Data recently released by the United States Drug Enforcement Administration shows more than 245 million prescription pain pills were supplied to Montana from 2006 to 2012, with about 13 percent of that total being confined to Flathead County.
The database, supervised by the federal agency, monitors the path of every legal pain pill in the nation and was made public by way of a court order from The Washington Post and HD media. According to The Post, the government and the drug industry had sought to keep the information secret. It was released as part of the largest civil legal action in U.S. history.
The robust data set was analyzed and then published by The Post. It shows where more than 76 billion oxycodone and hydrocodone pills were distributed and which companies manufactured them during a segment of the opioid crisis that claimed nearly 100,000 lives in the U.S.
Jason Cohen, chief medical officer at North Valley Hospital and a hospitalist with Kalispell Regional Healthcare, offers multiple possibilities as to why so many opioids saturated the U.S. during that particular time period.
He said it could be traced back to the early 2000s when drug companies began campaigning for doctors to prescribe long-acting pain medication to their patients.
“We were being told by these companies that we were under-treating pain,” Cohen said. “The message was very pervasive.”
It was also in the early 2000s when pain was declared the fifth vital sign, which are “measurements taken to help assess the general physical health of a person.”
“One of the questions patients were being asked was 'how effectively did we treat your pain?' and their answers had a lot of weight,” said Cohen, who wrapped up his residency in Oregon in 2006, right around the time the opioid crisis started escalating.
The over-prescribing of opioids and unabated manufacturing and distributing of the pills then continued until a crisis ensued.
And according to The Post's data, many opioids that entered Montana during the unfolding of the epidemic found their way to Flathead County and the northwest region of the state.
Of the more than 245 million pills supplied to Montana, the Walgreens pharmacy in Kalispell received the highest number of pills by a sizable margin, at just over 4.1 million pills. The second highest pharmacy, Montana CVS in Butte, received nearly 3.1 million during the seven years, according to The Post's county-level analysis.
Walgreens officials offered a statement regarding The Post's coverage, saying “Walgreens pharmacists are highly trained professionals committed to dispensing legitimate prescriptions that meet the needs of our patients. Walgreens has not distributed prescription controlled substances since 2014 and before that time only distributed to our chain of pharmacies. Walgreens has been an industry leader in combating this crisis in the communities where our pharmacists live and work.”
Flathead County as a whole saw the second highest number of pills in the state prescribed during the seven-year stretch, at almost 32.1 million pills. That's about 51 pills per person per year during that time. Yellowstone county was supplied the most pills, at nearly 39 million, which comes out to about 38 pills per person per year for the area.
Of the 32.1 million pills in Flathead County, nearly 14 million were manufactured by Actavis Pharma and more than 11 million were distributed by McKesson Corporation — two companies identified by the database as some of the most prolific manufacturers and distributors in the nation.
The bulk of legally prescribed opioids in Montana was mostly confined to the northwest corridor of the state. Other counties that saw a steady stream of opioids included Missoula, Cascade, and Lewis and Clark counties.
Cohen offered several possibilities as to why Flathead County and surrounding counties amassed a large portion of the state's opioid supply. He said one can start by looking at the populations of people who look to chronic painkillers, which can include people on disability, veterans, elderly residents and others, and see where they are located.
For example, Lincoln County, which was supplied with the 10th highest number of pain pills in the seven years for all of Montana, historically has a high population of disabled individuals. According to U.S. Census data compiled by the University of Montana, Lincoln County — where asbestos disease linked to the W.R. Grace vermiculite mine is still prevalent — was one of six counties in Montana to have a disability rate between 19 and 36.9 percent from 2012 to 2017.
“There was a rise in disabled people, which increased the chronic pain diagnosis,” Cohen said.
Flathead County is also one of the fastest aging counties in the states, with about one quarter of the current population being 60 years of age and older. Lincoln and Flathead counties also have some of the highest percentages of veteran populations in the state, according to U.S. Census data.
Cohen said Flathead County is one of the primary destinations for those in Northwest Montana seeking medical care, not only because of Kalispell Regional Healthcare but also because the county has several physician-owned clinics and independent primary-care doctors.
Due to the nature of rural health care, many people from surrounding counties would travel to Flathead County for most of their medical needs.
According to Brian Saari, pharmacy manager of Granite Pharmacy in Libby, their popular pharmacy serves patients all over Lincoln County. The area saw 61 pills per person per year — the most in the state based on the measurement of pills per person during the 2006 to 2012 time-frame, according to The Post's database.
At the time, Granite Pharmacy was Franks 293 Drug, but is now under new management. Franks 293 Drug was supplied the majority of pills for all of Lincoln County during the seven years. Saari said he couldn't comment on operations as they pertained to Franks 293 Drug because he was not an employee of the pharmacy at the time, but said Granite Pharmacy “tightly controls and regulates the filling of opioid prescriptions at every level.”
Saari also said the pharmacy fills a good number of prescriptions from Flathead County in addition to those from local providers such as Cabinet Peaks Medical Center.
“For those [prescriptions] coming from the Kalispell area, many are part of a pain contract,” Saari explained. “So those patients are assigned a specific pain doctor and work with a specific pharmacy and can't have their medications filled elsewhere.”
While data from 2006 to 2012 shows Montana was no exception to the nationwide spike in opioid abuse, other data shows the epidemic began to subside in most parts of the nation soon after, following a nationwide outcry that pushed the epidemic into the limelight.
“We started recognizing it as being something that crossed socioeconomic lines. This isn't a problem that is just isolated to people who have addictive personalities, it was impacting your neighbor, the person at the gym, your friend's son,” Cohen said. “It wasn't affecting your preconceived notion of what a drug addict was.”
Maps compiled by the Centers for Disease Control and Prevention show estimates for the geographic distribution of retail opioid prescriptions dispensed per 100 U.S. persons per year from when the epidemic took off in 2006 up until 2017.
Among other key findings, the Centers report “the overall national opioid prescribing rate declined from 2012 to 2017, and in 2017, the prescribing rate had fallen to the lowest it had been in more than 10 years at 58.7 prescriptions per 100 persons.” This is down from 81.3 prescriptions per 100 persons at the peak of the crisis in 2012.
According to Jon Ebelt, a public information officer for the Montana Department of Health and Human Services, while most of the nation peaked in opioid use around 2012, Montana's use actually peaked in 2009 and has been declining ever since.
“There have been many people, organizations (public and private) working together to address the opioid epidemic,” Ebelt said. “We do know the issue of increased opioid overdoses has been well noted, there has been more training around opioid prescribing, such as when to prescribe, how much to prescribe, proper disposal of medication.”
Cohen said he doesn't know if there is one factor alone that can be credited with the start of the opioid crisis subsiding, but noted the push for electronic health records and a standardization system such as the drug registry has played an instrumental part.
“Between the bigger hospitals and smaller clinics, it's very hard for any one person or one entity to get a close-up on prescribing patterns,” Cohen said. “There was essentially no central oversight available. Electronic record keeping kind of helped with that.”
In 2011, the Montana Legislature authorized the Montana Prescription Drug Registry as an online tool to “provide a list of controlled substance prescriptions to health-care providers to improve patient care and safety.” Ebelt acknowledged the registry system has “helped providers.”
And up until the 2019 legislative session, use of the system was optional. But as of July 2021, physicians — with a few exceptions — will be required to look at their patient's history in the system prior to prescribing opioids and other drugs.
In Flathead County in recent years, Kalispell Regional and other clinics have moved to a system called Meditech. According to Cohen, all prescriptions are presumably flowing through the system, allowing for physicians and others to see what someone has been prescribed, how much they were prescribed, and when.
In addition to shifting toward a standardized electronic system, the Centers for Disease Control and Prevention recently rolled out a guideline for prescribing opioids and chronic pain. According to Cohen, hospitals began adopting some of those practices.
At Kalispell Regional, risk assessments were implemented, or what are essentially questionnaires for patients that allows doctors to see if a patient has a low, medium or high risk of becoming addicted to opioids. On top of the assessments, physicians have started running various drug screens on patients who have been prescribed opioids to make sure its the patients themselves who are taking the pain killers.
“It's not so much about catching people, although there are people who sell the pills,” Cohen said. “The intent is to make sure that if we are prescribing something, it's safe and we can counsel patients.”
Cohen said recent strides are only the beginning of addressing the opioid crisis and medical providers are finding other means, such as acupuncture, to treat chronic pain.
A key finding in the Centers' data shows prescribing rates continue to remain very high in certain areas of the country as of 2017. In 16 percent of all counties, enough opioid prescriptions were dispensed that year for every person to have at least one prescription.
“The standardization across the system is only the foundation. It's incredibly important that that is established so we can move forward from there,” Cohen said.
AT THE state level, Ebelt said among other things, officials are “working closely with the Montana Primary Care Association, which is offering trainings for health-care providers on treating opioid use disorder and have also given community presentations for the public to learn more and ask questions.”
Soon, with the assistance of the Montana Medical Association, the state will be releasing a series of “continuing medical education videos for providers including topics such as working with patients who have opioids as part of their treatment plan for chronic pain,” and more.
Ebelt also said that while opioid prescribing has decreased nationally, officials with the state health department “are concerned about the increase in heroin and fentanyl deaths.”
Reporter Kianna Gardner can be reached at 758-4439 or firstname.lastname@example.org