The Opioid Epidemic: It s Time to Act Integrated Pain Symposium Intermountain Park City Hospital

Transcription

1 The Opioid Epidemic: It s Time to Act Integrated Pain Symposium Intermountain Park City Hospital David Hasleton, MD Associate Chief Medical Officer Intermountain Healthcare

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4 The Opioid Epidemic Narcotic drug addiction is one of the gravest and most important questions confronting the medical profession today. Editorial Comment, American Medicine, 21 (O.S.), 10 (N.S.) (November 1915):

5 The Opioid Epidemic: It s Time to Act Objectives: 1) Acquire a foundational knowledge of the opioid epidemic 2) Develop the ability to converse with patients regarding pros and cons of opioids for acute pain 3) Critique personal opioid prescribing habits for acute pain

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7 Opioid Crisis: A Call to Action Surgeon General s Report on Alcohol, Drugs and Health (2016) I am issuing a new call to action to end the public health crisis of addiction. Vivek H. Murthy, M.D., M.B.A. Vice Admiral, U.S. Public Health Service Surgeon General

8 The War Against Opioid Misuse Historical Perspective

9 Opium: The Foundation Opiates: Derived from the opium poppy Scientific Name: Papaver somniferum Somniferum: Latin for inducing sleep Morphine: most active substance in opium o Named after the Greek god of dreams Morpheus

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12 The Portland Experience Cold water shower / bath to pull victim out of heroin OD Naloxone (Narcan) reversal agent used, ½ life mins (depends on route of administration) Patient leaves against medical advice

13 Time Line: Morphine Active narcotic ingredient in opium 1804: first isolated from opium Used in Civil War Thousands of addicted soldiers

14 Time Line 1804 Morphine distilled from opium 1839 First Opium War British take Hong Kong, opium in China 1857 Second Opium War 1898 Bayer Company uses diacetylmorphine (heroin) 1914 U.S. Congress passes Harrison Narcotics Tax Act 1935 U.S. Narcotic Farm opens (prison vs. hospital)

15 Time Line 1980: NEJM publishes Porter and Jick letter to the editor 11,882 hospitalized patients evaluated who received narcotics 4 patients became addicted Conclusion:... despite widespread use of narcotics in hospitals, the development of addiction is rare in medical patients with no history of addition.

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18 Time Line: Letter to the Editor NEJM, June 1, 2017, A 1980 Letter on the Risk of Opioid Addiction 608 citations increased amount of citations after 1995 (introduction of Oxycontin) 439 (72%) authors cited as evidence that addition is rare 491 (81%) did not note these were hospitalized patients Less affirmational studies in recent years

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20 Time Line: Porter and Jick letter For reasons of public health, readers should be aware that this letter has been heavily and uncritically cited as evidence that addition is rare with opioid therapy. -- NEJM editor s note

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22 Time Line 1980s: First Xalisco migrants set up heroin business in California 1984: MS Contin marketed to cancer patients 1986: Portenoy and Foley paper in journal Pain 1996: Oxycontin released for chronic-pain patients 1996: American Pain Society pain is 5 th vital sign 1999: JCAHO adopts pain as 5 th vital sign

23 Time Line 2007: Big Pharma and execs plead guilty to false claims of narcotics 2014: FDA approves Zohydro (extended-release hydrocodone)

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32 Current State of Crisis

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35 Opioid Crisis: General Data Since 1999, the number of overdose deaths from opioids has quadrupled. 91 Americans die each day from an opioid overdose Medicaid patients are prescribed a higher rate of opioids than privately insured patients. CDC, 2017 Annual Surveillance Report of Drug-Related Risks and Outcomes

36 Opioid Crisis: General Data opioid prescriptions per 100 Americans million people in US ages 12 and over used illicit drugs / misused prescription drugs (17.8 / 100 persons) million prescription pain relievers (4.7 / 100 persons) million initiated use of prescription pain relievers CDC, 2017 Annual Surveillance Report of Drug-Related Risks and Outcomes

37 Opioid Crisis: Hospitalizations 260k for nonfatal, unintentional drug poisoning 53k (20.4%) for opioid poisoning 12k (21.7%) related to heroin of total opioids CDC, 2017 Annual Surveillance Report of Drug-Related Risks and Outcomes

38 Opioid Crisis: ED Visits 418k for nonfatal, unintentional drug poisoning 92k (22%) for opioids 54k (59%) related to heroin CDC, 2017 Annual Surveillance Report of Drug-Related Risks and Outcomes

39 Opioid Crisis: US Drug Overdose Mortality 52,404 overdose deaths in % unintentional -- 33,091 (63%) were from opioids -- 12,989 of all opioid deaths from heroin -- 15,281 from prescription opioids CDC, 2017 Annual Surveillance Report of Drug-Related Risks and Outcomes

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43 Opioid Crisis Utah Perspective

44 KSL.com, Nov 28, 2017, Fentanyl-related deaths in Utah up nearly 80%

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46 Opioid Crisis: Utah Perspective 2014 Data States with highest rates of death (per 100,000) due to drug overdose: 1) West Virginia (35.5) 627 deaths 2) New Mexico (27.3) 3) New Hampshire (26.2) 4) Kentucky (24.7) 5) Ohio (24.6) 7) Utah (22.4) 603 deaths Source: CDC/NCHS, National Vital Statistics System, Mortality

47 Opioid Crisis: Utah Perspective 2015 Data States with highest rates of death (per 100,000) due to drug overdose: 1) West Virginia (41.5) 725 deaths 2) New Hampshire (34.3) 3) Kentucky (29.9) 4) Ohio (29.9) 5) Rhode Island (28.2) 9) Utah (23.4) 646 deaths Source: CDC/NCHS, National Vital Statistics System, Mortality

48 Opioid Crisis: Utah Perspective 2012: 21 adults die of prescription overdose each month Prescription pain killers caused more deaths than all other drug categories, including heroine and cocaine combined Top three pain medications contributing to death: 1) oxycodone 2) methadone 3) hydrocodone Utah Department of Health, Indicator-Based Information System for Public Health Web site:

49 Opioid Crisis Clinician Perspective

50 HPI: Clinician Perspective: Patient #1 32 yo male presents to the ED with acute on chronic LBP Acute pain started 2 weeks ago while jumping on trampoline No complaints of numbness / weakness PHx: History of LBP for 2 years

51 Clinician Perspective SHx: Presents with his wife Works at Subway sandwich shop Frequent visits for pain relief to four different EDs Uninsured and no primary care doctor

52 Clinician Perspective PE: nl vital signs nl neuro exam nl musculoskeletal exam no red flag signs / symptoms

53 Discussion: Plain film indicated Clinician Perspective MRI not indicated Non-narcotic pain medications will be used Need to f/u with physical therapy Could take several weeks to recover

54 HPI: Clinician Perspective: Patient #2 42 yo female with rght leg pain, 8 days s/p ankle surgery c/o right calf pain, worried about blood clot has been on oxycodone post-op PHx: some form of chronic pain, including ankle pain chronic, intermittent migraine headaches on intermittent opioids

55 Clinician Perspective PE: post-op splint removed from leg Tender leg diffusely No obvious infectious component Eval: U/S shows small DVT below the knee No surgical complication

56 Clinician Perspective Disposition: pt states almost out of pain medications has 3 pills left pt given script for Percocet Pharmacist calls me 3 days prior received Percocet 10mg tabs #60 Husband of patient returns to ER upset

57 Personal Experiences Personal threats -- called the chairman of dept to have me fired -- called in a death threat against me and family -- went to media -- Followed home -- police escort off hospital property

58 Opioid Crisis Next Steps

59 1) Provider education Opioid Crisis: Next Steps 2) Decrease number of tablets prescribed 3) Work with state agencies to better detect trends 4) Multi-disciplinary approach: team-based effort

60 5) Expand use of Naloxone Opioid Crisis: Next Steps 6) Promote state prescription drug monitoring program (PDMP) 7) Expand access to Medication Assisted Treatment

61 Opioid Crisis: Next Steps Multidisciplinary Approach

62 Opioid Crisis: Operation Rio Grande Phase 1: began Aug 14, 2017 focused on law enforcement Phase 2: Provide assessment and treatment for addiction and behavioral disorders Phase 3: provide meaningful work opportunities

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68 Opioid Crisis: Next Steps Prescription Drug Monitoring Program

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71 Opioid Crisis: Next Steps Naloxone

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73 Naloxone: What is it? Designed to rapidly reverse opioid overdose Opioid antagonist Restores normal respiratory drive

74 Naloxone: Forms 1) Injectable (professional training required) 2) Autoinjectable: prefilled device to inject, gives verbal instructions to user 3) Nasal Spray: goes into nostril as patient lying on back

75 Naloxone: Utah Utah Pharmacy Practice Act allows pharmacists to practice under a collaborative practice agreement with providers Emergency Administration of Opiate Antagonist Act allows dispensing and administration of opiate antagonist Does not require prescriber-patient relationship

76 Opioid Crisis: Next Steps Medication Assisted Treatment

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78 Opioid Epidemic: Medication Assisted Treatment Opiates are given that activate brain receptors 1) Absorbed into the blood over longer period of time 2) Helps diminish withdrawal symptoms 3) Breaks psychological link between taking a drug and feeling high 4) Normalize body functions without the negative effects of the abused drug

79 Opioid Epidemic: Medication Assisted Treatment 1) Methadone: long-acting opioid, blunts highs and lows of abused opioid 2) Buprenorphine: suppresses cravings for other opioids, similar to methadone Other names: Suboxone, Subutex, Zubsolv, Probuphine 3) Naltrexone: blocks opioid receptors in the body; no abuse or diversion potential; prevents high of abused drug

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81 Opioid Epidemic: Medication Assisted Treatment If we re just substituting one opioid for another, we re not moving the dial much. Folks need to be cured so they can be productive members of society and realize their dreams. -- Tom Price, US Dept. of HHS Secretary Charleston Gazett , May 9, 2017

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83 Opioid Epidemic: Medication Assisted Treatment Science, not opinion, should guide our recommendations and policies, he said, after tweeting that there is a lot of confusion about addiction treatment. -- Vivek Murthy, MD, former US Surgeon General Charleston Gazett , May 9, 2017

84 Opioid Epidemic: It s Time to Act Narcotic drug addiction is one of the gravest and most important questions confronting the medical profession today. Editorial Comment, American Medicine, 21 (O.S.), 10 (N.S.) (November 1915):