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Responsible Prescribing PracticesNational Rx Drug Abuse Summit 4-11-12

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  • 1. ResponsiblePrescribing Practices April 10-12, 2012 Walt Disney World Swan Resort
  • 2. Learning Objectives:1. Describe how cautious, evidence-basedprescribing practices can lower opioid-relatedoverdose deaths while maintaining appropriateaccess for medically needed treatment of chronicpain.2. Identify best practice strategies that can beused by clinicians for pain management treatment.3. Explain evidence-based practice and policies forprovider education and patient educationprograms being utilized across the US.
  • 3. Disclosure Statement All presenters for this session, Dr. Rollin M. Gallagher, Dr. Andrew Kolodny, and Robert Sproul, have disclosed no relevant, real or apparent personal or professional financial relationships.
  • 4. The Opium Poppy Papaver Somniferum
  • 5. Crude Opium Latex on Poppy Head
  • 6. Opioids Morphine Codeine Heroin Hydrocodone (Vicodin, Lortab) Methadone Oxycodone (Percodan, Oxycontin) Hydromorphone (Dilaudid) Meperidine (Demerol)
  • 7. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  • 8. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  • 9. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  • 10. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  • 11. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  • 12. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
  • 13. Characteristics of opioid-addicted, treatment-seeking patients
  • 14. Rates of ED visits for nonmedical use of selected opioid analgesics increased significantly in the US 40 35 2004 2005 2006 2007 2008ED visits per 100,000 population 30 25 20 * 15 * * * * 10 * 5 * * 0 * * Fentanyl Hydrocodone Hydromorphone Methadone Morphine Oxycodone * Indicates a rate that was significantly less than the rate in 2008. Note: Drug types include combination products , e.g, combinations of oxycodone and aspirin.
  • 15. Number of of drug-induced deaths compared with Number drug-induced deaths compared with other types of deaths, US, 1999-2006other types of deaths, US, 1999-2006
  • 16. Unintentional Drug Overdose Deaths United States, 19702007 36,450 drug overdose deaths in 2008 Cocaine Heroin Year National Vital Statistics System, http://wonder.cdc.gov25
  • 17. Unintentional overdose deaths involving opioid analgesics parallel per capita sales of opioidanalgesics in morphine equivalents by year, U.S., 1997-2007 * Number of Opioid sales (mg/ Deaths person)Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS* 2007 opioid sales figure is preliminary.
  • 18. Dollars Spent Marketing OxyContin (1996-2001)Source: United States General Accounting Office: Dec. 2003, OxyContin Abuse and Diversion andEfforts to Address the Problem.
  • 19. Industry-influenced Education on Opioidsfor Chronic Non-Cancer Pain Emphasizes: Opioid addiction is rare in pain patients. Physicians are needlessly allowing patients to suffer because of opiophobia. Opioids are safe and effective for chronic pain. Opioid therapy can be easily discontinued.
  • 20. Photo taken at the The 7th International Conference on Pain and Chemical Dependency, June 2007
  • 21. Federation of State Medical Boards of the United States, IncModel Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards House of Delegates, May 2004. http://fsmb.org. Accessed March 2010.
  • 22. The Emperor s New Paradigm:Patient Selection, Risk Stratification & Monitoring
  • 23. ? Chronic Opioid Therapy Guidelines Trial of Opioid Therapy Patient Reassessment Continue Opioid Implement Exit Strategy TherapyChou R, et al. J Pain. 2009;10:113-130.*Clinician accepting primary responsibility for a patient s overall medical care.
  • 24. Stratify Risk Low Risk Moderate Risk High Risk No past/current History of treated Active substance history of substance abuse abuse substance abuse Significant family Active addiction Noncontributory history of Major untreated family history of substance abuse psychological substance abuse Past/comorbid disorder No major or psychological Significant risk disorder untreated to self and psychological practitioner disorderWebster LR, Webster RM. Pain Med. 2005;6:432-442.
  • 25. Clozapine vs Opioids Comparison of methods for preventing serious adverse events Clozapine for Opioids for Schizophrenia Chronic PainEvidence-Based Treatment Yes NoAdverse Event (AE) Agranulocytosis AddictionRisk(%) 1% 25%Routine lab monitoring Weekly WBCs Urine ToxicologyMonitoring can prevent AE Yes NoPatient Registry Yes No
  • 26. Prevalence of Misuse, Abuse, and Addic

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