There are lots of things to like about Northern California’s beautiful Marin County. First, my wife is from there. Second, there’s great cycling, hiking on the county’s signature mountain, Tamalpais, or if you like swimming with baby great white sharks (no kidding), you can head to Stinson Beach. Third, there’s San Quentin, the only state prison with a million dollar view of San Francisco. Fourth, and the subject of today’s post, the county is home to RxSafe Marin, a local prescription drug task force which is educating doctors and saving lives. It’s setting a standard other counties should follow.
In a time when statewide prescribing guidelines are not well or widely taught to physicians, and are used as more of a hammer than a teaching tool by the state’s Medical Board, and when the Centers for Disease Control delays releasing the closest thing to national opioid prescribing guidelines, because of lobbying pressure, Marin’s work at the county level is just what is needed.
A recent study shows that since Rx Safe Marin formed, opioid related deaths in the county have dropped significantly within a year. The prescription drug problem still exists in the county, and in every county in California and the nation – Marin officials use the words “scourge,” “epidemic” and “crisis” to describe it – and the problem won’t ever be completely solved. But a big drop in death rates means, well, it means fewer people receiving prescriptions from their genuinely well-intentioned doctors are dying. Martha Stewart would call this “a good thing,” if Martha Stewart talked more about Oxycontin.
RxSafe Marin, comprised of health officials, electeds, law enforcement, public defenders, social workers and others, developed guidelines for opioid prescribers within the county. The guidelines didn’t reinvent the wheel – at their core, they call for lower doses to be prescribed, and for doctors to check online databases to help ensure patients aren’t doctor shopping. And according to recent statistics, it’s working. What are the lessons we can learn from this?
The first lesson is that opioid prescribing guidelines only work when they’re widely taught to doctors, and just as widely followed. RxSafe Marin puts something on paper, talks about it in the medical community, and has “action teams” to try and implement and spread the gospel of the medical-legal framework it has developed. The second lesson is that local efforts can quickly get more done, and more effectively, than at the state or federal level. The Medical Board of California is too bureaucratic, too unwieldy, and too afraid of assuming liability or having insufficient enforcement flexibility, to be clear with doctors about what should and should not be done. In the absence of state leadership in responsible physician education, a county has taken the initiative and filled vacuum. And third, local guidelines offer new protection for doctors who take the time to learn and implement them. In practice, a doctor who takes advantage of a new educational opportunity, and who utilizes this new tool in her work, is declaring to all who’d ask that she knows the science, carefully decides whether to prescribe opioids for chronic pain, and voluntarily and consistently advances what the local medical community views as the safest and best way to treat patients in pain.
The flipside, of course, is that if you’re a doctor in a community such as Marin, who doesn’t know what RxSafe Marin is, or who otherwise doesn’t practice well within available prescribing guidelines, you’re running an added risk of being arrested and prosecuted for drug crimes. With everybody else on notice that there’s a problem that the county is trying to address, what’s your excuse for not knowing about it and not doing anything about it? I’ve heard DEA agents, detectives and prosecutors say that many, many times about the doctors they arrest and throw into criminal court. From the patient safety and medical practice perspective, programs like RxSafe Marin are great, and they offer support for doctors to meet the legal test of medical judgment. Doctors who don’t make the most of the opportunity are taking a huge risk, and running out of excuses.