Turn Off the Spigot: Opioid Addiction May Start in Acute Care Setting

Rx Abuse Summit: Vision Session

April 8, 2015

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Our Panel

Laura Clark, MD

Anesthesiology and Acute Pain

Specialist, University of

Louisville (KY) and VA Medical

Centers

.

Gregory J. Mancini, MD

Associate Professor of Surgery

Fellowship Director - Bariatric

and Robotic Surgery

Medical Director - University

Bariatric Center

University of Tennessee

University of Tennessee

Medical Center

Michael A. Kelly, MD

Chairman, Department of

Orthopaedic Surgery,

Hackensack University Medical

Center

Amy Smalarz, PhD, CEO,

Strategic Market Insight

Moderator

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Our SponsorKevin D. JacksonPresident & CEO

Surgical Momentum is a Patient Safety Organization

and a Healthcare Data Analytics firm.

The company brings a specialized knowledge that

allows the community to service patients better, more

economically and with safer outcomes.

Opioid crisis in the United States01

agenda

Less Is More: Reducing the Use of Opioids through Multimodal Pain Management

02

Opioid reduction in action: Examples from Clinical Practice03Too Much of a Good Thing: Overprescribing Opioids Can Lead to Misuse, Abuse, and Diversion

04

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There is an acute opioid crisis

What is our crisis?

The overuse and presumed safety of opioids leads to

preventable harm to our patients in the hospital.

The overabundance of opioids and access to opioids in

hospitals is a problem.

The opioid addiction is particularly problematic in the hospitals

(awareness and need for non opioids) and the overuse in

prescribing after surgery leading to misuse, abuse, diversion.

opioid crisis in the United States

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Opioid Epidemic in the US

“Prescription drug overdose is

epidemic in the United States. All

too often, in far too many

communities, the treatment is

becoming the problem” Thomas

Frieden, Director of the CDC

45

45 days

6

Every 6 hours

5

5mg of

hydrocodone

.Breakdown of the

Storyline

There are enough opioids

prescribed in the United

States so that every

American could have a full

bottle of pills—the

equivalent of…

(Centers for Disease Control and Prevention (CDC) 2011)

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2014 Guidance and RecommendationsIn 2014, the CDC, CMS, and JACHO all provided guidance and recommendations regarding

mitigating the risk associated with opioids in the hospital setting.

CDC along with JCAHO have issued public statements urging a

call to action, beginning with a change in opioid-centric treatment

habits.

Strategies should reflect a [patient]-centered approach and consider the

patient’s current presentation, the health care providers’ clinical judgment,

and the risks and benefits associated with the strategies, including

potential risk of dependency, addiction and abuse.

With respect to the hospital setting, “An individualized, multimodal

treatment plan should be used to manage pain – upon assessment, the

best approach may be to start with a non-narcotic.”

Healthcare providers should only use opioids in carefully screened and

monitored patients with non-opioid treatments are insufficient to manage

pain.

opioid crisis in the United States

… patients receiving inpatient

IV opioids need risk

assessment and appropriate

monitoring during and after

medication administration,

particularly for post-operative

patients receiving IV opioid

medications, in order to

prevent adverse events

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan

for Adverse Drug Event Prevention. Washington, DC.

What is the evidence?

What is the situational

analysis?

How much opioids are really

used?

Do patients want them?

Reducing the Use of Opioids

through Multimodal Pain

Management

Multiple Organizations Have Urged a Shift Toward Non-Opioid Options

JCAHO recommends “An individualized, multimodal treatment

plan should be used to manage pain—upon assessment, the best

approach may be to start with a non-narcotic”

CDC recommends “Health care providers should only use opioids

in carefully screened and monitored patients when non-opioid

treatments are insufficient to manage pain”

ASA recommends “a multimodal approach to pain management—

often beginning with a local anesthetic where appropriate”

The Joint Commission. Revisions to pain management standard effective January 1, 2015. Available at: http://www.jointcommission.org/assets/1/23/jconline_November_12_14.pdf. Accessed November 19, 20141. CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999—2008. Nov 2011;60(43);1487-1492.

Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm

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Pain Opioids

Predominant Current Treatment Has

Consequences

Inadequate treatment

of pain

Prolonged

Recovery

Opioid Dependence

and Addiction

Chronic Pain

Opioid Side

Effects

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56,000

Estimated adverse

events

62%

Patients

experiencing and

opioid-related side

effect

700

Deaths

.

Adverse Events

Multimodal pain management avoids an

inadequate over-reliance on opioids

>56,000 adverse events and 700 deaths have

been linked to patient controlled analgesia &

up to 62% of patients may experience an

opioid-related side effect

BUT, it’s more than

just the side-effects….

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There is a disconnect

multimodal pain management

What makes patients anxious or fearful?• Their postsurgical

treatment regimen• The use of opioids• Addiction• Opioid-related adverse

events

What do patients want?• Non-narcotic

medications• Would rather endure

some pain (and not take narcotics)

What do patients get?• 95% of patients receive

opioids after surgery

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Sophisticated acute pain treatment

is available but underutilized

Acute Pain Specialty –

Culture change is slow Difficult to change from the

“single-shot” block therapy

Access--More trained physicians

The science of pain has exploded in recent years – new knowledge, new drugs

Multimodal Therapy

Regional Infiltration /

Blocks

Combination of Several

Different Medications

targeting different

receptors

Individualized

management and follow-

up during the course of

acute recovery

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There is a disconnect in delivery of sophisticated pain treatment

Surgeons

Many varied beliefs and individual practice patterns

May not have been exposed

Pressure to maintain OR schedule

Insurance Companies Bundled payment for pain treatment with surgery

Lag between recognizing new therapies and payment

plans

Leading to a Lack of specialists

Hospitals- Support

More Acute Pain Nurses

Patients Really do not know what may be available

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There are alternativesWe MUST treat pain adequately in the acute pain setting

We should be providing Sophisticated multimodal pain

treatment therapy

Only reserving opioids for rescue therapy

There are non-opioid options that adequately control pain in

the postsurgical setting

Regional Analgesia

Liposomal Bupivacaine

IV Acetaminophen

Others

-

We can do more

It’s possible to reduce opioid

consumption and maintain or

even improve clinical

outcomes

Opioid reduction in action:

Examples from clinical practice

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Who we are

An advanced surgical practice that is

patient-focused

We address pain management

challenges in surgery head-on

opioid reduction in action

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The State of Tennessee

opioid reduction in action

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Tennessee At-A-Glance

opioid reduction in action

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Technique evolution but what about pain medication evolution?

While there have been advances in techniques of

managing complex ventral hernias, including minimally

invasive surgery, less work has been done when it

comes to perioperative pain planning.

In our practice, we changed that!

Assessment of current pain levels

and pain management

Assess patient risk for opioid

dependence based on past history

Discuss the likely disability or

improvement with the surgical

procedure

Agree on pain treatment plan and

duration

Ask for help and collaboration from

medical colleagues

opioid reduction in action

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Preoperative goals for ME

“Failing to prepare is

preparing to fail.”

- Coach John Wooden

opioid reduction in action

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Our resultsNo TAP

Block (51)

TAP Block

(50)

Percent

Change

Length of

stay

4.6 (0-19)

days

2.7 (0-13)

days

Decrease

41%

PACU

Morphine

equiv.

12.0 (0-41.6)

mg

8.2 (0-43.3)

mg

Decrease

32%

No pain in

PACU

8/51 (15.7%) 13/50 (26%)

Total

Morphine

equiv.

159.1 (0-

1019.3) mg

91.9 (0-

546.6) mg

Decrease

42%

No TAP

Block (17)

TAP Block

(43)

Percent

Change

IV/IM

Morphine

equiv.

276.3 mg 99.3 mg Decrease

64%

Oral

Morphine

equiv.

55.6 mg 44.7 mg Decrease

20%

Total

Morphine

equiv.

331.9 mg 143.0 mg Decrease

57%

Length of

stay

6.8 days 4.5 days Decrease

34%

opioid reduction in action

Decreased PACU and total morphine equivalent

Decreased IV/IM, oral and total morphine equivalent

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Where surgeons go from here

Need continued support from states

to facilitate narcotic reporting and

surveillance

Need to invest time in our patients to

set expectations about pain

management and recovery to

minimize opioid use

Need Pharma to provide affordable

and effective pain medications that

minimize abuse potential

opioid reduction in action

Not providing alternatives to

opioids following surgery has

created an Acute Opioid Crisis

The acute hospitals setting is a

leading source contributing to

the Opioid Epidemic

Too Much of a Good Thing:

Overprescribing Opioids Can

Lead to Misuse, Abuse, and

Diversion

1. http://www.economist.com/news/united-states/21633819-old-sickness-has-returned-haunt-new-generation-great-american-relapse2. http://usatoday30.usatoday.com/news/health/2002-08-13-detox_x.htm

3. http://health.usnews.com/health-news/patient-advice/articles/2015/01/09/prescription-opioids-pain-relief-comes-with-risks

The New Face of the Opioid EpidemicConsequences of Acute Care Opioids are far reaching

A young grandmother from a middle-class suburb1

• Battling heroin addiction after developing dependence on OxyContin® following hip surgery

An accomplished athlete2

• Struggling with prescription opioid abuse following back surgery

A 16 year-old high school student 3

• Died from taking just 1 pill originally overprescribed to someone else

too much of a good thing

How did we get here?˃70 million patients per year are prescribed opioids for postsurgical pain1

1 in 15 will go on to long-term use or abuse2,3

Resulting in the rapid proliferation of new opioid users coming from the acute care

setting2,3

too much of a good thing

1.Adamson, et al. Hosp Pharm. 2011;46(6 Suppl 1):1-3.2.Alam A, et al. Arch Intern Med, 2012; 172(5): 425-30.3.Carroll I, et al. Anesth Analg, 2012; 115(3): 694-702.4. Office of National Drug Control Policy. Available at: http://www.whitehouse.gov/blog/2014/06/19/white-house-summit-opioid-epidemic.

Accessed November 25, 2014;. 2. http://www.cdc.gov/vitalsigns/pdf/2014-07-vitalsigns.pdf

Long-term use is demonstrated across surgical settings…

too much of a good thing

In patients undergoing various soft tissue or orthopedic

procedures1:

of patients continued on new opioids after surgery

1 year after elective spine surgery2:

of all patients were still using opioids

of previously opioid-naïve patients were still using1.Carroll I, et al. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg. 2012;115:694-702.2.Wang M, et al. Predictors of 12-Month opioid use after elective cervical spine surgery for degenerative changes. Spine. 2013; 13(suppl):S6-S7.

In patients ˃65 undergoing low-risk surgery who received an opioid Rx within a week of

surgery 1:

were still taking opioids a year later.

There was a in the likelihood they would become long-term opioid

users

Compared to non-athletes, adolescents males who participate in organized sports

have2:

…And across patient typesBoth our elderly & children are at risk

too much of a good thing

2x 4x 10xthe odds of

misusing opioids

to get high

the odds of

medical misuse

of opioids due to

taking too muchthe risk for being

prescribed an

opioid medication

1.Alam A, et al. Arch Intern Med. 2012;172:425-30.2. P. Veliz et al. Journal of Adolescent Health 54 (2014) 333e340

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Over-prescription leads to a high potential for diversionIn patients undergoing outpatient upper extremity surgery¹

too much of a good thing

1. Rogers J, et al. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am.

2012;37:645-50.

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Diversion of pain relievers is common

68% of people using pain

relievers non-medically obtain

them from a friend or

relative.¹

According to a 2009 survey of

substances most easily

bought by teenagers

prescription drugs are easier

to obtain than beer.²

too much of a good thing

Free from Friend/Relative

(53.0%)

Bought/Took from Friend/Relative

(14.6%)

Drug Dealer/Stranger (4.3%)

Internet (0.1%)

Other (4.3%)

One Doctor (21.2%)

More than One Doctor (2.6%)

Sources Where User Obtained

*Data are from 2012–2013.

1. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings,

NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

2. The National Center on Addiction and Substance Abuse at Columbia University: National Survey of American Attitudes on Substance Abuse XIV: Teens and

Parents. New York, NY; August 2009.

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Healthcare providers and diversion

too much of a good thing

Substandard care delivered by an impaired healthcare provider

Denial of essential pain medication or therapy

Risk of infection

There are many risks when healthcare providers

steal controlled substances such as opioids for

their own use.

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Infection and healthcare providers

too much of a good thing

http://www.cdc.gov/injectionsafety/drugdiversion

What can we do today?

What can we do tomorrow?

What message should we

share?

Call to Action

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Why are we here?

call to action

We can do more

We need to do more

Patients need a choice

The time for change is now

The ability to reduce, delay, or eliminate the need for opioids in the

postsurgical setting is critical to curbing the rapid proliferation of new

opioids—and new opioid users—across the United States

Our patients deserve better. Our communities and families deserve better. We

can, and must, do better

call to action

Thank you!