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David Hasleton, MDAssociate Chief Medical Officer
Intermountain Healthcare
The Opioid Epidemic: It’s Time to Act
Integrated Pain SymposiumIntermountain Park City Hospital
NY
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
CDC, 2017 Annual Surveillance Report of Drug-Related Risks and Outcomes
Opioid Crisis: Hospitalizations
260k for nonfatal, unintentional drug poisoning
53k (20.4%) for opioid poisoning
12k (21.7%) related to heroin of total opioids
CDC, 2017 Annual Surveillance Report of Drug-Related Risks and Outcomes
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
CDC, 2017 Annual Surveillance Report of Drug-Related Risks and Outcomes
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
Clinician Perspective
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
Clinician Perspective
PE: nl vital signs
nl neuro exam
nl musculoskeletal exam
no “red flag” signs / symptoms
Clinician Perspective
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
Clinician Perspective
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
Clinician Perspective
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
Opioid Crisis: Next Steps
5) Expand use of Naloxone
6) Promote state prescription drug monitoring program (PDMP)
7) Expand access to Medication Assisted Treatment
Multidisciplinary Approach
Opioid Crisis: Next Steps
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
Opioid Crisis: Next Steps
Naloxone
Opioid Crisis: Next Steps
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 Crisis: Next Steps
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
Opioid Epidemic: Medication Assisted Treatment
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
Opioid Epidemic: Medication Assisted Treatment
“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
Opioid Epidemic: Medication Assisted Treatment
“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.