Though Hawaii has been spared some of the worst of the opioid epidemic plaguing other parts of the U.S., recent data shows that some parts of the state — neighbor islands in particular — have seen a heavy flow of pain pill prescriptions.

Between 2006 and 2012, in fact, opioid prescriptions added up to more than 40 pills per resident each year on Maui, the Big Island and Kauai. That compared to about 15 pills for each Oahu resident.

Hawaii doctors want to make sure that flow doesn’t turn into a flood, and that rural residents have adequate access to other forms of pain management, everything from physical therapy to acupuncture. And, for those who’ve already gotten hooked, doctors are looking for ways to provide the most effective forms of treatment.

It was the topic of discussion at this year’s Hawaii Health Workforce Summit, where doctors and pharmacists spoke about how to approach pain management care, especially in rural areas.

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Health providers are concerned that an opioid addiction crisis could affect neighbor island residents more severely in the future because there are fewer paths to supportive care. Across the state, Hawaii has just 15 facilities that provide medication-assisted treatment for substance abuse.

Roy Goo, a clinical pharmacotherapy specialist at Wilcox Memorial Hospital and an associate professor at the University of Hawaii Hilo’s Daniel K. Inouye College of Pharmacy, said the scarcity of primary care providers, pain specialists, physical therapists and mental health professionals on neighbor islands exacerbates the issue.

“If you don’t have someone to counsel you, the only other thing you do have is a pill,” he said.

Like elsewhere in the U.S., Hawaii doctors are trying to reverse a legacy of overprescribing opioids.

Goo says the data from the Drug Enforcement Administration reflects the prescription trends he’s seen over the past years.

“Typically what I see in the outpatient setting is we kind of only have one strategy for managing pain, and that’s using opioids,” Goo said. “When it doesn’t work, they’ll give them a higher dosage, which is what they shouldn’t do. You might have to give a higher dose in that moment, but you have to be thinking about how to control it long term.”

Misuse of prescriptions has increased in recent years, leading to a troubling growth in the number of opioid overdose fatalities across the nation.

Millions Of Pills Prescribed

The crisis has not been as severe in Hawaii, but the numbers here are still eye-opening.

More than 44 million prescription pain pills were supplied to Maui County pharmacies between 2006 and 2012 according to Drug Enforcement Administration data recently made public by the Washington Post. During the same time period, nearly 53 million prescription pain pills were supplied to the Big Island — enough for 42 pills per Big Island and Maui resident each year. Approximately 19 million pain prescription pills were supplied to Kauai during the same time period, enough for 41 pills per Kauai resident.

Oahu, by comparison, was supplied with 103 million prescription pain pills, approximately 15 pills per person annually.

Maui physician Jeffrey Chester specializes in pain management. But then the growing need among patients for addiction treatment and counseling led him to pursue a second board certification in addiction medicine. He continues to run his private practice and serves as medical director of Akamai Recovery Maui, a clinic that treats addiction with both medication and counseling.

Chester said it wasn’t long ago, in the early 2000s, when doctors were encouraged to use opioids to treat patient pain because they were thought to have fewer side effects compared to alternatives such as anti-inflammatories and muscle relaxants.

Today, he encourages alternatives, like physical therapy, acupuncture, massage therapy, or counseling, for chronic body pain as well as insomnia, anxiety and depression.

“We talk a lot more about non-medicine treatment than we used to,” he said.

He has also mandated a toxicology test for all new patients.

“No matter what they come in for, they are screened with a toxicology test, interviewed and given a physical exam to assess any past family history of addiction, childhood trauma and childhood abuse — factors that we know increase the risk of addiction,” he said.

One of the challenges in treating addiction is the stigma that can surround it, especially in a small, rural community.

“Just yesterday someone said, ‘I can’t go to a group counseling setting, I’m too involved in the community,’” Chester said. “It’s a huge barrier. We need more awareness that treating addiction is similar to treating diabetes and high blood pressure so people aren’t afraid.”

Grant Money To Fill The Gaps

Since 2017, the Hawaii Department of Health has received more than $10 million in grant funding to address and prevent the opioid crisis.

Lisa Rantz, president of the Hawaii State Rural Health Association, is overseeing a community needs assessment throughout the neighbor islands thanks to a $100,000 planning grant provided by the federal Health Resources and Services Administration in July.

She said the association will apply for an additional $1 million for the implementation of Hawaii Opioid Prevention and Education, or “HOPE” grant programming.

Rantz said the funding will bolster the way Hawaii approaches substance abuse treatment and prevention, for opioids and other issues, like addiction to methamphetamines.

“Because of the prevalence of opioids in rural communities, they’re throwing money behind opioids, but treatment programs for addiction are treatment programs for addiction,” she said. “We’re starting to see more overdoses. The (community needs assessment) is hope that we’re going to be able to get a handle on this, and we want neighbor islands represented.”

Another effective tactic for overdoses is the overdose reversal drug known as Narcan or Naloxone. It’s been administered in Hawaii more than 230 times since it became legal in 2016.

In 2017, 53 people died in the islands from an overdose involving opioids.