The Opiate ‘Crisis’: Physician Perspective and Opiate

Stewardship

Eric A. Voth, M.D., FACPVice-President Primary Care

Stormont-Vail Health Topeka, KS

Background Nationwide opioid epidemic

https://www.cdc.gov/drugoverdose/data/overdose.html

Drug Overdose Death Rates Never Higher.

Nationally 16 % increase in deaths from opioid pain relievers 2013-2014 to18,893.

200% increase in opioid O.D since 2000 Deaths involving synthetic opioids, such as

fentanyl & tramadol, increased by 79% from 2013 – 2014 Totaling 5,544 death in 2014.

Heroin-related deaths have more than tripled since 2010 to 10,574 deaths in 2014 and Increased 28% 2013 – 2014.

MMWR December 18, 2015 / 64(Early Release);1-5

Opioid-related DeathsMMRW 2015 Dec

Adolescent Opiate Overdoses Increased

Opiate death rate aged 15–19 more than tripled from 1999 (0.8 per 100,000) to 2007 (2.7) OD Rate stable between 2007 and 2011. The rate declined to 2.0 in 2012–2014 Then increased between 2014 and 2015

(2.4)NCHS Data Brief ■ No. 282 ■ August 2017

Data Sources: 2005-2016 Kansas Vital Statistics, Bureau of Epidemiology and Public Health Informatics

Figure 2. Drug Poisoning Deaths with Mentions of Selected Drugs, 2005-2009 and 2011-2016, Kansas

residents.**

Kansas Statistics vs. other statesper 100,000

Opioid ED visits 81.8 vs Mass. 450.2 Rate of change 2009-2014 Ks second

lowest 11.4 vs Ohio 106.4 Opioid inpatient stays 5th lowest 104.3 vs

Maryland 403.8 Percent of change -18% national lowest vs

Georgia 99.8%Statistical Brief Jan 2017 AHRQ HHS

(Agency for Healthcare Research and Quality)

Multiple Sources of Overdoses

Overdoses among drug abusers Heroin and other street drugs Overdoses from illegal prescription drugs

Accidental overdoses with pain patients Intentional overdoses for suicide

No surprise that OD’s are rising

Broad use of drugs of abuse-Marijuana Major medical initiatives focus on pain-

”The Fifth Vital Sign” Availability of narcotic pain meds Lack of adequate national Rx monitoring Lack of communication between medical

world and law enforcement.

Marijuana Annual Use-peak 1997MTF 2014

Non-Heroin Narcotics-peak 2001MTF 2014

(Am J Public Health. 2017;107: 1827–1829. doi:10.2105/AJPH.2017.304059)

(Am J Public Health. 2017;107: 1827–1829.

doi:10.2105/AJPH.2017.304059)

Mandatory PMP Plus pot legalization

Pain management is the only medical area where: Patients are often presumed to be liars Medical providers are taught to believe

patients thus conflict with our training A variable percentage are liars Healthcare providers are expected to be

policemen Patients misbehave and we will be blamed

by regulatory agencies, the press, and the public.

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

Unintentional Mortality inLong-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 VanderbiltJAMA 2016;315:2415-2423

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 VanderbiltJAMA 2016;315:2415-2423

“But What About My Pain?”

Triad of Issues When Treating Pain

Physiological

SocialPsychologicalBipolar IllnessDrug addictionPersonality disorders

EmploymentSecondary GainDrug DealingProstitutionPoverty

InjuryIllnessFeigned illness

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

Consider Alternative Modalities

TENS Physical Therapy Regional or Epidural Blocks Nerve ablation or stimulators Accupuncture Psychotherapy

Pharmacologic Ladder

AcetaminophenNSAIDS/COX-2 Inhibitors

TramadolNeuroleptics/Tricyclics

PropoxypheneOxy/Hydrocodones

Long-Acting Narcotics

Long acting narcotics

Methadone Morphine--MS Contin, Oramorph Oxycodone sustained release-Oxycontin Fentanyl patch-Duragesic Suboxone Intrathecal preparations

Long-Acting OpiatesConsiderations

Ease of abuse GI motility Half-life Painful Timeframes Ability to administer given form Black Box warnings

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

Suboxone

Tightly Regulated Must Differentiate Pain from Narcotic

Addiction Management when prescribing Buprenorphine/naloxone Half-life 20-40 hours Dose forms: Sublingual Strips Tablets

Aberrant Behavior:Dependence vs. Addiction

Improvement in sx Increased tolerance

and dose requirement 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)

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

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

The Opiate “Crisis”

2016 CDC Opiate Guidelines

Non-opiate Rx Preferred before opiates

Set Realistic goals for pain control

Discuss Risks and benefits Start with short-acting **Lowest effective dose

preferably. <50mme/day Carefully Justify if>90mme

Limit supply especially for acute pain

Evaluate benefits and harms within 4 wks and within 3 mos

Assess risk of opiate harms (OD/ interactions)

**Review State PMP Urine drug screening Avoid benzodiazepines

(and other drugs of abuse) Consider referral for

addiction treatmentJAMA March 15, 2016

Opiate Stewardship Committee

Emphasize the Burning Platform Review and Revise Policies and Procedures Gap analysis Identify Stakeholders Activate Stakeholder Involvement Pathway Design and Buy-in Monitoring and Education Support non-opiate pain alternatives

SVH Opioid Stewardship Workgroup developing program

Vice President for Primary Care Services -Chairman Medical Director Family Medicine/Family Practice Physician PharmD – Medication Safety Coordinator PharmD – Clinical Pharmacy Manager PharmD- Clinical Staff Pharmacist Physician Advisor Informatics Hospitalist Director of Accreditation PCS Administrative Director Medical, Surgical, Critical Care & 7N

Cardiac Director of Cancer Center Director of MSD Medical Specialty patient care services PharmD – Director of Pharmacy Learning & Talent Development liaison

Opioid MetricsHospital MetricsInpatient utilization of opioids (e.g., daily MME) Discharge opioid prescriptions, MME and days of therapyNaloxone prescriptions on discharge Identify High-risk patients (e.g., concomitant benzodiazepines) Utilization of non-opioids Pain control Patient knowledge and satisfaction surveys

Ambulatory Metrics Analyze number of patients on chronic opioid therapy that are not utilizing a pain management contract Analyze number of patients on chronic opioid therapy who have not been risk stratified for risk of aberrant behaviorPrescribed opioid utilization (e.g., daily MME)Pain ControlPatient knowledge and satisfaction surveys

Pain Management Best Practices

Pain agreement-Mixed benefits. Prescription Monitoring Programs KTracs Drug screening Pain scoring tools Consultations Adjunct medication or procedures Background checks Pain templates in electronic medical record

Best Practices-General Elements

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

Best Practices-System Level

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 Define documentation requirements

Best Practices-Ambulatory

Lockbox for medications Involve family member Offer/provide opportunities for disposal Consider household Narcan availability Arrange for transitional responsibility

between healthcare settings Background checks???

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

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 Recommending for doses >90 MME

Is there a solution? Education of Healthcare Providers to not be

inadvertent source of drugs Rigorous monitoring of Patients Mandatory National Rx monitoring Communication With Law Enforcement ?? Protection from Regulatory bodies if

Providers Using Guidelines ?? Mandatory CME/Education?? Aggressive Work to Reduce Drug Abuse