Lessons Learned from Drug Court

JUDGE DAVID T. MATIACUYAHOGA COURT OF COMMON PLEAS

Who is behind this crisis?

Not necessarily these guys

Well, maybe after these folks work their “magic”

The Scope of the Problem

7

1997 Ohio Per Capita Dosage: 7 Pills

2010 Ohio Per Capita Dosage: 67 Pills

First In State2010 Jackson County: 130

Pills per cap. Scioto 2nd place: 123 per cap.

2010 Holmes County: 18 Pills per cap.

Even the Amish Ache!

2010 Cuyahoga County51 pills per person

13

2010 Enough prescription pain medication was prescribed to medicate every adult American around the clock for 1 month!

AddictionPrior to 2011 Boscarino study rates of addicition assiciated with prescription opiod therapy were believed to be 2-18%.July 2011 study assessed rates of opioid abuse/dependence using both DSM-IV and proposed DSM-V criteria in CNCP:

Credits to Dr. Binit Shah at UHHS.

Boscarino JA, Rukstalis MR, Hoffman SN. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. Jour of Add Dis 2011;30:185-94.

35%!!!!!

Are Opiods worth it?34% of the patients treating with opioids used illegal drugs in addition to those prescribed.1

Only 15% of the chronic pain patients who were not treated with opioids used illegal drugs.

1. Christo PJ, Manchikanti L, Ruan X, et al. Urine drug testing in chronic pain. Pain Phys

2011;14:123-43 2 Wong WS, Chen PP, Yap J, et al. Chronic pain and psychiatric morbidity: a

comparison between patients attending specialist orthopedics clinic and multidisciplinary pain clinic. Pain Med 2011;12:426-59.

Well, at least they work…In a large epidemiologic study in Denmark, chronic pain patients using opioids had worse pain, higher health care utilization and lower activity levels than matched chronic pain patients not using opioids.1

Opioid use may go against important principles of chronic pain management including increased self-efficacy, reduced reliance on the health care system, reinforcement of pain behavior, and passivity and loss of autonomy by externalization of the locus of control.2

Credits to Dr. Binit Shah at UHHS.

1. Eriksen J, Sjogren P, Bruera E, et al. Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain 2006;125:172-9. 2. Large RG, Schug Sa. Opioids for chronic pain of non-

malignant origin- caring or crippling? Health Care Anal 1995;3:5-11.

…or maybe not.A systematic review of randomized trials for multiple opioids utilized for managing various chronic pain conditions, showed fair evidence for tramadol in managing osteoarthritis. For all other conditions and all other drugs excluding tramadol, the evidence was poor based on either weak positive evidence or indeterminate or negative evidence.

Credits to Dr. Binit Shah at UHHS.

Manchikanti L, Ailinani H, Koyyalagunta D, et al. A systematic review of randomized trials of long-term opioid management for chronic non-cancer pain. Pain Phys 2011;14:91-121.

Progress in the fight against addiction! Pill Mills are on the decline.

2007 10 pill mills in Scioto County alone2011 1 pill mill (Thank you House Bill 93).

Progress in the fight against addiction!

UNIVERSITY HOSPITALS HEALTH SYSTEM’S GUIDELINES REGARDING THE PRESCRIBING OF OPIOIDS FOR CHRONIC

INTRACTABLE NON-CANCER PAIN

Chronic Intractable Pain is a challenging problem faced by the practicing physician. It is a common presenting complaint in the outpatient setting. The treatment of this condition is complex and nuanced, but for some patients, after a thorough evaluation has been completed and after numerous alternate treatments have been considered or attempted, opioid therapy may be a consideration.  

It is well known that there are substantial risks associated with the treatment of chronic pain with opioids, including but not limited to, tolerance, physical dependence, psychological dependence, addiction, opioid-induced hyperalgesia and death. There is also a risk of diversion that may complicate this form of treatment. University Hospitals (“UH”) wishes to mitigate the treatment risks and professional risks of its physicians associated with the prescribing of opiods for the treatment of chronic non-cancer pain. After extensive review and discussion, UH is recommending the following set of guidelines for its physicians to follow when the treatment of chronic intractable non-cancer pain with opioids is undertaken. 1. Prior to considering any prescription of opioids for a chronic non-cancer pain condition, such as low back pain, a referral to a pain medicine specialist should be sought to evaluate for other treatment options besides opioids. Chronic opioid therapy should be considered only after exhausting other non-opioid options.

What is Drug Court?

Specialized DocketWhat is a “specialized” docket?

Specialized Docket

Extra resources to handle a common reoccurring issue.

Extra

•JUDICIAL ATTENTION•SUPERVISION•TREATMENT OF SUFFICIENT DURATION

Drug Court History•1996 Common Pleas Judges reject drug court funds.•Cleveland Municipal Court (Judge Larry Jones) starts county’s first drug court.•2008 Judge Jones leaves for Court of Appeals.•2008 Common Pleas Judges vote to take over Drug Court•May 2009 Common Pleas admits first defendant to Drug Court.

Drug Court – The Numbers

254 Admitted100 Graduates

47 Terminations5 Deaths

The GraduatesNo future cases.G.E.D.Get jobs, pay taxes. Less gov’t aid to dependants.Raise their children.

The Targets•Prefer 2nd time offenders.•No violent or sex offenders.•Dependants, not abusers.•Those likely to be back without intervention.

Who is in Drug Court?

•60% Opiate dependant

•Over half of those opiate dependant started by treating a medical condition.

•Treating a public health issue under a criminal justice umbrella!

Dependency is a disease!ONE OF THE MOST EXPENSIVE

$$$$ Spent to treat symptoms

$ Spent to treat the disease.

THROW AWAY YOUR PILLS!

Lessons learned

1. Dependency is a disease.2. It’s really, really expensive.3. It’s a big believer in diversity.4. Too much spent treating symptoms and too little

spent treating the disease.5. Medical profession is an unwitting partner.

The End