Ron Morton, M.A. Director of Recovery and Resiliency ValueOptions Tennessee

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1 Ron Morton, M.A. Director of Recovery and Resiliency ValueOptions Tennessee Copyright December The abuse of opiates and benzodiazepines has increased to a frightening degree nationally and in the state of Tennessee. As a result, it is rare that we (ValueOptions) review a substance abuse related admission during rounds that does not indicate the concomitant use of benzodiazepines and opiates. We know that opiates and BZDs are being abused individually and concomitantly. What we may not realize is the financial and human burden to the citizens of Tennessee. 2 1

2 This presentation is not a critique of prescribing practices. Both opiates and BZDs allow many people a quality of life that they would not otherwise experience. This presentation is an assessment of the nature of the problem and the cost in human lives and the resulting financial burden to Tennessee. The likely scenario for acquisition of these drugs is receiving BZDs from a mental health provider and opiates from a primary care physician or pain clinic. 3 According to the Drug Abuse Warning Network, the estimated number of ED visits for nonmedical use of opioid analgesics increased 141% during The estimated number of ED visits involving nonmedical use of benzodiazepines increased 118% during

3 In 2009, ED room visits for opiates accounted for 416,458 visits nationally, benzodiazepines accounted for 312,931 nationally. Visits involving multiple pharmaceuticals were 579,141 in ,644 involved at least 2 drugs(cdc, DAWN, 2009). The 2 opiates most commonly listed were Oxycodone/combinations; Hydrocodone/combinations. The 2 most commonly listed benzodiazepines were Alprazolam (Xanax); clonazepam (Klonopen) 5 In 2009, DAWN estimated 198,403 visits to Emergency Departments for drug related SA. 73% involved CNS agents. (CDC, DAWN, 2009) In 2008, DAWN estimated that 129,162 visits to Emergency Departments for SA involved multiple pharmaceuticals In ,318 people were seen in emergency departments because of poisoning. (CDC, 2011). 93% of unintentional poisoning deaths are a result of drug overdose most commonly from opioid pain medications such as methadone, hydrocodone, or oxycodone.(cdc, 2011) 6 3

4 The increases in numbers of ED visits during for individual benzodiazepines were frightening: alprazolam, Xanax (142%), clonazepam, Klonopin (104%), diazepam, Valium (61%), and lorazepam, Ativan (107%). A sleep aid previously seen as relatively harmless, zolpidem, Ambien (128%). (MMWR, CDC, June 18, 2010.) 7 OxyContin, methadone, morphine, and Xanax were identified as being among the most commonly abused and diverted pharmaceuticals in Tennessee. (U.S.DEA website, 2009). Tranquilizers and opiates were the second and third most frequent cause of intentional selfpoisoning death in Tennessee between 2003 and (CDC,WISQUARS, 2009) 8 4

5 Benzodiazepines potentiate the actions of other (central nervous system) depressant drugs. The effects are mainly additive, although some authors suggest that synergistic effects may occur (Ashton, June, 1986) Benzodiazepines have multiple uses for polydrug addicts: they are used to enhance the euphoriant effects of opioids (such as to "boost" methadone doses). (Longo and Johnson, 2000, Am. Family Physician). 9 Many opiate addicts will use benzodiazepines because they enhance the effects of narcotics. A Vicodin, or heroin addict could actually reduce the amount of narcotics needed if benzodiazepines were used with them. Unfortunately, the combination can be lethal, and often are. (Velardo, 2009, Examiner.com) In our more technologically astute society, substance abusers can actually acquire information on the internet that teaches them how to mix benzodiazepines with opiates in order to potentiate or strengthen the effect html 10 5

6 Concomitant use of opiates and BZDs is connected to deaths nation-wide. In a 2003 study of Oxycodone Involvement in Drug Abuse Deaths Cone, Kaplan, and Ballina found that of 889 multiple drug abuse deaths involving oxycodone/oxycontin, 603 included a benzodiazepine. Of the 889 deaths, 128 were deemed suicide, 513 accidental, 173 undetermined, by medical examiners and coroners. 11 The cost to the system of intentional and unintentional overdose is well established when reviewing Emergency Department visits, Inpatient Confinement, and Hospitalizations in Tennessee. The costs related to suicide attempts in Tennessee have been extreme. Total Hospitalization Cost for intentional self-harm, for the period was $70,628,533. Based on DAWN national estimates that 57% of Suicide Attempts are due to opiates and/or BZDs, estimated cost to TN for SA hospitalizations was $40,258,

7 Total Inpatient Confinement cost for intentional self-harm for the period was $49,328,540. Based on DAWN national estimates that 57% of Suicide Attempts are due to opiates and BZDs, estimated cost to TN for SA Inpatient Confinement was $28,117, Emergency Room Only cost for intentional self-harm for the period was $21,299,993 (State of TN, 2010). Based on DAWN national estimates that 57% of Suicide Attempts are due to opiates and BZDs, estimated cost to TN for SA Emergency Department Only visits would have been $12,140,996. (CDC, DAWN, 2009). 14 7

8 clinicdoctor thrives amid deaths lawsuits html against Milton doctor?r=p file lawsuit against vancouver pain clinic/ 15 It has been established that the Medicaid population is at greater risk for unintentional and intentional overdose, especially those who suffer from a mental illness. In Washington state medical examiners and coroners recorded methadone on death certificates nearly three times more often than the next most common opioid, oxycodone. At least one nonopioid prescription drug was reported in 54.6% of the deaths. 16 8

9 A benzodiazepine was listed on the death certificate in 20.9% of the deaths, and an antidepressant in 31.7%. The age-adjusted risk of such a death [opioid overdose] for a Medicaid enrollee was 5.7 times the risk for a person not enrolled in Medicaid. (CDC, MMWR, 2009). 17 In North Carolina a study was done of unintentional overdose deaths in the Medicaid population during Among the Medicaid population, the age-adjusted UO death rate was 34.9/100,000. In 2007, the North Carolina UO death rate was 9.9/100,000. Of the 901 North Carolina UO deaths identified in 2007, 301 (33.4%) were enrolled in Medicaid in

10 In this group, 42.2% had a mental health related diagnosis. The top four most prescribed medications for this group were: 1.) Hydrocodone; 2.) Alprazolam; 3.) Oxycodone; 4.) Clonazepam. 19 In rural Virginia, drug overdose deaths increased 300% from 1997 to Polydrug deaths predominate (57.9%) in this review of 893 medical examiner cases. Prescription opioids (74.0%), antidepressants (49.0%), and benzodiazepines (39.3%) were more prevalent than illicit drugs. (Wunsch, et al. 2009)

11 In Georgia, prescription drugs account for 85% of drug related deaths. (Savannah Morning News, August 15, 2010). In 2007, 82 percent of overdose deaths in the state were from prescription drugs. In those two years, methadone was the most prominent drug fatally abused, followed by alprazolam - also known as Xanax - hydrocodone and oxycodone. 21 Last year alone, (2008) at least 485 people died in Kentucky from prescription drug overdoses, according to the state's Cabinet for Health and Family Services. Medical Examiners' records indicate the drugs most commonly found in those death cases were methadone, the painkillers oxycodone and hydrocodone, alprazolam (Xanax), morphine, diazepam (Valium) and fentanyl. (NBC News, August, 2009)

12 The second leading cause of accidental death in Mississippi is poisoning (MI State Vital Statistics, 2008). Poisoning statistics typically include accidental overdose. 23 Addiction to prescription drugs is as real and as devastating as addiction to illegal drugs. In Shelby County, the abuse of prescription drugs is growing at an alarming rate among teens as well as adults. Because these problems often begin in the home, we as parents must do everything possible to address these problems in the home. Talk to your children about all types of drug abuse. - J. Michael Joiner, Presiding Circuit Judge, Shelby County, Alabama

13 1. Use opioid medications for acute or chronic pain only after determining that alternative therapies do not deliver adequate pain relief. The lowest effective dose of opioids should be used. 2. In addition to behavioral screening and use of patient contracts, consider random, periodic, targeted urine testing for opioids and other drugs for any patient less than 65 years old with non-cancer pain who is being treated with opioids for more than six weeks If a patient s dosage has increased to 120 morphine milligram equivalents per day without substantial improvement in pain and function, seek a consult from a pain specialist. 4. Do not prescribe long-acting or controlledrelease opioids (e.g., OxyContin, fentanyl patches, and methadone) for acute pain. 5. Periodically request a report from your state prescription drug monitoring program on the prescribing of opioids to your patients by other providers 26 13

14 My Recommendations: 1. Educate emergency room doctors about the need to do drug screens before prescribing opiates and BZDs, and/or to limit the amount prescribed until drug screen results are acquired. 2. Encourage emergency room staff to do urine drug screens on any suicide attempt or any presentation of suicidal ideation. 3. Educate clinical staff within all our organizations about the risk of concomitant use of opiates and BZDs Require medication reconciliation, (a JCAHO standard), among providers, both Medical and Behavioral. 5. Encourage drug screening for any patient on longterm use of opiates or BZDs. 6. Educate providers on the use of the drug monitoring program maintained by the Department of Pharmacy of Tennessee. When used, information about current use of benzodiazepines should also be determined. 7. Work with the Bureau of TennCare to create a database of opiate and BZD use and its connection to suicide, suicide attempts, and emergency room visits in TN

15 Our responsibility is to intervene when we suspect an abuse or addiction problem. This intervention may be as simple as providing the patient with a list of 12 step meetings or referral to a psychiatrist or psychologist. Can you have a difficult conversation with your patient about addiction? 29 Rapid increases in the amount of a medication needed - which may indicate the development of tolerance frequent requests for refills before the quantity prescribed should have been used. Reports by a patient that medication has been lost or stolen. "doctor shopping,. A pattern in the medical record that indicates most complaints are pain or anxiety focused. Symptoms of withdrawal such as shaking hands elevated blood pressure or rapid pulse 30 15

16 Symptoms of withdrawal: 1. Agitation 2. Anxiety 3. Tremors 4. Muscle aches 5. Hot and cold flashes 6. Nausea 7. Vomiting 8. Diarrhea 31 Frequent accidental injuries Reports of pain levels that appear incongruent with injury or reported problem. Use of more than one pharmacy Getting medications without using insurance. Just because they fill out a health history doesn t mean that it is honest. If a person indicates they have a history of substance abuse, does this mean that they don t want opiates or benzodiazepines or are they using the information to manipulate the doctor? 32 16

17 1. Have you ever felt the need to Cut down on your use of prescription drugs? 2. Have you ever felt Annoyed by remarks your friends or loved ones made about your use of prescription drugs? 3. Have you ever felt Guilty or remorseful about your use of prescription drugs? 4. Have you Ever used prescription drugs as a way to "get going" or to "calm down?" 33 One cannot refute the implications of the information offered in this presentation. The evidence procured is based on real numbers acquired through the Substance Abuse and Mental Health Services, the Center for Disease Control, and other reputable sources. We are confronted with a serious problem that is not receiving the attention that is necessary to develop tactics and processes that protect the consumer and the tax payer

18 When it is added to existing lists of problems that we need to address, it becomes just that. It becomes one more problem that we do not have the time or money to confront. Even as one reviews this information, someone in Tennessee is under the influence of opiates and benzodiazepines and is toying with the idea of committing suicide or with the idea of taking a couple of more pills in order to increase the effect of the drug they are abusing. 35 Unfortunately, some of these people will die, maybe from unintentional substance induced respiratory arrest, an accident in a motor vehicle, or they will succumb to the overpowering desire for peace, a peace they may only find in death

19 We can save lives if we act. If we refuse to let this issue be relegated to another unnamed list of things we need to do we can combine our efforts and energy and change the system. Each of us must become an advocate and a voice

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