A Brief History of the Opioid CrisisP h i l l i p C o f f i n , M D M I A FA C P F I D S A

S a n F r a n c i s c o D e p a r t m e n t o f P u b l i c H e a l t h

U n i v e r s i t y o f C a l i f o r n i a S a n F r a n c i s c o

U.S. Opioid Overdose Deaths 2000-2016

www.cdc.gov/drugoverdose/data/analysis.htmlBeginnings of Opioid Stewardship

Social Security Disability Beneficiaries

Welfare reform

1990s Healthcare Reform: HMO Coverage

U.S. Opioid Prescribing Trends

Pezala, J Pain Res. 2017

Oxycontin

Dilaudid/ Duragesic

Kadian

Norco

Atiq

HMO enrollment >80 million

Welfare reform

State law/boards

liberalize opioids for

chronic pain

JCAHO 5th Vital Sign

Fentora

Subsys

Abstral

Roxicodone

Embeda

Exalgo

Acurox

generic morphines

Palladone

Avinza

generic fentanyllozengegeneric

oxycodones

Opana

Opana ER

Dilaudid(lower dose)

Onsolis

Lazanda

Oxecta Zohydro

Hysingla

generic oxymorphone Targiniq

CDC reports rising Rx deaths

Policy and practice changes to reduce OA prescribing begin

19951990

generic hydrocodone

Shift from manufacturing

to service economy

The 7 OxyContin “Poster Children”: 15 Years Later

Helped with pain

(2 still using)

Died of likely overdose

Died of complications

related to OUD

Struggled with addiction

🎼🎼 Get in the

Swing of OxyContin

🎵🎵

Pop. W Untreated Pain

(Phys/Psych)

Pop. in Alternative Treatment

Pop. Using Rx Opioids

Pop. Misusing Rx Opioids

Pop. Misusing Non-Rx Opioids

Pop. Dying From Opioid

Overdose

Pop. in Treatment

Pop. in Recovery

Adapted from Georgia Health Policy Center & Pontifex Consulting, 2017

Opioid Stewardship Objectives and Goal

Reduce Supply

Reduce Diversion

Improve Safety

Reduce Harms

Opioid Stewardship and Chronic Pain. A Guide for Primary Care Providers.

Patients in Pain

Patients with Opioid Use Disorders

• An HIV+ man is transferred to your service.• He has generalized body pain that was treated with fentanyl patch

150mcg and morphine ER 100mg BID with oxycodone 60mg QID for breakthrough pain.

• He was also on lorazepam, alprazolam, aripiprazole, bupropion, and fluoxetine.

• He is also in a methadone program for opioid use disorder.• He requested a change of provider because he wanted

hydromorphone. • No Utox is available and his VL is always suppressed.

Preliminary results of Transitions analysis (N=200):opioid dose change and use of opioid analgesics not as prescribed

0.65 (0.35 – 1.20)

0.76 (0.44 – 1.33)

2.51 (1.18 – 5.36)*

Reference Level: No Change in Opioid Dose *p<0.05

% of injections resulting in (non-fatal) OD at Sydney injection facility, by opioid type

0%

1%

2%

3%

4%

5%

Rx opioid Heroin Fentanyl

Latimer. Intl J Drug Policy. 2016

Naloxone

Patients with Personal and Environmental Trauma• 46yo woman with chronic lower back treated for past 20 years with

escalating doses of opioids• Currently taking long-acting morphine sulfate 100mg twice daily, with short-

active morphine sulfate 30mg three times daily as needed for breakthrough pain. She also receives lorazepam 0.5mg twice daily.

• She lives in public housing, has been threatened with eviction, has been incarcerated twice, has lost two children to child protective services, and has not followed up with referrals to physical therapy because it takes 45 minutes to get there, visits last only 10 minutes, and she has no space to do the exercises.

• Her twice annual urine toxicology consistently demonstrates morphine and cocaine. She’s never had an opioid overdose.

Opioids and the Pain of Life

I’ll die young, but it’s like kissing God

-Lenny Bruce

I stood at a distance, and aloof from the uproar of life.

-Confessions of an Opium Eater

… poverty, lack of opportunity, and substandard living and working conditions

…-Dasgupta etal., AJPH 2018

Take it

s l o w

Shared Opioids: An HIV Analogy

Safe Sex

Sero-concordant

Protected

Risky Sex

Sero-unknown or discordant

Unprotected

Two Approaches to Opioid Stewardship

Aggressive(the same way we expanded opioid prescribing)

Changes in prescribing based on fear and excessive workload

Rapid reduction or discontinuation of opioid prescribing

Patient abandonment

Providers abort plans to provide addiction care

Cautious

Evidence-based changes

Slow, patient-centered changes

Expansion of non-medication pain management

Emphasis on maintaining patients in care

Use of OUD medications

Phillip O. Coffin MD, MIA, FACP, FIDSA

San Francisco Department of Public HealthUniversity of California San Francisco

phillip.coffin@ucsf.edu