The Trifecta: Kids, Pot, & Opiates. Drug Overdose Death Rates Never Higher. Adolescent Opiate Overdoses Increased. Eric A.

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1 The Trifecta: Kids, Pot, & Opiates Eric A. Voth, MD, FACP Drug Overdose Death Rates Never Higher. Nationally 16 % increase in deaths from opioid pain relievers to18, % increase in opioid O.D since 2000 Deaths involving synthetic opioids, such as fentanyl & tramadol, increased by 79% from Totaling 5,544 death in Heroin-related deaths have more than tripled since 2010 to 10,574 deaths in 2014 and Increased 28% MMWR December 18, 2015 / 64(Early Release);1-5 Adolescent Opiate Overdoses Increased Opiate death rate aged more than tripled from 1999 (0.8 per 100,000) to 2007 (2.7) OD Rate stable between 2007 and The rate declined to 2.0 in Then increased between 2014 and 2015 (2.4) NCHS Data Brief No. 282 August

2 Opioid-related Deaths MMRW 2015 Dec Figure 2. Drug Poisoning Deaths with Mentions of Selected Drugs, and , Kansas residents.** Data Sources: Kansas Vital Statistics, Bureau of Epidemiology and Public Health Informatics Kansas Statistics vs. other states per 100,000 Opioid ED visits 81.8 vs Mass Rate of change Ks second lowest 11.4 vs Ohio Opioid inpatient stays 5 th lowest vs Maryland Percent of change -18% (decreased) national lowest vs Georgia 99.8% Statistical Brief Jan 2017 AHRQ HHS (Agency for Healthcare Research and Quality) 2

3 Unintentional Mortality in Long-Acting Opiates Ave age 48 Well matched groups Risk first 30 days 4.16 After 6 mos no diff from controls Low dose risk (<60 MS equivalent ) 1.54 High dose risk (>60 MS equivalent ) 1.94 Ray et al from Vanderbilt JAMA 2016;315: Mortality cont. Most common dx back pain (75%) 96% had filled short-acting in prior year 68% had Rx for other meds 63% psychotropics NSAIDS 70% Benzodiazepines 52% SSRI or SNRI 45% Ray et al from Vanderbilt JAMA 2016;315: No surprise that OD s are rising Broad use of drugs of abuse Marijuana use becoming acceptable Major medical initiatives focus on pain Availability of narcotic pain meds Lack of adequate national Rx monitoring Lack of communication between medical world and law enforcement. 3

4 Appropriate Prescribing: How Can The Health Care System Impact the problem? By providing reasonable doses of effective medications to the correct patients in a manner that is carefully monitored and which provides the patient with improvement in daily life functions 2016 CDC Pain Guidelines Urging careful selection Reduction of short acting narcotics to under 7days Drug Testing Overlooks the reinforcing effect of short acting Supports Rx monitoring programs Max morphine equivalent 90 mg JAMA March 15, 2016 Pharmacologic Ladder Acetaminophen NSAIDS/COX-2 Inhibitors Tramadol Neuroleptics/Tricyclics Propoxyphene Oxy/Hydrocodones Long-Acting Narcotics 4

5 Issues to Consider in Choosing Medication Historical use of medications Short vs. Long acting medications History of abuse, chemical dependence, Use of SNRI s or sedatives with Bipolar Sx or history of other psych disorders Duration of pain Etiology and Type of pain Cost Challenges When Prescribing Narcotic Pain Medicine Must understand pharmacology-eg methadone toxicity, over dose. All have abuse potential with street values Variably expensive Stigma Narcotic Plateau and tolerance Pseudoaddiction Narcotic-Induced Hyperalgia 5

6 Tolerance vs. Abuse Tolerance Plateau in dose benefit Gradual increase in dose No aberrant behavior Some benefit to dose adjustments Abuse Dose increase unstable Sky is the limit Aberrant behavior Variable excuses. Aberrant Behavior: Dependence vs. Addiction Improvement in sx Increased tolerance Withdrawal if stopped Dose related Pseudoaddiction Narcotic induced Hyperalgia Dependence plus behavioral parameters Manipulation Illegal activity Unstable doses Lack of improvement Preference for reinforcing meds (rapid uptake-shorter half-life) 6

7 Co-morbid Conditions Addiction Psychiatric disorders Unemployment Poverty Frankly criminal or illegal lifestyle Family / friend drug source Dealing with Abusers Minimize Amount but Treat Adequately Obtain Pharmacy Records Drug Test to determine presence of prescribed drug and absence of illegal drugs One Pharmacy Be Consistent Use Consultants Confront Patient Warning Signs Early Refills!!! Numerous Changing Complaints Missing appointments Lost Prescriptions or Fake history Overt Intoxication Provider Feeling Manipulated Fake pain syndromes Fake intolerance of meds Fake cancers 7

8 Long acting narcotics Methadone Morphine--MS Contin, Oramorph Oxycodone sustained release-oxycontin Fentanyl patch-duragesic Suboxone Intrathecal preparations Methadone Excellent pain medicine BUT dangerous Inexpensive Useful in neuropathic pain Delayed pain effect/ early toxicity Baseline and periodic QT interval on EKG Dosing Start slowly-5-10 mg daily to BID, slow increase Fentanyl Patches Reservoir membrane vs. matrix Modes of abuse Absorption Never occlude or use heat pad Mark date of application Has become a serious drug of abuse 8

9 Suboxone Tightly Regulated Must Differentiate Pain from Narcotic Addiction Management when prescribing Buprenorphine/naloxone Half-life hours Dose forms: Sublingual Strips Tablets Pain Management Best Practices Drug screening Pain agreement-mixed benefits. Consultations Pain scoring tools Review pharmacy records-ktracs Adjunct medication or procedures Background checks Pain templates in electronic medical record An Effective Approach Identify and clearly document indication Actively look for complicating disorders Psych: Depression, Bipolar illness, Addiction Sleep apnea/ COPD/ Narcolepsy Cardiac illness Minimize dose of any opiate & titrate slowly Simplify regimen (minimize side effects) Assure legitimacy Lock medication 9

10 Prescribing Documentation Intent Effect Control Legality Pattern of Use System Approach Flag patients in the electronic medical record that are receiving narcotics Pros and cons of firing patients Centralize prescribing of narcotic use and super-utilizers to one or limited providers Emergency Department controls and policy Support systems/ ancillary services Pain Management Checklist eg. Has an agreement been signed? : Yes When was the agreement signed?: 12/07/15 Has K-Tracks been reviewed? : Yes When was K-Tracks Reviewed? : 12/07/15 Has a Random UA been done?: Yes When was the UA completed? : 12/07/15 Has the patient had any prior imaging? : Yes What imaging studies has the patient had? : (2009) Have any alternate therapies been attempted?: Yes What therapies? : minimally effective epidurals 10

11 Public Availability of Narcan Potential serious effects if given for other than narcotic overdose Diabetic coma Head injury Cardiac syncope/stroke Must have training on admin and indication Must not replace medical evaluation The Opiate-Marijuana connection Brain Development Amygdala Judgment Emotion Motivation Prefrontal Cortex Nucleus Accumbens Physical coordination Sensory processing Cerebellum Maturation starts at the back of the brain and moves to the front Judgement is last to develop! 11

12 Commercializing pot Marijuana and Fatal Crashes Colorado Since Dispensaries Fatal crashes THC Ave Percent THC Colo Dept of Transportation 12

13 Past Month Usage of Marijuana National vs Colorado ages Source: Data from SAMHSA.gov, National Survey on Drug Use and Health 2013 Past Month Usage of Marijuana US vs. Colorado & Washington Source: Data from SAMHSA.gov, National Survey on Drug Use and Health 2014 Colorado Marijuana Interdiction Seizures El Paso Intelligence Center, National Seizure System 13

14 14

15 Pediatric Marijuana Intoxication Wang found that in states with legal recreational or medical use, marijuana increased by 30% annually 2005 to % increase poison control calls Colorado 19% increase across the US 48 % of the cases in Colorado attributed to the ingestion of edible marijuana products Increase in Marijuana Use in Medical Pot States to , illicit cannabis use increased significantly more in states that passed MML than in other states Compared with never-mml states, increases in use were significantly greater in late-mml states Medical Marijuana laws appear to have contributedto increased prevalence of illicit cannabis use and cannabis use disorders. AMA Psychiatry. doi: /jamapsychiatry Published online April 26, 2017 Marijuana Annual Use-peak 1997 MTF

16 Non-Heroin Narcotics-peak 2001 MTF 2014 Is there a solution? Education of Healthcare Providers Rigorous Monitoring of Patients Mandatory National Rx monitoring Communication With Law Enforcement?? Protection from Regulatory bodies if Providers Using Guidelines Availability of CME/ and protocols Aggressive Work to Reduce Drug Abuse 16

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