The Opioid Epidemic: What is the Role of Acute Pain Prescribing?

Transcription

1 The Opioid Epidemic: What is the Role of Acute Pain Prescribing?

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3 How did we get here?

4 2012: 259 million opioid prescriptions 40% : Levy B, Paulozzi L, Mack KA, Jones CM. Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., Am J Prev Med. 2015;49(3):

5 Our Patients

6 Will I get addicted to painkillers?

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8 Chronic Opioid Users ~8%

9 Intermittent Opioid Users ~30%

10 Pre-Operative Opioid Use and Associated Outcomes after Major Abdominal Surgery Cron DC, Englesbe MJ, Bolton CJ, Joseph MT, Carrier KL, Moser SE, Waljee JF, Hilliard PE, Kheterpal S, Brummett CM. Annals of Surgery 2016.

11 New Persistent Users ~6%

12 New persistent opioid use Previously opioid naïve patient still filling opioid Rx s 3 mo postop 1 What is the risk after surgery? Kehlet H, Rathmell JP. Persistent postsurgical pain: the path forward through better design of clinical studies. Anesthesiology. 2010;112(3):

13 New chronic use of opioids after surgery was 6% and did not differ between major and minor surgeries Brummett et al. JAMA Surg. 2017

14 Postoperative opioid dependence happens in pediatric patients Surgical Population Nonoperative Comparison (Control Group) 0.2% 4.8% Tonsillectomy and/or adenoidectomy Inguinal hernia (open or laparoscopic) Umbilical or epigastric hernia Pectus repair, open or minimally invasive (Nuss) Appendectomy Cholecystectomy Colectomy, open or laparoscopic Supracondylar fracture fixation Epicondylar fracture fixation Posterior arthrodesis Arthroscopic knee repair (ACL, meniscal) Orchiopexy, inguinal, open or laparoscopic Hypospadias repair 2.9% 2.7% 2.9% 4.8% 4.1% 5.2% 4.1% 5.1% 4.7% 4.0% 7.3% 7.4% 15.2% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0%

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16 6 tabs/day of Norco 5/325

17 6 tabs/day of Norco 5/325

18 Pain Management Is Not Uniformly Taught

19 20 tablets of oxycodone (5 mg/tab) 100 tablets of oxycodone (5 mg/tab)

20 45 tablets of Norco (5/325) 70 75% unused Hill MV, McMahon ML, Stucke RS, Barth RJ, Jr. Wide Variation and Excessive Dosage of Opioid Prescriptions for Common General Surgical Procedures. Ann Surg. 2017;265(4):

21 Quantity Does Not Predict Refill Probability of Refill 14% 12% 10% 8% 6% 4% 2% 0% >60 # of pills (~Norco 5mg)

22 33 extra pills per prescription 62 million X unused pills/year 1,881,481 operations / year 1,2 1. HCUP Fast Stats. Healthcare Cost and Utilization Project (HCUP). March Agency for Healthcare Research and Quality, Rockville, MD. 2. HCUP Central Distributor SASD File Composition. Healthcare Cost and Utilization Project (HCUP). March Agency for Healthcare Research and Quality, Rockville, MD.

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25 62 million unused pills/year DIVERSION Leftover Opioids Share Opioids Kennedy-Hendricks A, Gielen A, McDonald E, McGinty EE, Shields W, Barry CL. Medication Sharing, Storage, and Disposal Practices for Opioid Medications Among US Adults. JAMA Intern Med. 2016;176(7):

26 High-risk opioid prescribing 70% 1 prescriber 2 prescribers 3 or more prescribers 60% 58% 50% 40% 30% 34% 25% 31% 25% 20% 17% 17% 19% 10% 0% Any high-risk prescribing 12% High daily doses 1% 11% Overlapping prescriptions 6% Concurrent benzodiazepine 0% 1% 4% Long acting opioids

27 Our Role

28 How Will We Have Impact? Educate patients and providers about appropriate opioid management for acute care Create guidelines for postoperative pain management Develop interventions to reduce postoperative opioid prescribing and use Implement new methods for safe opioid disposal

29 U-M is Uniquely Positioned to Make a Difference in the Opioid Epidemic Michigan Surgical Quality Collaborative (MSQC) participating sites

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31 Opioid Prescribing Guidelines: Laparoscopic Cholecystectomy

32 Laparoscopic Cholecystectomy % Prescriptions 30% 25% 20% 15% 10% Opioids Prescribed After Surgery 77% of rx s 5% 0% 30 Norco 60 Norco 90 Norco 120 Norco OME Total (mg)

33 Laparoscopic Cholecystectomy 30% Opioids Used After Surgery % Prescriptions 25% 20% 15% 10% 5% Average use = 50 OME (10 Norco/7 Oxy) Median use = 30 OME (6 Norco/4 Oxy) 70% did not dispose of leftover 0% OME Total (mg)

34 Let s get smart about prescribing 15 Oxycodone 5 mg 1q4-6 PRN 15 Norco 5/325 mg 1q4-6 PRN + Tylenol AND Motrin

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36 After the new protocol, patients also reported less opioid use

37 Supersize it! David Marchiori, Esther K. Papies, Olivier Klein, The portion size effect on food intake. An anchoring and adjustment process?, Appetite (2014), doi: /j.appet

38 Proposed Prescribing Guidelines

39 Opioid Recovery Drives Medication Take-Back Day Saturday, May 20, a.m. 2 p.m.

40 Total number of people 349 Pills Estimated weight of pills lb Estimated total number pills 139,658.5 Opioid pills 13,784 Most common - Hydrocodone 5,714 Other medications of interest Benzodiazepines and sedatives 3,002 Anti-depressants 6,401 Stimulants 623 Muscle relaxants 565 Anti-epileptics 4,156 Additional information Oldest opioid date (by year) 1981 Second oldest opioid (different person) 1985 Most common reason for opioid Surgery

41 Opioid Recovery Drive May 20 Escanaba/St Francis Hospital: TBA Traverse City/Munson Medical: Thomas Judd Care Center Saginaw/CMU Health: Heritage High School Parking Jackson/Allegiance: Jackson Police Department Lobby 41 Ann Arbor/UM: Pioneer High School Parking Lot

42 umhealth.me/takebackmap

43 umhealth.me/takebackmap

44 umhealth.me/takebackmap

45 Moving to a Preventative ModelPreventive Model

46 Surgical Prescribing is Fueling the Opioid Epidemic 6-15% Incidence of new chronic opioid use after surgery ~70% Opioids prescribed after surgery are unused Postoperative prescribing is not currently tailored to the individual Hill et al. Ann Surg. Sept

47 Precision Opioid Prescribing Informed prescribing and personalized pain management Goal: Reduce downstream chronic opioid use, abuse and overdose through a precision prevention strategy Not taking opioids Chronic opioid use Opioid abuse Opioid overdose Proposed precision preventative strategy Focus of existing public health measures

48 Contact us