The Epidemiology of Opioid Abuse. Thomas Dobbs, MD, MPH Mississippi State Department of Health

Transcription

1 The Epidemiology of Opioid Abuse Thomas Dobbs, MD, MPH Mississippi State Department of Health 1/12/2018

2 ACKNOWLEDGEMENTS DRUG ABUSE WORKING GROUP MISSISSIPPI STATE DEPARTMENT OF HEALTH Manuela Staneva, MPH, Project Epidemiologist Meg Pearson, PharmD, MS, Project Leader Thomas Dobbs, MD, MPH, Medical Consultant Nykiconia Preacely, DrPH, MPH, CDC Epidemiologist Paul Byers, MD, State Epidemiologist

3 The project s mission is to evaluate the scope of the opioid epidemic in Mississippi and build statewide surveillance systems utilizing different data sources. Objectives: Research, data analyses, and public health reporting Translating data and research into action Achievements: In 2017, the Mississippi State Department of Health was awarded a threeyear grant from the Department of Justice Five national conferences: 6 oral presentations Five public health reports Multiple state presentations

4 In 2015, opioids killed over 33,000 people In 2016, opioids killed over 42,000 people

5 How Did We Get Here? The Genesis of an Epidemic During the 1990s, the American Pain Society introduced the concept of pain as the 5th vital sign, along with temperature, respiratory rate, pulse, and blood pressure, leading to a liberalization in prescribing laws. Resulting in a parallel increase in drug marketing ARE THESE THE ONLY REASONS? WHAT ABOUT OTHER FACTORS?

6 Is the USA Facing an Epidemic of Deaths of Despair? Between 1998 and 2013, midlife all-cause mortality declined among Africans Americans and Hispanics but surged among Caucasians. All-Cause Mortality Caucasians, Ages The increase in all-cause mortality among aged Caucasians was due to: Suicides Drug overdoses Chronic liver disease The most affected groups: Less-educated Rural residents A parallel decrease in: Labor force participation Marriage rates Lack of economic opportunities Lack of social support Deaths of despair

7 Drug Overdose Deaths: US and MS USA, 2016 Drug overdose deaths: 63,600 Age-adjusted rate = 19.8 Mississippi, 2016 Drug overdose deaths: 352 Age-adjusted rate = 12.1 In 2016, the five states with the highest rates of death due to drug overdose were West Virginia (52.0 per 100,000), Ohio (39.1 per 100,000), New Hampshire (39.0 per 100,000), Pennsylvania (37.9 per 100,000) and (Kentucky (33.5 per 100,000). Source: Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, NCHS Data Brief, no 294. Hyattsville, MD: National Center for Health Statistics

8 Deaths Involving Opioids: US, 2016 Opioids were involved in 42,249 deaths in 2016, and opioid overdose deaths were five times higher in 2016 than 1999.

9 Deaths Involving Opioids: Changing Patterns THREE WAVES* Still - 40% all opioid overdose deaths involved a prescription opioid in prescription opioids heroin 2013-present fentanyl and fentanyl analogues Age-adjusted drug overdose death rates, by opioid category: United States, ,9 4,4 Natural and semisynthetic opioids ,2 3,1 Synthetic opioids 4,1 4,9 Heroin *International Overdose Awareness Day August 31, MMWR Morb Mortal Wkly Rep 2017;66:897. DOI:

10 The Mississippi Opioid Epidemic: Surveillance Data What data sources do we have to track the MS opioid epidemic? What can we measure with these data sources?

11 MORTALITY DATA

12 Mortality Data: Patterns and Trends Number of Overdose Deaths Involving Opioids, MS, During 2016 Natural or semisynthetic opioids such as hydrocodone were involved in the majority of opioid deaths (98 cases or 57.0%) Synthetic opioids such as fentanyl or tramadol were documented in 41 deaths (23.4%) Heroin accounted for 28 deaths (16.3%) Mortality Trends, Deaths involving natural or semisynthetic opioids doubled from 49 in 2011 to 98 in 2016 Deaths due to synthetic opioids increased by 156.3% from 16 in 2011 to 41 in 2016 The number of heroin overdose deaths demonstrated a steep and steady increase from 2011 until From 2015 to 2016 heroin deaths decreased by 7 cases.

13 Mortality Data: Demographics Overdose Deaths Involving Opioids by Race, MS, Caucasian 649 (90.8%) All other races 8 (1.1%) African American 58 (8.1%) Overdose Deaths Involving Opioids by Sex, MS, Male 402 (56.2%) Female 313 (43.8%) Education: Only 49 (6.9%) of all decedents from opioid overdoses had a college degree or higher level of education. Marital Status: Less than one third (217 cases or 30.3%) of all decedents were married or not separated at the time of their death

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15 Controlled Substances and Opioids in MS: Rates Prescribing Rates per State, 2014 (CDCs) In 2014, MS had the 5th highest opioid prescription rates in the country. In 2016, MS had the 5th highest opioid prescription rates in the country. Source: QuintilesIMS Transactional Data Warehouse (TDW) ( based on a sample of approximately 59,000 pharmacies). During 2014 in Mississippi: There were 7,287, 299 prescriptions for controlled substances, of which 3,356,455 (46%) were for opioid analgesics On average for every resident in the state, there were 2.4 prescriptions for controlled substances and 1.1 prescriptions for opioids. Prescriptions for Controlled Substances and Opioid Analgesics, MS, 2014 All other controlled substances 54% Opioids 46%

16 Prescriptions for Opioids: Numbers and Trends Opioid analgesics accounted for 88% of all opioids. These prescriptions decreased marginally since 2012 Between 2011 and 2014, prescriptions for addiction-treatment, however, steadily increased. This trend suggests a significant surge in opioid use disorders in the state Opioid-containing antitussives.

17 Top Prescribed Opioid Analgesics, 2014 Hydrocodone accounted for 60%, tramadol for 16%, oxycodone for 13%, codeine for 4%, morphine for 3 %, and fentanyl for 2% of all dispensed opioid analgesics. Oral Morphine Milligram Equivalent Conversion Factors Opioid (strength in mg) Hydrocodone Tramadol Oxycodone Codeine Morphine Fentanyl Source: CDCs MME Conversion Factor (Range) ( )

18 Multiple Provider Episodes Multiple provider episodes 6 doctors 6 pharmacies Case Study Doctor Shopping, 2011 Female patient born in 1974 Number of prescriptions for opioids:146 Number of different prescribers: 76 Number of different pharmacies used: 30 Number of different patient names: 10 Number of cities of residence: 6 Number of different payment types: 5 The number of MPEs showed a downward trend from 5,357 episodes in 2011 to 4,493 in 2014.

19 Prescribing Patterns, MS, 2014 Statewide, 9,333 providers issued prescriptions for opioid analgesics in The majority of them (66.7%) issued less than 200 prescriptions. Pareto principle: 80% of the effects come from 20% of the causes Statewide, 17% of all prescribers issued 500 or more prescriptions during There were several outliers: 12 prescribers issued more than 10,000 prescriptions each.

20 Prescribing Patterns The Power of Community Reports: The Case of Laurel, MS During 2014 in Laurel: The number of prescribers issuing opioid prescriptions was 158. These prescribers issued a total of 108,276 prescriptions for opioid analgesics. The majority (57%) of prescribers wrote less than 200 prescriptions. In fact, the top 6 prescribers of opioids prescribed 59% (64,137) of all prescriptions. One prescriber wrote 31,713 or 29% of all prescriptions for opioid analgesics dispensed in Laurel during 2014

21 Prescriptions for Opioid Analgesics: Jackson, MS

22 Clinic: Prescriptions for Opioid Analgesics, 2014 Prescriber 1 = 31,713 Prescriber 2 = 14,887 Total = 46, 600 Every working day (261 workdays) opioid prescriptions Every working hour (8 hour days) 22.3 opioid prescriptions Every 2.7 minutes 1 opioid prescription

23 High-Dose and Long-Term Opioid Therapy, Compared to 2012, MME and days of supply increased in 2012 There was a total of 245,969 high-dose opioid prescriptions ( 90 MME/day), accounting for 7.3% of all opioid prescriptions during Preliminary statistics

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25 Opioid-Related Hospitalizations: Types Opioid-Related Hospitalizations, 2014 Total Number = 6,355 Dependence 4,013 (63%) Abuse 1,059 (17%) Overdose 722 (11%) Adverse Effects 766 (12%) Multidrug Use Disorders, 2014 Opioid-related and other drug-related discharges 38% Opioid-related discharges only 62% Over one third (2,393 or 38%) of all opioid-related discharges had a coexisting diagnosis of another type of drug misuse.

26 Opioid-Related Hospitalizations: The number of opioid-related discharges increased by 33% (+1,571 discharges) The hospitalization rate (number of opioid-related discharges/number of all other discharges) increased by 32% from 12.7 to 16.8 opioid-related discharges per 1,000 discharges.

27 Opioid-Related Hospitalizations: Race and Sex Compared to patients hospitalized for all other causes Caucasians (81% vs. 55%, p <.001) and males (45% vs. 42%, p <.001) were more likely to be hospitalized with a diagnosis indicating opioid misuse

28 Opioid-Related Hospitalizations: Age Group Females between the age of 25 and 44 years (reproductive age) accounted for 1,465 or 23.1% of all opioid-related discharges.

29 Residence Patterns There were 19.8 opioid-related hospitalizations per 10,000 MS residents during Nationwide range: between 7 and 40 per 10,000 persons. We identified a cluster of high hospitalization rates in the Southeast region of the state during This trend persisting during

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31 Societal Cost Mean Length of Stay 5.7 days 6.5 days Year Sum Total Charges $20,444 $29,383 Length of Stay 27,424 days 41,480 days Total Charges $97,804,656 $186,727,420 Opioid-Related Discharges: Total Charges, 2010 and The hospital charges almost doubled between 2010 and 2014 $ $ Societal Cost Health care cost Lost workforce Disruption of family relations Criminal justice cost

32 Key Findings Summary of MS Data Findings and Prevention Strategies High rates of opioid prescribing Increasing number of opioid use disorders and high level of multidrug use Minimize the number opioid prescriptions Support effective treatment methods, including medicationassisted treatments High prevalence of mental health issues among patients with opioid use disorders High prevalence of chronic pain conditions among patients with opioid use disorders Increasing number of deaths due to dangerous synthetic opioids Caucasian race, low SES, social isolation Expand the state capacity to diagnose and treat mental health disorders Teach and financially incentivize forms of alternative pain management Collaborate with law enforcement to find ways to combat illicit drug use Study the underlying causes of the opioid epidemic. Target both supply and demand

33 Acute Pain Recommended < 3 days Max 10 days, may give 1 additional prescription Chronic pain Use lowest effective dose < 50 MME daily Should not exceed 90 MME daily If > 100 MME must be in pain clinic Methadone for chronic pain only through pain clinics

34 Benzodiazepines Max 90 days per prescription Should not co-administer with opioids Short term acceptable Patients on chronic benzodiazepines and opioids should be gradually weaned of one or both Chronic co-administration in rare, extreme circumstances

35 All licensees must register with PMP Must check on all new prescriptions Patients on chronic opioid must have check every 3 months (every encounter in pain clinics) Must document PMP review PMP check not required for inpatients but must be checked if discharged on opioids

36 Many adjustments to pain management and weight loss clinics (not covered here) If > 30% of patients receive controlled substances for chronic pain, must register as pain clinic

37 Every 4 months for prescription for chronic pain Inpatients exempt

38 Terminal / Cancer treatment Hospice patients Inpatients (nursing home, rehab, hospitals, etc.)

39 THANK YOU!