Attorney General Swanson examines problems fueling Minnesota's opioid epidemic

State Attorney General Lori Swanson issued a sweeping report Tuesday on the toll of opioids in Minnesota, which has seen a rising number of deaths - including pop icon Prince - despite growing warnings about the addictive dangers of both illicit and prescription painkillers.

The report makes a series of recommendations, including requiring doctors to review patients' drug histories before prescribing opioids, reducing the duration of controlled substance prescriptions and expanding access to drug treatment and emergency Narcan that can reverse the effects of an overdose.

"Growing addiction to prescription opioid painkillers is devastating families from all walks of life across all parts of our state," said Swanson, noting that as many as three-fourths of heroin addicts first abused prescription opioids.

Deaths from opioid overdoses spiked from 54 in 2000 to 355 in 2015, according to the state Department of Health.

Prince died April 21 from an overdose of fentanyl, a powerful synthetic opioid, amid last-minute efforts to wean him off painkillers.

A Star Tribune review of preliminary state death certificate data for 2016 found 239 deaths caused by opioids through September. The state is on pace to be at or just below the record 2015 death toll.

Swanson's recommendations come as two influential state medical groups complete their own guidelines advising doctors on how to use opioids and when to use alternatives for patients' pain.

The guidelines by the Institute for Clinical Systems Improvement (ICSI) and a state Department of Human Services work group are critical, because they address the upstream problem of doctors prescribing opioids for unproven uses, said Dr. Chris Johnson, an ER physician who serves on both groups.

Identifying abusers and treating addictions is "not enough," he said. "We need to stop flooding the population with these medicines in the first place. … They are oral heroin."

Swanson's proposals build on existing work in recent years in response to the opioid epidemic. Doctors and other health care providers are now required to at least register with the Minnesota Board of Pharmacy's online monitoring system, which documents their patients' drug histories.

Swanson said she wants to make checking the system mandatory so health care providers can identify patients who are overusing opioids or fueling their addictions by shopping among multiple doctors for prescriptions.

Supporters include Sen. Chris Eaton, DFL-Brooklyn Center, who lost her daughter to an opioid overdose in 2007 and spearheaded a state law granting immunity to anyone calling 911 to report an overdose.

Anoka County Attorney Tony Palumbo also favors Swanson's measures - noting that on Oct. 26 alone the county suffered six opioid overdoses and two deaths. A relative also died in February from an addiction that started years earlier with a painkiller prescription after dental work.

"It is a public health crisis," he said. "It affects us all."

Requiring doctors to always check their patients' drug histories before prescribing opioids could face opposition. While doctors in high-risk settings such as the emergency room should check the database on every patient first, that would be overkill for primary care doctors who know their patients, said Dr. Dave Thorson, a past president of the Minnesota Medical Association, who helped draft the ICSI pain management guidelines.

"We just have seen no evidence to support every script, every time," he said, "and it would be adding to the bureaucracy of practicing medicine." Swanson also wants to make the pharmacy board's prescription monitoring database a better investigative tool.

Right now, one data analyst at the pharmacy board actively searches the database for patients with suspect prescribing histories. In 2015, this resulted in letters to doctors about 214 people with suspicious drug histories. Opioid dispensing subsequently declined in 205 of those cases.

But Swanson said the Legislature could expand access so that her office and others could use it to root out "pill mills" that are profiting on excessive opioid prescribing. "They need to be dealt with," she said.

ICSI's guidance on pain management was released earlier this month; it recommends a change in thinking away from current practice - driving patients' pain scores down to zero at all costs - and instead focusing on pain management to support their daily lives.

Research doesn't support the use of opioids alone for long-term or chronic pain, said Dr. Michael Hooten, a Mayo Clinic specialist who helped draft the guidelines, so ICSI instead recommends using low-dose opioids in combination with alternatives, or avoiding opioids altogether.

"I think we can really close the door on this whole era of using high dose opioid therapy alone," he said. "Those days are gone."

The DHS opioid prescribing work group is still drafting its guidelines. Johnson said it will ultimately approve opioids for acute pain relief immediately after injuries or surgeries, but will encourage doctors after that to consider the risk of continued opioid usage as equally threatening to patients as their pain levels.

"The clock is ticking on the human brain" when it is exposed to addictive opioids, Johnson said. "Even if there is a big injury and these medicines are appropriate for use, the clock is ticking in terms of how long you can be on them before the brain starts getting adjusted or changed."