Opioids – Do the Math

FMA 2017 Opioid Summit

Hector Vila Jr., MDFlorida Board of Medicine

Anesthesiology

Questions

1. How did we get here?

2. Who is overdosing in Florida?

3. How many patients are getting acute pain Rx?

4. What are the demographics? Rx Sizes?

5. What is the effect of the amount of pills given?

6. How many are becoming long term users?

7. Will limiting opioids harm patients?

8. Are there Specialty Medical Societies statements?

9. Are Florida doctors becoming opioid dependent too?

• January 1, 2001, JCAHO required hospitals insure pain be assessed and managed in all patients.

• Most hospitals adopted policy of “pain as the fifth vital sign.”

How did we get here?

Anesth Analg 2005;101:474-80

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Percent increase in ADRs and oversedation or respiratory failure after implementation of JCAHO pain management standard

Overdose death trends

Source: Christopher M. Jones, PharmD, MPH CDC, NVSS, 2016

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Percent of Total Deaths Drug Overdose Any Opioid

Commonly Prescribed Opioids Heroin Synthetic Opioids

Number and Rate of drug overdose deaths involving opioids by age group, Florida, 2015

Age group (yrs) Opioid overdose deaths (crude rate*)

18-54 1068 (11.2)

55+ 338 (5.1)

* Deaths per 100,000 population Source: CDC WONDER

Dependence vs. Quantity of 1st PrescriptionMMWR / March 17, 2017 / Vol. 66 / No. 10

GOV. SCOTT TO PROPOSE MAJOR LEGISLATION TO COMBAT OPIOID ABUSE

• Three-day limit on prescribed opioids, unless strictconditions are met

• Require healthcare professionals to participate in theFlorida PDMP

• Additional reforms:– Pain management clinics, – Continuing education courses– Federal grant funding.

2016 Opioid Naïve* PatientsDemographics

Opioid naïve patients in 2016 (N = 3,563,533)N %

GenderFemale 2,045,724 57.4

Age Group (years)18-24 228,538 6.425-34 513,048 14.435-44 505,461 14.245-54 594,443 16.755-64 637,256 17.965+ 1,084,787 30.4

*No opioid Rx in the prior 180 days; excluding patients w/ buprenorphine in 2015-2016Fl. population 20.6MSource: Florida Prescription Drug Monitoring Program (E-FORCSE)

2016 Opioid Naïve PatientsOpioid Use Characteristics

Opioid naïve patients in 2016 (N = 3,563,533)N

Days Supply Mean=9.5 days>=3 3,086,208 86.6%>=5 2,104,587 59.1%>=7 1,383,589 38.8%

Morphine Milligram Equivalent Daily Mean=37.4

>=90 206,088 5.8%Initial is long-acting

opioid Rx 76,630 2.2%Long-term user1 193,608 5.4%

1If any episode is followed by opioid Rx covering a cumulative 90 out of 180 daysSource: Florida Prescription Drug Monitoring Program (E-FORCSE)

Initial Rx for opioid naïve patients in 2016Payment Method N* %

Private Pay 636,052 17.0Medicaid 171,909 4.6Medicare 646,998 17.3

Commercial Insurance 1,915,731 51.2

Prescription Characteristics

long-acting 79,624 2.1other Schedule (S) II short-acting 119,170 3.2

oxycodone short-acting 1,044,843 27.9hydrocodone short-acting 1,457,214 38.9SIII-SIV and Nalbuphine 272,236 7.3

tramadol 765,411 20.5

2016 Opioid Naïve Prescriptions

• Rx counts do not add to total number of patients• Source: Florida Prescription Drug Monitoring Program (E-FORCSE)

2016 Opioid Naïve PatientsAge Groups

18-54 (N = 1,841,490) 55+ (N = 1,722,043)N % N %

Female 1,097,741 59.6% 947,983 55.1%Days Supply Mean=7.6 Mean=11.6

>=3 1,555,946 84.5% 1,530,262 88.9%

>=5 941,438 51.1% 1,163,149 67.5%

>=7 533,630 28.9% 849,959 49.4%

MME Mean=37.0 Mean=37.9>=90 88,425 4.8% 117,663 6.8%

Initial is long-acting opioid Rx

26,101 1.4% 50,529 2.9%

Long-term user1 74,472 4.0% 119,136 6.9%

1If any episode is followed by opioid Rx covering a cumulative 90 out of 180 daysSource: Florida Prescription Drug Monitoring Program (E-FORCSE)

Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures

• 215 ,140 individuals

• Length of opioid prescriptions - between the median and the early nadir– 4 to 9 days for general surgery procedures, – 4 to 13 days for women’s health procedures, – 6 to 15 days for musculoskeletal procedures.

Rebecca E. Scully, MD; Andrew J. Schoenfeld, MD, Wei Jiang, JAMA Surg. Published online September 27, 2017. doi:10.1001/jamasurg. 2017.3132

Parecoxib, propacetamol, and their combination for analgesia after total hip arthroplasty

Parecoxib and parecoxib+propacetamol provided significant opioid-sparing efficacy compared with placebo

Opioid-sparing - significant reductions in pain, improved functional outcome, and less opioid-related symptom distress.

Study medications were well tolerated.

Acta Anaesthesiol Scand. 2017 Jan;61(1):99-110. doi: 10.1111/aas.12841. Epub 2016 Nov 30.

• General Strategy• No long acting opioids• Check statewide database • Post Procedure

• Small -10 pills• Medium – 20 pills• Large – 40 pills• Opioid alternatives encouraged

• ED – 10 pills

Other Medical Societies

• Anesthesiology

• Emergency Physicians

• Dentistry

vStart with non-opioid medications / nerve blocksvShort acting opioidsvMinimize opioidsvPatient education

Florida Board of Medicine: PRN Experience

• Addiction: Ø Genetics Ø Environmental stress (pain) Ø Prescription medication Ø Access

• Physicians – Overall addiction similar to general popoulation– Higher opioid addiction– Better recovery rate - 78%+

Alexis Polles, M.D. – Medical Director, Professionals Resource Network

The numbers of MD and DO physicians in PRN monitoring program :

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Opioids Summary

• Prescribing limits will impact some Florida prescriptions and likely decrease the number of new dependent patients.

• Regulatory changes should include Doctors, Nurses, Dentists, Hospitals, and Pharmacies

• Non-Opioid alternatives are available to provide similar and likely better outcomes

• Patient education is important to acceptance and success of opioid reduction strategies

Medmarx Annual Reports• Morphine-related errors resulting in patient

harm increased from 4% in 2000 to 6% in 2001

• Fraction of total errors resulting in harm – 2000 - 5%– 2001 - 2.4%– 2002 - 1.67%

• In 2002, opioids accounted for 12.4% of errors, exceeding any other class of medication and up from 9.5% in 2001.

Conclusions• Opioid related adverse drug

reactions doubled

• Likely to be a nation-wide problem

• Respiratory Rate – poor predictor of oversedation or respiratory arrest

Opioid prescription practices at discharge and 30-day returns in children with sickle cell disease and pain.

Prescription of NSAIDs only, without opioids, was an independent predictor of higher 30-day ED revisits.

Conclusions• Increased use of opioid pain medications

associated with increase in adverse drug reactions

• Decreased consciousness predicts patients at risk for respiratory arrest

• Consider non-sedating pain medications in patients with decreased consciousness

• Supplemental oxygen can mask hypoventilation from opioids

• Airway soft tissue obstruction can occur in sedated patients

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The mission of the Office of Diversion Control is to prevent, detect, and investigate the diversion of pharmaceutical controlled substances and listed chemicals from legitimate channels of distribution

while …ensuring an adequate and uninterrupted supply of controlled substances to meet legitimate medical, commercial, and scientificneeds.

Mission

U.S. Drug Enforcement AdministrationOffice of Diversion Control

Foreign Mfr Importer Manufacturer

Distri-butor

PractitionerPharmacyHospitalClinic

?

Closed System of Distribution

U.S. Drug Enforcement AdministrationOffice of Diversion Control

U.S. Drug Enforcement AdministrationOffice of Diversion Control

MOST COMMONLY ABUSED PRESCRIPTION CONTROLLED SUBSTANCES

• Oxycodone• Oxycontin ®• Percocet ®

• Hydromorphone• Dilaudid ®

• Hydrocodone• Vicodin ®• Lortab ®

• Oxymorphone• Opana ®

• ADHD Medications• Adderall ®

• Alprazolam• Xanax ®

• Diazepam• Valium ®

• Buprenorphine• Suboxone ®