The Opioid Epidemic: Current State and the Path Forward

Transcription

1 The Opioid Epidemic: Current State and the Path Forward Teresa Rummans, MD Jenna K Lovely, Pharm D, BCPS Julie Cunningham, Pharm D, BCPP Halena Gazelka, MD 2015 MFMER slide-1

2 Disclosures No relevant financial disclosures 2015 MFMER slide-2

3 Objectives Describe the current prevalence of opioid misuse in the US. Identify non-opioid alternatives for the treatment of pain Recognize the correlation with acute opioid prescribing and chronicity of opioid use. Describe current Mayo Clinic Enterprise initiatives to curb opioid prescribing MFMER slide-3

4 Opioids and Addition: Origin of the Myth MFMER slide-4

5 Prevalence of Substance Misuse in General Substance abuse now is as prevalent as diabetes and 1.5 x more common than all the cancers combined 50% of those with substance misuse also have mental illness More are dying from substance abuse (opioids being the main one) than car accidents annually Yet only 10% get any help JAMA, MFMER slide-5

6 Opioid Misuse in US Affects people of all ages, ethnicities, and all socioeconomic groups 2.1 million people in the United States suffering from substance use disorders related to prescription opioid pain relievers in 2012 and an estimated 467,000 addicted to heroin. Opioid abuse is increasing dramatically 3,900 individuals start non-medical use of prescription opioids each day 580 individuals start using heroin each day SAMHSA National Survey on Drug Use and Health, MFMER slide-6

7 70,000 60,000 Drug Overdose Deaths, ,000 to 65,000 people died from overdoses in the U.S. in 2016* Peak car crash deaths (1972) 50,000 Peak HIV deaths (1995) *46,000 40,000 Peak gun deaths (1993) *39,000 30,000 deaths 20,000 10, Katz J: Drug Deaths in American Are Rising Faster Than Ever (The Upshot), The New York Times; June 5, *Approximate Estimate per Data Obtained 2015 MFMER slide-7

8 Prescription Trends Number of prescription opioids sold has nearly quadrupled since 1999 More than 650,000 opioid prescriptions are filled everyday In Minnesota, there are opioid prescriptions per 100 people CDC 2015 MFMER slide-8

9 Worldwide Statistics about Opioids 80% of all opioids in world are used in US with the fastest growing group of people in US using heroin being middle aged women WHO, MFMER slide-9

10 Opioid Misuse in Minnesota In Minnesota, there were 2,273 opioid overdose deaths between In Olmsted County, there were 43 opioid deaths between (~58%) of those were between MN Health Dept 2015 MFMER slide-10

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13 Unnecessary opioid exposure Adolescents and adults reporting recent nonmedical use of opioid medications obtain these medications through their family or friends Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: mental health findings. Surgical meta-analysis % opioids prescribed went unused Only 9 % met FDA recommended disposal methods Bicket, Long, Provonost, et al JAMA Surg MFMER slide-13

14 Stop the cycle for each area you serve Example: vicious cycle of opioid use in IBD - IBD pt paradoxical response of hyperalgesia Loftus et al Am J Gastroenterology Narcotic bowel syndrome (NBS) Drossman DA, Szigethy EM. Am J Gastroenterol Higher overall use in this patient population leading to a high preoperative use compared to other diseases Submitted for publication: Lovely, Larson et al Opioids 30 days prior to ostomy surgery had increased risk of postoperative complications (p=0.03, OR=2.57, 95 % CI= ) Hirsch et al DCR MFMER slide-14

15 How can we reduce opioid exposure? Proactive plans for managing pain Maximize non-pharmacologic options Ex: Counseling, Physical Therapy, Cognitive Behavior Therapy, Surgery where indicated, etc. Maximize non-opioid options Acetaminophen, NSAIDs, adjunct agents Systematic approach for dismissal Paradigm shift for just in case prescribing Systematic approach for patient calls/triage 2015 MFMER slide-15

16 Myth/Myth buster Myth: Surgery = Opioid Myth Buster: Only subsets of patients need post operative opioids. Examples: 24% require no post op opioids in CRS with Enhanced Recovery Pathway 25% require no post op opioids in Ortho with Total Joint Pathway Larson, Lovely, et al JACS 2011; Horlocker et al 2013, Hebl, Pagnano et al J Bone Joint Surg Am MFMER slide-16

17 Myth/Myth buster: Myth: Prescribing more opioids on dismissal, reduces call backs/additional RXs. Myth Buster: 4286 CRS patients % of patients received additional opioid Regardless of dismissal opioid amount (range zero to 30,000 MME) More opioids on dismissal did nothing to change the call back rate. Submitted for publication Lovely, Huang, Meyers, Larson et al MFMER slide-17

18 Paradigm shift of just in case prescribing Patients do not need an opioid Extra scripts/more tabs do not help Increasing dose, additional scripts don t prevent calls I don t have time to explain. MAKE THE TIME! I don t want backlash from the patient. Of survey responses, 37 % were NOT confident in their ability to manage chronic (non-cancer) pain. Ebbert, Philpot, Clements, Lovely et al Pain Medicine MFMER slide-18

19 We need a Paradigm Shift Proactively plan for non-pharm and opioid sparing Deprescribe: focused taper to off plan Currently only 6% have taper OFF Plan Set patient and team expectations Define when and how to dispose properly 2015 MFMER slide-19

20 Opioid use in Chronic pain: Controversial 2015 MFMER slide-20

21 CDC: Goals for safer opioid prescribing Reduce use to only when benefit outweighs risk. For acute pain, prescribe only for expected duration of pain. Use the lowest effective dose. CDC: Vital Signs, July MFMER slide-21

22 Chronic opioid use often begins with treatment of acute pain episode Random 10% sample IMS Lifelink+ database Episode defined as: continuous use of opioids with a gap of not more than 30 days) Reviewed Opioid prescriptions in opioid naïve patients; Defined as no opioid prescription in past 6 months 2015 MFMER slide-22

23 Characteristics of acute prescriptions Higher dose on initiation First prescription supply exceeded 10 days or 30 days Pt received 3 rd prescription Cumulative dose >700 MME Long acting opioid formulations Initial treatment with tramadol Characteristics of patients Older Female Pain diagnosis prior to opioid initiation Initiated on higher doses 2015 MFMER slide-23

24 Acute Opioid Use and Relationship to Chronicity of Use Statewide retrospective cohort review Opioid naïve users (no use in previous 365 days) n= 536,767 Long term users: 6 or more subsequent fills in next year; n= 26,785 (5%) Correlation with long term users: Number of refills (2 = 10.6%; 4 or more = 26.1%) Cumulative MME during initiation month 120 MME or less = 2%; >400 MME= 10.6%; >800 MME = 18.6% Deyo RA et al. J Gen Intern Med 32(1): MFMER slide-24

25 Acute Use for Chronic Opioid patient CDC principles still apply: For acute pain, prescribe only for expected duration of pain. Use the lowest effective dose. Tips: Continue home opioid medications if possible Higher opioid doses will generally be necessary after surgery compared to opioid naïve patients Wean quickly thereafter back to home dose by 7 days Consider alternative strategies: epidural, nerve block, pain consult Huxtable CA et al. Anaesth Int Care 39: MFMER slide-25

26 Case: SB 71 year old female on fentanyl 75 mcg/hr + prn oral opioids (unknown frequency) with acute fracture of arm due to fall S/P shoulder arthroplasty. Post op course: Fentanyl 75 mcg/hr Q72 hrs Acetaminophen 1gm qid Baclofen 20 mg qid Hydromorphone PCA transition to po 6-8 mg q3hr prn Day prior to DC = 56 mg hydromorphone (224 MME) Transition to SNF 2015 MFMER slide-26

27 CDC Guidelines (2016) Recommendations Chronic Opioid Use Prescribe dose of <50 morphine milligram equivalents (MME)/day Carefully justify an increase to MME Should avoid increasing dosage to 90 MME/day Justifying a decision to titrate dosage to 90 MME Very few benefits past this dose Evaluate benefits and harms with patients within 1 to 4 weeks Starting opioid therapy Dose Escalation Clinicians should evaluate benefits and harms of continued therapy at least every 3 months If benefits do not outweigh harm work with patients to taper Continue to optimize non-opioid and nonpharmacological therapies. Dowell et al. CDC Guideline for Prescribing Opioids for Chronic Pain United States, Recommendations and Reports / March 18, 2016 / 65(1); MFMER slide-27

28 Lack of solid evidence for tapering Taper speed advice: 25% reduction of previous daily dose to prevent acute withdrawal Fast or ultrafast taper con be considered when inpatient taper is needed First reduce to smallest available dose unit and then increase time between doses Author center experience: decrease by 10% every 5-7days until 30% of original dose is reached, followed by weekly 10% reductions Berna C et al. Mayo Clin Proc. 2015;90: MFMER slide-28

29 2015 MFMER slide-29

30 Opioid Work Group Formation Formed by MCCPC (Dr. Mike Harper) Charges High level internal assessment of enterprise risk of overprescribing and diversion Review internal and external existing guidelines, policy, workflows, and controls governing opioid prescription process Review and document current state best practices Identification of best practice (consider similar method developed by drug diversion committee) Define a standardization plan starting with areas of highest risk Develop timeline and implementation plan for diffusing best practices 2015 MFMER slide-30

31 Wide Variation and Over-Prescription of Opioids following Elective Surgery Thiels CA, Anderson SS, Ubl DS, Hanson KT, Bergquist WJ, Gazelka HM, Cima RR, Habermann EB Accepted by the American Surgical Association; Presented at the Department of Surgery s Balfour Research Day 2015 MFMER slide-31

32 Goal Describe opioid prescribing practices across surgical specialties at our three main sites with the ultimate goal of optimizing post-operative prescription practice MFMER slide-32

33 Methods Adults undergoing 25 common elective procedures Mayo Clinic Rochester, Scottsdale, or Jacksonville ACS-NSQIP institutional data Patient and procedural characteristics Complications Pharmacy data Opioids prescribed at discharge (outcome of interest) Identification of opioid naïve patients 2015 MFMER slide-33

34 Results 7651 adults underwent one of 25 common elective procedures and were sampled for three-site institutional ACS-NSQIP data RST FL AZ 2015 MFMER slide-34

35 Opioids Prescribed at Discharge Oral Morphine Equivalents (OME): Range: Mean 675 Median 450 Interquartile range (225,750) 2015 MFMER slide-35

36 Median OME Prescribed at Discharge by Site MCR MCF MCA p< MFMER slide-36

37 Response Standardized guidelines for ortho surg patients Enacted July 1, 2017 Plan: survey patients to study How much they are using What do they do with the leftover opioid How was their pain control/were they satisfied Did they call for refills Etc MFMER slide-37

38 Result OWG developed: Mayo Clinic Guidelines for Acute Opioid Prescribing Mayo Clinic Guidelines for Chronic Opioid Prescribing These have now been endorsed by the CPC, leading to the next phase of the project: Mayo Clinic Opioid Stewardship Program (OSP) 2015 MFMER slide-38

39 Opioid Stewardship Program Timeline MAY 17 JUL 17 OCT 17 JAN 18 Jun 18 Project Oversight Project Oversight Group Created & Sub-groups Established Planning & implementation of Opioid Stewardship Committee Ongoing Stewardship Start: May, 2017 End: Transition to On-going Structure June 1, 2019 RST: Iterative pilots & diffusion targeting improvement in acute prescribing RST ECH MCHS: Iterative pilots & diffusion of chronic guidelines EPIC Roll-out Opioid registry & workflows Project Subgroups AME guidelines, care processes PMP interface planning & implementation Inventory patient / staff education needs & resources Create robust toolkits targeting roles; leadership Implementation Plan to meet immediate education needs Patient / staff : close gaps in education resources Transition to ongoing program EPIC Roll-out prescribing dashboards to provide real-time monitoring Plan for site-specific oversight / structure Define site targets Ongoing Stewardship 2015 MFMER slide-39

40 Primary Goals of OSP Consistent, safe approach to opioid prescribing throughout the enterprise Reduce risk: to patients, to providers, to institutions, to the public Educate: providers, patients, staff on appropriate use and monitoring of opioids and on alternative therapies Monitor: the effects of changes on prescribing practices, pain management, patient and provider satisfaction, etc. Make the guidelines do-able EMR, workflows, staffing, etc Empower each Mayo institution, clinic, hospital, department, and division to self regulate opioid prescribing/monitoring 2015 MFMER slide-40

41 Learning Assessment Question #1 The rate of opioid related deaths has surpassed then number of motor vehicle related deaths in the US. True False 2015 MFMER slide-41

42 Learning Assessment Question #2 Proactive planning to optimize non-pharmacologic and non-opioid options leads to reduced opioid use True False 2015 MFMER slide-42

43 Learning Assessment Question #3 There is not good evidence to support reducing opioids quantities for acute pain. True False 2015 MFMER slide-43

44 Learning Assessment Question #4 Quantities of opioids prescribed at the Mayo Clinic following elective surgical procedures are generally less than 200 MME for the total prescription. True False 2015 MFMER slide-44

45 Questions & Discussion 2015 MFMER slide-45