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Opiate Abuse 2011 Dr. Stephen H. Anderson MD Opiate Abuse 2011 Dr. Stephen H. Anderson MD

Goals & Objectives • How did we get here & where ARE we • Goals & Objectives • How did we get here & where ARE we • Understand “What’s the harm? ” • Whose to “blame” & what are some solutions? • The Washington State Opioid Prescription Guidelines for Treating Chronic Pain • The “Script” • How can I help?

Historical Opium • First used Medicinally in the Stone Age • • • Sumerian, Historical Opium • First used Medicinally in the Stone Age • • • Sumerian, Assyrian, Egyptian, Indian, Minoan, Greek, Roman, Persian, & Arab Empires all report medicinal use. Fifteenth Century China first reported recreational use Opium Wars in 1839 & 1858 International Opium Commission of 1914, followed by the International Narcotics Control Board DEA

Historical Opiates • 1804 Friedrich Serturner isolated Morphine • Morphine first marketed by Heinrich Historical Opiates • 1804 Friedrich Serturner isolated Morphine • Morphine first marketed by Heinrich Merck • Codeine isolated in 1832 • Heroin synthesized in 1874 by the Bayer Pharmaceutical Company

Opium in Society Opium in Society

It’s the Damned Taliban It’s the Damned Taliban

Joint Commission Standard • Joint Commission Standard - PC. 01. 02. 07 : The Joint Commission Standard • Joint Commission Standard - PC. 01. 02. 07 : The hospital assesses and manages the patient's pain. Pre Pain Standard Patient satisfaction with pain control Post Pain Standard 4. 13 ± 0. 16 4. 38 ± 0. 08* Opioid adverse drug reactions per 11. 0 100, 000 inpatient hospital days * P<0. 001 Source: Vila et al. , 2005 24. 5*

Prescription Opiate Analgesics and Relative Potency • Demerol 4 • • Hydrocodone 5 5 Prescription Opiate Analgesics and Relative Potency • Demerol 4 • • Hydrocodone 5 5 -7 Oxycodone 7 Oxycontin 40 8. 5 Fentanyl 9 MS Contin 30 10 Hydromorphone 2 11 Oxymorphone 5 ? ? ?

Acute Overdose Presentation • • Decreased level of consciousness Decreased respiration Pinpoint pupils Vomiting Acute Overdose Presentation • • Decreased level of consciousness Decreased respiration Pinpoint pupils Vomiting Loss of muscle tone & airway control Seizure Cardiopulmonary Arrest (PEA-VF-Asystole)

Treatment of Acute Overdose • Protection from harm (rhabdomyolysis, etc) • Airway control • Treatment of Acute Overdose • Protection from harm (rhabdomyolysis, etc) • Airway control • IV/IO access, blood pressure control • Naloxone SQ/IM/IV 0. 4 - ? ? ?

Anything Else? • Tylenol Overdose? Acetylcysteine • Poly Drug Overdose? . . NO Flumazenil Anything Else? • Tylenol Overdose? Acetylcysteine • Poly Drug Overdose? . . NO Flumazenil !!!

Are Overdoses a Problem? FEEL MY PAIN Are Overdoses a Problem? FEEL MY PAIN

Dramatic Increase in Emergency Department Visits Resulting From Prescription Opioid Use Deborah Brauser From Dramatic Increase in Emergency Department Visits Resulting From Prescription Opioid Use Deborah Brauser From Medscape Medical News June 29, 2010 The estimated number of emergency department (ED) visits involving nonmedical use of prescription opioids increased by 111% during a 5 -year period, according to a new study by researchers from the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA). Oxycodone, hydrocodone, and methadone products were the opioid pain relievers most frequently involved in these visits, with increases of 152%, 123%, and 73%, respectively. "These alarming findings provide 1 more example of how the misuse of prescription pain relievers is impacting lives and our health care system, " said Pamela S. Hyde, JD, administrator of SAMSHA, Rockville, Maryland, in a statement. "This public health threat requires an all-out effort to raise awareness of the public about proper use, storage, and disposal of these powerful drugs. “ "We urgently need to take action, " echoed Thomas R. Frieden, MD, MPH, director of the CDC in Atlanta, Georgia, in the same statement. "[ED] visits involving non-medical use of these prescription drugs are now as common as [ED] visits for use of illicit drugs. These prescription medicines help many people, but we need to be sure they are used properly and safely. “ The findings were reported jointly in a SAMHSA survey report and in the CDC's Morbidity and Mortality Weekly Report, published online June 17. Dramatic Increases Results showed that the nonmedical use of prescription opioids rose significantly from 144, 600 ED visits in 2004 to 305, 900 visits in 2008 (P <. 001). It also increased by 29% just between the years 2007 and 2008. In addition, ED visits during the 5 -year period involving nonmedical oxycodone use rose significantly from 41, 700 to 105, 214 visits a year (P <. 001). Hydrocodone involvement rose from 39, 844 to 89, 051 visits, and methadone product involvement rose from 36, 806 to 63, 629 visits. These increases "reflect, in part, substantial increases in the prescribing of these classes of drugs, " the investigators write. "These findings indicate substantial, increasing morbidity associated with the nonmedical use of prescription drugs. . . despite recent efforts to control the problem, " write the study authors. "Stronger measures to reduce the diversion of prescription drugs to nonmedical purposes are warranted. “ "The abuse of prescription drugs is our nation's fastest-growing drug problem. And this new study shows it is a problem that affects men and women, people under 21, and those over 21, " said R. Gil Kerlikowske, director of the Office of National Drug Control Policy in Rockville, Maryland, in a statement. 8

So, What’s the Problem? It’s Not Like People Are Dying. . So, What’s the Problem? It’s Not Like People Are Dying. .

Unintentional Injury Deaths Washington State, 1999 -2008 Source: Washington State Department of Health, Death Unintentional Injury Deaths Washington State, 1999 -2008 Source: Washington State Department of Health, Death Certificates 23

 • Wednesday, July 14, 2010 Last updated 11: 26 a. m. PT • • Wednesday, July 14, 2010 Last updated 11: 26 a. m. PT • Prescription drugs more deadly than car crashes, state report says • • By GERRY SPRATT SEATTLEPI. COM STAFF Prescription drug overdoses have replaced car accidents as the leading cause of injury-related death for 35 - 54 -year-olds in Washington, according to a report from the state Department of Health. The rate of death from prescription overdoses increased 90 percent between 2003 and 2008, the report said. In 2008, the last year for which numbers are available, 505 people in the state died from prescription drug overdoses and 646 people were hospitalized. Stevens, Clallam, Spokane, Grant and Snohomish counties led the way in 2008 death rates from prescription medications. In Stevens County, the rate was 18. 6 per 100, 000 population. King County's rate was 6. 8 per 100, 000. "Too many people treat these powerful drugs as casual medications, " state health officer Dr. Maxine Hayes said in a news release. "This stuff isn't aspirin, and it should be handled with care. " More information on proper use of prescription drugs can be found at the Department of Health website. Gerry Spratt can be reached at 206 -448 -8012 or [email protected] com. Follow Gerry on Twitter at twitter. com/gspratt 76. 6

Drug overdose death rates in the United States have never been higher 12 Drug overdose death rates in the United States have never been higher 12

Epidemics of unintentional drug overdose deaths in the United States, 1970 -2006 Prescription drugs Epidemics of unintentional drug overdose deaths in the United States, 1970 -2006 Prescription drugs Crack cocaine Heroin • Source: National Vital Statistics System 14

Prescription for Tragedy | A Journal Sentinel Watchdog Update Role of prescription drugs in Prescription for Tragedy | A Journal Sentinel Watchdog Update Role of prescription drugs in area overdose deaths rising In first half of year, prescription medications were involved in 78% of fata overdoses By Tom Kertscher of the Journal Sentinel July 31, 2010 The role of prescription drugs in fatal overdoses is rising in the four-county Milwaukee area, a Journal Sentinel analysis has found. During the first six months of 2010, prescription drugs - either alone or mixed with illegal drugs - were involved in 78% of the fatal overdoses. That's up from 70% from 2002 through 2009. When you look at deaths caused by prescription drugs alone, the increase is even sharper. From 2002 through 2009, prescription medicines by themselves caused just over half of the more than 1, 200 overdose deaths, according to a Journal Sentinel analysis published in February. But during the first six months of 2010, nearly two out of every three fatal overdoses were caused by prescription drugs alone, the new figures show. Those totals do not include suicides. Among those who died: Jason Oddsen, 24, of Oconomowoc. He lived with his mother, Carolyn Oddsen, and died in the emergency room at Oconomowoc Memorial Hospital, where his mother works as an emergency room nurse and emergency medical technician instructor. Oddsen said her son had developed an addiction to the prescription painkiller oxycodone before graduating, with honors, from the University of Wisconsin-Milwaukee in May 2009. On the night before his death, while with friends in Hartland, he overdosed after taking oxycodone, two other pharmaceuticals and heroin, according to a medical examiner's report. Like 15 -year-old Madison Kiefer, a Whitefish Bay prescription drug overdose victim, Oddsen was left dead or nearly dead in a driveway on a cold winter morning. Kiefer's death in March 2009 raised alarms about prescription drug abuse in the community. The Oddsen case remains under investigation by Hartland police, but no decision has been made on whether criminal charges will be filed. Oddsen wasn't pronounced dead until after being taken to the hospital emergency room. "Every day I go to work I get to walk into the place where my son died and try to help people, " his mother said. 9

Where All These Drugs Coming From? Where All These Drugs Coming From?

Overdose Death Rate correlates directly with Opioid sales (Prescription) rate Unintentional drug overdose death Overdose Death Rate correlates directly with Opioid sales (Prescription) rate Unintentional drug overdose death rates & sales of Rx painkillers in US: Source: National Vital Statistics System & Drug Enforcement Administration, ARCOS 18

Prescription Opioids (oxycodone, methadone and hydrocodone) • The increase in drug overdose death rates Prescription Opioids (oxycodone, methadone and hydrocodone) • The increase in drug overdose death rates is largely because of prescription opioid painkillers. • Among deaths attributed to drugs, the most common drug categories are cocaine, heroin, and a type of prescription drug called opioid painkillers. • “Opioids” are synthetic versions of opium. They have the ability to reduce pain but can also suppress breathing to a fatal degree when taken in excess. Examples of opioids are oxycodone (Oxy. Contin® ), hydrocodone (Vicodin® ), and methadone. • In 2006, the number of deaths involving opioid analgesics was 1. 63 times the number involving cocaine and 5. 88 times the number involving heroin. • There has been at least a 10 -fold increase in the medical use of opioid painkillers during the last 15 years because of a movement toward more aggressive management of pain. • Because opioids cause euphoria, they have been associated increasingly with nonmedical, recreational use. Opioids are now widely available in illicit markets in the United States. • By 2006, opioids were involved in more overdose deaths than heroin and cocaine combined. 16

That’s Not Around Here! That’s Not Around Here!

Availability correlates with poisoning rate: Opioid Analgesics and Rates of Fatal Drug Poisoning in Availability correlates with poisoning rate: Opioid Analgesics and Rates of Fatal Drug Poisoning in the United States American Journal of Preventive Medicine, Volume 31, Issue 6 , Pages 506 -511, December 2006 Leonard J. Paulozzi, MD, George W. Ryan, Ph. D • Objective: To determine whether the variability in rate of sale of prescription opioid analgesics is related to the variability in rates of drug poisoning mortality among states in the United States in 2002. • Methods: Drug poisoning deaths were defined as unintentional deaths or those of undetermined intent whose underlying cause was coded to “narcotics” (X 42) or “other and unspecified” drugs (X 44) in the National Vital Statistics System. Per capita sales of ten opioid analgesics from the Drug Enforcement Administration and combined sales in morphine equivalents were correlated with drug poisoning mortality rates by state using multivariate linear regression. Regression coefficients between mortality rates and sales rates were adjusted for race (percent white, percent black) and age (percent aged 24 years or younger, and percent aged 65 years and older). • Results: There was over a ten-fold variability in sales of some opioid analgesics. Combined sales ranged 3. 7 -fold, from 218 mg person in South Dakota to 798 mg person in Maine. Drug poisoning mortality varied 7. 9 -fold, from 1. 6/100, 000 in Iowa to 12. 4/100, 000 in New Mexico. Drug poisoning mortality correlated most strongly with non. Oxy. Contin® oxycodone (r=0. 73, p<0. 0001), total oxycodone (r=0. 68, p<0. 0001), and total methadone (r=0. 66, p<0. 0001) in the multivariate analysis. A scatterplot demonstrated a linear relationship between total opioid analgesic sales and drug poisoning mortality. Conclusions. The extent of opioid analgesics use varies widely in the United States. Variation in the availability of opioid analgesics is related to the spatial distribution of drug poisoning mortality by state. • Conclusions: The extent of opioid analgesics use varies widely in the United States. Variation in the availability of opioid analgesics is related to the spatial distribution of drug poisoning mortality by state. 20

Overall drug overdose death rates in the United States vary by state and region. Overall drug overdose death rates in the United States vary by state and region. • 21

Unintentional Opioid Overdose Related Deaths & Sales of Rx Opioid Painkillers in WA Source: Unintentional Opioid Overdose Related Deaths & Sales of Rx Opioid Painkillers in WA Source: Washington State Department of Health, Death Certificates & Drug Enforcement Administration, ARCOS 19

Washington • Data Summary • • • • Overdose deaths and hospitalizations involving prescription Washington • Data Summary • • • • Overdose deaths and hospitalizations involving prescription pain medicine have increased in Washington State from 1995 to 2008: 17 times more deaths. 7 times more hospitalizations. Since 2003, four times more people are receiving addiction treatment for prescription pain medicine. According to the Health Youth Survey, Washington teens are using prescription pain medicine to get high. This includes: four percent of 8 th graders 10 % of 10 th graders 12% of 12 th graders 22

26 26

Unintentional Injury Deaths Washington State, 1999 -2008 Source: Washington State Department of Health, Death Unintentional Injury Deaths Washington State, 1999 -2008 Source: Washington State Department of Health, Death Certificates 23

Not in My Patients! Not in My Patients!

Pain Physician. 2008 Mar; 11(2 Suppl): S 63 -88. Therapeutic opioids: a ten-year perspective Pain Physician. 2008 Mar; 11(2 Suppl): S 63 -88. Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Manchikanti L, Singh A. • Abstract: Therapeutic opioid use and abuse coupled with the nonmedical use of other psychotherapeutic drugs has shown an explosive growth in recent years and has been a topic of great concern and controversy. Americans, constituting only 4. 6% of the world's population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply, as well as two-thirds of the world's illegal drugs. With the increasing therapeutic use of opioids, the supply and retail sales of opioids are mirrored by increasing abuse in patients receiving opioids, nonmedical use of other psychotherapeutic drugs (in this article the category of psychotherapeutics includes pain relievers, tranquilizers, stimulants, and sedatives, but does not include over-the-counter drugs), emergency department visits for prescription controlled drugs, exploding costs, increasing incidence of side effects, and unintentional deaths. However, all these ills of illicit drug use and opioid use, abuse, and non-medical use do not stop with adults. It has been shown that 80% of America's high school students, or 11 million teens, and 44% of middle school students, or 5 million teens, have personally witnessed, on the grounds of their schools, illegal drug use, illegal drug dealing, illegal drug possession, and other activities related to drug abuse. The results of the 2006 National Survey on Drug Use and Health showed that 7. 0 million or 2. 8% of all persons aged 12 or older had used prescription type psychotherapeutic drugs nonmedically in the past month, 16. 387 million, or 6. 6% of the population, had used in the past year, and 20. 3%, or almost 49. 8 million, had used prescription psychotherapeutic drugs nonmedically during their lifetime. Sadly, the initiates of psychotherapeutic drugs used for nonmedical purposes were highest for opioids. Therapeutic opioid use has increased substantially, specifically of Schedule II drugs. Apart from lack of effectiveness (except for short-term, acute pain) there are multiple adverse consequences including hormonal and immune system effects, abuse and addiction, tolerance, and hyperalgesia. Patients on long-term opioid use have been shown to increase the overall cost of healthcare, disability, rates of surgery, and late opioid use. 31

Non-medical Use of Pain Relievers 12 or Older, 2005 & 2006 Source: National Survey Non-medical Use of Pain Relievers 12 or Older, 2005 & 2006 Source: National Survey on Drug Use & Health, SAMSHA 35

Overdose Deaths Involving Prescription Opioids among Medicaid Enrollees—Washington, 2004– 2007 From Morbidity & Mortality Overdose Deaths Involving Prescription Opioids among Medicaid Enrollees—Washington, 2004– 2007 From Morbidity & Mortality Weekly Report 2009; 58(42): 1171 -1175. © 2009 Centers for Disease Control and Prevention (CDC) P Coolen, MN; S Best; A Lima; J Sabel, Ph. D; L Paulozzi, MD During 1999– 2006, the number of poisoning deaths in the United States nearly doubled, from approximately 20, 000 to 37, 000, largely because of overdose deaths involving prescription opioid painkillers. [1] This increase coincided with a nearly fourfold increase in the use of prescription opioids nationally. [2] In Washington, in 2006, the rate of poisoning involving opioid painkillers was significantly higher than the national rate. [1] To better characterize the prescription opioids associated with these deaths and to reexamine previously published results indicating higher drug overdose rates in lower-income populations, [3] health and human services agencies in Washington analyzed overdose deaths involving prescription opioids during 2004– 2007. This report describes the results of that analysis, which found that 1, 668 persons died from prescription opioid-related overdoses during the period (6. 4 deaths per 100, 000 per year); 58. 9% of decedents were male, the highest percentage of deaths (34. 4%) was among persons aged 45– 54 years, and 45. 4% of deaths were among persons enrolled in Medicaid. The age-adjusted rate of death was 30. 8 per 100, 000 in the Medicaid-enrolled population, compared with 4. 0 per 100, 000 in the non-Medicaid population, an age-adjusted relative risk of 5. 7. Methadone, oxycodone, and hydrocodone were involved in 64. 0%, 22. 9%, and 13. 9% of deaths, respectively. These findings highlight the prominence of methadone in prescription opioid–related overdose deaths and indicate that the Medicaid population is at high risk. Efforts to minimize this risk should focus on assessing the patterns of opioid prescribing to Medicaid enrollees and intervening with Medicaid enrollees who appear to be misusing these drugs. During 2004– 2007, approximately 90% of clients in the Washington PRC program misused prescription opioids by doctor shopping, frequent cycling through emergency departments, and prescription forgery. WSHRSA attempted to limit such misuse by restricting PRC clients to one primary-care provider, one narcotics prescriber, one pharmacy, and one hospital for nonemergency care. In addition, WSHRSA could require prior authorization for all opioid prescriptions. Methadone's use as a painkiller increased more than twelvefold in the United States and Washington during 1997– 2006 driven in part by its low cost. Washington ranked fourth among states in the per-capita cosumption of methadone in 2005 and 2006. 25

Yes, But. . “I” Don’t Do It. . . Yes, But. . “I” Don’t Do It. . .

Sources of Narcotic Analgesics Setting Type % Distribution Emergency department 39% Primary care office Sources of Narcotic Analgesics Setting Type % Distribution Emergency department 39% Primary care office 31% Medical specialty office 13% Surgical specialty office 10% Hospital outpatient department 7% Source: National Center for Health Statistics. Medication therapy in ambulatory medical care: United States, 2003 -04 37

Where do they get prescription opiates that are used ‘non-medically’? 56% get free from Where do they get prescription opiates that are used ‘non-medically’? 56% get free from friend or family member 19% from a doctor 9% bought them from friend or family 4% from a drug dealer 0. 1% purchasing them from the internet Source: National Survey on Drug Use & Health, 2006 38

OK, So What. Their Dead! “No Skin Off My $$$$$ Teeth” OK, So What. Their Dead! “No Skin Off My $$$$$ Teeth”

State-Funded Substance Abuse Treatment Admissions for Rx Opioids - Adults Source: WA Department of State-Funded Substance Abuse Treatment Admissions for Rx Opioids - Adults Source: WA Department of Social & Health Services, TARGET, 2009 33

State-Funded Substance Abuse Treatment Admissions for Rx Opioids -Teens Source: WA Department of Social State-Funded Substance Abuse Treatment Admissions for Rx Opioids -Teens Source: WA Department of Social & Health Services, TARGET, 2009 34

Anesthesiology: April 2010 - Volume 112 - Issue 4 - pp 777 -778 Opioid Anesthesiology: April 2010 - Volume 112 - Issue 4 - pp 777 -778 Opioid Medication Management: Clinician Beware! Jamison, Robert N. Ph. D. ; Clark, J. David M. D. , Ph. D. • Fitzgibbon et al. 1 presents summary data of malpractice claims about opioid medication management for chronic pain between 2005 and 2009. The investigators examined 8, 962 closed claims from 35 liability insurance companies and determined that 295 claims involved chronic pain management. Of these, 17% (51) directly related to medication management, mostly for prescribing opioids for chronic low-back pain. Unfortunately, death was the most common outcome involved in these claims. The authors note that compared with a previous review by their same group, 2 the number of claims related to medication management had increased from 2 to 8%. The primary reasons for medication management claims, which may surprise some readers, included (1) failure by the prescribing physician to communicate a care plan, (2) inadequate monitoring and documentation of care, (3) inappropriately high-prescribed doses of opioids, or (4) unethical or illegal clinical practices. • Prescription opioid precautions should include careful patient selection including assessment of pain, mood, function, and misuse risk factors, a treatment plan accompanied with a patient–physician treatment agreement, and an appropriate level of monitoring of the patient during opioid therapy based on the level of risk to assess efficacy, adverse effects, and aberrant drug-taking behavior. Unfortunately, documentation of patient evaluation, formulation of treatment plans, and follow-up on treatment plans are absent from the medical records of many patients managed with opioids. 8 Implementation of these procedures takes time and requires thorough documentation but results in reduced opioid misuse. For those patients with high-risk chronic pain who have a history of abuse but for whom a trial of opioid therapy is still to be undertaken, structural interventions including frequent urine screen monitoring, self-report compliance checklists, and individual and group substance abuse counseling, can result in improved compliance with prescription. 30

OK, It’s a Problem. What’s Getting Done About It? OK, It’s a Problem. What’s Getting Done About It?

Hippocrates Greek: 460 BC-370 BC “First. . . Do No Harm” Hippocrates Greek: 460 BC-370 BC “First. . . Do No Harm”

ESHB 2876 (Moeller) Pain management Passed House: 96 --‐ 0 Passed Senate: 37 -10 ESHB 2876 (Moeller) Pain management Passed House: 96 --‐ 0 Passed Senate: 37 -10 Passed Senate: 36 -12 Passed House: 96 -1 Governor signed March 25 th, 2010, with a partial veto This legislation seeks to decrease accidental overdoses from opioid prescriptions. Washington is in the upper third of states for opioid death rate in the country. The amended bill directs medical and nursing boards and commissions to write rules regarding pain management. Boards and commissions are to consider a number of issues during rule making, including special circumstances when dosage amounts maybe exceeded without consultation from a pain specialist, sufficient training and experience to exempt a practitioner from the specialty consultation requirement, guidance on tracking opioid use among others. 27

Public Response: ESHB 2876 • The public (WA state) perceived the medical community as Public Response: ESHB 2876 • The public (WA state) perceived the medical community as being unresponsive and not policing themselves. • The 2010 legislature passed Engrossed Substitute House Bill 2876 in response to concerns about the consequences and risks of managing chronic, long-term pain. • The bill requires the boards and commissions repeal existing rules about pain management by June 30, 2011. MQAC, BOMS, and PMB currently have rules that must be repealed • The bill requires five boards and commissions to adopt new rules related to pain management by June 30, 2011. These boards and commissions have separate disciplining and rulemaking authority. It does require separate rules for each profession. • The rules required by the legislation will not apply to treatment of chronic cancer pain or acute pain caused by an injury or a surgical procedure. It also does not apply to palliative, hospice and other end of life care. 28

DOH ED Opioid Abuse Work Group • A sub work group of: • Interagency DOH ED Opioid Abuse Work Group • A sub work group of: • Interagency Workgroup to Prevent Prescription Opioid Misuse, Abuse and Overdose (June 2008) • Coordinated by Washington Dept of Health • ED Work Group Started February 2009 • Monthly Conference calls • Guidelines in progress since April 2009 (18 months)

45 47 Guidelines Adopted For The Prescribing of Opioid Drugs for the Treatment of 45 47 Guidelines Adopted For The Prescribing of Opioid Drugs for the Treatment of Chronic (non-cancer) Pain through the Emergency Department. Morphed at some institutions into “Guidelines to Prevent Prescription Drug Abuse From the ED” 21 Point Plan

Guidelines to Prevent Prescription Drug Abuse from the ED 1. One prescriber, not multiple Guidelines to Prevent Prescription Drug Abuse from the ED 1. One prescriber, not multiple ED physician prescribers. 2. Avoid IV/IM opioids for the treatment of chronic pain in the ED. 3. Require picture ID to fill opioid prescriptions from the ED. 4. Photograph ED patients without ID.

Guidelines to Prevent Prescription Drug Abuse from the ED 1. Don’t replace lost or Guidelines to Prevent Prescription Drug Abuse from the ED 1. Don’t replace lost or stolen prescriptions. 2. Don’t give replacement doses of methadone. 3. Don’t use Oxy. Contin and Fentanyl patches for acute pain. 4. Share ED visit information with all EDs in WA. “EDIE” (Emergency Department Information Exchange)

Guidelines to Prevent Prescription Drug Abuse from the ED 9. Have pain agreements accessible Guidelines to Prevent Prescription Drug Abuse from the ED 9. Have pain agreements accessible to ED physician. 10. ED care coordination programs are encouraged. 11. Keep a list of primary care and chemical dependency resources. 12. Implement screening and brief intervention programs for substance abuse.

Guidelines to Prevent Prescription Drug Abuse from the ED 13. Demerol usage is discouraged. Guidelines to Prevent Prescription Drug Abuse from the ED 13. Demerol usage is discouraged. 14. Contact the PMD when possible and prescribe only enough pill to last until PMD office opens. 15. Prescribe no more than 30 pills. 16. Screen for previous addiction when prescribing opioids from the ED. 17. EMTALA does not require the treatment of pain.

51 52 Tweaks At ARMC and with Cascade Emergency Physicians • #2) All other 51 52 Tweaks At ARMC and with Cascade Emergency Physicians • #2) All other methods of treating acute exacerbation of chronic pain prior to the use of IV/ IM opioids should be explored. The use of opioids is discouraged. In the event opioids are used, such use will be accompanied by a complete and open discussion of the risks of addiction and death, as well as the formulation of alternative treatments & resources in the future. This conversation will be documented. • #4) Administration is encouraged to explore the photographing of patients without ID.

Due to Recent Increase in Prescription Medication Addiction, Overdose and Deaths the Cherry Hill Due to Recent Increase in Prescription Medication Addiction, Overdose and Deaths the Cherry Hill Emergency Department Follows These Guidelines to Reduce Prescription Drug Abuse ** • • One provider should provide all opioids to treat a patient’s chronic pain: We do not prescribe additional narcotic pain medications after the first visit or when you are already receiving or have received medications from another doctor or ED. Any exception will be made only after a urine tox screen and direct contact with your regular doctor. The administration of intravenous and intramuscular opioids in the emergency department for the relief of acute exacerbations of chronic pain is discouraged: We do not give pain medication shots (injections) for exacerbations of chronic pain. Prescriptions for controlled substances from the emergency department should state the patient is required to provide a government issued picture identification (ID) to the pharmacy filling the prescription: You will be asked to show a state ID (Drivers License or similar) when you get a narcotic prescription from our ED filled at the pharmacy. Emergency departments should photograph patients who present for pain related complaints without a government issued ID: If you do not have photo ID and are requesting or prescribed narcotic pain medication we will take your photograph for the medical record. • • • Emergency medical providers should abstain from providing replacement prescriptions for controlled substances that were lost, destroyed or stolen: We do not refill stolen or lost prescriptions for narcotics or controlled substances. Emergency medical providers should not provide replacement doses of methadone for patients in a methadone treatment program who have missed a dose: We do not provide missed methadone doses. Long acting or controlled release opioids (such as Oxy. Contin, fentanyl patches and methadone) should not be prescribed for acute pain: we do not prescribe long acting or controlled release opioids (Oxy. Contin, MSContin, fentanyl, Duragesic, methadone. . ) Emergency departments should share the ED visit history of a patient with other emergency physicians who are treating a patient: Health care laws allow us to share and request your medical record and visits with other doctors. Emergency departments should coordinate the care of patients who frequently visit the ED using an ED coordination program: Frequent users of the ED will often have care plans made to facilitate and optimize their care including avoidance of use of medications associated with abuse or addiction. 44

Due to recent increase in prescription drug addiction, overdose and death the Swedish Emergency Due to recent increase in prescription drug addiction, overdose and death the Swedish Emergency Departments Follows These Guidelines to Reduce Prescription Drug Abuse 1. One provider should provide all opioids to treat a patient’s chronic pain: We do not prescribe additional narcotic pain medications after the first visit or when you are already receiving or have received medications from another doctor or ED. Any exception will be done only after a urine tox screen and direct contact with your regular doctor. 2. The administration of intravenous and intramuscular opioids in the emergency department for the relief of acute exacerbations of chronic pain is discouraged: We do not give pain medication shots (injections) for exacerbations of chronic pain. 3. Prescriptions for controlled substances from the emergency department should state the patient is required to provide a government issued picture identification (ID) to the pharmacy filling the prescription: You will be asked to show a state ID (Drivers License or similar) when you get a narcotic prescription from our ED filled at the pharmacy. 4. Emergency departments should photograph patients who present for pain related complaints without a government issued ID: If you do not have photo ID and are requesting or prescribed narcotic pain medication we will take your photograph for the medical record. 5. Emergency medical providers should abstain from providing replacement prescriptions for controlled substances that were lost, destroyed or stolen: We do not refill stolen or lost prescriptions for narcotics or controlled substances. 6. Emergency medical providers should not provide replacement doses of methadone for patients in a methadone treatment program who have missed a dose: We do not provide missed methadone doses. 7. Long acting or controlled release opioids (such as Oxy. Contin, fentanyl patches and methadone) should not be prescribed for acute pain: we do not prescribe long acting or controlled release opioids (Oxy. Contin, MSContin, fentanyl, Duragesic, methadone. . ) 8. Emergency departments should share the ED visit history of a patient with other emergency physicians who are treating a patient: Health care laws allow us to share and request your medical record and visits with other doctors. 9. Emergency departments should coordinate the care of patients who frequently visit the ED using an ED coordination program: Frequent users of the ED will often have care plans made to facilitate and optimize their care including avoidance of use of medications associated with abuse or addiction. 10. The Swedish Emergency Physicians do not prescribe Schedule 2 Controlled Substances --those most associated with abuse or addiction-- including oxycodone or oxycodone containing medications (Percocet, Oxy. Contin), Dilaudid (hydromorphone), Morphine (MSContin) and others. ** from the Washington ED Opioid Abuse Work Group sponsored by the Washington State DOH 46

Everyone On The Same Page Everyone On The Same Page

“The Script” “This is a policy the doctors across the state of Washington have “The Script” “This is a policy the doctors across the state of Washington have adopted in response to an alarming increase in complications from prescription narcotics. All situations, such as yours, are unique. But that doesn’t change the fact that addiction & overdose deaths are skyrocketing in Washington. We as doctors in order to create a healthier state, are taking a decisive step to correct a health epidemic we have partially helped to create. Now our goals are to find you solutions, referrals, and answers to your pain management, not just more drugs. So lets talk about your long term health plan going forward, and how I can help you, WITHIN MY GUIDELINES. ”

How Can I Help? • Examine your own prescribing habits • Reach for a How Can I Help? • Examine your own prescribing habits • Reach for a non-opioid first • Share Practice Plans & Pain Management Contracts (EDIE & with Primary Care) • DON’T give false expectations to patients about their ED visit (know our guidelines) • For Consultants, be available & expect “the call”

Thank-You. Questions for the panel Disclaimer: This slide in no way advocates the substitution Thank-You. Questions for the panel Disclaimer: This slide in no way advocates the substitution of alcohol for opioids, the over exposure to UV sunshine, the utilization of non optometrical supplied eye protection, or the proximity to open water without a Coast Guard approved floatation device. . .