 Aloha, welcome to health care in Hawaii. I'm your host Josh Green, Senator from the Big Island ER physician. Today I'm joined by a good friend, Dr. Scott Miscovich. He's a family practitioner, trained in the East, grew up in Pennsylvania like me, went to Harvard and Yale and Cornell actually all three. He's become an expert in an area that's very important to our state and that is the prescription drug epidemic. Pills are being prescribed at record rates across the country. In Hawaii, like other states, we've had very serious concerns about overdose from prescription drugs. We've become so worried about it because in, I guess, an easy to review statistic, more people died last year from overdoses on pain pills than people died from car accidents. So just two years ago I reached out to some colleagues and friends, Scott being my most expert colleague in this area, to look at solutions. We wanted to know what legislative solutions would be necessary, what medical discipline solutions would be necessary to implement in our state to help protect young and old from this major problem. So Scott put together a work group of experts. He's gonna talk about that today. He's gonna talk about solutions where Hawaii can lead the country. Good to see you. Good to see you. Thanks for having me. You bet. Okay, so let's cut right to the chase. You really have done a very deep dig and dive right into this problem. Explain to us why we're talking about prescription drug overdose issues. Well, you already alluded to a key statistic that we all know, that we now have more people that are dying from overdose. Excuse me. Where are people dying from overdose from prescription drugs than we have from car accidents in the state? Well, excuse me. No problem. And as Scott gets a sip, I wanted to share that when you see numbers like that, and you wonder why is the medical community letting that happen, we really uncovered many, many reasons that nationally were having this crisis. One statistic that came to light was that though we have only 4% of the world's population in America, as many as 80% of all pain pills were being consumed by our citizens. So when you look at this problem as a doctor and an expert, what do you see? Well, we've become a society that looks for immediate gratification. I mean, we're a hardworking country, and people want some results now. And back in the turn of the century around 2000, there was a big push that pain we called the fifth vital sign where people were pushed to say you've got to pay attention to patients pain. And then we had a big push from the pharmaceutical companies that were making statements at some of the pain medicines that were newer and cutting edge were not a problem. They weren't addictive, and they weren't a problem. So the physicians were led through the experts at the time to say, Hey, it's not a problem. Give people pain medicine. It's going to just take care of their problem. As a return, Americans said, Okay, my pain is not as bad. I'm still working. But the problem was addiction, dependence and addiction became a huge issue. Have you seen as far as trends go? Have you seen things change? You've been you came to Hawaii in the 80s, right after finishing your training. And so you've experienced that, you know, the Hawaii medical climate in the 80s, the 90s and the, you know, the 2000s past decade. What's been kind of your perspective as a doc? Well, I think we'd really be amiss to not go a little bit away from the narcotic and the opiates and not mentioned what really still is our massive problem. And that's crystal methamphetamine. Yeah. And, and, you know, we still I will believe are probably the meth capital of the United States. Dr. Judge Stephen Ohm, who's just recently left the bench and a terrific advocate with drug court, yes, had in his drug courts, 90% still of his positive drug tests were coming with crystal meth. But the problem is, is that meth led to other other drugs, these people will also using opiates to counteract or to enhance methamphetamine, or that use benzodiazepines like Valium and other meds to come down off of it from there. So we now have an amazing culture where drugs are now in the form of crystal meth three generations into our family. Yeah, I have to tell you that Josh, the most incredible thing for me is when I can sit and I can do a random urine drug test and I have positive methamphetamine and opiates on patients that shouldn't that are over the age of 70. And in the same family, you can have an 18 year old, there's three generations where this is passing through the family. So it's so ingrained in the families. It's a huge problem right now. Yeah, you know, you really explained it very well, because as you've told me on numerous occasions, you have patients coming in with pain pain problems, severe injuries, drug addiction with the methamphetamine and heroines, pain pills that you're trying to help them work through their pain issues, but also to to bring them down off of pain addiction. And then also these other drugs that people are getting off the streets in other ways. So you were able to bring together a lot of people to look at this as a kind of a multifactorial problem. And throughout the show, I'm hoping that we're going to get to even some of the social and cultural implications of this drug addiction concern. Who did you bring together when I you know, when I was able to reach out to you and say, Hey, Scott, I think we've got a problem here. What kind of team did you put together so that we can start talking about this issue? Sure. You know, I like to qualify to I'm I'm a family physician in Kaniyia. I'm not, you know, a certified addiction specialist. But I think credit your judgment to let me help lead this up because where I stand as I stand in the middle, you know, I represent my patient and and I represent the people of Hawaii and the people I serve. And and so when you look at the group, we put together, for example, doctors from the pains association that are certified in pain that have special treatment to treat addiction. We have the University of Hawaii addiction psychiatry resident who are exactly on the other end who are saying no, we have to do with addiction and keep these people off. We have orthopedists. We have psychiatrists. Then we go. We have all the health plans, the major health plans represented. We had the courts represented. We have the narcotic enforcement division. We have medical directors from different independent organizations. We've reached out now and we have the nurse practitioners. We have the directors of all the pharmacies represented. We have independent pharmacists. I strongly believe now because I have studied and I've been in contact with most of the organizations throughout the United States. We have the most broad scale, inclusive group of leaders than anywhere in the United States that are all coming together. And we're trying to let all of those voices come together to come up with what's best and safe for the patients and people of Hawaii. And I think that was very smart when you did that because by bringing all these different perspectives to the table, some people from the clinical side. The reason I wanted you is because you see patients more than anybody. My interest was as an ER doc, I suppose. But when you brought in the judges and the pharmacy individuals and the insurance plans that have the data, the judge who was dealing with the people who would otherwise have to be incarcerated if we didn't get them better. I think all the perspectives were quite well balanced. Now this group of experts has come together and we're hoping, I think, that other states across the country will follow your lead, frankly, and bring these kind of coalitions together. I think it's happening in certain places. What was, what became evident to you right away? You know, in those first meetings, as you were looking at the scope of the problem, what were your first observations? My first observation, and it still is my observation, which makes me really proud of our leadership is the commitment. Remember, these are all really busy people. These are experts in their fields and we have attendance of over 95 percent for people coming together. The involvement, these people are not afraid to stand up. But the cohesiveness where everybody tries to be respectful of the other person's opinion. But again, it's just the heart and soul that everybody realizes that this is a problem, enough of a problem, that they're going to take their private time away from families and come together. Okay, so that's just, I mean, it is extraordinary and I've witnessed this with you, the amount of commitment and time. So people now know the shape of this committee, which we're calling Ho'ola, which is Hawaii Opioid and Overdose Leadership Action Work Group, Ho'ola. So the group's together, it's been together now for two years. Just over two years. Okay. You had some successes. You were able to change policy. Why don't you run through some of the basic policy concerns and issues that are, I guess, emerging? The first two policy issues, I think there have been successes with that and I want to also step out the say there's broad groups that have also stepped up to become part of making those policies a success, was dealing with a medication called naloxone. If you go up to the federal level and remember, I'm also helping to get information and working through the White House and we're working through NIDA and SAMHSA, which are federal organizations. This was the number one objective that they had to saving lives now. Tell people out there who might not be in the clinical world, what does naloxone do? Okay. Naloxone is an extraordinarily safe medication. It can be sprayed in the nose through a little device or it can be given as a shot and it immediately overturns an overdose. So it kicks out the medications that are in the receptor and it is one of the most dramatic things and as emergency physician you've used it, you've seen it, someone can actually be blue and not breathing and they can get naloxone and within 20 to 30 seconds their eyes open and they're awake and they're breathing. So it is something that actually saves lives. The states who have instituted this, I believe we're the 37th, are finding that it is the short, a very short term antidote. We want it in the hands of first responders who would like to get HPD to be considering to carry it or paramedics are carrying it but our law has gone now to parallel of the United States where we can give a prescription now to grandma. Yes. If she has a grandson that is using heroin or addiction where she's seen that they're not breathing, she can get a prescription from her physician even though she is not the addict but that's the first thing that we're doing to save lives. And I think that that was featured very nicely by some of the news media with Heather, right? Heather Luss. She's been terrific with Child Project. Right. So this coalition now is growing so just for those out there who might not spend as much time in a clinical setting as you and I do, if a person takes a bunch of morphine, if they take heroin, if they take lots and lots of pain pills and they overdose, this is a potential life-saving solution, remedy. Absolutely. Yeah, absolutely. And you know one of the bigger issues we're very fortunate not to have as much of it running through the state but we have the Narcotic Enforcement Division team on our committee. We're starting to see a push-up and we need to stop it before it becomes a real issue and that's heroin. I mean heroin if you look at some of the Appalachian states which are decimated. I mean we have had, there is a county in West Virginia that had more deaths than our entire state from heroin overdose. Wow. I mean so we don't let that, we don't want that to happen. Those, that type of medication can really make a big difference. And I would imagine that those counties in West Virginia and Western Pennsylvania and Kentucky and everywhere where we're having these problems, they're going to probably benefit from some of the recommendations that you've been able to get implemented in our state because when they see those kind of overdoses it's not just going to be life-saving treatment when they get to the ER to see me or you know in the outpatient setting quickly to get care. A lot of times it's going to have to be delivered by those medics or the firefighters or the family members and though that won't solve the person's addiction problem it may buy them you know one more opportunity. Well an opportunity to live and hopefully an opportunity to get into treatment which is a whole other topic that is part of what we're going to be trying to address to broaden treatment options. Absolutely and I can't wait to discuss that moment because in the course of some of my committee hearings at the Health Committee over the years it was brought to my attention that at the moment we only treat 3.3% of all necessary addiction treatment. So our capacity is very low we just don't have enough providers and we don't have enough coverage from insurance in general. I think we have to change the paradigm of the health care system and treat people, get them over their addiction when we can rather than incarcerate them rather than watch them go down the fatal road of additional addiction and overdose. Okay so we're actually coming quite close to the halfway point of our show. You passed the you got the recommendation out we had very good help from Senators Baker Representative Bellotti, lots of legislators. Let's finish this point up on the lock zone. Also liability people can give it without the concern of being sued. Correct they can give it without being sued if someone is overdosing and it's actually two other people that are present that are also under the influence of the same medication. They can call they can use it without being arrested to you know save the life of that individual. It's very very critical that we broaden the education to the public and broaden the education and access to the public with us. That's excellent. Okay so we're part way through our show. I'm Josh Green healthcare in Hawaii's host ER physician and senator I'm joined today by Dr. Scott Miskovich who is one of my favorite people and is a leader leading the group. Hawaii's opioid and overdose leadership action work group. We are putting together a plan to make sure that we can protect people from overdose deaths and from this epidemic of prescription drug addiction. We'll be right back. 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Aloha welcome back to healthcare in Hawaii I'm your host Josh Green senator from the Big Island and ER doc. I'm joined today by Dr. Scott with Dr. Scott Miskovich terrific gentleman who's a family practitioner leader in kind of a new emerging and concerning field which is how to deal with policy questions related to the drug and the drug epidemic the prescription drug epidemic in our state. I mentioned earlier in our first segment that more people died in Hawaii from drug overdose and they did from car accidents that was a kind of an eye-opening moment it lit a fire under us we decided to put together a policy group which Scott's leading he's brought together judges experts in pain management physician leaders pharmacy leaders leaders from the health insurance industry who really know the data many other groups those who lead in hospice care all of the experts that you would expect on such a panel in the first couple years of this group we've already passed legislation to change kind of the tone and discussion on how to keep people alive people who overdose now can get a messing called naloxone by prescription to basically reverse the effects of a potentially life threatening overdose but that's not the end of it this is just the beginning of the process other legislation and recommendations came correct Scott correct talk to us about the prescription drug monitoring program we call the PDMP but to be descriptive when a person gets a prescription there is a database we're able to log on to to find if that person has received other prescriptions from other pharmacies unfortunately when people do have a problem with addiction they do something called doctor shopping meaning they'll go to one doctor to another doctor and they in some cases could see ten different doctors you know in a week and there have been circumstances in patients that I've you know worked with a narcotics enforcement division on where they may get two thousand to three thousand pills of something like a Percocet those can be used for their personal consumption or that could be 15 to 20 thousand dollars of street value of medication and that's how these pills are getting spread out all over society they could be found in almost any park any bus stop there there they could be found throughout our state they're getting down into our middle schools so that's that's a concern well brief and yet about that I was contacted by a physician in Hilo and they told me that kids were getting pills on the black market on the street crushing oxycodone tablets and putting them in Coca-Cola and then sipping it getting high all day long and we were seeing overdoses as well so these were these were middle schoolers and high schoolers so what you describe is something that's familiar to me on the big island okay so the PDMP the prescription drug monitoring program my understanding was it was out there but it wasn't effective yet or wasn't being used what did you recommend and what are we doing now well there's a couple things it's a multi-tiered approach the bill we got passed basically helped to increase funding for the narcotic enforcement division to upgrade to a much more modern database and a contractor who is going to now start to be able to work over the next couple years to get the data pushed out to the doctors which is something we heard the physician community asking but the other thing is now the doctors are required to sign up for the database now that is different than being required to use it yeah so that is one of the things we're now trying to work with the state medical association because really to be effective you've got to use this and I would like to bring up a perfect example New York State mandated that their physicians use it within an 18 month period after it became law they had a 37% decrease in the county in the borough of Manhattan of the number of pills in circulation amazing so that's one of the measurements we're going to look at we need to decrease the total number of pills that are in circulation by all measures yes and this is one of them that's amazing and it's very rare that you see a change that dramatic in such a short period of time yeah and so I think that that's got to be discussed I you know my experience is and I think it's very similar to yours is I see patients all the time a lot of times real pain you someone comes in with a terrible fracture that bone cancer of course that is not the concern I have but not a shift goes by where I meet a patient for the first time that's many on many occasions has come in from the mainland they are now only in Hawaii for a couple months they haven't found a provider yet and they want a very large prescription and when I look into it I find very quickly what you described which is they've had two or three prescriptions already I don't want to be tough or too hard here but in that particular case they were trying to pull one over on the dock and we didn't need to see all those extra pills in their system or in the systems of our our teenagers and children and and that's why your solution is so valuable do you expect that we will have to in the coming years you know enhance the PDMP make it mandatory under some circumstances is that something that we should be talking about I believe we will I believe that right now we're probably going to be first working on improving the technology which has been a little bit cumbersome and I do believe for this to be effective if we can get the data to be pushed out using electronic records using iPhones and other things that it will become mandatory especially for people who are on chronic medication like some of the best practices for example what we do in our practice based on what is going on in some of the best practices across the country if anybody is getting medication at the beginning we get it to see if they have other prescriptions and then every three months we we pull a PDMP or if there's some change in behavior that makes us wonder I lost my prescription oh the dog ate it or oh geez it just doesn't work I need double the amounts things that we would never do we start to look or even a behavioral change so you're saying it's just good medicine it's good medicine it's it helps the patient yeah and and you came up with a very good idea in the course of our work together where you recommended that we have a delegate so a team member on the staff can also help check this thing just for people out there if they're health care providers or or even lay people takes two minutes to check this it's online and you have a password you check it the information comes up it's not quite in real time yet I think it's back dated about seven days we're hoping we're working on that I understand we need to fund our guys better to get that to real-time technology is improving it's going to happen but I guess the idea is we get there you have the delegate that's able to help that doc or the nurse practitioner whoever's prescribing the medications you can catch it in the New York case proves true 37% in an ideal situation when the doctors log in to their computer it should flash and just hit them right in the face and let them know that did you know your patient just filled up a prescription if you try to if you push this button to renew it yes they already have had one just three days ago that's really what we're trying to push for yeah and I think we would get broad support from the rest of the physician community on it's it's coming in you already got a lot of people on board yeah give me a couple other examples of proposals that you'd like to see that would make a difference I'm very very big and we're going to be pushing hard for generally what we call informed consent in health care we have to understand we have approximately say for example some people are getting a medication like a percoceteroxycodone and something like a volume yes six times the increased risk of overdose when you combine those two it is one of the biggest national best practice data points we're we're putting out there don't do it or be very careful I think the doctor has an obligation to look that patient in the eye and explain to them hey if I'm giving you these two prescriptions and you decide to take them together or feel they're not working and take another or wash them down with a beer or two you're gonna die or you could die so telling patients the risks of being on meds when you start someone on a new medication a lot of patients think oh it's being med my doctor gave it to it must be safe while there are certain people genetically or who are going to quickly be addicted to that med so I think we have an obligation to inform the consumer along those lines there are there are basic very user friendly informed consent agreements that the doctor and the patient sit down and go over before they start I'm a big believer that that should be happening across our state that's excellent okay so naloxone saves people from overdose PDMP helps doctors and nurse practitioners and other providers make sure that we're not putting too many pills into circulation or getting in some cases the wool pulled over our eyes when someone's doctor shopping three informed consent teach people that's got to be safer I've heard some talk about take back programs that say you know it's this easy thing to do take pills out of circulation I'd like to take it further and I'd like to be the first state in the country that does something even more progressive and and I'd like to tell the listeners 50% of all the medications that are taken illegally are taken out of the family's medicine cabinet 50% only 25% are coming directly from the doctor and 25% are coming actually from the streets and being bought so families have the option to be do their part and we do have drug take back programs but the problem is if someone's bringing their old amoxicillin that's not stopping addiction I want to have narcotics specific drug take back programs and I want to create some incentives for people to bring their narcotics in to get those off because that will be something that will also reduce overdose deaths so we're going to be pushing that too That's excellent and once again we're going to have to support our drug enforcement groups and Department of Health and the administration will be there for them you've mentioned some interesting things to me as we come down the kind of home stretch of our program today Dr. Scott you know you've said to me that you've witnessed over these last two or three decades homeless concerns that have kind of overlapped in some ways with behavioral health problems with mental illness with drug addiction and I think you've spoken more eloquently than most people on this matter could you unpack that a little bit because we all know those who are watching those who will see this in the coming days we all know that homelessness has been at a crisis level in Hawaii for the last certainly the last couple of years it's been in some ways that the most visible issue you've told me that it's very intimately tied with some of the work that you're doing could you break that down I absolutely believe it it is the cause and you know I take it back even further homelessness is not a single event homelessness is a process and and I believe that the future homeless are actually in every doctor's office and everybody's family and living room right now there are processes that are occurring that are eventually leading people to become homeless and as we know with the own statistics that were just published from 2015 at least 50 percent of the people that are homeless right now unsheltered have severe mental illness 70 percent have some form of addiction many of them have dual diagnosis and so when you treat these patients and you're with them I have over 100 homeless patients in my practice and have for a while and I have a so I sit and spend so much extra time to try to understand how did you get there how do we get you out of there and the ones who are no longer homeless how did it happen you then realize that until we get to the root cause of addiction and help treat their mental illness we're never going to solve homelessness and that's the people who are already out there right we need to reach back further as in any other process we need to start aggressively stopping that conveyor belt to homelessness we need to start with stopping people from becoming addicted in the first place and that's also looking at the crystal meth and which is also a big part of that which is what we need to we've almost we're almost blind to meth in Hawaii now because it's been here so long right but my belief is addiction is the probably single largest root cause more than not having enough homes to our problem yeah I'm so glad that you have been focusing on that because I think what many people at least in the medical community and I think a lot of a lot of civilians out there not in medicine they see it happen before their very eyes they see a person's life come apart they don't know why later on they find out they were severely addicted and then sometimes families and it's true of all of us doesn't matter whether you're rich or poor black or white it it can unravel the bonds between parents and children and and loved ones because addiction is so hard to treat and before you know it when life gets totally out of control when addiction and then theft occurs and then violence in the home and then people are sent to the wind they become those homeless individuals that unfortunately may only be a statistic in many people's mind but really they're casualties of this prescription drug epidemic and the methamphetamine epidemic and your opinion has been resonating with me solve that problem or else we're never going to solve the homeless problem absolutely agree and I want to tell you just a personal note people will ask me well why are you so passionate about this why do you devote your time and and I would tell you that one of the most sad things I see in my practice I'll get a long time patient who will come in who will be 70-72 and they'll bring in adoption forms for me and you kind of tilt your head and say you're 72 why are you adopting well I'm adopting my grandchildren why are you adopting your grandchildren well my son and the mother of the children they're nowhere to be found they're addicted to meth they're in prison they've been in and out of rehab Josh I have over 150 grandparents that have adopted their grandchildren because their parents are so far into and out of you know being involved with their children I mean everybody knows somebody like that so I mean when I see that it's I stand up and say why that's why that's one of the reasons why it's a fantastic message to end on which is to say we're here today talking about the prescription drug epidemic and we've now been able to also uncover its connections to homelessness and really many devastating moments in society but the good news is we've got an expert in our midst which is Dr. Scott Miskovich and his team of collaborative experts across the state Ho'ola Hawaii opioid and overdose leadership action work group is on the issue it's on the problem we'll have solutions for society in the coming months and years thanks for joining us healthcare in Hawaii I'm Josh Green