Opioid Management Ashok Kumar MD FACP Associate Professor Dept of Internal Medicine Sanford Medical School UNDERSTAND THE EXTENT OF UNINTENTIONAL EXCESSIVE USE OF OPIOIDS IN OUR PRACTICE AND ABUSE BY ID: 768456
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Opioid Management Ashok Kumar MD FACP. Associate Professor Dept of Internal Medicine Sanford Medical School
UNDERSTAND THE EXTENT OF UNINTENTIONAL EXCESSIVE USE OF OPIOIDS IN OUR PRACTICE AND ABUSE BY PATIENTS Analyze the risk versus benefit of high dose opioid use in chronic non-cancer pain (CNCP) Discuss implementation of an opioid surveillance program targeted at patients currently receiving high dose opioidsLEARN SAFE UTILIZATION OF OPIOIDS IN PAIN MANAGEMENT PRESENTATION OBJECTIVE
TREATMENT GOAL Reduce abuse and overdose of opioids and other controlled prescription drugs while ensuring patients with pain are safely and effectively treated .
22,134 prescription drug overdose deaths in 2010Opioid analgesics75% of Rx overdose deaths (16,651) 76% increase in opioid overdose deaths than in 1999 (4,030 deaths) Other medication classes highly associated with overdose deathsBenzodiazepines Antidepressants Antipsychotics2012 CDC Update
Develop and Test Prevention Strategies Identify Risk and Protective Factors Define the Problem Ensure Widespread Adoption The Public Health Approach to Prevention
Rates of Opioid Overdose Deaths, Sales, and Treatment Admissions, United States, 1999–2010 CDC. MMWR 2011 . http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60e1101a1.htm?s_cid=mm60e1101a1_w . U pdated with 2009 mortality and 2010 treatment admission data.
National DataNearly 15,000 people die yearly from Rx opioid overdoses Deaths now outnumber motor vehicle accidents Deaths outnumber combined deaths from heroin plus cocaineEnough opioid analgesics were prescribed in 2010 to treat every adult around the clock for 1 month in the U.S. The excessive use of opioid analgesics has now been labeled an “epidemic” Background, Relevance, & Importance CDC. Vital Signs. Novermber 2011. Available from: http://www.cdc.gov/vitalsigns
Motor Vehicle Traffic, Poisoning, and Drug Poisoning (Overdose) Death Rates United States, 1980–2010 NCHS Data Brief, December, 2011. Updated with 2009 and 2010 mortality data.
Deaths Related to Drug Overdoses CDC. Vital Signs. November 2011. Available from: http://www.cdc.gov/vitalsigns
Opioid Prescriptions Dispensed by Retail Pharmacies—United States, 1991–2011 IMS Vector One. From “Prescription Drug Abuse: It’s Not what the doctor ordered.” Nora Volkow National Prescription Drug Abuse Summit, April 2012. Available at http://www.slideshare.net/OPUNITE/nora-volkow-final-edits .
2012 MOST RX PRESCRIPTIONS QUANTITYQUANITIY/RX Hydrocodone/APAP 295,073 16,675,025 57 Zolpidem 102,625 3,293,422 32 Lorazepam 86,333 4,083,256 47 Clonazepam 74,990 4,625,870 62Alprazolam58,837 3,417,89558Methylphenidate50,9642,297,92245Amphetamine 46,5472,075,44145Oxycodone/APAP 44,966 2,753,41161Oxycodone42,852 3,533,26482APAP/Codeine 37,5271,439,87240 TOP 10 CONTROLLED SUBSTANCES IN SD BY NUMBER OF DOSES DISPENSED : 2012
Trends for Drug Use and Death CDC. Vital Signs. November 2011. Available from: http://www.cdc.gov/vitalsigns . Goodman, F. THE TALK. Opioid Trial Exit Strategy. VA PBM December 18,2012.
DEATHS FROM UNINTENTIONAL OVER DOSEOF MEDICATIONS ARE INCREASING OVER THE YEARS PROBLEM
Develop and Test Prevention Strategies Identify Risk and Protective Factors Define the Problem Ensure Widespread Adoption The Public Health Approach to Prevention
High Risk Populations People taking high daily doses of opioids People who “doctor shop” People using multiple abusable substances like opioids, benzodiazepines, other CNS depressants, illicit drugs Low-income people and those living in rural areas Medicaid populations People with substance abuse or other mental health issues White AG, Birnbaum HG, Schiller M, Tang J, Katz NP. Analytic models to identify patients at risk for prescription opioid abuse. Am J Managed Care 2009;15(12):897-906. Hall AJ, Logan JE, Toblin RL, Kaplan JA, Kraner JC, Bixler D, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA 2008;300(22):2613-20. Paulozzi LJ, Logan JE, Hall AJ, et al. A comparison of drug overdose deaths involving methadone and other opioid analgesics in West Virginia. Addiction 2009;104(9):1541-8. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152(2):85-92. Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305(13):1315-1321.
Middle-aged adultsMen: higher riskPeople living in rural areas Twice as likely to overdose on Rx painkillers Whites and Native AmericansMost likely ethnicities to overdose1 in 10 Native Americans report using opioid analgesics for nonmedical purposes in 2010Large percentage of VA Black Hills patientsPatient Population Most at Risk CDC. Vital Signs. November 2011. Available from: http://www.cdc.gov/vitalsigns
WHEN DOES THE RISK OUTWAY BENEFIT?
Three studies have assessed dose cutoffs for safetyBohnert et al. Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths. 2011 Dunn et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010 Gomes et al. Opioid Dose and Drug-Related Mortality in Patients With Nonmalignant Pain. Arch Intern Med. 2011
High Opioid Dose and Overdose Ris k Dunn et al. Opioid prescriptions for chronic pain and overdose. Ann Int Med 2010;152:85-92. 1.00 1.19 3.11 11.18 * Overdose defined as death, hospitalization, unconsciousness, or respiratory failure.
Doses over 50 mg ME dailyIncreased risk for overdose or death Doses over 100 mg ME Further elevation in risk of overdose or deathDoses above 100 mg ME daily where risk elevates the most?Doses greater than 200 mg ME daily provide the most riskUnknown what dose above 200 infers highest riskRisk of death and overdose-related adverse events is highly associated with total daily dose Summary of Study Safety Information Bohnert et al. Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths. 2011 Dunn et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010 Gomes et al. Opioid Dose and Drug-Related Mortality in Patients With Nonmalignant Pain. Arch Intern Med. 2011
The Public Health Approach to Prevention Develop and Test Prevention Strategies Identify Risk and Protective Factors Define the Problem Ensure Widespread Adoption
BLACK HILLS VA INITIATIVE
VA Black HillsHighest utilizer of oxycodone SA in VISN 23 2 nd highest utilizer of long-acting opioids in VISN 23VISN 23 4th highest user of oxycodone SAAugust 2012 VA Black Hills dispensing numbers (for perspective)136,128 opioid analgesic tablets dispensed Does not include: Any codeine formulation Cough syrup Fentanyl patches 77,000 tablets containing oxycodone 6500 tablets of oxycodone SA VA Black Hills Specific Information
HEALTH CARE l Defining EXCELLENCE in the 21 st Century BHVAPD Drugs 2012
Opioid Analgesic Dosing: What is high dose?
Focus on patients receiving oxycodone SA Convert to alternative analgesics as appropriateEliminate new prescribing of oxycodone SA It is a nonformulary agent Utilize other analgesics Focus on patients receiving greater than 200mg ME daily Dose reduction to less than or equal to 200 mg ME daily 30 Identified as Next Steps by VISN CMO
Minneapolis VA200 mg ME dailyBelieved that other VAs have gone to this cutoff as well Orlando VA Currently seeking P&T for approval of 200 mg ME daily cutoffState of Washington120 mg ME daily For doses over 120 mg ME daily, Patient mustDemonstrate improved function orSeek pain consultation What Cutoffs Have Others Used?
VA DIRECTOR SENT A LETTER TO ALL PATINTS ABOUT THE ISSUE OF OPIOD USE IN THE VA FOR CHRONIC PAIN , AND THE ASSOCIATED INCREASED RISKS INCLUDING DEATHPOSTERS AT VA ENTERANCE AND AT PATIENT WAITING AREASPROVIDER EDUCATIONELECTRONIC TEMPLATE CREATED FOR DOSE REDUCTION PROCESS IMPLEMENTED
Chart review assessed patients receiving oxycodone SAExcluded patients with active cancer Chart review assessed patients receiving ≥ 200 mg ME daily Excluded patients with active cancer Provided education regarding safetyHigh dose opioid analgesic use for CNCPOpioid analgesic tapering and oxycodone SA conversions Current Processes
Random decrease in dose without patient education at a face to face encounter STRATEGIES THAT WAS NOT EFFECTIVE
Prescription Drug Monitoring Programs (PDMPs) Operational in 42 states Focus PDMPs on Patients at highest risk of abuse and overdose Prescribers who clearly deviate from accepted medical practice Implement PDMP best practices
CAUTION FEDERAL PRACTIONERS CAN GET DATTA ON PRESCRIPTIOS FROM PRIVATE SECTOR BUT NOT THE OTHER WAY AROUND PRACTIONERS CAN CALL VA TO GET PRESCRIPTION INFORMATION ON VA PATIENTS.
Patient Review and Restriction Programs (aka “Lock-In” Programs) Applies to patients with inappropriate use of controlled substances 1 prescriber and 1 pharmacy for controlled substances Improve coordination of care and ensure appropriate access for patients at high risk for overdose Evaluations show cost savings as well as reductions in ED visits and numbers of providers and pharmacies
Appropriate uses of pain medication Risk/benefit framework Screening toolsEpidemiology of prescription drug abuseExpectations of opioid treatment Universal precautions approach Treatment agreements Signs of possible abuse vs. under-treatment of pain Discontinuing treatment/proper disposal Safe Prescribing for Pain
Clinical Guidelines Improve prescribing and treatment Basis for standard of accepted medical practice for purposes of licensure board actions Several consensus guidelines available Common themes among guidelines
Adverse events and death associated with opioid analgesic use have increased substantially over the past 20 years Risk of opioid-related adverse events increases with dose Doses greater than 50 mg ME daily show elevated riskHighest risk appears to be in those on more than 200 mg ME daily Risk stratify your patient population on opioids Implement a structured stepwise program to reduce dose in patients on high dose Conclusion