Addressing the Opioid Epidemic

Transcription

1 Addressing the Opioid Epidemic Joseph Bianco, MD, FAAFP Essentia Health AHCAP Webinar June 7, 2018 Our Mission We are called to make a healthy difference in people s lives. 1

2 Our Values Quality Hospitality Respect Justice Stewardship Teamwork Our Service Area 2

3 Opioids: A trip through time A brief history of opioids The earliest reference to opium growth and use is in 3400 B.C. when the opium poppy was cultivated in lower Mesopotamia. Hippocrates, the Alexander the Great father of medicine, introduces opium to acknowledges opium s India. The Arabs, usefulness as a Greeks and Romans narcotic and styptic in use it as a sedative. treating disease B.C. 460 B.C. 330 B.C. Source: 3

4 A brief history of opioids Opium becomes a In 1527, In 1806, Swiss-German taboo subject during the alchemist chemist Paracelsus Friedrich Inquisition. References discovers Wilhelm a tincture Adam of Sertürner to opium disappear for opium isolates that helped morphine from 200 years from reduce opium. pain. He names calls it after European historical this preparation the god of dreams, record. laudanum. Morpheus A.D A.D A.D. Source: A brief history of opioids Heroin is synthesized as a Spurred The by FDA growing approves derivative to morphine. addiction Oxycodone, rates, making it German company Bayer Congress widely outlaws available the in the offers heroin as a cough importation, U.S., a precursor to suppressant and nonaddictive morphine manufacture, growing abuse sale and of use of prescription heroin. opioids. alternative Source: 4

5 A brief history of opioids Vicodin becomes available in a generic version. Yet doctors are reluctant to prescribe opioids in general. Following a surge in Concern about the opioid marketing by under treatment of pain drug manufacturers, prompts increased use an estimated 4 million of opioids for all pain people are using types, including noncancer pain. prescription opioids non-medically s 1999 Source: A brief history of opioids Criminal Charges filed against Purdue Pharma for false advertising Oxycontin President Trump Opioid related deaths declares a National surpass car accidents Public Health as the leading cause of Emergency accidental death Source: 5

6 Opioids: An exploding problem 6

7 Porter /Jick letter cited over the next 26 years 7

8 Opioid use skyrockets A change in prescribing habits and a decade of aggressive marketing of prescription opioids to American physicians has led to increased use: Hydrocodone 198% Fentanyl 423% Oxycodone 588% Methadone 933% Source: Manchikanti, Laxmaiah, MD Pain Physician 2007; 10: ISSN Oxycontin Introduced in 1996 Long action oxycodone Blueprint for modern advertising Purdue Pharma 8

9 And so it went. OxyContin first, introduced by reps from Purdue Pharma over steak and dessert and in air-conditioned doctors offices. Within a few years, black tar heroin followed in tiny, uninflated balloons held in the mouths of sugarcane farm boys from Xalisco driving old Nissan Sentras to meet-ups in McDonald s parking lots. Sam Quinones, Dreamland: The True Tale of America's Opiate Epidemic Opioids: The Science 9

10 The root of the problem: What is pain? Acute Post-operative Malignant Chronic Opioids Natural opioid analgesics, including morphine and codeine, and semi-synthetic opioid analgesics, including drugs such as oxycodone, hydrocodone, hydromorphone, and oxymorphone; Methadone, a synthetic opioid; Synthetic opioid analgesics other than methadone, including drugs such as tramadol and fentanyl Heroin, an illicit (illegally-made) opioid synthesized from morphine that can be a white or brown powder, or a black sticky substance 10

11 Pain Receptor Activity Mu- analgesia, euphoria, miosis, sedation, constipation, respiratory depression, addiction, hormonal changes Kappa- analgesia, diuresis, sedation, miosis, dysphoria, psychomimetic effects, respiratory depression, constipation Delta- analgesia Pain receptors 11

12 Now we know We should have proceeded with caution. Opioids are not the only way or even an effective way to treat chronic non-malignant pain. Adverse effects of narcotics Constipation Nausea Somnolence Obesity Narcotic bowel syndrome Hyperalgesia Hypogonadism Dependence is inevitable Traffic collisions/impaired work Sleep disturbance Source: Benyamin, R, et. al. Pain Physician; 2008, Mar. 12

13 Long-term effects of opioid dependence Source: Essentia Health patient education materials Progression of opioid dependence Source: Ballantyne, Jane, Essentia Health Friday Grand Rounds, Jan. 10,

14 The 16% of Americans that have mental health disorders receive over 50% of all opioids prescribed From the CDC. 14

15 Opioid Use Disorder source: Psychiatric Times Source: USA Today 15

16 Sobering statistics The amount of opioids prescribed and sold in the U.S. quadrupled since 1999, but the overall amount of pain reported by Americans hasn t changed. Source: Centers for Disease Control and Prevention Bottom Line The evidence to support chronic opioid analgesic therapy for chronic pain is insufficient at this time, but the evidence of harm is clear. 16

17 Opioids: The Data Sobering statistics 115 Americans die every day from an opioid overdose. At least half of all opioid overdose deaths involve a prescription opioid. Source: Centers for Disease Control and Prevention 17

18 A dangerous trend Source: National Center for Health Statistics, CDC Wonder The number of drug overdose deaths among Minnesota residents continued the alarming rise in 2016 Source:Drug Overdose Deaths among Minnesota Residents, ; MDH, SOURCE: 18

19 Opioid-involved drug overdose deaths continue to rise in Minnesota, driven by heroin and other synthetic opioids Source:Drug Overdose Deaths among Minnesota Residents, ;MDH Unintentional drug overdose deaths have risen dramatically, while suicide and undetermined deaths have remained stable over the last five years Source:Drug Overdose Deaths among Minnesota Residents, :MDH 19

20 Sobering statistics 249 million That s enough prescriptions for opioid pain prescriptions medication for every were written by American adult healthcare to have providers in a bottle of pills. Source: Centers for Disease Control and Prevention 20

21 Per capita opioid use Map shows grams per 10,000 people of prescriptions for painkiller opioids, such as oxycodone, hydrocodone, codeine, morphine. Source: Drug Enforcement Administration; Pioneer Press, Prescription opiates and heroin in Minnesota 21

22 Sobering statistics Source: Minnesota Public Radio; Centers for Disease Control and Prevention An American issue of the world s prescription opioid supply is consumed in the U.S. Source: Manchikanti, Laxmaiah, MD Pain Physician 2007; 10: ISSN

23 Opioid use at least once during past year Source: Much of World Suffers Not From Abuse of Painkillers, but Absence of Them May 17,

24 Impact on our tiniest patients Percentage of Duluth NICU patients born suffering from opioid withdrawal with a diagnosis of Neonatal Abstinence Syndrome or NAS 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% Source: Essentia Health-St. Mary s Medical Center NICU admission diagnosis - NAS Taking on Opioids: Essentia s Approach OP-01 24

25 Characterizing Pain Acute Pain Post Acute Pain (up to 45 days) Chronic Pain (>45 days) Malignant Pain (continuous tissue inflammation or damage) Post surgical (minor vs major) Opioid Naïve (90 days) vs Opioid tolerant Prescribing Principles Minnesota Department of Health Prescribe the lowest effective dose and duration of opioid analgesia when indicated for acute pain. Clinicians should reduce variation in opioid prescribing for acute pain. The post acute pain period (up to 45 days following an acute event) is the critical timeframe to halt the progression to chronic opioid use. 25

26 Risk Factors Nora D. Volkow, M.D., and A. Thomas McLellan, Ph.D. N Engl J Med 2016; 374: March 31, 2016DOI: /NEJMra MME=MED Alosa Health 26

27 Acute Pain (minor surgery) MDH, ICSI, CDC No more than a three day supply No more than 100 MME Do not take more than 50 MME in one day Reduce by 50% if patient is taking benzodiazepines or is elderly Rarely will more that 7 days be needed or up to 200 MME Consider no opioids No long acting opioids Acute Pain (Major Surgery) No more than 200 MME total prescription No more that 7 day supply Consider reducing dosage by 50% for patients who are elderly or on benzodiazepines. No more than 50 MME to be taken in one day 27

28 One- and 3-year probabilities of continued opioid use among opioid-naïve patients, by number of days supply* of the first opioid prescription United States, MMWR, March One- and 3-year probabilities of continued opioid use among opioid-naïve patients, by number of prescriptions* in the first episode of opioid use United States, MMWR,March

29 Acute Opioid Dosing Limits No more than a three day supply, short acting opioid No More than 100 MME for entire prescription or 50 MME per day MEDICATIONS Sig Max QTY MME** Codeine/APAP* 30/325 mg tab 1 Q4H PRN X 3 days #18 81 Hydrocodone/APAP* 5/325 mg tab 1 Q4H PRN X 3 days #18 90 Hydromorphone 2 mg tab 1 Q6H PRN X 3 days #12 96 Oxycodone/APAP* 5/325 mg tab 1 Q6H PRN X 3 days #12 90 Tramadol 50 mg tab 1 Q4H PRN X 3 days #18 90 Opioid Tolerant One week of opioids 60 MME/day (FDA) OUD or non medical use Opioid induced hyperalgesia Offer multimodal analgesia COAT patients- consider different opioid at 30-50% equianalgesic dose (tolerance not complete OUD multidisciplinary approach 29

30 Post Acute Pain MDH,ICSI,CDC Assess and document risk factors for opioid related harm and chronic use with increasing frequency if the patient continues to receive opioid therapy during the post acute pain phase Consider patient risk factors including age, SUD, Anxiety, Depression, PTSD Check PMP Prescribe opioids in multiples of 7 days, with no more than 200 MME per 7 day period, and no more dispensed than the number of doses needed Prescribing should be consistent with expected tissue healing Avoid prescribing more than 700 cumulative MME during the postacute pain interval Develop a referral network for mental health, substance use disorder, pain education, and pain medicine. Cumulative Dose Source, Shah, Available at: w.cdc.gov/ mmwr/vol umes/66/wr /mm6610a1.htm?s _cid=mm66 10a1_w ks.cdc.gov/v iew/cdc 30

31 Chronic Pain (COAT) CDC guidelines Prescribe opioids at the lowest dose, with no more than 50 MME/day. Avoid increasing daily dosage to 90 MME/day. Face to face visits with provider every three months Risk assessment Discuss tapering at every visit Monitor for diversion Harm reduction strategies Monitor for withdrawal and manage appropriately Be alert to OUD. Assessment and Monitoring At each pain visit: (at least four per year) PMP checked Assess for risk of abuse, treatment efficacy, depression and anxiety Patient education on risks and alternatives Offer to help patients taper if ready Annually: Treatment agreement signed Random UDS (may be more frequent) 31

32 Tapering Assist PCP with alternate pain management options if patient requires taper to discontinue opioids Is patient on methadone? YES See Appendix 3 NO Is the patient taking both short and long-acting agents? YES NO Decrease short-acting agent by 10% of total MDE every 3-7 days until gone Decrease dose of long-acting agent by 10-25% every 3-7 days until only 30% of original MDE remains Withdrawal Symptoms? YES NO NO Are all shortacting opioids discontinued? Slow taper and/or initiate adjunctive therapies (See Appendix 4) YES Decrease dose of long-acting agent by 10-25% every 3-7 days until only 30% of original MDE remains Withdrawal Symptoms? YES Providing withdrawal symptoms are controlled, continue to decrease opioid dose by 5-10% of initial MDE every 1-4 weeks until taper complete NO Naloxone (Narcan) Antagonist Is patient at risk? MME/day results in 4X increase in overdose risk >100 MME/day results in 9X increase in overdose risk IM (30-90min half-life) Intranasal (120 min half-life May elicit withdrawal Cost $

33 OUR RESULTS 33

34 Scope of Work Current COAT patient volumes April 2018 Essentia Region Central 642 East 3365 West 1635 Patients without an Essentia PCP # of patients 559 Total

35 Our progress March 2015 March % fewer new COAT patients started on therapy each month Our progress March 2015 March % fewer COAT patients 35

36 Continued work regarding COAT patients Pharmacy tapering via telehealth or in person. Change from three months of chronic opioids to a 45 day window before patient is considered on COAT Increased focus on the post acute period New surgical guidelines Data mining for patients at high risk for overdose (total MME >90, benzodiazepines) Naloxone prescribing EPIC MME conversion at prescribing Continue through operations monitor our standard processes regarding monitoring and prescribing, current data reveals some major gaps Inpatient, Outpatient, ED/Urgent Care, Post Surgical ACUTE PAIN 36

37 Acute Pain MDH, ICSI, CDC No more than a three day Supply No more than 100 MME Do not take more than 50 MME in one day Reduce by 50% if patient is taking benzodiazepines or is elderly Rarely will more that 7 days be needed or up to 200 MME Acute Pain (non-surgical) Opioid Prescribing Data for Emergency Room (non-surgical) Care % of opioid naive*patients with a short-acting index order of > 100 MEUs or a long acting index order January March % 90% 80% 70% 60% 50% 40% 30% 28.31% 20% 10% 0% 10.12% *Opioid Naïve Patient = Patient has had no opioid order in the previous 90 days from the measurement month's index opioid order date. 37

38 100% Acute Pain (non-surgical) Opioid Prescribing Data for Ambulatory (non-surgical) Care % of opioid naive*patients with a short-acting index order of > 100 MEUs or a long acting index order January March % 80% 76.51% 70% 60% 50% 63.90% 40% 30% 20% 10% 0% *Opioid Naïve Patient = Patient has had no opioid order in the previous 90 days from the measurement month's index opioid order date. A case for transparency EHR reports allow providers to drill down to list of COAT patients. 38

39 Community coalitions formed Began monthly meetings October 2015 Share best practices, ideas and information Created joint news release Includes law enforcement and dentistry representatives Community education efforts Community coalitions formed 39

40 Opioid Use Disorder, Opioid Dependence- Harm Reduction Strategy (Vision) Addiction sub committee DFPR directors with suboxone waivers are working with Center for Alcohol and Drug Therapy in Duluth on a pilot model for suboxone induction and outpatient therapy. Educating practice regarding MAT ( buprenorphine, buprenorphine/naloxone, methadone, naltrexone) Continue to build our IBH Participate in ECHO programs from St Gabriel s and HCMC Recruit physicians to obtain their suboxone wavers Continue to build out our centralized pain and integrative health programs Revamping our Cannabis committee and approach to chronic pain Myths Opioid Abuse in Chronic Pain Misconceptions and Mitigation Strategies N Engl J Med 2016; 374: Addiction is the same as physical dependence and tolerance Addiction is simply a set of bad choices Pain protects patients from addiction to their opioid medications Only long acting opioids cause addiction Only certain patients are vulnerable to addiction Medication-assisted therapies are just substitutions for heroin and opioids 40

41 Discussion OP-01 Contact Information Dr. Bianco: 41