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Bay Area Prescription Drug Abuse Summit:Pharmacist Perspective

Lori Reisner, Pharm.D.Health Sciences Professor of Clinical PharmacyUniversity of California Medical Center, San FranciscoMay 7, 2014

Opioid use in primary care: 300% increase in opioid analgesic prescriptions between

1999 -2010 Painkiller overdose deaths among women increased 5-

fold and 3.6 times among men increased Similar increases occurred in opioid-related ED visits

and hospitalizations Mean annual direct health care costs for patients who

abuse opioids are 8.7-times higher than for non-abusers Chronic pain may be present in up 20-50% of primary care

physicians’ patients, and opioids are an essential component of their armamentarium

Regulatory responsibilities and scrutiny of opioid prescribing are increasing

Background

CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008. MMWR 2011; 60: 1-6

Prescription drug-related deaths now outnumber those from illicit substances

CDC reported 14,800 deaths from opiate overdose in 2008

Sedative combinations contribute to a significant percentage of deaths Benzodiazepines Non-benzodiazepine sedatives (e.g., carisoprodol,

zolpidem) Alcohol and other sedatives

Background

CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008. MMWR 2011; 60: 1-6

Overdose rates by state

rate, Nebraska.4

Drug Overdose Rates by State, 20084

 

209 drug-related deaths, up from 41 the year prior Oxycodone was detected in 53 of the total

25 percent of accidental drug-related deaths in San Francisco involved oxycodone

Dr. Nikolas Lemos, chief forensic toxicologist at the Office of the San Francisco Medical Examiner, quoted by SF Weekly

Contrast with 29 deaths due to motor vehicle accidents during that period

San Francisco 2009 and 2010

Underlying comorbidities Sleep apnea/respiratory disease Cardiovascular diseases Obesity/metabolic diseases

Reimbursement systems Less face-to-face patient time More reliance on medications/prescribing options Limited options (insurance restrictions)

HCAHPS Scores Reimbursement determined by percentiles

Reliance on pain scores may pressure prescribers to use more opioids

Prescriber Education Lack of knowledge about non-opioid options

Inadequate trial periods/Inadequate dosing Drug-drug interactions Pharmacokinetics: Frequency of long-acting meds/Dose adjustments

Regulatory Intensifying scrutiny of less offensive agents, e.g., tramadol

Influences on Morbidity/Mortality

Retail Pharmacist have little experience with appropriate pain regimens

May lack information regarding combination therapies (multiple prescribers/pharmacies)

Fear of challenging physician prescribing Cannot reliably confirm misuse/abuse or counterfeits

Integrating non-pharmacological interventions and modalities

Prescribers subscribing to “harm reduction” philosophies

Developing safer medications: abuse-limiting modifications

Challenges

Example Multimodal RegimenUCSF Arthroplasty (Joint replacement) Service:

Acetaminophen 1000 mg PO Q6H Celecoxib 200 mg PO BID* Gabapentin 300 mg PO TID* Oxycodone 10 mg PO Q4H PRN moderate

pain Morphine 2 mg IV Q2H PRN severe pain Epidural catheter w/ ropivacaine &

fentanyl +/- peripheral nerve infusion (local

anesthetic)

*may be omitted or dose-adjusted depending on comorbidities or meds prior to admission

Improved Prescriber Education Limited utility and persistence Mandated curriculum? Mandated re-certification? Prescription pattern audits (Controlled Substance

Utilization Review and Evaluation System, CURES) Development of Pain Management Specialist/Consultant

Certification across Professional Domains Will require accepted certification/accreditation standards

Pharmacist Empowerment Retail, hospital and ambulatory practices

Patient Education Balancing portrayal in popular media, e.g., television Instruction in proper use and risks

Reimbursement: adequate for appropriate patient care

Recommendations