A Brief History of the Opioid CrisisP h i l l i p C o f f i n , M D M I A FA C P F I D S A
S a n F r a n c i s c o D e p a r t m e n t o f P u b l i c H e a l t h
U n i v e r s i t y o f C a l i f o r n i a S a n F r a n c i s c o
U.S. Opioid Overdose Deaths 2000-2016
www.cdc.gov/drugoverdose/data/analysis.htmlBeginnings of Opioid Stewardship
Social Security Disability Beneficiaries
Welfare reform
1990s Healthcare Reform: HMO Coverage
U.S. Opioid Prescribing Trends
Pezala, J Pain Res. 2017
Oxycontin
Dilaudid/ Duragesic
Kadian
Norco
Atiq
HMO enrollment >80 million
Welfare reform
State law/boards
liberalize opioids for
chronic pain
JCAHO 5th Vital Sign
Fentora
Subsys
Abstral
Roxicodone
Embeda
Exalgo
Acurox
generic morphines
Palladone
Avinza
generic fentanyllozengegeneric
oxycodones
Opana
Opana ER
Dilaudid(lower dose)
Onsolis
Lazanda
Oxecta Zohydro
Hysingla
generic oxymorphone Targiniq
CDC reports rising Rx deaths
Policy and practice changes to reduce OA prescribing begin
19951990
generic hydrocodone
Shift from manufacturing
to service economy
The 7 OxyContin “Poster Children”: 15 Years Later
Helped with pain
(2 still using)
Died of likely overdose
Died of complications
related to OUD
Struggled with addiction
🎼🎼 Get in the
Swing of OxyContin
🎵🎵
Pop. W Untreated Pain
(Phys/Psych)
Pop. in Alternative Treatment
Pop. Using Rx Opioids
Pop. Misusing Rx Opioids
Pop. Misusing Non-Rx Opioids
Pop. Dying From Opioid
Overdose
Pop. in Treatment
Pop. in Recovery
Adapted from Georgia Health Policy Center & Pontifex Consulting, 2017
Opioid Stewardship Objectives and Goal
Reduce Supply
Reduce Diversion
Improve Safety
Reduce Harms
Opioid Stewardship and Chronic Pain. A Guide for Primary Care Providers.
Patients in Pain
Patients with Opioid Use Disorders
• An HIV+ man is transferred to your service.• He has generalized body pain that was treated with fentanyl patch
150mcg and morphine ER 100mg BID with oxycodone 60mg QID for breakthrough pain.
• He was also on lorazepam, alprazolam, aripiprazole, bupropion, and fluoxetine.
• He is also in a methadone program for opioid use disorder.• He requested a change of provider because he wanted
hydromorphone. • No Utox is available and his VL is always suppressed.
Preliminary results of Transitions analysis (N=200):opioid dose change and use of opioid analgesics not as prescribed
0.65 (0.35 – 1.20)
0.76 (0.44 – 1.33)
2.51 (1.18 – 5.36)*
Reference Level: No Change in Opioid Dose *p<0.05
% of injections resulting in (non-fatal) OD at Sydney injection facility, by opioid type
0%
1%
2%
3%
4%
5%
Rx opioid Heroin Fentanyl
Latimer. Intl J Drug Policy. 2016
Naloxone
Patients with Personal and Environmental Trauma• 46yo woman with chronic lower back treated for past 20 years with
escalating doses of opioids• Currently taking long-acting morphine sulfate 100mg twice daily, with short-
active morphine sulfate 30mg three times daily as needed for breakthrough pain. She also receives lorazepam 0.5mg twice daily.
• She lives in public housing, has been threatened with eviction, has been incarcerated twice, has lost two children to child protective services, and has not followed up with referrals to physical therapy because it takes 45 minutes to get there, visits last only 10 minutes, and she has no space to do the exercises.
• Her twice annual urine toxicology consistently demonstrates morphine and cocaine. She’s never had an opioid overdose.
Opioids and the Pain of Life
I’ll die young, but it’s like kissing God
-Lenny Bruce
I stood at a distance, and aloof from the uproar of life.
-Confessions of an Opium Eater
… poverty, lack of opportunity, and substandard living and working conditions
…-Dasgupta etal., AJPH 2018
Take it
s l o w
Shared Opioids: An HIV Analogy
Safe Sex
Sero-concordant
Protected
Risky Sex
Sero-unknown or discordant
Unprotected
Two Approaches to Opioid Stewardship
Aggressive(the same way we expanded opioid prescribing)
Changes in prescribing based on fear and excessive workload
Rapid reduction or discontinuation of opioid prescribing
Patient abandonment
Providers abort plans to provide addiction care
Cautious
Evidence-based changes
Slow, patient-centered changes
Expansion of non-medication pain management
Emphasis on maintaining patients in care
Use of OUD medications
Phillip O. Coffin MD, MIA, FACP, FIDSA
San Francisco Department of Public HealthUniversity of California San Francisco