Opioid Overutilization

Transcription

1 Technician Educatin Day September 24, 2016 Jacksnville, FL Opiid Overutilizatin Disclsure I have nthing t disclse cncerning pssible financial r persnal relatinships with cmmercial entities (r their cmpetitrs) that may be referenced in this presentatin. Brittany Jhnsn, Pharm.D. PGY-2 Pain and Palliative Care Pharmacy Resident UF Health Jacksnville, FL Brittany Jhnsn, PharmD Objectives Prevalence and Incidence f Pain Outline the prevalence and incidence f piid use in the United States Review the pathphysilgy f pain and the cmmn agents used t treat it Identify piid medicatins that may be high risk fr abuse Discuss the parameters cntributing t the verutilizatin f piids Csts the United states ver $100 billin dllars annually Mst cmmn symptm reprted in the medical setting Pain medicatins are the secnd mst prescribed drug in the United States Highlight the pharmacy teams rle in ensuring safe piid use Krenke K et al. Gen Hsp Psychiatry. 2009;31(3): What is Pain? Pathphysilgy f Pain Whatever the Patient says it is Image Surce: 1

2 Assessment f Pain Classifying Pain Types Pain Chrnic Acute Neurpathic Nciceptive Visceral Smatic Image surce: Backnja, M.P&T Digest. 2005; Vl 30(12):9-14. Treatment Ladder f Pain Nn-Opiid Therapy Opiid fr mild t mderate pain All steps include: +/- Adjuvant therapy Opiid fr mderate t severe pain Wrld Health Organizatin, WHO s Pain relief ladder (2009). Cmmunity management f piid verdse. WHO. 2014; Dwell D, Haegerich TM, Chu R. CDC Guideline fr Prescribing Opiids fr Chrnic Pain. 2016;65(N. RR-1):1 49. Cmmn Agents t Treat Pain Adjuvant Therapy Shrt Acting Opiids Lng Acting Opiids Acetaminphen Hydrcdne/acetaminphen Fentanyl Amitriptyline Hydrmrphne Methadne Baclfen Mrphine IR Mrphine ER Capsaicin Oxycdne IR Oxycdne ER Cyclbenzaprine Oxycdne/acetaminphen Dulxetine Gabapentin Ibuprfen Melxicam Pregabalin Tizanidine Venlafaxine Dwell D, Haegerich TM, Chu R. CDC Guideline fr Prescribing Opiids fr Chrnic Pain. 2016;65(N. RR-1):1 49. Histry f Opiid Use in Chrnic Pain 1986: Case reprts n safety and efficacy f piid use in chrnic nn-malignant pain K. Prteny and K. M. Fley Chrnic use f piid analgesics in nn-malignant pain: Reprt f 38 cases. Pain 1986; 25: : MS Cntin apprved 1990: The Tragedy f Needless Pain by Rnald Melzack Cntrary t ppular belief, mrphine taken slely t cntrl pain is nt addictive. Yet patients wrldwide cntinue t be undertreated and t suffer unnecessary agny 1990 s: Endrsement f piids fr chrnic nn-malignant pain American Academy f Pain medicine (AAPM): 1997 American Pain Sciety (APS): 1997 American Geriatrics Sciety (AGS): 1998 Melzack R. The tragedy f needless pain. Scientific American 1990; 262(2). Histry f Opiid Use in Chrnic Pain 1995: OxyCntin apprved FDA believed it wuld result in less abuse ptential due t slw absrptin and decrease chances f peak effects 2000: Reprts f verdses start t rise sharply 2001: Jint Cmmissin Standard: Pain is the 5 th vital sign MMWR Mrb Mrtal Wkly Rep 2011; 60: (89). Centers fr Disease Cntrl and Preventin. Vital signs: Overdses f prescriptin piid pain relievers United States,

3 Opiid Epidemic Opiid Epidemic Prviders wrte 259 millin prescriptins fr narctics in f the highest prescribing states fr narctics are lcated in the suth In 2011 Flrida prescribed mre xycdne than all ther states cmbined 46 peple die daily due t an piid verdse JAMA 2003; 290: Opiid Epidemic Where Are Opiid Medicatins Cming Frm? Image Surce : Challenges Leading t Opiid Overuse Weak regulatry versight f pain management practices Limited supervisin f physician dispensing habits N statewide prescriptin drug mnitring prgram Criminal enterprises explited Flrida's regulatry system P.Bndi, Flrida s Prescriptin Drug Diversin and Abuse Radmap

4 Challenges Leading t Opiid Overuse Challenges Leading t Opiid Overuse Physician Challenges Pharmacist Challenges Patient Challenges Regulatry Agency Challenges Physician Challenges Difficult t assess pain Hard t tell a patient n Dn t want t play detective Fear f legal ramificatins Physicians trying t prtect their license Pharmacist Challenges Nt enugh knwledge regarding patient case Patients may nt have a valid medical diagnsis fr cntrlled substances DEA mnitring n high vlumes f cntrlled substances Pharmacists trying t prtect their license Challenges Leading t Opiid Overuse The Respnse t Opiid Overutilizatin Patient Challenges Scial stigma surrunding piid use Cncerns f develping dependency r addictin Diversin and sales Regulatry Challenges Interfering with patient care Difficulty differentiating verprescribing frm clinical judgment Determining apprpriateness f therapy fr a highly subjective disease state Develped plans t Reduced the supply f systematically shut dwn illegally diverted "pill mills prescriptin drugs Flrida Initiatives Decreased the demand Prtect patients and their fr diverted drugs right t access scheduled prescriptin drugs The Respnse t Opiid Overutilizatin Unintended Cnsequences Image Surce: 4

5 Unintended Cnsequences The Pharmacy Teams Rle Red Flags Efrcse Nalxne Increased Patient Safety Hw t Identify Red Flags Prescriptin Drug Mnitring Prgram Cash payments Multiple drivers licenses r patient addresses Prescriptins frm different prviders fr similar medicatins Out f area prescriptins High quantities False phned in r written prescriptins High vlume prescribing Physicians Ccktails f frequently abused cntrlled substances The Flrida Prescriptin Drug Mnitring Prgram (E-FORCSE ) Electrnic-Flrida nline reprting f cntrlled substance evaluatin prgram Created by the 2009 Flrida Legislature Encurages safer prescribing f cntrlled substances Fcuses n reducing drug abuse and diversin within the state f Flrida 64B Standards f Practice fr the Filling f Cntrlled Substance Prescriptins Prescriptin Drug Mnitring Prgram Prescriptin Drug Mnitring Prgram E-FORCSE Flrida s Prescriptin Drug Mnitring Prgram Database that stres prescribing and dispensing data fr schedule II, III, and IV drugs Purpse f the PDMP Prvide infrmatin cllected in the database t health care practitiners Guide decisins in prescribing and dispensing Reduce drug abuse and diversin within the state f Flrida Encurage safer prescribing E-FORCSE Requires health care practitiners t reprt each time a cntrlled substance is dispensed t an individual Infrmatin must be reprted n later than 7 days frm dispensing Ensures health care practitiners have the mst up-t-date infrmatin Health Insurance Prtability and Accuntability Act (HIPAA) Cmpliant Additinal infrmatin Flrida statutes sectin

6 Prescriptin Drug Mnitring Prgram Mnitring t Increase Safety Prspective Drug Utilizatin Review Nalxne Candidacy Risk Assessment Flrida s Prescriptin Drug Mnitring Prgram (EFORCE ) Pain Management Agreements Urine Drug Screening Nalxne Candidacy Respiratry disease Alchl cnsumers Cncmitant benzdiazepines Receiving mre than 50 mrphine equivalents daily Hepatic r renal insufficiency Over 65 years ld Histry f aberrant behavir Cmmunity management f piid verdse. WHO. 2014; 1-88 Dwell D, Haegerich TM, Chu R. CDC Guideline fr Prescribing Opiids fr Chrnic Pain. 2016;65(N. RR-1):1 49. Image surce: Nalxne fr Opiid Overdse Educatin n Opiid Overdse N respnse t stimuli Lss f alertness Slurred speech Signs and symptms f piid verdse Itchy skin Pale clammy skin Respiratr y depressin Vmiting Cmmunity management f piid verdse. WHO. 2014;

7 Evzi Intranasal Nalxne 1 2 Tilt head back, supprt the patients neck D NOT prime prir t administratin Administer nalxne nasal spray as quickly as pssible Seek immediate medical attentin after administratin and rtate patient n their side 3 Re-administer nalxne nasal spray in ppsite nstril in 2 t 3 minutes if the patient des nt respnd r relapses Evzi. Package Insert Narcan Nasal Spray. Package Insert Nalxne Instructins Flrida Legislatin n Nalxne Evzi (Injectable Nalxne) Inject ne aut injectr (0.4mg) as a single dse fr piid reversal Call 911 right away May repeat in 2 t 3 minutes while waiting n medical assistance t arrive Intranasal Nalxne Instill ne spray (4mg) as a single dse fr piid reversal Call 911 right away May repeat in 2 t 3 minutes in ther nstril until medical assistance becmes available Flrida Statute (3) An authrized health care practitiner may prescribe and dispense an emergency piid antagnist t a patient r caregiver fr use in accrdance with this sectin, and pharmacists may dispense an emergency piid antagnist pursuant t such a prescriptin r pursuant t a nn-patient-specific standing rder fr an autinjectin delivery system r intranasal applicatin delivery system, which must be apprpriately labeled with instructins fr use. Such patient r caregiver is authrized t stre and pssess apprved emergency piid antagnists and, in an emergency situatin when a physician is nt immediately available, administer the emergency piid antagnist t a persn believed in gd faith t be experiencing an piid verdse, regardless f whether that persn has a prescriptin fr an emergency piid antagnist (3) Emergency treatment fr suspected piid verdse Drug Take Back Days Summary Encurage patients t dispse f undesired medicatins thrugh apprpriate avenues Analgesic medicatins are the 2 nd mst prescribed medicatin in the United States Natinal Drug Take-Back Day Prvides a safe, cnvenient, and respnsible means f dispsing f prescriptin drugs, while als educating the general public abut the ptential fr abuse f medicatins Octber 22, :00 2:00 PM Pharmacy Technicians are nw able t access the Flrida PDMP Nalxne use is expanding in the cmmunity setting and patient educatin will be essential in its success The pharmacy team plays an essential rle in the respnsible utilizatin f cntrlled substances 7

8 References References 8 64B Standards f Practice fr the Filling f Cntrlled Substance Prescriptins; Electrnic Prescribing; Mandatry Cntinuing Educatin. Accessed 7/ Kahan, B.A. The Validatin f Prescriptins fr Cntrlled Substances.Rxlaw.rg. Accessed 7/ Drug Enfrcement Agency Pharmacist Manual Accessed 7/2016 Technician Educatin Day September 24, 2016 Jacksnville, FL Opiid Overutilizatin Brittany Jhnsn, Pharm.D. PGY-2 Pain and Palliative Care Pharmacy Resident UF Health Jacksnville, FL 8