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Addressing the Opioid Epidemic

Joseph Bianco, MD, FAAFP

Essentia Health

AHCAP Webinar

June 7, 2018

Our Mission

We are called to make a

healthy difference in

people’s lives.

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Our Values

Quality

Hospitality

Respect

Justice

Stewardship

Teamwork

Our Service Area

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Opioids:

A trip through time

460 B.C.

Hippocrates, the

“father of medicine,”

acknowledges opium’s

usefulness as a

narcotic and styptic in

treating disease.

3400 B.C.

The earliest reference

to opium growth and

use is in 3400 B.C.

when the opium poppy

was cultivated in lower

Mesopotamia.

330 B.C.

Alexander the Great

introduces opium to

India. The Arabs,

Greeks and Romans

use it as a sedative.

A brief history of opioids

Source: www.TheAtlantic.com; www.opioids.com

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1527 A.D.

In 1527, Swiss-German

alchemist Paracelsus

discovers a tincture of

opium that helped

reduce pain. He calls

this preparation

laudanum.

1300 A.D.

Opium becomes a

taboo subject during the

Inquisition. References

to opium disappear for

200 years from

European historical

record.

A brief history of opioids

Source: www.TheAtlantic.com; www.opioids.com

1806 A.D.

In 1806, German

chemist Friedrich

Wilhelm Adam Sertürner

isolates morphine from

opium. He names it after

the god of dreams,

Morpheus.

1924

Spurred by growing

addiction rates,

Congress outlaws the

importation,

manufacture, sale and

use of heroin.

1898

Heroin is synthesized as a

derivative to morphine.

German company Bayer

offers heroin as a cough

suppressant and “non-

addictive” morphine

alternative.

A brief history of opioids

Source: www.TheAtlantic.com; www.opioids.com

1950

The FDA approves

Oxycodone, making it

widely available in the

U.S., a precursor to

growing abuse of

prescription opioids.

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1990s

Concern about the

under treatment of pain

prompts increased use

of opioids for all pain

types, including non-

cancer pain.

1983

Vicodin® becomes

available in a generic

version. Yet doctors

are reluctant to

prescribe opioids in

general.

A brief history of opioids

Source: www.TheAtlantic.com; www.opioids.com

1999

Following a surge in

opioid marketing by

drug manufacturers,

an estimated 4 million

people are using

prescription opioids

non-medically.

2010

Opioid related deaths

surpass car accidents

as the leading cause of

accidental death

2007

Criminal Charges

filed against Purdue

Pharma for false

advertising

Oxycontin

A brief history of opioids

Source: www.TheAtlantic.com; www.opioids.com

2017

President Trump

declares a National

Public Health

Emergency

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Opioids:

An exploding problem

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Porter /Jick letter cited over the next 26 years

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Source: Manchikanti, Laxmaiah, MD Pain Physician 2007; 10:399-424• ISSN 1533-3159

A change in prescribing habits and a decade of

aggressive marketing of prescription opioids to

American physicians has led to increased use:

Hydrocodone 198%

Fentanyl 423%

Oxycodone 588%

Methadone 933%

Opioid use skyrockets

Oxycontin

• Introduced in 1996

• Long action oxycodone

• Blueprint for modern advertising

• Purdue Pharma

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“And so it went. OxyContin first, introduced by reps from Purdue Pharma over steak and dessert and in air-conditioned doctors’ offices. Within a few years, black tar heroin followed in tiny, uninflated balloons held in the mouths of sugarcane farm boys from Xalisco driving old Nissan Sentras to meet-ups in McDonald’s parking lots. “― Sam Quinones, Dreamland: The True Tale of America's Opiate Epidemic

Opioids:

The Science

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The root of the problem: What is pain?

• Acute

• Post-operative

• Malignant

• Chronic

Opioids

• Natural opioid analgesics, including morphine and codeine, and semi-synthetic opioid analgesics, including drugs such as oxycodone, hydrocodone, hydromorphone, and oxymorphone;

• Methadone, a synthetic opioid;

• Synthetic opioid analgesics other than methadone, including drugs such as tramadol and fentanyl

• Heroin, an illicit (illegally-made) opioid synthesized from morphine that can be a white or brown powder, or a black sticky substance

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Pain Receptor Activity

• Mu- analgesia, euphoria, miosis, sedation, constipation, respiratory depression, addiction, hormonal changes

• Kappa- analgesia, diuresis, sedation, miosis, dysphoria, psychomimetic effects, respiratory depression, constipation

• Delta- analgesia

Pain receptors

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Now we know…

We should have proceeded with caution.

Opioids are not the only way or

even an effective way to treat

chronic non-malignant pain.

Adverse effects of narcotics

• Constipation

• Nausea

• Somnolence

• Obesity

• Narcotic bowel syndrome

• Hyperalgesia

• Hypogonadism

• Traffic collisions/impaired work

• Sleep disturbance

Dependence

is inevitable

Source: Benyamin, R, et. al. Pain Physician; 2008, Mar.

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Long-term effects of opioid dependence

Source: Essentia Health patient education materials

Progression of opioid dependence

Source: Ballantyne, Jane, Essentia Health Friday Grand Rounds, Jan. 10, 2014

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The 16% of Americans that have mental health

disorders receive over 50% of all opioids prescribed

From the CDC….

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Opioid Use Disordersource: Psychiatric Times

Source: USA Today

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Sobering statistics

The amount of opioids

prescribed and sold in

the U.S. quadrupled

since 1999, but the

overall amount of pain

reported by Americans

hasn’t changed.

Source: Centers for Disease Control and Prevention

Bottom Line

The evidence to support chronic opioid analgesic therapy for chronic pain is insufficient at this time, but the evidence of harm is clear.

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Opioids:

The Data

Sobering statistics

Americans die every day

from an opioid overdose.

Source: Centers for Disease Control and Prevention

At least half of all opioid overdose

deaths involve a prescription opioid.

115

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A dangerous trend

Source: National Center for Health Statistics, CDC Wonder

The number of drug overdose deaths among Minnesota residents continued the alarming rise in 2016

Source:Drug Overdose Deaths among Minnesota Residents, 2000 – 2016; MDH ,

SOURCE:

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Opioid-involved drug overdose deaths continue to rise in Minnesota, driven by heroin and other synthetic opioids

Source:Drug Overdose Deaths among Minnesota Residents, 2000 – 2016;MDH

Unintentional drug overdose deaths have risen dramatically, while suicide andundetermined deaths have remained stable over the last five years

Source:Drug Overdose Deaths among Minnesota Residents, 2000 – 2016:MDH

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Sobering statistics

249 million prescriptions for opioid pain

medication were written by

healthcare providers in 2013.

Source: Centers for Disease Control and Prevention

That’s enough

prescriptions for every

American adult to have

a bottle of pills.

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Per capita opioid use

Map shows grams

per 10,000 people of

prescriptions for

painkiller opioids,

such as oxycodone,

hydrocodone,

codeine, morphine.

Source: Drug Enforcement Administration;

Pioneer Press, Prescription opiates and

heroin in Minnesota

20052011

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Sobering statistics

Source: Minnesota Public Radio; Centers for Disease Control and Prevention

Source: Manchikanti, Laxmaiah, MD Pain Physician 2007; 10:399-424• ISSN 1533-3159

An American issue

of the world’s prescription

opioid supply is consumed

in the U.S.

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Opioid use at least once during past year

Source: http://data.unodc.org/, 2000-2012

Much of World Suffers Not From Abuse of Painkillers, but Absence of ThemMay 17, 2016

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Impact on our tiniest patients

0%1%2%3%4%5%6%7%8%9%

10%

2005 2006 2010 2011 2012 2013

Source: Essentia Health-St. Mary’s Medical Center NICU admission diagnosis - NAS

Percentage of Duluth NICU patients born suffering

from opioid withdrawal with a diagnosis of “Neonatal

Abstinence Syndrome” or NAS

OP-01

Taking on Opioids:

Essentia’s Approach

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Characterizing Pain

• Acute Pain

• Post Acute Pain (up to 45 days)

• Chronic Pain (>45 days)

• Malignant Pain (continuous tissue inflammation or damage)

• Post surgical (minor vs major)

• Opioid Naïve (90 days) vs Opioid tolerant

Prescribing PrinciplesMinnesota Department of Health

• Prescribe the lowest effective dose and duration of opioid analgesia when indicated for acute pain. Clinicians should reduce variation in opioid prescribing for acute pain.

• The post‐acute pain period (up to 45 days following an acute event) is the critical timeframe to halt the progression to chronic opioid use.

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Risk FactorsNora D. Volkow, M.D., and A. Thomas McLellan, Ph.D.

N Engl J Med 2016; 374:1253-1263March 31, 2016DOI: 10.1056/NEJMra1507771

MME=MEDAlosa Health

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Acute Pain (minor surgery)

MDH, ICSI, CDC

• No more than a three day supply

• No more than 100 MME

• Do not take more than 50 MME in one day

• Reduce by 50% if patient is taking benzodiazepines or is elderly

• Rarely will more that 7 days be needed or up to 200 MME

• Consider no opioids

• No long acting opioids

Acute Pain (Major Surgery)

• No more than 200 MME total prescription

• No more that 7 day supply

• Consider reducing dosage by 50% for patients who are elderly or on benzodiazepines.

• No more than 50 MME to be taken in one day

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One- and 3-year probabilities of continued opioid use among opioid-naïve

patients, by number of days’ supply* of the first opioid prescription —

United States, 2006–2015

MMWR, March 172017

One- and 3-year probabilities of continued opioid use among opioid-naïve

patients, by number of prescriptions* in the first episode of opioid use —

United States, 2006–2015

MMWR,March 172017

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MEDICATIONS Sig Max QTY MME**

Codeine/APAP* 30/325 mg tab 1 Q4H PRN X 3 days #18 81

Hydrocodone/APAP* 5/325 mg tab 1 Q4H PRN X 3 days #18 90

Hydromorphone 2 mg tab 1 Q6H PRN X 3 days #12 96

Oxycodone/APAP* 5/325 mg tab 1 Q6H PRN X 3 days #12 90

Tramadol 50 mg tab 1 Q4H PRN X 3 days #18 90

No more than a three day supply, short acting opioid

No More than 100 MME for entire prescription or 50 MME per day

Acute Opioid Dosing Limits

Opioid Tolerant

• One week of opioids 60 MME/day (FDA)

• OUD or non medical use

• Opioid induced hyperalgesia

• Offer multimodal analgesia

• COAT patients- consider different opioid at 30-50% equianalgesic dose (tolerance not complete

• OUD – multidisciplinary approach

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Post Acute PainMDH,ICSI,CDC

• Assess and document risk factors for opioid‐related harm and chronic use with increasing frequency if the patient continues to receive opioid therapy during the post‐acute pain phase

• Consider patient risk factors including age, SUD, Anxiety, Depression, PTSD

• Check PMP

• Prescribe opioids in multiples of 7 days, with no more than 200 MME per 7 day period, and no more dispensed than the number of doses needed

• Prescribing should be consistent with expected tissue healing

• Avoid prescribing more than 700 cumulative MME during the postacutepain interval

• Develop a referral network for mental health, substance use disorder, pain education, and pain medicine.

Cumulative Dose

Source, Shah, 2017. Available at:https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm?s_cid=mm6610a1_whttps://stacks.cdc.gov/view/cdc

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Chronic Pain (COAT)

CDC guidelines

• Prescribe opioids at the lowest dose, with no more than 50 MME/day.

• Avoid increasing daily dosage to ≥ 90 MME/day.

• Face to face visits with provider every three months

• Risk assessment

• Discuss tapering at every visit

• Monitor for diversion

• Harm reduction strategies

• Monitor for withdrawal and manage appropriately

• Be alert to OUD

Assessment and Monitoring

.

At each pain visit:

(at least four per year)

• PMP checked

• Assess for risk of abuse,

treatment efficacy, depression

and anxiety

• Patient education on risks and

alternatives

• Offer to help patients taper if ready

Annually:

• Treatment

agreement signed

• Random UDS (may

be more frequent)

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Assist PCP with alternate pain

management options if patient requires taper to discontinue opioids

Is the patient taking both short and long-acting

agents?

NO

Decrease short-acting agent by 10% of total MDE every 3-7 days until gone

YES

Decrease dose of long-acting agent by 10-25% every 3-7 days until only 30% of original MDE remains

NO

Decrease dose of long-acting agent by 10-25% every 3-7 days until only 30% of original MDE remains

Withdrawal Symptoms?

Slow taper and/or initiate adjunctive therapies

(See Appendix 4)

YES

NO

Withdrawal Symptoms?

Are all short-acting opioids discontinued?

YES

Is patient on methadone?

YES See Appendix 3

NOProviding withdrawal symptoms are controlled, continue to decrease opioid dose by 5-10% of

initial MDE every 1-4 weeks until taper complete

YES

NO

Tapering

Naloxone (Narcan)

• Antagonist• Is patient at risk?• 50-99 MME/day results in 4X increase in

overdose risk• >100 MME/day results in 9X increase in overdose

risk• IM (30-90min half-life)• Intranasal (120 min half-life• May elicit withdrawal• Cost $75-150

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OUR RESULTS

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Scope of Work

Current COAT patient volumes

Essentia Region # of patients

Central 642

East 3365

West 1635

Patients without

an Essentia PCP

559

Total 6201

April 2018

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Our progress

52% fewer new COAT patients

started on therapy each month

March 2015 March 2018

March 2015

Our progress

March 2018

45% fewer COAT patients

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Continued work regarding COAT patients

• Pharmacy tapering via telehealth or in person.

• Change from three months of chronic opioids to a 45 day window before patient is considered on COAT

• Increased focus on the post acute period

• New surgical guidelines

• Data mining for patients at high risk for overdose (total MME >90, benzodiazepines)

• Naloxone prescribing

• EPIC MME conversion at prescribing

• Continue through operations monitor our standard processes regarding monitoring and prescribing, current data reveals some major gaps

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ACUTE PAINInpatient, Outpatient, ED/Urgent Care, Post Surgical

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Acute PainMDH, ICSI, CDC

• No more than a three day Supply

• No more than 100 MME

• Do not take more than 50 MME in one day

• Reduce by 50% if patient is taking benzodiazepines or is elderly

• Rarely will more that 7 days be needed or up to 200 MME

Acute Pain (non-surgical) Opioid Prescribing Data for Emergency Room (non-surgical) Care

% of opioid naive*patients with a short-acting index order of > 100 MEUs or a long acting index

order

January 2016- March 2018

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28.31%

10.12%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

*Opioid Naïve Patient = Patient has had no opioid order in the previous 90 days from the measurement month's index opioid order date.

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76.51%

63.90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Acute Pain (non-surgical) Opioid Prescribing Data for Ambulatory (non-surgical) Care

% of opioid naive*patients with a short-acting index order of > 100 MEUs or a long acting

index order

January 2016- March 2018

*Opioid Naïve Patient = Patient has had no opioid order in the previous 90 days from the measurement month's index opioid order date.

A case for transparency

EHR reports allow providers to drill down to list of COAT patients.

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Community coalitions formed

• Began monthly meetings

October 2015

• Share best practices, ideas

and information

• Created joint news release

• Includes law enforcement

and dentistry

representatives

• Community education

efforts

Community coalitions formed

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Opioid Use Disorder, Opioid Dependence-

Harm Reduction Strategy (Vision)

• Addiction sub committee• DFPR directors with suboxone waivers are working with Center for

Alcohol and Drug Therapy in Duluth on a pilot model for suboxone induction and outpatient therapy.

• Educating practice regarding MAT ( buprenorphine, buprenorphine/naloxone, methadone, naltrexone)

• Continue to build our IBH• Participate in ECHO programs from St Gabriel’s and HCMC• Recruit physicians to obtain their suboxone wavers• Continue to build out our centralized pain and integrative health

programs• Revamping our Cannabis committee and approach to chronic pain

MythsOpioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies

N Engl J Med 2016; 374:1253-1263

• Addiction is the same as physical dependence and tolerance

• Addiction is simply a set of bad choices

• Pain protects patients from addiction to their opioid medications

• Only long acting opioids cause addiction

• Only certain patients are vulnerable to addiction

• Medication-assisted therapies are just substitutions for heroin and opioids

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OP-01

Discussion

Contact Information

Dr. Bianco:

joseph.bianco@essentiahealth.org