Lisa Marzilli, PharmD, CDOE TOP 3 REASONS PEOPLE VISIT THEIR DOCTOR

Transcription

1 Lisa Marzilli, PharmD, CDOE TOP 3 REASONS PEOPLE VISIT THEIR DOCTOR 1

2 1. Skin disorders, including cysts, acne, and dermatitis. 2. Joint disorders, including osteoarthritis. 3. Back problems. Source: Mayo Clinic TOP 10 DRUG THERAPEUTIC CLASSES BY UTILIZATION 2

3 1. Diabetes 2. High Blood Pressure Cholesterol 3. High Blood Pressure Heart Disease 4. Asthma 5. Ulcer Disease 6. Depression 7. Attention Disorders 8. Mental/Neurological Disorders 9. Pain 10. Infections Source: 2013 Express Scripts Drug Trend Report SALES Expanding Diversion and Abuse of Prescription Medications 3

4 Basic Supply and Demand Source: NYT 6/22/13: The Soaring Cost of the Opioid Economy DRUG % Increase Oxycodone 1259% Hydrocodone 556% Methadone 1099% Fentanyl 711% Morphine 246% McDonald DC, Carlson KE (2013) Estimating the Prevalence of Opioid Diversion by Doctor Shoppers in the United States. PLoS ONE 8(7): e69241.doi: /journal.pone

5 CDC Vital Signs Update 5

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8 Emergency Treatment Utilization 8

9 Source: NYT 6/22/13: The Soaring Cost of the Opioid Economy In 2011 there were 1,244,872 Emergency Department (ED) visits that involved nonmedical use of pharmaceutics 50% of ED visits for drug abuse or misuse involved nonmedical use of pharmaceutics. 53% of these visits involved MULTIPLE DRUGS Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) , DAWN Series D-39. Rockville, MD: Substance Abuse and Mental Health Services administration,

10 Pain Relievers were the most common type of drugs involved in medical emergencies with 573,497 ED visits 366,181 ED visits (29.4%) associated with NARCOTIC pain relievers Anxiolytics, sedatives, and hypnotics were the second most common type of drugs involved in medical emergencies with 421,940 ED visits 357,836 ED visits (28.7%) associated with BENZODIAZEPINES Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2011: National Estimates of Drug- Related Emergency Department Visits. HHS Publication No. (SMA) , DAWN Series D-39. Rockville, MD: Substance Abuse and Mental Health Services administration, Drug Category and Selected Drugs ED Visits 2011 Percent of ED visits 2011 Anxiolytics, Sedatives and Hypnotics 421, Benzodiazepines 357, Alprazolam (Xanax) 123, Clonazepam (Klonopin) 61, Pain Relievers 573, Narcotic Pain Relievers 366, Hydrocodone Products (Vicodin) 82, Methadone 66, Oxycodone Products (OxyContin) 151,

11 Source: NYT 6/22/13: The Soaring Cost of the Opioid Economy 14,800 deaths in US 2008 Triple of 1999 data Continuing to rise 2010 data: 1.2 million Americans 12yo> report nonmedical use in past year 2011 data: 4.5 million (1.7%) current nonmedical users Opioid abuse and misuse costs health insurers up to $7.5 billion annually in direct health care costs!! 11

12 Heroin use tripled 2006 to ,000 deaths 75% started Rx opioid 12

13 St. Louis City, MO had the HIGHEST rate of death (city) at 31.7 per 100,000 persons. Charleston, WV was a close second with 30.6 West Virginia had the HIGHEST rate of death per any state at 28.3 per 100,000 persons. Not all states volunteered to report to the Drug Abuse and Warning Network (DAWN) Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2010: Area Profiles of Drug-Related Mortality. HHS Publication No. (SMA) , DAWN Series D-36. Rockville, MD: Substance Abuse and Mental Health Services Administration,

14 More men than women die of OD People in rural counties are more likely to OD than those in big cities Roughly ½ of deaths involve at least one other drug (benzos, cocaine, heroin) State by State Overdose Death Rates 14

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17 Rx Opioid OD death increased 400% in women, 265% in men In ,600 women died!!!! Equates 18 per day Rx meds (esp. Oxycontin & Vicodin) comprised 34% of suicide deaths in women and 8% in men >200,000 women ER visits were due to misuse or abuse of these drugs, ~one every three minutes Dr. Thomas Frieden, CDC Director now estimates 42 women deaths each day from Rx Opioid ODs 17

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19 CDC Vital Signs (July 2014) 68.9% of Pain Relievers were given for free, bought or stolen from friends or family 82.2% of friends and family received their supply from ONE doctor Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration,

20 Also many horror stories of overzealous restriction of such medications from appropriately medical uses Pseudo Addictions? Many states have regulations recognizing pain to be the Fifth Vital Sign of medical treatment and recognize the right of patients to appropriate assessment and management of pain 20

21 Hyperalgesia abnormal pain sensitivity Chemokines/cytokines released Abnormal activation of NMDA receptors and/or abn conduction C fibers resulting in hypersensitivity (pronocioceptive mechanisms) Hyperpathia (neuropathic pain) Peripheral nerve and spinal dorsal horn sensitization Loss of fibers and afferent CNS input Allodynia pain due to temp or touch Pain due to stimulus that typically does not evoke pain Hyperkatifeia hypersensitivity or increased emotional pain/distress with chronic opioid treatment May be due to amygdala changes and decrease functional connectivity to PFC Right shift dose/response curve Higher doses required to maintain analgesia Tissue dependence PK & PD Up regulation of metabolic pathways Receptors change Desensitization Down regulation 21

22 Analgesic response with tolerance: Pain continues to overcome increased doses of opiates Courtesy of Andrew Mendenhall M.D. Uppers, Downers, All Arounders 8 th Ed., in publication, Courtesy Dr. Darryl Inaba, PharmD 22

23 State Regulation & Registration of Pain Clinics State Prescribing Regulations & Recommendations State PDMPs State Requirements for UDT Education Explaining to young adults that prescription medications can be dangerous and only taken when prescribed by a medical professional NSDUH and other surveys showing decline in Rx drug abuse most likely due to increased monitoring of who is prescribed, who prescribes and high risk medication protocols State Successes 23