PRESCRIPTION DRUG ABUSE

Robert L. “Chuck” Rich, Jr. MDCHAIR, COMMISSION ON HEALTH OF THE PUBLIC AND SCIENCE

PERSONAL INFO

AAFP REPRESENTATIVE TO MULTIPLE OPIOID INTIATIVES;

NO DISCLOSURES; OPIOID INTEREST SECONDARY TO PRACTICE

DEMAND AND STATE EDUCATOR RE SAFE PRESCRIBING EFFORTS;

DESIRE TO “DO NO HARM”

THE BASICS

OPIOIDS BIND TO RECEPTORS IN THE CENTRAL NERVOUS SYSTEM CAUSING PAIN RELIEF;

INCLUDES MULTIPLE PRESCRIPTION OPIOID MEDICATIONS( OXYCODONE, HYDROCODONE, ETC) AS WELL ILLICIT ONES SUCH AS HEROIN;

ADDICTION DEFINED AS A PROGRESSIVE , TREATABLE BRAIN DISEASE;

ANY OPIOID CAN TRIGGER ADDICTION;

THE PROBLEM IN 2015

24.6 MILLION U.S. PEOPLE LIVE WITH SUBSTANCE DEPENDENCE OR ABUSE;

1.9 MILLION U.S. CITIZENS LIVE WITH OPIOID ABUSE OR DEPENDENCE;

517,000 U.S. CITIZENS LIVE WITH HEROIN ADDICTION; 23% OF HEROIN USERS ALSO HAVE OPIOID

ADDICTION. OPIOID ADDICTION FOUND IN EVERY CITY,

COUNTY ,U.S. ETHNIC GROUP. INCREASING NUMBER OF U.S. OPIOID USERS HAVE

SWITCHED TO HEROIN SECONDARY TO EXPENSE.

OVERDOSE AND DEATH IN 2015 46 U.S. CITIZENS DIE DAILY FROM OPIOID

OVERDOSE, 17,000 ANNUALLY, 2 DEATHS A HOUR; OVERDOSE THE LEADING CAUSE OF INJURY DEATH

IN 2013, GREATER THAN FROM MVAS OR HOMICIDE; 8,200 U.S. CITIZENS DIED OF HEROIN IN SAME YEAR; 259 MILLION PRESCRIPTIONS WRITTEN IN 2012,

ENOUGH FOR EVERYONE TO HAVE A RX; OVERDOSE RATE FROM OPIOIDS STABILIZING BUT

RATE OF OVERDOSE FROM BENZODIAZEPENES INCREASING.

YOUTH AND OPIOIDS

2,500 YOUTH DAILY ABUSE A PRESCRIPTION OPIOID FOR THE FIRST TIME;

50% OF YOUTH GET OPIOIDS FROM A FRIEND OR RELATIVE;

OPIOID ABUSE IN YOUTH ASSOCIATED WITH OF ABUSE OF OTHER DRUGS AND ALCOHOL.

WOMEN AND OPIOIDS

IN THE MOST RECENT DATA (2010), 6,600 WOMEN DIED FROM OPIOID OVERDOSE (18/DAY);

4.4% OF PREGNANT WOMEN REPORTED ILLICIT DRUG USE IN PRECEDING 30 DAYS;

1% OF PREGNANT WOMEN REPORTED NONMEDICAL USE OF OPIOIDS IN SAME PERIOD;

0.1% OF PREGNANT WOMEN REPORTED HEROIN USE IN THE SAME PERIOD.

OBAMA ADMINISTRATION EFFORTS INTIATIVE ANNOUNCED 10/21/2015; PUBLIC AND PRIVATE SECTOR EFFORT TO ADDRESS

PRESCRIPTION DRUG ABUSE AND HEROIN USE; EMPHASIS ON PRESCRIBER TRAINING INCLUDING EXPANDED

TRAINING OF PROVIDERS TO TREAT OPIOID DEPENDENCE AND IMPROVING ACCESS TO TREATMENT INCLUDING EXPANDED USE OF THE OVERDOSE ANTIDOTE NALOXONE;

MORE THAN FOURTY PROVIDER GROUPS AGREE TO PARTICIPATE IN EFFORT INCLUDING AAFP, ACOFP, AMA, ACP;

LIAISON EFFORTS WITH MULTIPLE NONMEDICAL ORGANIZATIONS SUCH AS THE NCAA, NBA, MLB TO EDUCATE THE PUBLIC, PARTICULARLY YOUTH ABOUT THE DANGERS OF OPIOID MISUSE AND ABUSE.

FSMB POLICY

REVISED OPIOID POLICY IMPLEMENTED BY MOST STATE BOARDS IN 2013;

COMPONENTS INCLUDE: 1)PATIENT EVALLUATION AND RISK STRATIFICATION 2) DEVELOPMENT OF A TREATMENT PLAN AND GOALS 3) INFORMED CONSENT AND TREATMENT AGREEMENT 4) ONGOING MONITORING AND ADAPTING THE

TREATMENT PLAN 5) PERIODIC DRUG TESTING 6) CONSULTATION AND REFERRAL 7) DISCONTINUING OPIOID THERAPY

NASS LIAISON EFFORTS

WORKING GROUP TASKED WITH DEVELOPING GUIDELINES FOR MANAGEMENT OF VARIOUS ASPECTS OF BACK PAIN INCLUDING THE TRANSITION FROM ACUTE TO CHRONIC;

TASK FORCE MEMBERS INIATIALLY ASKED TO HELP DEVELOP RESEARCH QUESTIONS RE VARIOUS ASPECTS OF BACK PAIN SUCH AS HISTORY AND EXAM ELEMENTS, IMAGING, TREATMENT INCLUDING SURGICAL AND NONSURGICAL OPTIONS;

RESEARCH QUESTIONS HAVE BEEN SUBMITTED TO GENERAL PUBLIC AND OTHER ORGANIZATIONS FOR COMMENT;

GROUP WILL LATER DEVELOP CARE RECOMMENDATIONS TO ADDRESS THE VARIOUS KEY QUESTIONS;

GUIDELINE TO BE RELEASED 2016.

ACP ACUTE PAIN EFFORTS ACP/AAFP AGREED TO COLLABORATE ON AN

ACUTE PAIN GUIDELINE 2015; GUIDELINE TO FOCUS ON TREATMENT OF

ACUTE PAIN SYNDROMES; KEY OUTCOMES TO INCLUDE INCREASED USE

OF NONPHARMACOLOGIC (NONOPIOID) TREATMENTS FOR PAIN, DECREASED OVERDOSE FROM OPIODS, DECREASED ADDICTION TO OPIOIDS;

KEY QUESTIONS BEING FORMALIZED TO SUBMIT FOR EVIDENCE REVIEW.

CDC OPIOID PRESCRIBING GUIDELINES EFFORTS CONDUCTED BY NCIPC/CDC; KEY QUESTIONS FOCUSED UPON

EFFECTIVENESS OF OPIOIDS USED PRIMARILY FOR CHRONIC PAIN, LESSER SO ACUTE PAIN;

EVIDENCE REVIEW CONDUCTED BY AHRQ IN 2014 LOOKING AT THE EFFECTIVENESS AND RISKS OF LONG-TERM OPIOID TREATMENT OF CHRONIC PAIN;

KEY RECOMMENDATIONS THEN DEVELOPED BY CDC STAFF USING GRADE CRITERIA.

CDC GUIDELINES CONT.

KEY RECOMMENDATIONS SUBSEQUENTLY SUBMITTED TO CORE EXPERT GROUP (CEG) WITH REPRESENTATION FROM AAFP, ACP, SGIM, VARIOUS STATE AGENCIES AND SUBJECT MATTER EXPERTS;

KEY RECOMMENDATIONS THEN REVISED AFTER COMMENTS FROM CEG;

REVISED RECOMMENDATIONS THEN SUBMITTED TO KEY STAKEHOLDER GROUPS FOR FURTHER COMMENT VIA WEBINAR SEPT. 2015;

FINAL VERSION OF GUIDELINES TO BE RELEASED EARLY 2016.

OTHER AAFP LIASONS

PCSS: AAFP CURRENTLY HAS REPRESENTATION TO THE PCSS ADVISORY BOARDS RE OPIOID THERAPIES AND MEDICATION ASSISTED TREATMENT; SPONSORED BY AAAP AND FUNDED BY SAMSHA AND TASKED WITH CREATING MULTIPLE EDUCATIONAL RESOURCES RE OPIODS AND ADDICTION FOR PROVIDERS;

PCORI: AAFP HAS REPRESENTATIVES ON SEVERAL WORKSHOPS LOOKING AT POTENTIAL RESEARCH TOPICS INCLUDING TREATMENT OPTIONS FOR LOW BACK PAIN, PHARMACOLOGIC OPTIONS FOR CHRONIC PAIN, NONPHARMACOLOGIC OPTIONS FOR CHRONIC PAIN;

AAPM/PRIMARY CARE SUMMIT: A CONSORTIUM OF SEVERAL PRIMARY CARE ORGANIZATIONS WHICH HAVE MET SEVERAL TIMES 2014- 2015 TO DISCUSS VARIOUS ISSUES RE PRIMARY CARE AND OPIOIDS INCLUDING EDUCATION OF THE PRACTICING MD; SPONSORED BY AAPM;

AMA/ PRIMARY CARE TASK FORCE

PDMPS

NOW PRESENT IN SOME FORM IN 49, SOON TO BE 50 STATES; SIGNIFCANT VARIABILITY BETWEEN STATES RE INFORMATION

CONTAINED IDEAL CHARACTERISTICS INCLUDE INTEGRATION INTO

PROVIDER EHRS OR AT LEAST EASY ACCESS AND DATA RETRIEVAL

DELEGATE AUTHORITY INTERSTATE SHARING OF DATA DATA STORED IN SYSTEM IS ACCURATE TO REAL TIME; EASY PROVIDER REGISTRATION SYSTEM CONTAINS USEFUL PROVIDER PROMPTS RE HIGH

DOSING, PATIENT “LOCKIN”, SIGNIFICANT MEDICATION INTERACTIONS

NALOXONE

OPIOID OVERDOSE ANTIDOTE, INCREASINGLY USED SINCE LATE 1990S IN LAYPERSON SCENARIOS TO RESCUE OVERDOSE VICTIMS;

AS OF JULY 30, 2015, 37 STATES HAVE PASSED LAWS ALLOWING THIRD PARTY PRESCRIBING OF NALOXONE TO CLOSE FRIENDS OR FAMILY MEMBERS, WITH 32 STATES GRANTING CIVIL IMMUNITY TO PRESCIBERS WHO PRESCRIBE NALOXONE;

27 STATES PERMIT PROVIDER PRESCRIBING BY STANDING ORDERS WITH SOME STATES EVALUATING PHARMACIST DISTRIBUTION TO ELIGIBLE PATIENTS UNDER A SYSTEMWIDE STANDING ORDER;

SOME STATES HAVE FUNDED THE PURCHASE AND DISTRIBUTION OF NALOXONE KITS TO EMS, LAW ENFORCEMENT AND BYSTANDERS;

CONSIDER FOR PATIENTS ON HIGH DOSE OPIOIDS, THOSE PATIENTS ALSO ON OTHER SEDATING MEDICATIONS SUCH AS BENZODIZEPENES AS WELL AS OPIOIDS, THOSE PATIENTS WITH MEDICAL CONDITIONS PLACING THEM AT HIGH RISK (COPD, LIVER DIESASE, ETC), THOSE PATIENTS WITH BEHAVIORAL HEALTH DISORDERS PLACING THEM AT RISK OF OVERDOSE.

GOOD SAMARITAN LAWS

PROVIDES PROTECTION FROM PROSECUTION TO INDIVIDUALS WHO PROVIDE ASSISTANCE TO SOMEONE WHO OVDEROSES, AS WELL AS, THE OVERDOSE VICTIM;

AS OF JULY 30, 2015, 34 STATES HAVE PASSED SUCH LAWS IN VARIOUS FORMS;

GOOD SAMARITAN LAWS PASSED TO ENCOURAGE FRIENDS, FAMILY MEMBERS AND BYSTANDERS TO CALL EMS IN THE EVENT OF AN OVERDOSE.

OPIOIDS AND PREGNANCY

CHRONIC OPIOID THERAPY AFFECTS BOTH MOTHER AND THE UNBORN CHILD;

PREGNANT FEMALE AT HIGH RISK OF MISCARRIAGE, PREMATURE LABOR AND DELIVERY IF WITHDRAWL OCCURS;

INFANT AT RISK OF NEONATAL ABSTINENCE SYNDROME (NAS) IF BORN TO MOTHER TAKING OPIOIDS CHRONICALLY; SX INCLUDE IRRITABILITY, POOR FEEDING, POOR WEIGHT GAIN AND MAY TAKE DAYS TO WEEKS TO SPONTAEOUSLY RESOLVE; 2012 DATA REVEALED 5.8 BABIES/ 1000 BIRTHS HAD NAS;

MOST RECENT DATA SHOWED THAT UPWARDS OF 1/3 MEDICAID PATIENTS FILLED A RX FOR OPIODS DURING PREGNANCY AND UP TO 1/4 PRIVATE INSURER PATIENTS FILLED AN OPIOID RX DURING PREGNANCY;

SAFEST ALTERNATIVE: MEDICATION ASSISTED TREATMENT VIA A TEAM APPROACH;

WHO PRESCRIBES FOR THE PREGNANT FEMALE ON CHRONIC OPIOID THERAPY?

Q&A

IF YOU DO NOT ASK, I WILL ASK YOU.