the opioid epidemic: it’s€¦ · surgeon generals report on alcohol, drugs and health (2016) –...

David Hasleton, MDAssociate Chief Medical Officer

Intermountain Healthcare

The Opioid Epidemic: It’s Time to Act

Integrated Pain SymposiumIntermountain Park City Hospital

The Opioid Epidemic

“Narcotic drug addiction is one of the gravest and most important questions confronting the medical profession today.”

Editorial Comment, American Medicine, 21 (O.S.), 10 (N.S.) (November 1915): 799-800.

The Opioid Epidemic: It’s Time to Act

Objectives:

1) Acquire a foundational knowledge of the opioid epidemic

2) Develop the ability to converse with patients regarding pros and cons of opioids for acute pain

3) Critique personal opioid prescribing habits for acute pain

Opioid Crisis: A Call to Action

Surgeon General’s Report on Alcohol, Drugs and Health (2016) –

“I am issuing a new call to action to end the public health crisis of addiction.”

Vivek H. Murthy, M.D., M.B.A.Vice Admiral, U.S. Public Health Service

Surgeon General

Historical Perspective

The War Against Opioid Misuse

Opium: The Foundation

Opiates: Derived from the opium poppy

• Scientific Name: Papaver somniferum

• Somniferum: Latin for “inducing sleep”

• Morphine: most active substance in opiumoNamed after the Greek god of dreams

Morpheus

The Portland Experience

Cold water shower / bath to pull victim out of heroin OD

Naloxone (Narcan) reversal agent used, ½ life 30 – 120 mins (depends on route of administration)

Patient leaves against medical advice

Time Line: Morphine

Active narcotic ingredient in opium

• 1804: first isolated from opium

• Used in Civil War

• Thousands of addicted soldiers

Time Line

1804 Morphine distilled from opium

1839 First Opium War – British take Hong Kong, opium in China

1857 Second Opium War

1898 Bayer Company uses diacetylmorphine (heroin)

1914 U.S. Congress passes Harrison Narcotics Tax Act

1935 U.S. Narcotic Farm opens (prison vs. hospital)

Time Line

1980: NEJM publishes Porter and Jick letter to the editor

• 11,882 hospitalized patients evaluated who received narcotics

• 4 patients became addicted

• Conclusion: “ . . . despite widespread use of narcotics in hospitals, the development of addiction is rare in medical patients with no history of addition.”

Time Line: Letter to the Editor

NEJM, June 1, 2017, A 1980 Letter on the Risk of Opioid Addiction

• 608 citations

• increased amount of citations after 1995 (introduction of Oxycontin)

• 439 (72%) authors cited as evidence that addition is rare

• 491 (81%) did not note these were hospitalized patients

• Less affirmational studies in recent years

Oxycontin

Time Line: Porter and Jick letter

“For reasons of public health, readers should be aware that this letter has been ‘heavily and uncritically’ cited as evidence that addition is rare with opioid therapy.”

-- NEJM editor’s note

Time Line

1980s: First Xalisco migrants set up heroin business in California

1984: MS Contin marketed to cancer patients

1986: Portenoy and Foley paper in journal Pain

1996: Oxycontin released for chronic-pain patients

1996: American Pain Society – pain is 5th vital sign

1999: JCAHO adopts pain as 5th vital sign

Time Line

2007: Big Pharma and execs plead guilty to false claims of narcotics

2014: FDA approves Zohydro (extended-release hydrocodone)

Questionable Practices

Current State of Crisis

Opioid Crisis: General Data

Since 1999, the number of overdose deaths from opioids has quadrupled.

91 Americans die each day from an opioid overdose

Medicaid patients are prescribed a higher rate of opioids than privately insured patients.

CDC, 2017 Annual Surveillance Report of Drug-Related Risks and Outcomes

Opioid Crisis: General Data

2016 66.5 opioid prescriptions per 100 Americans

2015 47.7 million people in US ages 12 and over used illicit drugs / misused prescription drugs (17.8 / 100 persons)

-- 12.5 million prescription pain relievers (4.7 / 100 persons)

-- 2.2 million initiated use of prescription pain relievers


Opioid Crisis: Hospitalizations

260k for nonfatal, unintentional drug poisoning

53k (20.4%) for opioid poisoning

12k (21.7%) related to heroin of total opioids


Opioid Crisis: ED Visits

418k for nonfatal, unintentional drug poisoning

92k (22%) for opioids

54k (59%) related to heroin

CDC, 2017 Annual Surveillance Report

of Drug-Related Risks and Outcomes

Opioid Crisis: US Drug Overdose Mortality

52,404 overdose deaths in 2015

-- 84% unintentional

-- 33,091 (63%) were from opioids

-- 12,989 of all opioid deaths from heroin

-- 15,281 from prescription opioids


Utah Perspective

Opioid Crisis

KSL.com, Nov 28, 2017, Fentanyl-related deaths in Utah up nearly 80%

Opioid Crisis: Utah Perspective 2014 Data

States with highest rates of death (per 100,000) due to drug overdose:1) West Virginia (35.5) – 627 deaths2) New Mexico (27.3)3) New Hampshire (26.2)4) Kentucky (24.7)5) Ohio (24.6)7) Utah (22.4) – 603 deaths

Source: CDC/NCHS, National Vital Statistics System, Mortality

Opioid Crisis: Utah Perspective2015 Data

States with highest rates of death (per 100,000) due to drug overdose:1) West Virginia (41.5) – 725 deaths2) New Hampshire (34.3)3) Kentucky (29.9)4) Ohio (29.9)5) Rhode Island (28.2)9) Utah (23.4) – 646 deaths

Source: CDC/NCHS, National Vital Statistics System, Mortality

Opioid Crisis: Utah Perspective

2012: 21 adults die of prescription overdose each month

Prescription pain killers caused more deaths than all other drug categories, including heroine and cocaine combined

Top three pain medications contributing to death:

1) oxycodone

2) methadone

3) hydrocodoneUtah Department of Health, Indicator-Based Information System for Public Health Web site: http://ibis.health.utah.gov

Clinician Perspective

Opioid Crisis

Clinician Perspective: Patient #1

HPI: 32 yo male presents to the ED with acute on chronic LBP

Acute pain started 2 weeks ago while jumping on trampoline

No complaints of numbness / weakness

PHx: History of LBP for 2 years


SHx: Presents with his wife

Works at Subway sandwich shop

Frequent visits for pain relief to four different EDs

Uninsured and no primary care doctor


PE: nl vital signs

nl neuro exam

nl musculoskeletal exam

no “red flag” signs / symptoms


Discussion:

Plain film indicated

MRI not indicated

Non-narcotic pain medications will be used

Need to f/u with physical therapy

Could take several weeks to recover

Clinician Perspective: Patient #2

HPI: 42 yo female with rght leg pain, 8 days s/p ankle surgery

c/o right calf pain, worried about blood clot

has been on oxycodone post-op

PHx: some form of chronic pain, including ankle pain

chronic, intermittent migraine headaches

on “intermittent” opioids


PE: post-op splint removed from leg

Tender leg diffusely

No obvious infectious component

Eval: U/S shows small DVT below the knee

No surgical complication


Disposition:

pt states almost out of pain medications

has 3 pills left

pt given script for Percocet

Pharmacist calls me

3 days prior received Percocet 10mg tabs #60

Husband of patient returns to ER upset

Personal Experiences

Personal threats

-- called the chairman of dept to have me fired

-- called in a death threat against me and family

-- went to media

-- Followed home

-- police escort off hospital property

Next Steps

Opioid Crisis

Opioid Crisis: Next Steps

1) Provider education

2) Decrease number of tablets prescribed

3) Work with state agencies to better detect trends

4) Multi-disciplinary approach: team-based effort


5) Expand use of Naloxone

6) Promote state prescription drug monitoring program (PDMP)

7) Expand access to Medication Assisted Treatment

Multidisciplinary Approach


Opioid Crisis: Operation Rio Grande

Phase 1: began Aug 14, 2017 – focused on law enforcement

Phase 2: Provide assessment and treatment for addiction and behavioral disorders

Phase 3: provide meaningful work opportunities

Prescription Drug Monitoring Program


Naloxone


Naloxone: What is it?

Designed to rapidly reverse opioid overdose

Opioid antagonist

Restores normal respiratory drive

Naloxone: Forms

1) Injectable (professional training required)

2) Autoinjectable: prefilled device to inject, gives verbal instructions to user

3) Nasal Spray: goes into nostril as patient lying on back

Naloxone: Utah

Utah Pharmacy Practice Act

allows pharmacists to practice under a collaborative practice agreement with providers

Emergency Administration of Opiate Antagonist Act

allows dispensing and administration of opiate antagonist

Does not require prescriber-patient relationship

Medication Assisted Treatment


Opioid Epidemic: Medication Assisted Treatment

Opiates are given that activate brain receptors

1) Absorbed into the blood over longer period of time

2) Helps diminish withdrawal symptoms

3) Breaks psychological link between taking a drug and feeling high

4) Normalize body functions without the negative effects of the abused drug


1) Methadone: long-acting opioid, blunts highs and lows of abused opioid

2) Buprenorphine: suppresses cravings for other opioids, similar to methadone

Other names: Suboxone, Subutex, Zubsolv, Probuphine

3) Naltrexone: blocks opioid receptors in the body; no abuse or diversion potential; prevents high of abused drug


“If we’re just substituting one opioid for another, we’re not moving the dial much. Folks need to be cured so they can be productive members of society and realize their dreams.”

-- Tom Price, US Dept. of HHS Secretary

Charleston Gazette-Mail, May 9, 2017


“Science, not opinion, should guide our recommendations and policies,” he said, after tweeting that “there is a lot of confusion about addiction treatment.”

-- Vivek Murthy, MD, former US Surgeon General

Charleston Gazette-Mail, May 9, 2017

Opioid Epidemic: It’s Time to Act

“Narcotic drug addiction is one of the gravest and most important questions confronting the medical profession today.”

Editorial Comment, American Medicine, 21 (O.S.), 10 (N.S.) (November 1915): 799-800.

the opioid epidemic: it’s€¦ · surgeon generals report on alcohol, drugs and health (2016) –...

Documents