As part of Hawaii’s response to the nation’s ongoing opioid crisis, medication drop boxes were installed this summer at county police stations on Maui, Kauai and Hawaii island. On Oahu, there’s one at the state Department of Public Safety’s Narcotics Enforcement Division, near Daniel K. Inouye International Airport.

Unused tablets, capsules and other sorts of solid dosage may be tucked into a clear bag and dropped in the hefty steel boxes. The no-questions-asked free service is among the latest tactics pushed by the Hawaii Opioid Initiative action plan, which aims to serve as a statewide road map for prevention and treatment of opioid and other substance misuse issues.

The multi-agency effort took shape last summer, when Gov. David Ige tasked the state Department of Health with coordinating an initiative to spare Hawaii the level of opioid-related devastation seen in many other states. “The plan allows us to coalesce our efforts and gives us a direction to be proactive and preventative,” said Edward Mersereau, chief for the state Alcohol and Drug Abuse Division.

The national count of overdose deaths involving opioids has soared by more than four-fold, from 2002 to 2017, according to new National Institutes of Health (NIH) figures. The provisional count for last year tops 49,000.

In 2016, about 42,000 people died from opioid overdoses — more than any previous year on record. Roughly 40 percent of those deaths involved prescription opioids — pain medicines that can touch off dependency problems within several weeks of use.

That year, Hawaii ranked among the bottom 10 states, with 77 opioid-related overdose deaths­­­ — a rate of 5.2 deaths per 100,000 persons — less than half the national rate of 13.3 deaths. West Virginia’s rate of 43.4 was the highest — 733 deaths, with the majority of attributed to opioids and heroin. Addiction to prescription opioids is now flagged as one of the strongest risk factors for starting street narcotics such as heroin.

Even though opioid misuse here is low compared to hot spots on the mainland, the action plan calls for sustained and aggressive moves to fend off public health woes. Backing up that take, Mersereau points out that like many other states, for about a decade now Hawaii’s count of annual drug poisonings has been out-pacing injuries tied to motor vehicle accidents as the leading mechanism of fatal injuries.

Among the collaborators in Hawaii’s DOH-led action plan are the state Attorney General’s Office, Department of Human Services Med-QUEST Division, and DPS — as well as federal and county departments and community groups. Intended as a “living document,” continuously reviewed and tweaked by stakeholders, the plan identifies six key focus areas.

>> Treatment access. Improving and updating health care strategies and access to treatment and recovery services.

“What we don’t have is a system that effectively links all of the different resources together to create a more seamless episode of care for somebody who’s trying to get treatment. … The access points are so diverse that somebody’s who’s trying to look for treatment oftentimes has to go through the phone book, essentially,” Mersereau said. “We’re changing that by creating a more coordinated entry system that allows people to access treatment through one door, one avenue. And then from there … regardless of whether you go to one or multiple providers, you’re still in the system.”

Among changes in the works is the creation of a universal intake packet — along with the phasing out of a practice in which scores of organizations have used many different types of packets.

In regards to whether Hawaii’s supply of treatment options is deep enough to handle demand, Mersereau said: “We do have plenty of resources, we could always use more. … A big part of (treatment access) is coordinating those resources effectively.”

>> Prescriber education. Among objectives now underway is standardized training on best practices for the state’s opioid prescribers. Also, by 2020, the action plan envisions that Hawaii will have in place universal screening for substance misuse in hospital and primary care settings.

>> Data-informed decision-making. According to the plan’s “Hawaii Opioid Initiative” report, released in December, “Health-care providers in Hawaii have a difficult time accessing complete, real-time patient information to make appropriate prescribing decisions. Important data related to current opioid use and treatment plans are spread over many systems that may or may not be available to a given provider.”

To remedy this, Hawaii is following the lead of several states that have put in place a systemwide method of data collection, sharing and dissemination that relays electronic data from multiple hospital and other sources directly to providers, while a patient is receiving care. Another action plan goal set for 2020 is to significantly step up health records integration between hospital and primary care settings.

>> Prevention and public education. Strides in outreach include the recent launch of a DOH-managed, information-packed website, www.hawaiiopioid.org, and the start of the Hawaii Medication Drop Box Program, which serves as a supplement to the twice-a-year National Take Back Initiative for a safe disposal of unused prescription drugs. Since the initiative began in 2010, nearly 30,500 pounds of prescription drugs have been collected and disposed of in the islands.

>> Pharmacy-based interventions. The action plan’s report noted that many states have instituted a standing order that allows pharmacists to dispense naloxone — a lifesaving medication in cases of opioid overdose. And it called for Hawaii to follow suit. Subsequently, the 2018 Legislature passed a measure that authorizes pharmacists to dispense, prescribe and provide related education to people deemed at risk of opioid overdose.

>> First responder/law enforcement support. An example of progress in this area is linked to a DOH grant through which the Maui Police Department secured 200 kits of naloxone nasal spray, worth a total of about $14,000. In early May, the Maui officers underwent training in how to administer the spray to offset the effects of an overdose, such as shallow breathing. Three weeks later, officers used the tool at the scene of a reported overdose.

An intervention approach to treat a person grappling with addiction more as a patient than perp is part of a much-needed change to successfully tackle the opioid crisis, Mersereau said.

“On a national level, and even in Hawaii, the opioid crisis has provided some cultural shift — from looking at addiction as a criminal issue to looking at it as a chronic illness, and the need to treat it as such,” he said.

Every day, according to the NIH’s estimate, more than 115 people in the United States die after overdosing on opioids.

The crisis has roots reaching back to the 1990s when pharmaceutical companies assured health care providers and others that patients would not become addicted to prescription opioid pain relievers, prompting a movement in which prescriptions for medicines like OxyContin and Vicodin were written at greater rates.

Daniel Galanis, an epidemiologist with the state Health Department, said: “There was basically a culture (among health care providers) to treat pain as the so-called fifth vital sign (in addition to body temperature, pulse and respiration rates, and blood pressure). To routinely screen for it, and to respond to it mostly with pain-relievers.”

That led to widespread misuse before it became clear that these medications could indeed be highly addictive.

Within about the past five years, health care culture has again shifted, with prescribers backing away from the fifth vital sign and related practices. Galanis said that’s likely contributing to what could be a tapering of the problem in Hawaii. In 2017, the state tally for opioid fatalities dropped to 49 — the lowest total going back to 2003.

Also expressing cautious optimism, Mersereau said, “The Hawaii perspective is: ‘We have our finger in the dam and we’re aware — being on guard for what might come next.’”

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