WHEN LESS IS MORE REDUCING OPIOID OVERPRESCRIBING

Transcription

1 WHEN LESS IS MORE REDUCING OPIOID OVERPRESCRIBING Maria Foy, PharmD, BCPS, CPE Pharmacy Care Coordinator, Palliative Care Abington Hospital Jefferson Health

2 Goals and Objectives Describe how opioid overprescribing is a catalyst for the opioid crisis Outline strategies for reduction of opioid use in the emergency room and post operative setting

3 Some PAINful Facts and Figures Survey of 8781 adults demonstrated 127 million Americans suffer from some type of pain in 3 months prior to the survey 25.3 million experienced daily pain Pain costs $635 billion annually (2010 dollars) Those with serious pain need and use more health care services and suffer greater disability then persons with less severe pain The United States utilizes 90% of the world opioids Opiophobia and bias are becoming more common

4 Truths and Myths Opiophobia: Fear of prescribing opioids Myth Truth There is always a biological reason for pain Four out of five patients on heroin start on prescription opioids Chronic pain is not helped by opioids unless the diagnosis is cancer Patients who misuse opioids are the ones prescribed the opioids Many prescriptions are written to patients who doctor shop (receiving prescriptions from multiple doctors) Chronic pain is highly influenced by thoughts and fears, especially if psych co-morbidities present Incidence is closer to 60% Opioids can be effective for many chronic pain indications. Focusing on function vs. pain number is the goal Majority of non-medical use of prescription opioids are obtained from relatives, friends. Only 0.7% of patients receiving opioids scripts are doctor shoppers and encompass 1.9% of prescriptions

5 The Other Side of the Coin Prescription drug dispensing quadrupled The US uses the majority of the worlds opioids Nearly 2 million people currently suffer from an opioid use disorder Opioid overdose deaths showed similar increase 175 people die of an opioid overdose daily Polypharmacy OD s common Benzodiazepine crisis? Substance use crisis? Prescribing of opioids have decreased every year since 2010 Deaths continue to rise

6 Overdose Death Statistics

7 National Opioid Overdose Deaths

8 Deaths from Prescription Opioid vs. Heroin

9 Lethal Doses

10 Is this the future? There are more than 150 deaths/day from opioids Increases of 250/day predicted if synthetic opioids continue to be abused Deaths can top 650,000 in the next decade if the trend continues Deep Medicaid cuts being currently proposed can influence death tolls Many low income adults will be left without insurance By 2027, opioid deaths will likely surpass deaths from gun violence

11 How Did We Get Here? Root of the crisis stretches back to the late 1990s Hydrocodone and oxycodone manufacturers claimed minimal risk of addiction Companies were reported to have bribed doctors and payed middlemen to bypass regulations on opioid prescribing Intense marketing of opioids ensued Opioids promoted as non-addictive and advantageous over existing therapies

12 Why did practitioners overprescribe? Overemphasis on pain control without sufficient education on management of pain 5 th vital sign Pharmacy and medical school curriculum inadequate Concept of no dose ceiling of opioids Reimbursement for ancillary care cut back drastically in the early 90 s Burden of prescribing put on family medicine physician Time of office visits (8-15 min) not sufficient to evaluate complexities of pain management Increasing incidence of disability also contributed to use in non-cancer pain Many recommended non-pharmacologic treatments not covered by insurance Often, the only tool remaining was for medication management

13 Sources for Obtaining Opioids for Non-Medical Use

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16 GENERAL CONCEPTS

17 Types of Pain Nociceptive (normal) pain Neuropathic (nerve) pain Cancer related pain Pathologic pain Mixed pain syndromes

18 Differentiating Types of Pain by Description Nociceptive (common) Described as sharp, aching, throbbing Somatic pain localized Visceral pain - generalized Neuropathic (nerve) Neuropathy explainable (MS, DPN) Described as burning, tingling, shooting, electric-like Pathologic pain Sensitized pain, often total body May not find any source for the pain

19 Determine Long Term Temporal Pattern ACUTE Onset well defined Resolves when underlying issue addressed CHRONIC Poorly defined onset with underlying cause difficult to determine Anxiety, depression often present

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21 Balancing Act Risk of abuse, misuse, diversion Benefit of opioids as analgesic Appropriate, safe, effective use

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24 Definitions Dependence Psychological and physiological need for habit-forming substances Tolerance Chronic exposure to a drug diminishes its anti-nociceptive effect or creates a need for a higher dose to maintain this effect Addiction Compulsive need for/use despite negative consequences; display tolerance and physiological symptoms upon withdrawal

25 Differences in Tolerance, Dependence, and Addiction (Substance Use Disorder) Tolerance and dependence can be predicted with higher dose, long term treatment Addiction is NOT a predictable result of opioid prescribing Risk can be determined by using assessment tools Mechanisms of addiction are different than those responsible for tolerance and dependence Multiple brain processes disrupted Signals evoked slowly and last longer Development of addiction will not cease when opioids are stopped Separate, chronic illness Carries high risk of relapse without treatment

26 Chemistry of Substance Use Disorder (SUD) Transmitter Location Function Substances Dopamine Midbrain, VTA, Cortex, hypothalamus Motivation, memory, motor behavior, reward Cocaine, amphetamine, final common pathway Endogenous Opioids Limbic system, brainstem, spinal cord Pain, emotion, bodily functions, mood Opioids Other major neurotransmitters affecting memory/neuroplasticity: serotonin, norepinephrine, acetylcholine, endocannabinoid, glutamate, GABA Adapted from: Kalant, H. Addiction, 2009;105:

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28 Behaviors Associated with severe SUD Noticeable elation/euphoria Marked sedation/drowsiness Confusion Myosis Slowed breathing Nodding off, or loss of consciousness Constipation Doctor shopping Shifting or dramatically changing moods Extra pill bottles in the trash Social withdrawal/isolation Sudden financial problems Withdrawal symptoms

29 Risk Factors for Abuse and Substance Use Disorder Genetic predisposition Psychological factors Stress, high impulsivity or sensation seeking personality, depression, anxiety, eating disorders, personality and other psychiatric disorders Environmental influences Physical, sexual, or emotional abuse or trauma, exposure to family/friends with substance use or addiction, access to an addictive substance Starting alcohol, nicotine or other drug use at an early age Adapted from: Kalant, H. Addiction, 2009;105:

30 EMERGENCY ROOM PRESCRIBING

31 Strategies to Reduce Harm Avoid prescribing extended release opioids and injectable opioids as first line (if tolerating oral medications) Avoid filling lost or stolen prescriptions Review Prescription Monitoring Program (PDMP) Avoid opioids in patients already receiving benzodiazepines or other medications that reduce the respiratory drive Large number of opioid deaths due to polypharmacy Avoid prescribing opioids in patient with alcohol dependence, substance abuse issues, or psychological comorbidities Prescribe the smallest amount of opioids needed Usually 2-3 days supply is sufficient

32 Develop Treatment Plans For Frequent Flyers Pain patients comprise of about 40% of frequent visits to the emergency room Develop a multidisciplinary committee to develop individualized care plans Buy in and following the developed plan is needed from all practitioners Develop plan in conjunction to the outpatient provider responsible for caring of the patients and reviewed by the committee Plans can include pre-determined limits or recommendations to withhold opioids Utilize case management to coordinate care with various agencies such as insurances, mental health and substance abuse treatments Reduction in ER visits can serve as an outcome measure for success Consider newer non-opioid treatments for acute severe pain control Ketamine Lidocaine

33 Non-opioid Pharmacologic and Nonpharmacologic Pain Treatments Ketamine Lidocaine Gabapentin Pregabalin Duloxetine, milnacipran, lamotrigine Cox-2 inhibitors Cognitive Behavioral Therapy Aerobic exercise/physical therapy Chronic pain rehabilitation Massage therapy Relaxation Acupuncture

34 POST OPERATIVE PRESCRIBING

35 Post-Operative Pain More than 80% of patients report post operative pain Moderate, severe or extreme pain reported in 75% of patients Majority of pain is acute and will resolve within a few days when pain is treated appropriately Post-surgical patients are at an increased risk for chronic pain Risk is times higher than in non-surgical opioid use Diversion is seen when opioids remain unused and not discarded 71% of patients who misuse opioids do not obtain medications from prescriptions Most obtain from friends or relatives Unused opioids increase availability for diversion

36 How Much is Too Much? Records of more than 200,000 opioid naïve patients who subsequently received an opioid prescription reviewed 4 Data obtained from the Department of Defense Military Health System Data Repository Eight common surgical procedures reviewed Findings Median length of initial prescription was 4-7 days Refills required ranged from 11 to 39% based on procedure Duration prescribed varied on procedure 9 days general surgery 15 days musculoskeletal conditions Approximately 40% of patients required refill at 7 days Mainly orthopedic and neurosurgical patients

37 Opioid Prescribing after Inpatient Surgery: American College of Surgeons Study conducted on patients who received targeted surgeries between July 2016 to Dec 2016 Laparoscopic gastric bypass, fundoplication, hernia repair, pancreatectomy or colectomy Sleeve gastrectomy Open hernia repair, pancreatectomy, colectomy Robotic colectomy Chart reviewed for length of stay (LOS), opioid use day prior to DC, outpatient opioid prescriptions, post-op complications, and opioid refills Only available on patients DCD post op day 2 or later Two hundred thirty four patients included in analysis Questionnaire sent to included patients Opioid usage, refills, disposals of remaining pills and satisfaction with pain control

38 Results Association seen between number of pills used prior to discharge and home usage of opioids After controlling for age, sex, procedure, LOS and adjunctive acetaminophen or ibuprofen use Older age also associated with less opioid use No correlation seen between amount taken at home and type of surgery Outliers: Reasons for more than recommended use Percent (%) Using for reasons other than acute pain 53 Sleep 18 No pain, using because given script 14 Fear of pain 7 Indigestion or GI upset 7 Non-surgical pain 7

39 Steps to Decrease Availability of Opioids Education needed Pain education in medical and pharmacy schools minimal Important to recognize different potencies of opioids Multimodal interventions required for chronic non-cancer pain Reduce amounts of opioids prescribed at discharge Limit supply based on type of surgery Don t overprescribe to avoid a phone call or just in case Multimodal strategies for pre-, peri- and post op pain control Pre-emptive analgesia Enhanced Recovery After Surgery Initiatives (ERAS)

40 Enhanced Recovery After Surgery Uses strategies before surgery, during surgery and after surgery to help decrease opioid requirements Multimodal analgesia Associated with shorter length of stay Wounds and other complications reduced by 50% Patients are counseled prior to surgery in order to promote realistic expectations for pain control Pain may never be 100% controlled Opioids just take the edge off the pain

41 Clinical Pearls Opioid analgesics are effective in acute pain but have limited effectiveness in chronic pain Appropriate when risk of abuse is low and functional improvement seen Using more than 100 mg of morphine equivalents has been shown to increase morbidity and mortality Chronic pain is often not relieved from opioid therapy alone and may sensitize the pain system and cause more pain Phenomenon called Opioid Induced Hyperalgesia/Neurotoxicity Opioids, when indicated for acute pain, should be used at the lowest effective dose for the shortest period of time Use of alternative means of pain control can decrease opioid consumption and reduce risk from harm

42 Questions?