Drugs in the Workforce: The Rise of Prescription Opioid Use and Abuse. Don Teater MD

Transcription

1 Drugs in the Workforce: The Rise of Prescription Opioid Use and Abuse Don Teater MD

2 Don Teater MD Medical Advisor National Safety Council Medical Provider Mountain Area Recovery Center Asheville, NC Medical Provider Meridian Behavioral Health Services Waynesville, NC Masters student UNC Gillings School of Global Public Heath

3 NIDAmed module

4 Opioid increase Drug distribution through the pharmaceutical supply chain was the equivalent of 96 mg of morphine per person in 1997 and approximately 700 mg per person in 2007, an increase of >600%.(Paulozzi & Baldwin, 2012) Centers for Disease Control and Prevention. CDC grand rounds: Prescription drug overdoses a U.S. epidemic. MMWR Morb Mortal Wkly Rep 2012; 61:10-13

5 The State of US Health Years lived with disability (in thousands) Low back pain Other MS disease Neck pain Osteoarthritis Murray, C. (2013). The state of US health, : burden of diseases, injuries, and risk factors. JAMA : The Journal of the American Medical Association, 310(6),

6 Institute of Medicine Relieving Pain in America 2011 Pain affects millions of Americans; contributes greatly to national rates of morbidity, mortality, and disability; and is rising in prevalence. IOM (Institute of Medicine) Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press.

7 Societal costs (annual) $55.7 billion (2007): $25.6 billion (46%) was attributable to workplace costs. May be up to $11,000 per year for each drug using employee 24 cents per MME. $54 for a bottle of 30 Percocet (5 mg)

8 Rate Rates of opioid overdose deaths, sales and treatment admissions, US, Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10, Year National Vital Statistics System, DEA s Automation of Reports and Consolidated Orders System, SAMHSA s TEDS

9 America land of excess Americans, constituting only 4.6% of the world's population, have been consuming 80% of the global opioid supply. 83% of the world s population does not have access to any opioids. Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician. 2008; 11(2 Suppl):S63-88

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11 Poppy plant

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13 Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. International Association for the Treatment of Pain

14 Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. International Association for the Treatment of Pain

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16 Pain Acute pain: Pain < 3 months Chronic pain: Pain > 3 months

17 Acute pain: treatment Acetaminophen NSAIDS Opioids Topical agents Nonpharmacologic (PT, ice, heat, etc.)

18 Pros: Acetaminophen Analgesic Antipyretic Oral and IV Minimal GI side-effects NNT is 3.5 for 500 mg for 50% pain relief Cons No anti-inflammatory properties Toms, L., Hj, M., Derry, S., & Ra, M. (2008). Single dose oral paracetamol ( acetaminophen ) for postoperative pain in adults. Cochrane Database of Systematic Reviews, (4). doi: / cd pub2

19 Pros: Analgesic Antipyretic Anti-inflammatory Oral, IM and IV NNT for 50% pain relief Ibuprofen 200 mg: 2.7 Cons: Side effects: GI Renal Cardiac NSAIDs

20 Pros Opioids Analgesic Oral, IM and IV NNT (morphine 10 mg IM) = 2.9 Cons Mentally impairing Delay recovery Increase medical costs Opioid hyperalgesia Double the chance of disability Increase falls Cardiac, GI? Addiction

21 One opioid prescription after an injury: Increases medical costs by 30% 1 Increases the risk of surgery by 33% 1 Doubles the risk of being disabled at one year 2 1. Webster BS, Verma SK, Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine (Phila Pa 1976). 2007;32(19): doi: /brs.0b013e318145a Franklin GM, Stover BD, Turner J a, Fulton-Kehoe D, Wickizer TM. Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. Spine (Phila Pa 1976). 2008;33(2): doi: /brs.0b013e c.

22 Efficacy of pain mediations Acute pain Percent with 50% pain relief Ibuprofen 200 mg Acetaminophen 500 mg Ibuprofen 400 mg Oxycodone 15 mg Oxy 10 + acet 1000 Ibu acet 500

23 Renal colic A 2005 Cochran review concluded: NSAID medications and opioids have equal effectiveness in treatment of acute renal colic but opioids have more side-effects.

24 Ibuprofen Single Dose Analgesic Efficacy of Tapentadol in Postsurgical Dental Pain: The Results of a Randomized, Double-Blind, Placebo-Controlled Study. Kleinert, Regina; Lange, Claudia; MD, MSc; Steup, Achim; Black, Peter; Goldberg, Jutta; Desjardins, Paul; DMD, PhD Anesthesia & Analgesia. 107(6): , December DOI: /ane.0b013e ca 2

25 CONCLUSION: Single oral doses of tapentadol 75 mg or higher effectively reduced moderate-to-severe postoperative dental pain in a dose-related fashion and were well-tolerated relative to morphine. These data suggest that tapentadol is a highly effective, centrally acting analgesic with a favorable side effect profile and rapid onset of action. But not as effective as ibuprofen!

26 Chronic pain No evidence that opioids are effective for longterm treatment of chronic pain. Safe and effective use of opioids for chronic pain is an invalid concept. No evidence that these can be used safely No evidence that they can be used effectively Epidemiologic studies have shown that those on chronic opioid therapy have worse quality of life than those with chronic pain who are not.

27 Tapentadol study

28 Additional tx in chronic pain PT Counseling CBT and mindfulness training Treatment of mood disorders Exercise Acupuncture Amitriptyline Duloxetine (and other antidepressants) Gabapentin (and other anticonvulsants)

29 CDC Opioid Guidelines 3 day limit for acute pain. Opioids are not the default treatment Use only when benefits are expected to outweigh the risks.

30 Acute prescriptions Approximately 30% of ALL ER visits end with a prescription for a opioid. 1 Approximately 60% of patients going to the ER with back pain will get an opioid prescription. 2 Primary care doctors give opioids to about 35% of their patients presenting with back pain. Pain is the most common reason for people to go to the ER or to their primary care doctor.

31 How many are diverted? It is estimated that between 4-23% of opioid doses are used for nonmedical purposes. (Katz, Birnbaum, & Castor, 2010) Katz, N. P., Birnbaum, H. G., & Castor, A. (2010). Volume of prescription opioids used nonmedically in the United States. Journal of Pain & Palliative Care Pharmacotherapy, 24(2),

32 Adverse opioid effects - again Mentally impairing Delay recovery Increase medical costs Opioid hyperalgesia Double the chance of disability Increase falls Cardiac, GI? Addiction

33 Weaning opioids Recommended by the CDC guidelines Average 20% reduction in pain There is no best practice for how this should be done Consider decrease 10% of the starting amount each month for 10 months for those on high doses. Pain will almost certainly get worse before it gets better

34 250,000 Number of deaths in the last 20 years from opioids. More than 4 times the number of American deaths in the Vietnam war This is an epidemic. And we are the vector! This epidemic is completely reversible with a change of behavior that will result in better pain management

35 Take home thoughts Opioids are no better than ibuprofen for pain relief Low-dose ibuprofen is very safe Not all NSAIDs are the same! Opioids delay recovery, increase costs, increase complications The most important effect of opioids is their ability to calm.

36 To write prescriptions is easy, but to come to an understanding with people is hard. -- Franz Kafka, A Country Doctor

37 Questions? Don Teater MD Cell: