Southern States Identified as Opioid Hotspots

By Pat Anson, Editor

If you suffer a sprained ankle, you’re 14 times more likely to get opioid pain medication at a hospital emergency room in Arkansas than one in North Dakota. That’s one of the unusual findings uncovered by researchers at Penn Medicine, who found a wide variability between states in opioid prescribing for a relatively minor injury.

Researchers analyzed private insurance claims for over 30,000 patients who visited hospital ERs in the U.S. for an ankle sprain from 2011-2015.

Nationwide, about 25% of the patients received an opioid prescription, with the chances of getting an opioid in Arkansas (40%) much better than in North Dakota (2.8%). The states with the highest prescribing rates were in the South and Southeast; while the lowest prescribing states were in the upper Midwest and Northeast.  





"Although opioids are not - and should not - be the first-line treatment for an ankle sprain, our study shows that opioid prescribing for these minor injuries is still common and far too variable," said M. Kit Delgado, MD, an assistant professor of Emergency Medicine and Epidemiology at Penn, who was lead author of the study published in the Annals of Emergency Medicine.

"Given that we cannot explain this variation after adjusting for differences in patient characteristics, this study highlights opportunities to reduce the number of people exposed to prescription opioids for the first time and also to reduce the exposure to riskier high-intensity prescriptions.”

Nearly two-thirds of the opioid prescriptions were for hydrocodone – a potent painkiller that was reclassified as a Schedule II controlled substance in 2014 to make it harder to obtain.

Most patients received only a 3-day supply of opioids for their ankle sprains, although 5% were given more than 30 tablets. Less than 1% of the patients were still getting opioid prescriptions 30 days after the initial one.  

The study period preceded the release of the CDC’s opioid guidelines and came before many states enacted laws that limit the supply of opioids for acute pain. Some health experts are calling for more specific guidelines for ankle sprains and other health conditions.

"There is a clear need for further impactful guidelines similar to the CDC guidelines that outline more specific opioid and non-opioid prescribing by diagnosis," said senior author Jeanmarie Perrone, MD, a professor of Emergency Medicine and director of Medical Toxicology at Penn Medicine.

"Medical, surgical, and subspecialty societies should convene to propose best practices similar to the popular 'Choosing Wisely' campaign, acknowledging that pain management for most diagnoses can be accomplished with non-opioids. And certainly, ankle sprains are a model example."

Alabama District Leads Nation in Opioid Prescribing

A recent study published in the American Journal of Public Health also found high opioid prescribing rates in the South, Appalachia and rural West.  Researchers at the Harvard T.H. Chan School of Public Health focused on opioid prescribing in congressional districts, rather than the state or county level.

"It is important for public health research to focus on geographical units such as congressional districts as it allows for elected representatives to be more informed about important issues such as the opioid epidemic. Because a congressional district has a named elected representative, unlike say a county, it brings a certain degree of political accountability when it comes to discussing the opioid epidemic," said S. V. Subramanian, professor of population health and geography.

The study found that Alabama's Fourth Congressional District had 166 opioid prescriptions per 100 people, the highest rate of any district in the nation. Congressional districts in Kentucky, Tennessee, Mississippi, Arkansas, Virginia, and Oklahoma rounded out the top ten areas with the highest prescribing rates. Other high prescribing rates were found in districts in eastern Arizona, Nevada, northern California, rural Oregon, and rural Washington.

The Republican congressman who represents Alabama’s 4th District said the opioid crisis is worse in rural areas because there are fewer jobs and opportunities.

“I think this crisis, particularly in rural America, corresponds directly to President Trump’s popularity in my district,” Rep. Robert Aderholt said in a statement. “People here have felt left behind and have seen their jobs and opportunities disappear. Due to the epidemic of depression, some people have turned to prescription drugs to dull the pain.  However, I believe that President Trump’s renewed focus on these areas and increasing jobs has resonated here strongly.”

Harvard researchers say the lowest opioid prescribing rates were concentrated in congressional districts in urban areas, including Washington, DC, New York, Boston, Atlanta, Los Angeles, and San Francisco.

What Grade Should Your State Get for Pain Care?

By Pat Anson, Editor

Millions of Americans who suffer from chronic pain are having trouble finding doctors, obtaining pain medication, and getting health insurance to cover their treatment. So imagine their surprise when a recent study gave passing grades to all 50 states for their pain care policies and said there was “an overall positive policy environment across the nation.”  

“We saw that report and were disgusted. At a time when chronic pain patients across the country are losing their medications and treatments to manage their pain, giving no state a grade below a 'C' is insulting,” said Amanda Korbe, who suffers from Reflex Sympathetic Dystrophy (RSD) and is a founder of Patients Not Addicts, a patient advocacy group.

“Achieving Balance in State Pain Policy” was released over the summer by the Pain and Policy Studies Group at the University of Wisconsin School of Medicine. The report looked at state laws and regulations in 2015 that governed drugs, prescribing and pain care practices.

“This evaluation is meant to identify relevant language in each state’s legislation or regulatory policies that have the potential to influence appropriate treatment of patients with pain, including controlled medication availability,” the study says.

The study gave 13 states an “A” for the quality of their pain care policies:  Alabama, Georgia, Idaho, Iowa, Kansas, Maine, Michigan, Oregon, Rhode Island, Vermont, Virginia, Washington and Wisconsin.

Thirty-one states were given B’s and the rest got C’s. No state was given a failing grade. A complete list of grades for all 50 states and Washington DC can be seen at the end of this story.

“I know that as an Oregon chronic pain patient, I can say my state does not deserve an 'A' right now. We have too many under treated patients, and too many that can't get care at all. For those of us that can't get proper pain management, these high grades are a slap in the face. It invalidates our experiences and struggles to get proper pain management,” said Korbe.

“Would pain management be in such a sorry state if these ‘grades’ actually meant anything? I personally think they are worthless,” said Janice Reynolds, a retired nurse, pain sufferer and patient advocate in Maine, which received an “A” grade.  

Rather than look at state policies and regulations, Reynolds said the study would be more meaningful if it examined whether opioids were being prescribed appropriately, if patients were having a difficult time finding providers, and if untreated pain was leading to more suicides.

“Every state would get a D or F if this was done,” she said.

Study Looked at Pain Policy, Not Practice

“To really look at this comprehensively, it requires a broader analysis to really get an understanding of things,” admits Aaron Gilson, PhD, the lead researcher for the study, which was funded by the American Cancer Society.

Gilson told Pain News Network the study only looked at state policies and regulations as they exist on paper – not how they were being implemented or even if they were effective.

“There’s not necessarily a 100% correlation between policies and practice. The policies in and of themselves don’t create barriers to pain management that we’ve identified. The grade that each state earned is really based on policies that can improve pain management for patients when put into practice,” he said.  

“Sound policy that's not implemented is only words wasted,” says Anne Fuqua, a pain sufferer and patient advocate, whose home state of Alabama was given an “A” grade.

“I'd give Alabama a 'C' for being better than the worst states like Ohio, Kentucky, Tennessee, Florida, West Virginia, Washington, and Oregon.  On paper the policy is excellent and it deserves the 'A' it gets. It just needs to be implemented.”

The study also didn’t look at insurance reimbursement issues or how doctors are responding to federal policies such as the CDC’s opioid prescribing guidelines, which were not released until this year and are having a chilling effect on both patients and doctors.    

Gilson said the methodology used to prepare the next pain care policy report – which was first released in 2000 – probably needs to be updated.

“That’s the first order of business in terms of continuing to do this, to really understand how policies have changed,” Gilson said. “I think it’s really time to examine the criteria that we use to see to what extent we might be missing policy because we’re not looking at the right thing, because barriers are erected in other ways than when we constructed this type of evaluation 16 years ago.”

Patient Survey Underway

One way to better understand those barriers is to simply ask patients what they are experiencing.

“Legitimate patients report the entire move to reduce (opioid) production and restrict prescribing is having a profoundly negative impact on their treatment protocols. Understanding how they are being impacted is important,” says Terri Lewis, PhD, a patient advocate and researcher.

Lewis is conducting a lengthy and detailed 29-question survey of pain patients to see how they are being impacted by efforts to reduce opioid prescribing. To take her online survey, click here.

Lewis will be able to breakdown the data state-by-state to get a real indication of how pain care policies and practices are being implemented.

“We will get that patient voice into this conversation,” she says. “Reports from patients are important and add value to the public conversation.  Reports will be analyzed and compared to months long data collection to look at trends, the impact of increasing restrictions, the fear of physicians to treat patients in this climate, and the influence of other factors like insurance restrictions and red flagging. This is a complex problem.”