Opiate Misuse, Abuse and

OHIO’S

OPIOID

EPIDEMIC:

EMERGENCY

DEPARTMENT

GUIDELINES

Ohio’s 2013 Opiate Summit: Turning the Tide Together

April 29, 2013

Ted E. Wymyslo, MD

Director, Ohio Department of Health

OBJECTIVES

• Share national and state data.

• Discuss the development and distribution of the Ohio

Emergency and Acute Care Facility Opioids and Other

Controlled Substances (OOCS) Guidelines.

• Provide an update on the implementation of the ED

Guidelines.

• Identify next steps.

• Share actions being taken by the Ohio Department of

Health (ODH) to address the opioid epidemic in Ohio.

Ohio Opiate Action Team – Public Education Work Group 2

NATIONAL DATA:

1999 – 2010


(Source: QuickStats: Number of Deaths From Poisoning, Drug Poisoning, and Drug Poisoning Involving Opioid Analgesics

— United States, 1999–2010)

NATIONAL DATA 2010

38,329 people died from drug overdoses in the United States in 2010, up from 37,004 deaths in 2009.1

Overdose deaths involving opioid pain medications have shown a similar increase. There were 16,651 in 2010, up from 15,597 in 2009 and 4,030 deaths in 1999.1

The quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices was four times larger in 2010 than in 1999.2

1 Jones C, Mack K, Paulozzi L. Pharmaceutical Overdose Deaths, United States, 2010. JAMA. 2013;309(7):657-659.

2 Centers for Disease Control and Prevention. Vital Signs: Prescription Painkiller Overdoses in the US. November 2011. http://www.cdc.gov/Vitalsigns/pdf/2011-11-vitalsigns.pdf


OHIO DRUG OVERDOSE

DATA 1999-2011

1 Source: Ohio Department of Health: Office of Vital

Statistics, Analysis by the Violence & Injury Prevention

Program, Ohio Department of Health.


327 411

555

702 658

904

1,020

1,261

1,351

1,475 1,423

1,544

1,765

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

0

300

600

900

1200

1500

1800

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

De

ath

rat

e p

er

10

0,0

00

Nu

mb

er

of

dru

g o

verd

ose

de

ath

s

Year

Figure 1. Number of deaths and death rate per 100,000 from unintentional drug overdose by year, Ohio residents, 1999-20111

Death Rate per 100,000

Number of Deaths

OHIO – FOLLOWS THE

NATIONAL TREND

Drug overdose deaths continue to be a public health crisis in Ohio with a 440

percent increase in the number of deaths from 1999 to 2011.

Unintentional drug overdoses caused 1,765 deaths to Ohio residents in 2011,

a 14.3% increase over 2008.

This is equivalent to nearly 5 (4.8) Ohioans dying every day or one Ohioan

dying every 5 hours.

Unintentional drug overdose continues to be the leading cause of injury-

related death in Ohio, ahead of motor vehicle traffic crashes, suicide and

falls.

Prescription drugs are involved in most of the unintentional drug overdoses

and have largely driven the rise in deaths. Pain medications (opioids) and

multiple drug use are the largest contributors to the epidemic.

Source: Ohio Department of Health; Office of Vital Statistics, Analysis conducted by the Violence and

Injury Prevention Program


PRESCRIPTION OPIOIDS

STILL ASSOCIATED WITH

MORE FATAL OVERDOSES

• 2011 saw a shift toward increasing heroin abuse: Heroin-involved deaths have continued to increase from 16 percent (233) in 2008 to 24.1 percent (426)*, or one in four, of all drug overdoses in 2011.

• Prescription opioids (pain medications) remain associated with more fatal overdoses than any other prescription or illegal drug including cocaine, heroin and hallucinogens and combined.

• More than one-fourth of the overdoses involved commonly-prescribed opioids such as oxycodone, hydrocodone and morphine (505; 28.6 percent*).

• Nine percent of the overdoses involved methadone (prescription opioid), demonstrating a slight reduction from 2010 (10 percent).

Ohio Opiate Action Team – Public Education Work Group

7

RESPONSE TO THE EPIDEMIC:

PROFESSIONAL EDUCATION

WORKGROUP - GCOAT

Co-Chaired by Dr. Ted Wymyslo, Director, Ohio Department of Health and Bonnie Kantor-Burman, Director, Ohio Department of Aging

Two subcommittees formed:

• Opioid Prescribing Guidelines for Ohio Emergency/Acute Care Facilities - Lead: Dr. Wymyslo

• Reforming Prescribing Practices in Ohio– Lead: Director Kantor-Burman

8

Professional Education

Workgroup

THANKS FOR THE

LEADERSHIP AND

SUPPORT!

Dawn Prall, MD, Emergency Physician,

Immediate Health Associates, Inc., Westerville

• Leadership with the Central Ohio Regional

Emergency Department Work Group

• Member of the ED Guidelines committee

• Planned and implemented trainings for Mt.

Carmel Health Systems staff

• Speaker - ODH-sponsored webinar on April

16, 2013


RESPONSE TO THE

EPIDEMIC

• The Ohio Emergency and Acute Care Facility Opioids and Other

Controlled Substances (OOCS) Prescribing Guidelines were

developed to provide a general approach in the prescribing of

OOCS. They are not intended to take the place of clinical

judgment, which should always be utilized to provide the most

appropriate care to meet the unique needs of each patient.


RESPONSE TO THE

EPIDEMIC

• The ED Guidelines were endorsed by:

• Ohio Chapter of the American College of Emergency Physicians

• Ohio Association of Health Plans

• Ohio Association of Physician Assistants

• Ohio Bureau of Workers’ Compensation

• Ohio Hospital Association

• Ohio Osteopathic Association

• Ohio Pharmacists Association

• Ohio State Medical Association


DISTRIBUTION OF THE

OHIO ED GUIDELINES

• Ohio Emergency and Acute Care Facility Opioids and

Other Controlled Substances (OOCS) Prescribing

Guidelines:

• Issued in May 2012 at the Opiate Summit.

• Distributed throughout the summer and fall in partnership

with the Ohio Hospital Association, the Ohio Chapter of the

American College of Emergency Physicians (OACEP) and

urgent care facilities.

• ED Guidelines pocket cards were distributed in August and

September of 2012 to all hospitals in Ohio with emergency

departments and members of OACEP.


OPIOID PRESCRIBING

GUIDELINES FOR E.D.’S &

ACUTE CARE FACILITIES

o A model patient handout was also developed to

accompany the prescribing guidelines. This

handout is intended to:

o Provide clear information to patients about the

position of the emergency/acute care facility

regarding the prescribing of opioids for pain

management.

o Be posted in the emergency facility and/or

provided as a handout to patients.


3


Workgroup

OPIOID PRESCRIBING

GUIDELINES FOR E.D.’S & ACUTE

CARE FACILITIES

GUIDELINES

PATIENT HANDOUT



Workgroup

OPIOID

PRESCRIBING

GUIDELINES FOR

E.D.’S & ACUTE

CARE FACILITIES

POCKET CARDS

15


Workgroup

Distributed in partnership with the Ohio Hospital Association and the Ohio

Chapter, American College of Emergency Physicians, and upon request.

ED GUIDELINE

COMPONENTS

AS APPROVED BY THE GCOAT ON APRIL 18, 2012

1. OOCS for acute pain, chronic pain and acute exacerbations of chronic pain will be prescribed in emergency/acute care facilities only when appropriate based on the patient’s presenting symptoms, overall condition, clinical examination and risk for addiction.

a. Doses of OOCS for routine chronic pain or acute exacerbations of chronic pain will typically NOT be given in injection (IM or IV) form.

b. Prescriptions for chronic pain will typically NOT be provided if the patient has either previously presented with the same problem or received an OOCS prescription from another provider within the last month.

c. IV Demerol (Meperidine) for acute or chronic pain is discouraged.

2. Emergency medical clinicians will not routinely provide: a. Replacement prescriptions for OOCS that were lost, destroyed or stolen. b. Replacement doses of Suboxone, Subutex or Methadone for patients in a

treatment program. c. Long-acting or controlled-release opioids (such as OxyContin®, fentanyl

patches, and methadone).


ED GUIDELINE

COMPONENTS

3. Prior to making a final determination regarding whether a patient will be provided a prescription for OOCS, the emergency clinician or facility:

a. Should search the Ohio Automated Rx Reporting System (OARRS) database (https://www.ohiopmp.gov/portal/Default.aspx) or other prescription monitoring programs, per state rules.

b. Reserves the right to request a photo ID to confirm the identity of the patient. If no photo ID is available, the emergency or other acute care facility should photograph the patient for inclusion in the facility medical record.

c. Reserves the right to perform a urine drug screen or other drug screening.

4. Emergency/acute care facilities should maintain an updated list of clinics that provide primary care and/or pain management services for patients, as needed.


https://www.ohiopmp.gov/portal/Default.aspx

GUIDELINE

COMPONENTS

5. Prior to making a final determination regarding whether a patient will be provided a prescription for an OOCS, the emergency clinician should consider the following options:

a. Contact the patient’s routine provider who usually prescribes their OOCS.

b. Request a consultation from their hospital’s palliative or pain service (if available), or an appropriate sub-specialty service.

c. Perform case review or case management for patients who frequently visit the emergency/acute care facilities with pain-related complaints.

d. Request medical and prescription records from other hospitals, provider’s offices, etc.

e. Request that the patient sign a pain agreement that outlines the expectations of the emergency clinician with regard to appropriate use of prescriptions for OOCS.


GUIDELINE

COMPONENTS

6. Emergency/acute care facilities should use available electronic medical resources to coordinate the care of patients who frequently visit the facility, allowing information exchange between emergency/acute care facilities and other community care providers.

7. Except in rare circumstances, prescriptions for OOCS should be limited to a three-day supply. Most conditions seen in the emergency/acute care facility should resolve or improve within a few days. Continued pain needs referral to the primary care physician or appropriate specialist for re-evaluation


GUIDELINE

COMPONENTS

8. Each patient leaving the emergency/acute care facility with a prescription for OOCS should be provided with detailed information about the addictive nature of these medications, the potential dangers of misuse and, the appropriate storage and disposal of these medications at home. This information may be included in the Discharge Instructions or another handout.

9. Emergency/acute care facilities should provide a patient handout and/or display signage that reflects the above guidelines and clearly states the facility position regarding the prescribing of opioids and other controlled substances.


0

SOME OF THE OHIO

HOSPITALS ADOPTING

THE ED GUIDELINES


FEEDBACK FROM

EMERGENCY

PHYSICIANS

OACEP conducted a survey of their members in the fall of

2012 with the following results:

Feedback was overwhelmingly positive from those

responding:

· 94.3 percent had seen a copy of the OOCS

· 87.8 percent rated the OOCS as “somewhat helpful” or

“very helpful”

· 70.4 percent reported that their emergency department

had implemented the OOCS


ADDITIONAL

FEEDBACK

Other responses from the OACEP survey included:

“We have a group of over 30 docs. The ones I have talked to so far

are positive about the guidelines.”

“This is a fantastic step in the right direction, but long overdue.

Thank you for all your efforts with this first step. Let’s keep this

going.”

“The fact that the [Ohio Hospital Association] was on board had the

[hospital administration’s] backing to help with posting signs and

information about this. Has helped us in refusing to meet unrealistic

demands for ED medication of chronic pain.”


NEXT STEPS

• Survey of Ohio hospitals in partnership with the Ohio

Hospital Association – May, 2013.

• Survey of OACEP members working with OACEP – May,

2013; to follow-up on the initial survey now that more time

has passed for implementation.

• Review responses and revise Ohio ED Guidelines as

needed.

• Issue updated ED Guidelines.

• Send comments to ODH by June 30, 2013.

• Goal: Completion of survey, review and revision by the

end of 2013.


COMMENTS ON ED

GUIDELINES

Send comments to:

• Ted Wymyslo, MD, Director, ODH at

[email protected]

• Judi Moseley, Program Consultant, Violence and Injury

Prevention Program, ODH at [email protected]


mailto:[email protected]


STATE-LEVEL ACTIVITIES

PRESCRIPTION DRUG ABUSE ACTION

GROUP (PDAAG)

Convened by the:

• ODH, VIPP

• Ohio Department of Alcohol and Drug Addiction Services

(ODADAS)

Meets quarterly in conjunction with Ohio Injury Prevention

Partnership Meetings

http://www.healthyohioprogram.org/vipp/oipp/oipp.aspx

http://www.healthyohioprogram.org/vipp/oipp/oipp.aspx

PRESCRIPTION DRUG

ABUSE ACTION GROUP

(PDAAG) Subcommittees

• Coalition Establishment- Support expansion of local coalitions

• Public Education - Promote permanent drug disposal sites

• Professional Education - Encourage the use of SBIRT

• Regulatory

• Recommend SBIRT Reimbursement through Medicaid - 15 other state

Medicaid programs have activated SBIRT billing codes .

• Address legal and regulatory barriers for implementation of Naloxone

Distribution Programs (NDPs).

• Obtain NDP-supportive policy statements from the medical, pharmacy

and nursing boards.

• Change rules allowing all EMTs to dispense and administer naloxone.

ODH ACTIVITIES

Naloxone Distribution Programs

• In response to the growing fatal opioid overdoses,

communities have implemented Naloxone Distribution

Programs (NDPs).

• NDPs provide overdose training and take-home doses of

naloxone to those who are deemed high-risk for an

overdose.

• Cameron McNamee, staff member of the VIPP, will be

discussing Naloxone Programs in Ohio in much more

detail following my presentation.

ACTIVITIES OF ODH VIPP

Pursuing Alternative and Sustainable Drug

Disposal Options

• Ohio Prescription Drug Drop Box Program

• Collaboration among:

• Ohio Attorney General’s Office

• Drug Free Action Alliance

• ODH Violence and Injury Prevention Program

• National Association of Drug Diversion

Investigators

• In October 2012, this pilot project provided 66

community drug drop boxes to Ohio law

enforcement agencies in high-risk counties to

encourage the disposal and destruction of

unused medications.

ACTIVITIES OF ODH VIPP

Pursuing Alternative and Sustainable

Drug Disposal Options

• ODH worked with Ohio EPA to locate

approved disposal sites around Ohio.

• Sites will be listed on NADDI website once

implemented and must report pounds of

drugs collected for at least 2 years.

• May be expanded to other parts of Ohio if

successful and funding is available.

OTHER ODH

ACTIVITIES

• SBIRT Training for Health Care

Professionals in June 2012

• Overdose Surveillance

• Updates to presentations, factsheets, etc.

• Prescription for Prevention (P4P)

Campaign continues in 5 counties to

encourage local coalitions and action

plans to address prevention of

prescription drug abuse/overdose.

31

http://www.P4Pohio.org

http://www.p4pohio.org/


OTHER ODH

ACTIVITIES

P4P has partnered with the Ohio High School Athletic Association to:

• Provide education about prescription drug abuse to student athletes, coaches and school administrators;

• Highlight stories of student athletes who have recovered from prescription drug abuse;

• Sponsor a poster/info graphic contest for students to develop prevention messages. Awarded a $500.00 scholarship.

• Feature prevention messages at state basketball championship games and spring track and field events.

• P4P materials are available in the Exhibit area.

http://www.p4pohio.org



CONTACT ODH

ODH Ohio Drug Overdose Website

(Data, factsheets, presentations, Guidelines, etc.)

www.healthyohioprogram.org/vipp/drug/dpoison.aspx

Christy Beeghly, MPH, Program Administrator

Violence and Injury Prevention Program

Ohio Department of Health

(614) 728-4116

[email protected]

Judi Moseley, PDAAG Coordinator

Violence and Injury Prevention Program

Ohio Department of Health

(614) 728-8016

[email protected]



Documents

Opiate Misuse, Abuse and