What prescription and practice strategies, patient education, and evidence‑based supports are most effective for addressing the opioid overdose crisis in Hawaii (older population with prescription opioid misuse) versus Maryland (urban population with heroin and illicit fentanyl use), including use of a Prescription Drug Monitoring Program (PDMP) and Medication‑Assisted Treatment (MAT)?

Comparing Hawaii vs Maryland's Opioid Overdose Crisis and Evidence-Based Strategies

Crisis Profiles and Epidemiologic Context

Maryland faces one of the nation's most severe opioid crises, with age-adjusted overdose deaths at 37.2 per 100,000 in 2018, ranking third highest nationally after West Virginia and Delaware. 1 The state's urban centers drive mortality through heroin and illicit fentanyl, with synthetic opioid deaths (primarily fentanyl) increasing 80% between 2013-2014 alone. 2 Hawaii's crisis, while less severe in absolute numbers, predominantly involves prescription opioid misuse in an older population, representing a fundamentally different epidemiologic pattern requiring distinct intervention strategies.

Maryland's Urban Heroin/Fentanyl Crisis

• Heroin deaths increased 533% nationally from 2000-2016, with synthetic opioid (fentanyl) deaths rising 520% from 2009-2016. 3
• Maryland's urban population faces the highest risk, with deaths concentrated in the 25-44 year age group (38.4-39.0 per 100,000). 1
• Illicitly manufactured fentanyl cannot be distinguished from prescription fentanyl in death certificates, complicating surveillance. 2

Hawaii's Prescription Opioid Crisis

• Older populations are at elevated risk, particularly those aged 45-54 years (37.7 per 100,000) and ≥55 years. 1
• Prescription opioid deaths increased 18% between 2009-2016, though prescriptions declined 9% annually from 2013-2017. 3

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Prescription and Practice Strategies by Region

For Maryland (Urban Heroin/Fentanyl Epidemic)

Medication-Assisted Treatment (MAT) with methadone or buprenorphine represents the gold standard and must be the immediate first-line intervention for all patients with opioid use disorder. 4, 5

Immediate MAT Implementation

• Methadone maintenance reduces heroin use, mortality, criminal activity, and HIV transmission. 5 This should be prioritized for patients with severe heroin dependence and those who have failed office-based treatment.
• Buprenorphine/naloxone is preferred for office-based treatment and patients with less severe dependence. 5 Start induction using the Clinical Opiate Withdrawal Scale (COWS score >8), with initial doses of 4-8 mg sublingual buprenorphine, targeting 16 mg/day maintenance. 5
• Never deny MAT to patients taking benzodiazepines or other CNS depressants—prohibiting treatment poses greater mortality risk than the opioid use disorder itself. 6 Instead, educate about risks, develop management strategies at induction, and consider higher-level monitoring for benzodiazepine taper. 6

PDMP Utilization Strategy

• Check PDMP data before every opioid prescription ideally, or at minimum every 3 months during ongoing treatment. 1 Maryland should mandate provider review given the severity of its crisis.
• Low-strength evidence suggests PDMP implementation reduces fatal overdoses, with specific features showing benefit: mandatory provider review, weekly data updates, monitoring of non-scheduled drugs, and proactive reporting to prescribers. 1
• Critical caveat: Three of six studies found increased heroin overdoses after PDMP implementation, 1 likely representing substitution from prescription opioids to illicit drugs. This necessitates simultaneous expansion of MAT access when implementing restrictive PDMP policies.

Harm Reduction Services (Essential for Fentanyl Crisis)

• Provide naloxone to all patients and their families for overdose reversal. 1, 4, 5 The American Heart Association emphasizes public education on naloxone use, CPR, and immediate 9-1-1 activation. 1
• Refer to syringe service programs to reduce HIV and hepatitis C transmission (rates exceed 50% in some populations with substance use disorders). 5
• Offer overdose prevention education at every clinical encounter. 5

For Hawaii (Prescription Opioid Misuse in Older Adults)

Implement aggressive prescribing restrictions combined with robust PDMP utilization and early identification of at-risk patients before progression to illicit drug use.

Prescribing Practice Modifications

• Limit new opioid prescriptions to lowest effective doses and shortest durations. Opioid prescribing increased 350% between 1999-2015, creating the foundation for the current crisis. 1
• Screen all patients using validated tools before prescribing opioids. Use the single-question screen (sensitivity 90-100%, specificity 74%) or DAST-10 (sensitivity 90-100%, specificity 77%). 5
• Co-prescribe naloxone for patients at high overdose risk: those on ≥50 MME/day, those with concurrent benzodiazepine use, those with history of overdose, and those recently released from incarceration. 1

Enhanced PDMP Implementation

• Check PDMP data when starting any opioid therapy and every 3 months minimum during chronic treatment. 1 For Hawaii's older population with multiple prescribers, this identifies dangerous combinations (opioids plus benzodiazepines) and high total dosages.
• Implement mandatory provider review, weekly data updates, and interstate data sharing—these specific features show association with reduced fatal overdoses. 1

Early MAT Intervention

• For patients already dependent on prescription opioids, transition to buprenorphine/naloxone rather than continuing escalating doses. 5 Buprenorphine is safer in older adults due to ceiling effect on respiratory depression.
• Screen for co-occurring mental health disorders (highly prevalent) and provide integrated treatment. 4, 5

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Patient Education Strategies

Universal Education Components (Both States)

All patients and their household members must receive training on overdose recognition and naloxone administration. 1

Overdose Recognition and Response

• Teach the chain of survival: recognize respiratory depression (slow/absent breathing, blue lips, unresponsiveness), administer naloxone immediately, call 9-1-1, provide rescue breathing or CPR until help arrives. 1
• Emphasize that opioid overdose causes respiratory arrest first, then cardiac arrest—bystander intervention is critical. 1
• Provide naloxone prescriptions with hands-on training through clinic resources or collaborative practice with pharmacists. 1

Risk Factor Education

• Warn about the extreme danger of combining opioids with benzodiazepines, alcohol, or other CNS depressants—this combination is associated with the majority of fatal overdoses. 6
• Educate that tolerance decreases rapidly: patients recently released from incarceration or after periods of abstinence are at highest overdose risk if they return to previous doses. 1
• For Maryland patients: Emphasize that illicit fentanyl is 50-100 times more potent than morphine and is increasingly mixed with heroin—even small amounts cause fatal overdoses. 2

Maryland-Specific Patient Education

Focus education on harm reduction and engagement with MAT rather than abstinence-only messaging. 4

• Explain that MAT with methadone or buprenorphine is not "trading one addiction for another"—it is evidence-based medical treatment that reduces mortality by over 50%. 5
• Teach safe injection practices and provide referrals to syringe service programs to reduce HIV/hepatitis C transmission while engaging patients toward treatment. 5
• Educate that continuing MAT during acute pain or surgery is essential—never abruptly discontinue, as this increases overdose risk. 5 Additional opioid analgesics can be added at higher doses and shorter intervals due to cross-tolerance. 5

Hawaii-Specific Patient Education

Emphasize safe storage and disposal of prescription opioids to prevent diversion and unintentional pediatric exposure. 6

• Store medications in locked containers out of sight and reach of children—buprenorphine and other opioids cause severe, potentially fatal respiratory depression in children who are accidentally exposed. 6
• Destroy unused medications immediately using drug take-back programs or FDA-approved disposal methods. 6
• For older adults: Educate about increased fall risk, cognitive impairment, and respiratory depression with opioid use, particularly when combined with other medications common in this population.

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Evidence-Based Support Systems

Behavioral Therapy Integration (Both States)

Combine all pharmacotherapy with cognitive-behavioral therapy (CBT), contingency management, or motivational enhancement therapy—combined treatment shows greater efficacy than pharmacotherapy alone. 4, 5

Specific Behavioral Interventions

• Contingency management plus Community Reinforcement Approach is most effective: only 4 patients need treatment for 1 additional patient to achieve abstinence. 5
• Brief counseling using motivational interviewing decreases quantity and frequency of drug use and can be delivered in primary care settings. 5
• Implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) in emergency departments, primary care, and community settings. 4

Maryland-Specific Support Systems

Establish low-barrier MAT access in emergency departments, jails, and community health centers. 5

• Emergency departments should initiate buprenorphine and provide bridge prescriptions with immediate referral to ongoing MAT providers—this reduces mortality in the critical period after ED discharge. 5
• Maintain nonjudgmental, blame-free clinical environments to encourage continued engagement, as relapse risk is highest in early recovery. 5
• Monitor treatment response with regular follow-up: weekly initially, then monthly, using urine drug testing to support diagnosis and monitor treatment (not as punitive measure). 5
• Integrate treatment for co-occurring mental health disorders—these are highly prevalent and require simultaneous management. 4

Hawaii-Specific Support Systems

Implement real-time PDMP alerts and clinical decision support systems integrated into electronic health records. 1

• Automated surveillance systems should flag high-risk prescribing patterns: multiple prescribers, high total daily doses (≥50 MME), concurrent benzodiazepines, and early refill requests. 1
• Establish multidisciplinary pain management programs offering non-opioid alternatives: physical therapy, interventional procedures, non-opioid medications, and psychological approaches. 4
• Create "warm handoff" systems where primary care providers can immediately connect patients showing signs of opioid use disorder to addiction specialists or MAT providers. 5

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Critical Pitfalls to Avoid

Universal Pitfalls (Both States)

Never abruptly discontinue opioid agonist therapy (methadone or buprenorphine)—this constitutes patient abandonment and dramatically increases overdose risk. 5, 6

• Never withhold MAT due to concerns about drug interactions with HIV or hepatitis C treatments—these medications are safe to use together. 4, 5
• Never use PDMP data to dismiss patients from practice—this harms patient safety by disrupting care continuity and driving patients to illicit drug markets. 1
• Never focus solely on abstinence rather than harm reduction approaches—this increases mortality by creating barriers to evidence-based treatment. 4

Maryland-Specific Pitfalls

Do not implement restrictive PDMP policies or prescribing limits without simultaneously expanding MAT access—this drives substitution to heroin and fentanyl. 1

• Never delay buprenorphine induction due to benzodiazepine use—adjust monitoring and provide education, but do not deny treatment. 6
• Do not use arbitrary dose caps for buprenorphine as a strategy to address benzodiazepine use—there is no evidence supporting this approach. 6

Hawaii-Specific Pitfalls

Do not prescribe multiple refills of opioids early in treatment without appropriate follow-up visits—this enables diversion and progression of opioid use disorder. 6

• Never prescribe opioids without checking PDMP data first—this is the only way to identify multiple prescribers and dangerous drug combinations in older adults seeing multiple specialists. 1
• Do not assume older adults are at lower risk for opioid use disorder—age-adjusted mortality rates are substantial in the 45-54 and ≥55 age groups. 1