Our Core Thoughts on Dealing with the Opioid Addiction Crisis Meghan McNelly, PharmD, MHA, FACHE Suzette Song, MD Joseph Alhadeff, MD
Outline Brief History of the Opioid Problem How did we as a medical profession get here? How did we contribute to the problem? Closer analysis of our own organization Developing and Implementing an action plan Results Recommendations for future improvements
History People have always had pain Morphine and opioid derivatives have been around for a long time (~1500 BCE) Long clinical history of use Merck began marketing it commercially in 1827 Long societal history of abuse What changed?
Past -> Present
Past -> Present
Pain as a 5 th Vital Sign Industry driven initiative Picked up on by the American Pain Society, the VA, the Joint Commission and others in the mid 1990 s Spread through the medical community Every patient had to have a plan for their pain Encouraged more liberal use of pain medication Financial and other incentives to prescribe more pain medication Explosion in the number of legal prescriptions written Patient satisfaction scores more recent, more financial incentive to prescribe. Pain = unhappy patient
Consequences In 2008, drug overdoses surpassed automobile accidents as the leading cause of accidental death in the US In 2015, opioids were involved in 33,091 deaths, with nearly half of those involving a prescription opioid. o The remaining deaths were from heroin use. 70% of heroin users cite use of a prescription opioid as a contributing factor to their addiction Overdoses and opioid addiction affect all sectors of our society, ignoring socioeconomic and racial differences to influence all of our communities
A True Crisis In a city of 645,000, the Baltimore Department of Health estimates there are 60,000 drug addicts, with as many as 48,000 of them hooked on heroin. A federal report released last month puts the number of heroin addicts alone at 60,000. (March 14, 2017 ABC News)
OSS Health s Involvement Discussion with local DEA and law enforcement officers Discussion with one of our local legislators Participation in the heroin task force Challenged to look at our role in the problem Part of our response was defensive whoa, it s not all our fault o Mischaracterization of physicians and providers o Bad consequences of good intentions o Multifactorial problem Second response What can we do to help?
Defining Physicians Role in the Problem Overprescribing of medications o Inappropriate prescriptions not indicated o Appropriate prescriptions but too many pills Residual Patient received 60 pills, only used 10, Patient now has a bottle of 50. o Continuing prescriptions beyond when they were necessary o Believing the pharmaceutical industry s hype of abuse deterrent medications o Illegal prescriptions Pill Mills Why do physicians overprescribe o Financial legitimate and illegitimate o Patient Convenience o Laziness o Good ratings patient satisfaction
External Factors Patients were encouraged to properly dispose of medications, or turn them in to approved disposal sites. Problems with that: o They were told not to flush them down the toilet, not to burn them and not to dispose of them in the regular trash so... o Physicians offices, police stations and pharmacies would not accept the unused opioid medications o There was one approved drop off site in York County at the time and it was often full There is a high street value for these medications - another perverse incentive to ask for more medications from the patient. o Street value for Oxycontin $50, Oxycodone $15
But We Don t Prescribe Much Pain Medication Then we looked at our numbers 18,000 prescriptions 800,000 pills
New Plan
Our Story Study each surgery Look at current prescribing patterns Consensus on which generic medications to prescribe Consensus on duration Adjustment of amounts
OSS Average Rx in 2015 Total Hip Replacements Oxycodone 90-120 pill prescriptions, often over first 6 weeks (Following dosage instructions of a prescription for 1-2 tablets every 4-6 hours can equate to a total consumption of 120 tablets in 10 days)
Total Hip Replacement Changes ofrom Oxycodone 90-120pill Rxs, often over first 6 weeks TO 30Oxycodone. Opioid Length 2 weeks Also otylenol 325mg. 2 po q 6 ATC (112) osenna-s take 2 tablets at nighttime. oplus Mobic 15mg q day x 14 days (14) OR Celebrex 200 q day x 14 days (14)
Multimodal Analgesia omultiple medications with varying mechanisms of effect in combination with appropriate opioids to lessen their need oice, rest, alternative positioning, therapeutic exercise, breathing techniques oextend these techniques
Rinse, wash, repeat!
Patient Conversations
Solutions Within the practice Standardized our prescribing for postoperative medications o There is an allowance for patients with allergies, tolerances or intolerances Strongly discouraged the prescribing of any narcotics past 6 weeks post op. Reinforced the idea of judicious use of pain medication for acute injuries. Required periodic follow up to assess continued need with patients on chronic pain medications Robust patient education efforts
Improved EDUCATION to patients You will have pain with surgery The pain will be tolerable and it won t last for long Alternative pain relief methods and medications HOW to limit reliance on these medications during the healing process Dangers of longer than short term use o Patients >90 days, >60% more likely 5 years later Our intentions to adhere with the shortest possible duration of opioid use in their treatment
Results 15% Rxs 33% Pills 8 pills/rx **No effect on Patient Satisfaction Scores**
External Factors
E-Prescribing Bill
Meghan Problems Upcoming legislation Insurance prescribing limits recommendations
Prescription Math
System Costs
System Costs Cook County Health System o Emergency Department Visit $6,000 Utilization o 30% Increase in ER utilization from 2016-2017
CARA 2.0 Federal Statute o Proposed Bipartisan Senate Bill o $1Billion in funding othree day limit on initial, acute opioid prescriptions o Buprenorphine prescriptions Permanently allow NPs and PAs to prescribe Remove the cap on patients per physician o Require the use of PDMPs
Solutions Outside of the practice Helped to get the Prescription Drug Monitoring Program (PDMP) up and running in our state Now required to check the PDMP prior to writing first time narcotic prescriptions More disposal sites for unused medications Have had multiple discussions with state and federal legislators and with insurance executives to remove questions about adequate pain control from patient satisfaction initiative and questionnaires Supported external patient education efforts
Further Recommendations Continue to refine and adapt our prescribing. Continue both internal and external patient education efforts Expand use of non-narcotic pain control regimens o Peripheral nerve blocks. o NSAID s o Multimodal analgesia to reduce overall usage Encourage development of other non-narcotic pain medications Encourage pharmaceutical companies to decrease the cost of some non-narcotic medications lidocaine patches, etc. Encourage insurance companies to cover non-narcotic pain control medications and treatments Encourage legislators to pass reasonable laws and regulations
Geisinger Health Plan Medication Therapy Disease Management Program o Multidisciplinary Team Approach Results o 74% of patients reported improvements in overall health o 86% of patients reported in improvement in physical functioning o 25% reduction in cost o 19% reduction in claims
Pyramid picture
Take Home Points Don t be passive You should DO something Standardize default prescription amounts Multimodal pain regimens for surgical patients Limit duration of prescriptions Increase patient education efforts Small, incremental changes work best
Thank You