image: WVU School of Medicine researchers Cara Sedney and Treah Haggerty are investigating the effects of Senate Bill 273 on opioid-prescribing practices in West Virginia. The mandate limits the initial amount of opioids that physicians can prescribe different classes of patients. view more
Credit: West Virginia University
In 2017, West Virginia healthcare providers wrote 81.3 opioid prescriptions for every 100 state residents, according to the Centers for Disease Control and Prevention. The national average? Just 58.7.
Treah Haggerty and Cara Sedney—researchers in the West Virginia University School of Medicine—are studying how a new West Virginia law has changed the way healthcare providers prescribe opioids. Working with the state’s Board of Pharmacy, they’re examining prescription practices before and after the law took effect on June 7, 2018, and pinpointing differences.
They’ll also interview healthcare providers, pharmacists and patients across West Virginia to understand how the law has shaped their experiences prescribing, dispensing and taking opioids.
“A lot of states have made this sort of law in various iterations, and we don’t really know if they work,” said Sedney, an associate professor in the Department of Neurosurgery and the Rockefeller Neuroscience Institute. “Because we have a dataset before and after the law went into effect, we can figure out if the law made any impact. If it works—or if it doesn’t work—we want to know why and how.”
The National Institute on Drug Abuse, a division of the National Institutes of Health, has funded their project. Sedney and Haggerty also receive support from the West Virginia Clinical and Translational Science Institute.
Talking to ‘all of the players’
The law originated with Senate Bill 273, which Gov. Jim Justice proposed. It curtailed the initial amount of opioids that a physician can prescribe a patient, under various circumstances.
For example, someone who visits an emergency room can’t receive more than a three days’ supply, but someone who undergoes surgery can get up to seven days’ worth. Neither can have the prescription refilled without a physician’s reassessment. Chronic-pain patients who have used opioids for more than five years are not subject to the restrictions.
To see how the law has influenced opioid prescribing, Haggerty and Sedney will assess prescription data from the Board of Pharmacy. The data will encompass the 15 months that preceded the law’s enactment and the 15 months that followed it. The researchers will track the number of opioid prescriptions, the number of pills in each prescription and other factors over time.
They will also interview patients, pharmacists and healthcare providers to discern how the policy changes have affected them individually. “If you think about it, anytime a physician writes a prescription, a pharmacist actually gives it to the patient,” Sedney said. “It forms this triad, and we’re trying to talk to all of the players.”
They’ll collaborate with harm reduction clinics to “get some stories from patients who are active users,” said Haggerty, an associate professor who directs the Rural Scholars Program for the Department of Family Medicine. “We’ll also be interviewing chronic-pain patients in mostly primary-care settings, through the West Virginia Practice-Based Research Network.”
Maximizing benefits, minimizing drawbacks
People who take opioids for a long time face a higher risk of becoming physically dependent on them. Keeping opioid prescriptions short may help lower that risk. But it’s possible that the law’s restrictions may also have negative, unintended consequences.
“I do spine surgeries, and many of my patients realistically need more than seven days of opiates after certain surgeries,” Sedney said. “I operate on people from all over the state. Say they drove five hours to come have their surgery. I can give them a week’s worth of opiates, and then they have to come back to get another prescription in a week. So they have to make that five-hour drive again, after having surgery.”
Because the patient hasn’t recovered from surgery yet, the return trip can be painful—particularly if the patient has to travel the bumpy, winding roads that branch across rural West Virginia.
Sedney continued, “At the other end of the spectrum, I know someone who called the dentist and asked for ibuprofen, and the dentist prescribed Tylenol 4.”
Tylenol 4 contains codeine, an opioid.
“He didn’t even want it,” she said.
The ‘misery’ of quitting cold turkey
Prescribing opioids too liberally—including to patients who don’t need them—cultivates dependence. And once someone is physically dependent on an opioid, quitting it is especially hard.
That’s the case whether someone has been taking the drug as directed by a doctor, in opposition to a doctor’s instructions or without a doctor’s knowledge at all. It’s also true regardless of how someone got the drug: by picking it up at a pharmacy, buying it from a neighbor or stealing it from a relative’s medicine cabinet.
“If somebody does have a dependence on an opiate, and we take them off the opiate abruptly, they can be put into a very desperate situation,” Haggerty said. “Somebody who’s actually a really good person can cross that bound into doing something illegal or getting into harder drugs off the street. That’s always a concern. That’s why we need to get the story straight from the patients.”
Symptoms of opioid withdrawal are far more severe than the headache coffee drinkers get when they forego caffeine.
“It makes you very, very miserable: horrible pain, nausea, sweats, diarrhea,” Sedney said. “It’s rarely life-threatening, but it makes you feel like you are going to die.”
What she and Haggerty learn may suggest ways policymakers—in West Virginia and elsewhere—can assist people in pain while also preventing opioid dependence and the “misery” of withdrawal.
“What things were helpful about the law? What was not helpful?” Haggerty said. “Everything we find out may not be generalizable to every state, but there’s going to be information we gather that can be useful as other states come up with their own prescribing-type laws.”
Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health, under Award Number 1R21DA049861-01, and the West Virginia Clinical and Translational Science Institute. WVCTSI is funded by an IDeA Clinical and Translational grant from the National Institute of General Medical Sciences, under Award Number U54GM104942, to support the mission of building clinical and translational research infrastructure and capacity to impact health disparities in West Virginia. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH or CTSI.