PORT ANGELES — Prescription pain pills that fueled the opioid epidemic poured into Clallam County at a greater rate per person than they did in almost any other county in the Pacific Northwest from 2006 through 2012, but prescription rates have decreased significantly in recent years.
Data obtained by The Washington Post shows that during that time Clallam County received 37,838,060 pain pills — or 76.6 pills per person per year. That’s more pills per person than any other county in Washington state and more than all but a handful of counties in the entire Pacific Northwest.
The Post made the data available last Thursday after gaining access to the DEA’s Automation of Reports and Consolidated Orders System, known as ARCOS, as the result of a court order. The Post and HD Media, which publishes the Charleston Gazette Mail in West Virginia, fought in court for a year to gain access to the database.
The data tracks which companies manufactured pills and exactly how many pills were sent to each pharmacy across the country.
For Clallam County Health Officer Dr. Allison Unthank, the data — which she called “disturbing” — is not surprising. She said it shows what officials already knew: Doctors in Clallam County were over-prescribing narcotics at dangerously high rates.
However, Unthank said this is the first time she has seen data that put prescribing practices in Clallam County into a national context. The data shows that Clallam County had as many pills per person as many counties in Appalachia, an area that has felt the brunt of the opioid epidemic.
In that region some counties saw averages of more than 100 or 200 pills per person per year and had some of the highest overdose death rates in the nation.
“I don’t think there was publicly national data that we could pull,” Unthank said. “We knew that Appalachia had a problem … but I don’t think we knew how close we were to that problem comparatively until we saw the Post data.”
Prescribing has improved
While the DEA data shows when Clallam County’s prescribing practices were at their worst, state data that documents prescribing practices after 2012 shows significant decreases in high-dose opioid prescriptions.
“The good news is those numbers are from 2012, which is when we knew we had a problem, but we’ve actually seen those numbers dramatically improve,” Unthank said.
The state Department of Health — which tracks prescriptions and not pills — has data shows Clallam County had more high-dose opioid prescriptions per 1,000 people than any other county in 2012. Doctors at the time were prescribing about 20 high-dose prescriptions per 1,000 people, about three times the state average.
Unthank said clinics have been encouraged to set prescribing policies and doctors are now informed when they become high prescribers.
In 2017, Olympic Medical Physicians Primary Care providers announced that it would no longer routinely prescribe opioids to patients who have non-cancer-related chronic pain.
“There’s been a lot of education,” Unthank said. “We’ve seen a pretty good effect from that.”
As of the last quarter of 2018, Clallam County’s high-dose prescription rate dropped to 8.8 prescriptions per 1,000 people, about 1.6 times the state average of 5.4 prescriptions per 1,000 people.
The county has also seen opioid-related deaths drop dramatically over the last three years.
The opioid-related death rate in Clallam County was 16.5 per 100,000 from 2012 to 2016, according to state Department of Health statistics.
Clallam County Health and Human Services has worked to increase the amount of naloxone — a drug that reverses opioid overdoses — in the community.
County data shows that last year there were only two opioid-related deaths, while there were 16 opioid-related deaths in 2016 and 10 opioid-related deaths in 2017.
Clallam vs. Jefferson
The data shows vastly different prescribing habits between doctors in Clallam County and its neighbor, Jefferson County.
While Clallam County received 76.6 pills per person per year, Jefferson County received 28.2 pills per person per year, well below the state average of 45 pills per person per year.
Pharmacies in Sequim distributed 13.8 million pills, more than twice as many than all of Jefferson County, where pharmacies distributed 5.8 million pills.
In 2012 Jefferson County had a high-dose prescription rate of about 10 prescriptions per 1,000 people. That has now dropped to slightly to 7.9 prescriptions per 1,000 people, or about 1.5 times the state average.
“When we look at the numbers for Clallam, most of our prescribers were prescribing poorly,” Unthank said. “A large majority of our providers were prescribing in dangerous ways, so we had to do a concerted effort at the county and clinic level to change that, which luckily has worked.”
She said doctors had been pressured by industry and by patients to prescribe at high levels, or they would risk bad reviews or losing their license for not treating pain.
For Jefferson County Health Officer Dr. Tom Locke, the data appears to be accurate.
“It’s measuring a period in time where opioids were very much overprescribed, at least relatively to where we think we should be prescribing now,” Locke said.
“Not only were pharmacies and prescribers told this is the right thing to do, they were told this was a safe and effective way to treat chronic pain.”
Locke said that perpetuated that problem.
“People who were addicted to the medication found it fairly easy to game the health care system and get people to prescribe more of the medication,” he said.
“That medication was diverted and sold on the street, driving new users and new addictions. That period of time was when it ramped up.”
The situation has changed, he said.
“The phase we’re in now, we really have turned the corner,” Locke said. “But we don’t have that based on local data. We have statewide and national trends.
“The numbers of prescriptions for opioids has been going down the last several years.”
Locke said the state Legislature has provided access to more local data through a prescription monitoring program, a database through which pharmacies report which controlled substances they have prescribed each day. County health departments can make requests to see the data through the state Department of Health, he said.
“We have some information about emergency room visits and overdoses, and, unfortunately, we do have death certificate information,” Locke said. “They’re little pieces of the puzzle, but we know what the general trends are now.”
Locke said as prescription opioids have gone down in Jefferson County, heroin use has gone up.
“We’re not seeing the kinds of changes to fatal overdoses that we’d like to see,” he said.
Locke said the Clallam, Jefferson and Kitsap tri-county area is working toward regional statistics, too.
“We’ve really been working to develop those local data sources because we need them to develop our efforts and to tell whether what we’re doing is working or not,” he said.
County sued Big Pharma
The data also provides greater context for Clallam County’s lawsuit against manufacturers and wholesalers of opioid pain killers. It makes clear exactly how many pills each company either manufactured or distributed to Clallam County during that time.
Clallam County is one of hundreds of local governments that have filed lawsuits against pharmaceutical companies and outlines how the county government has been impacted by the opioid crisis. Jefferson County and the Jamestown S’Klallam Tribe have also joined the multi-district litigation.
Clallam County Commissioner Mark Ozias, who described the DEA data as “shocking” said the county filing the lawsuit “was probably our most significant step” in response to the opioid crisis.
After attorneys for the county reviewed the ARCOS data, they filed an amended complaint in April that said drugs manufactured or sold by SpecGX, Par Pharmaceutical, West-Ward Pharmaceuticals, KVK-Tech, Walgreens, Walmart and Thrifty PayLess “represent a substantial market” in Clallam County.
The county’s amended complaint says each of the companies “directly caused the worst man-made epidemic in modern medical history — the misuse, abuse, and over-prescription of opioids across this country, including in [Clallam County].”
The ARCOS data shows that SpecGX — one of 25 companies that manufactured pills that were shipped to Clallam County — manufactured nearly 20 million of the 37.8 million pills that made it to Clallam County, or nearly 53 percent of the market.
“Prescription opioids are how the vast majority of people struggling with addiction get hooked. It is working professionals, moms, dads and teenagers who are struggling with this addiction,” Ozias said. “The statistics speak to how insidious of a problem this is … and how it has been supported by and promulgated by the pharmaceutical and medical community.”
Reporter Jesse Major can be reached at 360-452-2345, ext. 56250, or at [email protected].
Jefferson County Managing Editor Brian McLean contributed to this story.