Transcript Slide 1

Ashok Kumar MD FACP.
Associate Professor
Dept of Internal Medicine
Sanford Medical School
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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 opioids
LEARN SAFE UTILIZATION OF OPIOIDS IN PAIN
MANAGEMENT
 Reduce
abuse and overdose of opioids and
other controlled prescription drugs while
ensuring patients with pain are safely and
effectively treated.
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22,134 prescription drug overdose deaths in
2010
◦ Opioid analgesics
 75% 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 deaths
 Benzodiazepines
 Antidepressants
 Antipsychotics
The Public Health Approach to
Prevention
Ensure
Widespread
Adoption
Develop
and Test
Prevention
Strategies
Identify Risk
and Protective
Factors
Define the
Problem
Opioid Sales KG/10,000
Opioid Deaths/100,000
Opioid Treatment Admissions/10,000
8
7
6
Rate
5
4
3
2
1
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Year
CDC. MMWR 2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60e1101a1.htm?s_cid=mm60e1101a1_w. Updated with
2009 mortality and 2010 treatment admission data.
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National Data
◦ Nearly 15,000 people die yearly from Rx opioid
overdoses
 Deaths now outnumber motor vehicle accidents
 Deaths outnumber combined deaths from heroin plus
cocaine
◦ Enough 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”
CDC. Vital Signs. Novermber 2011. Available from: http://www.cdc.gov/vitalsigns
Motor Vehicle Traffic
Poisoning
Drug Poisoning (Overdose)
Deaths per 100,000 population
25
20
15
10
5
0
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
Year
NCHS Data Brief, December, 2011. Updated with 2009 and 2010 mortality data.
2000
2002
2004
2006
2008
2010
250
219
210
Number of Prescriptions (in millions)
201
200
202
192
180
169
150
139
144
151
158
131
120
109
100
76
78
80
86
91
96
100
50
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year
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
QUANTITY
QUANITIY/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
62
Alprazolam
58,837
3,417,895
58
Methylphenidate
50,964
2,297,922
45
Amphetamine
46,547
2,075,441
45
Oxycodone/APAP
44,966
2,753,411
61
Oxycodone
42,852
3,533,264
82
APAP/Codeine
37,527
1,439,872
40
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.
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DEATHS FROM UNINTENTIONAL OVER DOSE
OF MEDICATIONS ARE INCREASING OVER THE
YEARS
The Public Health Approach
to Prevention
Ensure
Widespread
Adoption
Develop
and Test
Prevention
Strategies
Identify Risk
and Protective
Factors
Define the
Problem
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
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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.
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Middle-aged adults
◦ Men: higher risk
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People living in rural areas
◦ Twice as likely to overdose on Rx painkillers
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Whites and Native Americans
◦ Most likely ethnicities to overdose
 1 in 10 Native Americans report using opioid
analgesics for nonmedical purposes in 2010
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Large percentage of VA Black Hills patients
CDC. Vital Signs. November 2011. Available from: http://www.cdc.gov/vitalsigns
WHEN DOES THE RISK
OUTWAY BENEFIT?
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Three studies have assessed dose cutoffs for
safety
◦ 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
12
11.18
Adjusted Hazard Ratio
10
8
6
4
2
3.11
1.00
1.19
0
1 - 19 mg/d
20 - 49 mg/d
50 - 99 mg/d
≥100 mg/d
Morphine MG Equivalent Dose
* Overdose defined as death, hospitalization, unconsciousness, or respiratory failure.
Dunn et al. Opioid prescriptions for chronic pain and overdose. Ann Int Med 2010;152:85-92.
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Doses over 50 mg ME daily
◦ Increased risk for overdose or death
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Doses over 100 mg ME
◦ Further elevation in risk of overdose or death
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Doses above 100 mg ME daily where risk
elevates the most?
◦ Doses greater than 200 mg ME daily provide the
most risk
◦ Unknown what dose above 200 infers highest risk
Risk of death and overdose-related adverse events
is highly associated with total daily dose
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
Ensure
Widespread
Adoption
Develop
and Test
Prevention
Strategies
Identify Risk
and Protective
Factors
Define the
Problem
BLACK HILLS VA INITIATIVE
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VA Black Hills
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VISN 23
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August 2012 VA Black Hills dispensing numbers
◦ Highest utilizer of oxycodone SA in VISN 23
◦ 2nd highest utilizer of long-acting opioids in VISN 23
◦ 4th highest user of oxycodone SA
(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
40
Number of Patients
35
35
Jan-13
32
30
Apr-13
25
20
Morphine Equivalents
15
12 11
10
5
3
4
1
3
2
2
0
200-400
400-600
601-800
801-1000
1001 or more
BHVAPD
Drugs 2012
HEALTH CARE l Defining EXCELLENCE in the 21st Century
Traffic
Traffic
Stop
Traffic
Welfare
Staff
Vandalism,
UOR-ROS,
Robbery,
Ticket
&Theft,
UOR,
Ticket
Accidents,
Question,
Assist,
Check,
USDCVN,
00CVN,
000 000 0
Contraband-Sales,
Manufacturing, 7
Larceny-Theft;Actual Drug
Theft-Controled Substance, 12
Contraband-Drug
Possession, 3
Forgery-Counterfeiting, 1
Fraud, 2
Patient Assist, 0
Non-Criminal-Staff Assist, 6
Information Joint
Lawenforcement Investigation,
1
Non-Criminal-Information, 10
Non-Criminal-Joint Law
Officer Assist, 1
American
Pain Society
American
Society of
Interventional
Pain
Physicians
VA/DoD
Guidelines
Canadian
Pain
Guidelines
High dose:
200 mg
morphine
equivalents
(ME) daily
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Focus on patients receiving oxycodone SA
◦ Convert to alternative analgesics as
appropriate
Eliminate 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
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Minneapolis VA
◦ 200 mg ME daily
◦ Believed that other VAs have gone to this cutoff as well
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Orlando VA
◦ Currently seeking P&T for approval of 200 mg ME daily
cutoff
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State of Washington
◦ 120 mg ME daily
 For doses over 120 mg ME daily, Patient must
 Demonstrate improved function
or
 Seek pain consultation
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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 DEATH
POSTERS AT VA ENTERANCE AND AT PATIENT
WAITING AREAS
PROVIDER EDUCATION
ELECTRONIC TEMPLATE CREATED FOR DOSE
REDUCTION
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Chart review assessed patients receiving
oxycodone SA
◦ Excluded patients with active cancer
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Chart review assessed patients receiving ≥
200 mg ME daily
◦ Excluded patients with active cancer
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Provided education regarding safety
◦ High dose opioid analgesic use for CNCP
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Opioid analgesic tapering and oxycodone SA
conversions
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Random decrease in dose without patient
education at a face to face encounter
Operational in 42
states
 Focus PDMPs on
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 Patients at highest
risk of abuse and
overdose
 Prescribers who
clearly deviate from
accepted medical
practice
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Implement PDMP
best practices
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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.
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
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Appropriate uses of
pain medication
 Risk/benefit
framework
 Screening tools
 Epidemiology of
prescription drug
abuse
 Expectations of opioid
treatment
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Universal precautions
approach
 Treatment
agreements
 Signs of possible
abuse vs. undertreatment of pain
 Discontinuing
treatment/proper
disposal
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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
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Adverse events and death associated with opioid analgesic
use have increased substantially over the past 20 years
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Risk of opioid-related adverse events increases with dose
◦ Doses greater than 50 mg ME daily show elevated risk
◦ Highest 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