Prescribing Opioids in the Opioid Epidemic. Scott Woffinden, PA-C Jason Chapman, JD

Transcription

1 Prescribing Opioids in the Opioid Epidemic Scott Woffinden, PA-C Jason Chapman, JD

2

3 What's the Problem?

4

5 What's the Problem? CDC 115 Americans die Daily from Opioid Overdose 1. Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths United States, MMWR Morb Mortal Wkly Rep. epub: 16 December DOI:

6 What's the Problem? ½ Overdose deaths related to prescription opioids Website ADHS

7 Whats the Problem? Among new heroin users, approximately 75% report abusing prescription opioids prior to using heroin 1. Muhuri PK, Gfroerer JC, Davies C. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review,

8 What's the Problem? 2 deaths per day in Arizona Website ADHS

9 What's the Problem? In 2015 alone, opioid-related encounters cost Arizona hospitals nearly $350 Million Website ADHS

10 What's the Problem? Arizona Opioid Related Dealth 74% increase since Website ADHS

11 What's the Problem? 32 Overdoses per day in Arizona 1. Website ADHS

12 Whats the Problem? The majority of drug overdose deaths (66%) involve an opioid. CDC

13 Whats the Problem? 5x increase in opioid related deaths from 1999 to 2016 CDC

14 Whats the Problem? The amount of prescription opioids sold to pharmacies, hospitals, and doctors offices nearly quadrupled from 1999 to 2010, yet there had not been an overall change in the amount of pain that Americans reported. 1. US Department of Justice. Automation of Reports and Consolidated Orders System (ARCOS). Springfield, VA: US Department of Justice, Drug Enforcement Administration (DEA); Paulozzi LJ, Jones CM, Mack KA, Rudd RA. Vital Signs: Overdoses of Prescription Opioid Pain Relievers United States, MMWR 2011; 60(43): Chang H, Daubresse M, Kruszewski S, et al. Prevalence and treatment of pain in emergency departments in the United States, Amer J of Emergency Med 2014; 32(5): Daubresse M, Chang H, Yu Y, Viswanathan S, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, Medical Care 2013; 51(10):

15 Whats the Problem? Providers wrote nearly a quarter of a billion opioid prescriptions in This is enough for every American adult to have their own bottle of pills 1. IMS Health, National Prescription Audit (NPATM). Cited in internal document: Preliminary Update on Opioid Pain Reliever (OPR) Prescription Rates Nationally and by State:

16 Whats the Problem? The most common drugs involved in prescription opioid overdose deaths include: 1. Methadone 2. Oxycodone (such as OxyContin ) 3. Hydrocodone (such as Vicodin )3 1. Ossiander EM. Using textual cause-of-death data to study drug poisoning deaths. Am J Epidemiol 2014 Apr 1;179(7):

17 Whats the Problem? As many as 25% of patients receiving long-term opioid therapy in a primary care setting struggles with opioid addiction 1. Banta-Green CJ, Merrill JO, Doyle SR, Boudreau DM, Calsyn DA. Drug Opioid Alcohol use Depend behaviors, 2009;104: mental health and pain development of a typology of chronic pain patients. 2. Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence 2010;105: among out-patients on opioid therapy in a large US health-care system. Addiction 3. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain 2007;8:

18 Why Prescribe Opioids? Pain!!

19 Why Prescribe Opioids? 10% of Adults have daily pain CDC

20 Why Prescribe Opioids? 20% of patients with chronic non cancer pain are prescribed Opioids. CDC

21 Why Prescribe Opioids? Evidence supports short-term efficacy of opioids for reducing pain and improving function in noncancer nociceptive and neuropathic pain in randomized clinical trials lasting primarily 12 weeks

22 Why Prescribe Opioids? patients receiving opioid therapy for chronic pain report some pain relief when surveyed. However, few studies have been conducted to rigorously assess the long-term benefits of opioids for chronic pain (pain lasting >3 months) with outcomes examined at least 1 year later CDC

23 Why Prescribe Opioids? evidence is insufficient for every clinical decision that a provider needs to make about the use of opioids for chronic pain CDC

24 CDC Guidelines These guideline provides recommendations that are based on the best available evidence that was interpreted and informed by expert opinion. The clinical scientific evidence informing the recommendations is low in quality.

25 CDC Guidelines Clinical Practice Guidelines Improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective chronic pain treatment while reducing the risk of opioid use disorder, overdose, and death.

26 CDC Guidelines Recommendation Categories Category A recommendation: Applies to all persons; most patients should receive the recommended course of action. Category B recommendation: Individual decision making needed; different choices will be appropriate for different patients. Clinicians help patients arrive at a decision consistent with patient values and preferences and specific clinical situations.

27 CDC Guidelines The balance between the benefits and the risks of long-term opioid therapy for chronic pain based on both clinical and contextual evidence is strong enough to support the issuance of category A recommendations in most cases.

28 CDC Guidelines Evidence Type Type 1 evidence: Randomized clinical trials or overwhelming evidence from observational studies. Type 2 evidence: Randomized clinical trials with important limitations, or exceptionally strong evidence from observational studies. Type 3 evidence: Observational studies or randomized clinical trials with notable limitations. Type 4 evidence: Clinical experience and observations, observational studies with important limitations, or randomized clinical trials with several major limitations.

29 CDC Guidelines 3 Categories 12 Recommendations

30 Category 1 Determining when to initiate or continue opioids for chronic pain

31 Category 1 1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate (recommendation category: A, evidence type: 3).

32 Category 1 2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety (recommendation category: A, evidence type: 4).

33 Category 1 3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy (recommendation category: A, evidence type: 3).

34 Category 2 Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation.

35 Category 2 4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids (recommendation category: A, evidence type: 4).

36 Category 2 5. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to 90 MME/day or carefully justify a decision to titrate dosage to 90 MME/day (recommendation category: A, evidence type: 3).

37 Category 2 6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed (recommendation category: A, evidence type: 4).

38 Category 2 7. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids (recommendation category: A, evidence type: 4).

39 Category 3 Assessing Risk and Addressing Harms of Opioid Use Therapy.

40 Category 3 8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages ( 50 MME/day), or concurrent benzodiazepine use, are present(recommendation category: A, evidence type: 4).

41 Category 3 9. Clinicians should review the patient s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months (recommendation category: A, evidence type: 4).

42 Category When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs (recommendation category: B, evidence type: 4).

43 Category Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible (recommendation category: A, evidence type: 3).

44 Category Clinicians should offer or arrange evidencebased treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder (recommendation category: A, evidence type: 2).

45 Opioid Use Disorder DSM5 Classification 11 criteria.

46 Solution: MAT Methadone Bupenorphine Naltrexone

47 Solution: Methadone Decreases overdose death rates by 75 percent.

48 Solution: Methadone By law, methadone can only be dispensed through an opioid treatment program (OTP) certified by SAMHSA.

49 Solution: Bupenorphine buprenorphine is the first medication to treat opioid dependency that is permitted to be prescribed or dispensed in physician offices

50 Solution: Bupenorphine CARA ACT July 22, 2016, President Obama NP and PA can prescribe Bunennoprhine 24 hour training

51 Solution: Naltrexone Opioid Antagaonist 50mg tablet (daily) 380mg IM injection (montly injection) 7-10 day opioid free to start

52 Solution: Regulation In response to this epidemic, Governor Doug Ducey, on June 5, 2017, issued a Declaration of Emergency

53 Solution: Regulation Opioid Prescribing and Treatment 23 A.A.R

54 Solution: Regulation Opioid Reporting 23 A.A.R

55 Solution: Regulation A decrease in the number of unnecessary opioid prescriptions

56 Solution: Regulation Make sure patients understand the dangers of combining opioids with other medications that could cause an overdose

57 Solution: Regulation Prescribers: Consider non-opioid alternatives when appropriate, and help safely taper patients on dangerously high doses.

58 Solution: Regulation Help us fill the treatment gap so more people will get the help they need.

59 Solution: Regulation Become Suboxone-waivered providers to help meet MAT needs statewide.