or accidentally misused, or to help prevent that they end up in the landfill and they're not going to inadvertently harm the water supply.

That wraps up this episode of HealthChangers. You can find more information on all of our episodes at cambiahealth.com. You can also follow us on Twitter, @Cambia. Please subscribe to HealthChangers on iTunes or Stitcher and leave a review. Thanks for listening.

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