reversing the overdose epidemic
TRANSCRIPT
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Reversing the Overdose
Epidemic:
A Toolkit for Oregon’s Clinicians
Katrina Hedberg, MD, MPH
Oregon Medical Association
October 29, 2020
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Disclosures
• I have no disclosures to report
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Target Audience
• The overarching goal of PCSS is to train healthcare
professionals in evidence-based practices for the
prevention and treatment of opioid use disorders,
particularly in prescribing medications, as well for
the prevention and treatment of substance use
disorders.
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Educational Objectives
• Describe current trends in the overdose epidemic
and the Oregon Health Authority data dashboard
• Identify ways to help make pain treatment safer and
more effective, emphasizing non-opioid and non-
pharmaceutical treatments
• Demonstrate tools to reduce harms for people
taking opioids
• Discover resources for treatment of substance use
disorders
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Oregon Toolkit Overview
• Scope of problem
• Strategies to reduce opioid misuse and abuse
• Treating pain with care and compassion
• Reducing harms using naloxone
• Treating substance use disorders
• Educating patients about pain management,
safe storage and disposal of medications
• Call to Action
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Age-adjusted Drug Overdose Death Rates,
US 2018
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Overdose Deaths, 2018
US
67,367 people in US died of overdose
46,802 (70%) of these involved opioids, of which 2/3 were
synthetic opioids (e.g. fentanyl)
Deaths from prescription opioids have been decreasing, BUT
deaths from illicit opioids (e.g. heroin, fentanyl) have been
increasing
Deaths from stimulants increased 5-fold from 2012-2018
Oregon
571 people in Oregon died of an overdose
336 (60%) involved opioids, of which 3/4 were illicit opioids
230 involved stimulants (e.g. methamphetamine)
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Drug Overdose Deaths,
Oregon 2000-2018
Prescription
opioids
Methamphetamine/
stimulants
Heroin
Synthetic opioids
(e.g. fentanyl)
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Drug Overdose Deaths by Age
Oregon 2012-2016 D
eath
s p
er
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0,0
00
re
sid
en
ts
Source: Oregon Vital Statistics, Death Certificates 9
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Scope of the Opioid Epidemic
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Opioid Use Disorder in US
• Opioid dependency
2015: 2.4 million persons diagnosed with a SUD
involving opioids (OUD)
2019: 1.6 million diagnosed with OUD
• Opioid Use Disorder Treatment
Only 18% (294,000) those diagnosed with an OUD
received Medication Assisted Treatment (MAT).
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Opioid Prescriptions
• Opioid prescriptions in US: 2018
168 million prescriptions for opioid pain
medications
Equals 3 bottles of pills for every 4
adults (age 18+)
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Oregon Prescribing: 2011-2019
Opioids
Benzodiazepines
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Oregon Prescribing: 2011-2019
Opioids
Benzodiazepines
Stimulants
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Oregon Opioid Prescription fills
by Age
Rec
ipie
nts
per
1,0
00
res
iden
ts
Age Group
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Oregon Opioid Strategies
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• Safe storage and disposal
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Pain Categories for Treatment
• Pain lasting > 3 months, or past
time of tissue healing
• Prevalence: ~15% of US adults
Acute Pain
Chronic non-
cancer pain
Cancer pain
End of life
pain
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Oregon Pain Commission Created by Oregon Legislature in 1999
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Pain Management Education
• Prescribers required to take online training: Changing
the Conversation about Pain
• Provider Tools available
• Domains
• Knowledge of Pain
• Sleep
• Mood
• Activity
• Nutrition
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Oregon’s Opioid Guidelines
Task Forces
Goal
• Standard for opioid prescribing across Oregon health care systems, practice settings
Oregon Health Authority
• Convener
Membership
• Subject matter experts
• Professional Assoc’s, licensing boards, organizations
• Health systems, hospitals, payers
• Regional task forces, public health departments
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Format for Oregon Guidelines
• One stop shopping for statewide guidelines
• Overarching foundational principles for opioid
prescribing in Oregon
• Specific prescribing guidelines:
Acute pain: emergency departments, post-
surgical
Chronic pain
For pregnant women
Dental clinics
• Opioid Tapering guidelines
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Acute Pain Prescribing Guidelines
In general, opioids should NOT be considered first line
therapy for mild to moderate pain.
If opioid is prescribed:
• Evaluate the Patient
• Assess history of long-term opioid use / substance use disorder (SUD)
• Check Prescription Drug Monitoring Program (PDMP)
• Provide Patient Education
• Amount and type:
• Lowest effective dose for shortest duration (usually <3 days).
• Patient follow-up
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Chronic Pain Prescribing Guidelines Endorse CDC Guideline as Foundation
1. Determine when to start or continue opioids for chronic pain • Non-pharmicologic, non-opioid therapies
• Establish treatment goals
• Discuss risks and benefits
2. Opioid selection, dose, duration, f/u • Immediate release
• Lowest dose, short duration
• Fewest number pills necessary
• F/U, re-evaluate, plan for discontinuation
3. Assess risk and address harms of opioid use • Evaluate need for naloxone/ SUD treatment
• Review PDMP
• Use urine testing as needed
• Limit co-prescribing with benzos
• Safe storage and disposal
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Oregon Chronic Opioid Prescribing
Guidelines
• Oregon-specific addenda: o Cannabis use
o Chronic (legacy) patients
o Naloxone
o Prescription Drug Monitoring Program
o OMB Material Risk Notice
• Finalized November 2016
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Misapplications of 2016 CDC
Opioid Prescribing Guideline
• Patients outside scope of guidelines: Inadequate or
refusal of pain meds for cancer patients, end-of-life
care, post-surgical, sickle cell crises, etc.
• Pharmacies and Benefit Managers adopting hard
MME thresholds in regulations
• Forced and inappropriate tapering
• Reluctance by physicians and pharmacies to
prescribe and fill opioid prescriptions
• Misapplication of dose rec’s to patients starting
MAT
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Tapering Guidelines-- Principles
• Pain management should be patient-centered, trauma-informed
and based on current pain science.
• Overarching goals: improve patient safety, maintain or improve
function, improve quality of life through provision of compassionate
care.
• Guidelines encourage conversations between clinicians and
patients; promote patient engagement and shared decision-
making; support informed consent; and apply easily to different
practice settings.
• Tapering plans should be individualized, collaborative, clear,
flexible, and include realistic goals.
• Health systems and payers must support a team-based, integrated
approach to tapering, and ensure access to non-pharmacologic
pain therapies, and multi-disciplinary supports
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Oregon Medical Board
Requirements
• 1995 the Oregon Legislature passed the
Intractable Pain Law, amended in 2007
• Required Material Risk Notification
when prescribing controlled substances
for chronic intractable pain
• MRN documentation of a detailed
Procedure, Alternatives, Risks and
Questions, with patient and physician
signatures
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Prescription Drug Monitoring
Program (PDMP)
• Passed 2009, went live 2011
• Tool to help healthcare providers and pharmacists provide patients better care in managing prescriptions.
• Provide data on controlled substance prescriptions to improve patient safety and health o Patients at risk for: overdose, side effects, other
drugs, physical dependence, drug abuse
• Integration into existing EHRs
• Prescribing Practices Review Subcommittee o Letters to high prescribers
o Provider “report cards”
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PDMP: Oregon Prescribing Data
• 7 million prescriptions annually
• 1.2 million queries to PDMP
• 4,000 prescribers write 80% of scheduled substance
prescriptions
• Opioids (e.g. hydrocodone, oxycodone) account for
~50% of prescriptions
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• Benzodiazepines 2nd most frequent
prescription
• Prescriptions for stimulants increasing
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OMA/ AMA Encourages
Clinicians to ….
• Support multi-disciplinary/ multi-modal approaches to pain
management, including: medication, behavioral and
complementary integrative treatment
• Individualize care for all patients with pain, focused on
evidence-based therapies
• Identify and treat mental
and behavioral health
disorders that can impact
pain
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Oregon Pain Guidance
• Pain treatment guidelines
• Assessment tools
• Morphine Equivalent Dose
calculator
• Provider resources
Having difficult conversations
• Patient resources
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Naloxone: Co-prescribing
• Patients at risk for overdose
High dose opioids
Concomitant benzo prescription
History of SUD
Mental health condition
Medical condition
Friend/ family at risk of OD
Recently been in detox or SUD treatment
Oregon law allows pharmacies to dispense without prescription after brief training
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Substance Use Disorder
Treatment: Oregon
• Oregon Medication-Assisted Treatment resources
Oregon Health Authority: Supports and Regulate addiction
prevention and treatment services in Oregon, including:
treatment, counseling, support
Oregon Substance Use Disorder Services Directory
• Northwest Addiction Technology Transfer Center
(Northwest ATTC)
services to strengthen the substance use disorder treatment
and recovery workforce in Alaska, Idaho, Oregon, and
Washington
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Substance Use Disorder
Treatment: National
• Substances Abuse and Mental Health Services
Administration (SAMHSA)
Overdose prevention toolkit
OUD treatment directory
Treatment of stimulant use disorder
• Providers’ Clinical Support System (PCSS)
Train primary care providers in the evidence-based prevention
and treatment of opioid use disorders (OUD)
Mentoring program
MAT waiver information
• American Society of Addiction Medicine
National practice treatment guidelines for OUD
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Substance Use Disorder Treatment
• Oregon Patient resources
Oregon Health Authority
Lines for Life
Oregon Recovers
NW Portland Area Indian Health Board
• US Surgeon General’s Turn the Tide
Addiction recovery resources
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Protect Community/ Support Patients
Heal Safely Campaign toolkit: • Insights into commonly-held beliefs about opioids and pain
• Understanding of how these beliefs affect people’s decisions about
their pain management options
• Key learnings around effective, research-tested language and
messages
• Strategies for adapting to better reflect the experiences and
concerns of communities of color
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OMA
Governor’s Opioid Task
Force Oregon Health
Leadership Council
Lines for Life
Oregon Pain
Guidance
Tri-county opioid Safety
Coalition
Multnomah County
Health Dept
Oregon Health
Authority
OR Medical Education
Foundation
Oregon Partnerships
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2015 AMA Physician
Recommendations
• Support use of PDMPs
• Use effective, evidence-based treatment for
pain and SUDs
• Increase access to comprehensive,
affordable, treatment for pain and SUDs
• End stigma for patients with pain or SUD
• Expand access to naloxone in community
and co-prescribing
• Encourage safe medication storage and
disposal
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AMA Call to Action
• Remove prior authorization or administrative barriers to MAT
• Support assessment and treatment for mental health
disorders; enforce mental health and SUD parity laws
• Remove barriers to comprehensive pain care and rehab
programs
• Support MCH by improving access to treatment that preserves
family structure
• Support needle exchange and criminal justice reform for drug
crimes
• Implement comprehensive data systems that enable analysis
by demographic characteristics, including race ethnicity
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PCSS Mentoring Program
PCSS Mentor Program is designed to offer general information to
clinicians about evidence-based clinical practices in prescribing
medications for opioid use disorder.
PCSS Mentors are a national network of providers with expertise in
addictions, pain, evidence-based treatment including medications for
addiction treatment.
• 3-tiered approach allows every mentor/mentee relationship to be unique
and catered to the specific needs of the mentee.
• No cost.
For more information visit:
https://pcssNOW.org/mentoring/
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PCSS Discussion Forum
Have a clinical question?
http://pcss.invisionzone.com/register
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PCSS is a collaborative effort led by the American Academy of Addiction
Psychiatry (AAAP) in partnership with:
Addiction Technology Transfer Center American Society of Addiction Medicine
American Academy of Family Physicians American Society for Pain Management Nursing
American Academy of Pain Medicine Association for Multidisciplinary Education and
Research in Substance use and Addiction
American Academy of Pediatrics Council on Social Work Education
American Pharmacists Association International Nurses Society on Addictions
American College of Emergency Physicians National Association for Community Health Centers
American Dental Association National Association of Social Workers
American Medical Association National Council for Behavioral Health
American Osteopathic Academy of Addiction
Medicine The National Judicial College
American Psychiatric Association Physician Assistant Education Association
American Psychiatric Nurses Association Society for Academic Emergency Medicine
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Educate. Train. Mentor
www.pcssNOW.org
@PCSSProjects
www.facebook.com/pcssprojects/
Funding for this initiative was made possible (in part) by grant no. 1H79TI081968 from SAMHSA. The views expressed in written conference materials or
publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does
mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.