safe prescribing saves lives
TRANSCRIPT
NoRxAbuse Kick-off Safe Prescribing Saves Lives
February 4, 2016
Housekeeping
Sign-in sheets
Action team sign-up
Restroom locations
Electronic devices
Begin and end on time
Presentation Material Online: www.norxabuse.org
SAFE PRESCRIBING SAVES LIVES Ivan Petrzelka, PharmD, JD, MBA February 4, 2016
www.NoRxAbuse.org 3
OUR MISSION
Improvement of patient safety and prevention of prescription drug abuse.
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DRUG ABUSE TRENDS
Paradigm shift in pain management
Shift from illicit drugs to Rx drugs
Accessibility Perception of safety Social acceptability
Rx Drug overdose deaths tripled since 1990 Rx Opioids are most abused – fastest growing
cause of death in US
5
WHAT IS RX DRUG ABUSE?
Use without a prescription Use in a manner other than prescribed Use to induce certain experience or feeling
Up to 30% of opioid users may be abusing Rx meds
CDC & NIDA
6
7
US RX OVERDOSE DEATHS
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EVERY
WEEK
9
MAGNITUDE OF RX ABUSE
10
25K >3 MM
>20 MM
HOW DID WE GET HERE?
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HOW DID WE GET HERE?
11
OxyContin® introduced in 1996 Pain as 5th Vital Sign initiative (VA 1999) Decade of Pain Control & Research 2001-2010 (HR3244)
PATHS TO RX DRUG ABUSE
Injury – overmedication
Well-meaning family member or friend
Peer pressure – teens Direct to consumer advertising
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No. 1 Drug Dealer in USA
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SOLUTIONS
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EDUCATION
TREATMENT
REGULATION
ENFORCEMENT
ROLE OF OUR COALITION
Coalition for responsible prescribing and dispensing Bring together key stakeholders
Prescribers Dispensers Health Plans Educators Law enforcement Local businesses Public officials, etc.
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CALL TO ACTION Prescribers – drive the change in prescribing patterns, use
CURES, random testing, use alternative treatment mods. Prescribers and dispensers – educate patients on risks of
using controlled substances Heath plans - expand coverage for
alternative treatment modalities Public officials – expand access to
treatment for dependence & addiction Patients – secure your prescriptions
and dispose of unused drugs
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CHCF GRANT NoRxAbuse received one of twelve grants provided by
California HealthCare Foundation for opioid safety coalitions
Grant funds will support: Education of prescribers & patients Expansion of access to Mediation Assisted Treatment Expansion of access to Naloxone for treatment of opioid
overdose Safe disposal of Rx Drugs Better communication between law enforcement and providers
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JOIN OUR COALITION
We welcome all interested parties to join our efforts to improve patient safety
Many opportunities to help: Subscribe to our updates Attend meetings Join task force Professional expertise Financial or organizational support
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Rx Opiates In Shasta County
Andrew Deckert, MD, MPH, Health Officer,
Shasta County HHSA—Public Health February 4, 2016
WHAT ARE OPIOIDS? Illegal Drugs: Heroin
Prescription (Rx) medications used to treat pain: Morphine Codeine (eg Tylenol #3) Methadone Oxycodone (OxyContin, Percodan, Percocet) Hydrocodone (Vicodin, Lortab, Norco) Fentanyl (Duragesic, Fentora) Hydromorphone (Dilaudid) Buprenorphine (Subutex, Suboxone) Illegal Use of Rx Drugs RX opiates not prescribed to user RX drugs not used as prescribed, e.g. diversion (sold)
Opiates are a new epidemic
• 4x more pain meds sold since 1999 in US • No reported increase in population’s pain • Rx opiates questionable help for chronic pain • 44 people die every day in US fm Rx opiates CDC.gov/DrugOverdose/epidemic/index.html
The Story of A Pill Culture
US Drug Related Deaths
CDC, National Center for Health Statistics, National Vital Statistics System
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Rx Opioids
Cocaine
Heroin
Opioid Prescriptions per 1,000 residents, 2013
1,313
572
0
200
400
600
800
1,000
1,200
1,400
Shasta County California
Source: Brandeis PDMP Center of Excellence, analysis of CURES data, 2013
Source: CDPH EpiCenter, ER Visits with Primary Diagnosis/Ecode of Opioid Drug Poisoning, 2006-2014
27.4
45.5
39.1
27.7
32.7
40.4 39.2 40.9
56.9
10.5 11.3 12.9 14.2 14.1 16.0 16.5 17.4 18.4
0
10
20
30
40
50
60
2006 2007 2008 2009 2010 2011 2012 2013 2014
Rate
per
100
,000
Res
iden
ts
Shasta vs CA Rate of Emergency Department Visits Related to All Opioids (Poisonings)
Shasta County California
Source: OSHPD ER and Hosp data. Any dx or E-code ICD9- Heroin: 965.01, E850.0; All Opioids: 304.0, 304.7, 305.5, 965.00, 965.01, 965.02, 965.09, E850.0, E850.1, E850.2
Opioid Related ER Visits, Shasta Co, 2008-2013
4 6 4 7 11 26 44
421 363 386
440 480 474
854
0
100
200
300
400
500
600
700
800
900
2008 2009 2010 2011 2012 2013 2014
Num
ber o
f ER
Visit
s Shasta County Opioid Related ER Visits, 2008-2014
Heroin All Opioids
“Did you know that narcotic prescription-related ER visits
have more than doubled in Shasta?
We’re coming together to fix this, and your voice is
important. Come join our coalition.”
Source: OSHPD ER and Hosp data. Any dx or E-code ICD9- Heroin: 965.01, E850.0; All Opioids: 304.0, 304.7, 305.5, 965.00, 965.01, 965.02, 965.09, E850.0, E850.1, E850.2
Opioid Related Hospitalizations, Shasta Co, 2008-2013
4 3 2 1 4 9 9
321 298
387 390
548
631 609
0
100
200
300
400
500
600
700
2008 2009 2010 2011 2012 2013 2014
Num
ber o
f Hos
pita
lizat
ions
Shasta County Opioid Related Hospitalizations, 2008-2014
Heroin All Opioids
5.7
10.8
15.3 15.8
13.5
9.5
13.4
11.7
4.1 4.5 4.8 5.3 5.1 5.1 4.5
5.1
0
2
4
6
8
10
12
14
16
18
2006 2007 2008 2009 2010 2011 2012 2013
Rate
per
100,
00
Crude Rate of Opioid Pharmaceuticals Deaths
Shasta County California
Source: CDPH EpiCenter, Drug Poisoning Deaths, 2006-2013
“Did you know that someone dies every 2-3 weeks in
Shasta from drug overdose?
We’re coming together to fix this, and your voice is
important. Come join our coalition.”
In the VA, 50% of opioid OD deaths are on concurrent benzodiazepines2
– Among opioid users, risk of death goes up with benzodiazepines in a dose-response fashion
After opioids, benzodiazepines (anti-anxiety meds) are drug class most commonly involved in pharmaceutical OD deaths (30%) 1
1. Jones CM, et al. JAMA 2013;309 (70):657-659. 2. Park TW, et al. BMJ. 2015;350:h2698.
Benzodiazepines and Overdose Deaths
596.3
1,249.0
1,210.7
922.3
596.8
435.6
223.8
32.3
0 200 400 600 800 1,000 1,200 1,400
Rate per 1,000 CA Residents
Age
Gro
up
Opioid Prescribing Rates by Age group
<18
18-24
25-34
35-44
45-54
55-64
>= 65
Total
27% 25%
21%
0%
10%
20%
30%
40%
50%
2006-2007 2008-2009 2009-2011
Percent of Shasta County 11th graders who have ever used prescription pain killers to “get high”
Source: OSHPD Hospitalizations ICD 9: 7795 (Drug Withdrawal in Newborn) or 76072 (Narcotics affecting fetus or newborn via placenta or breast milk)
8.8 7.1 7.3
4.9 4.2 4.1
13.5
18.3
24.6 22.9
14.8
23.2 23.8
0
5
10
15
20
25
30
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Rate
per
1,0
00 Li
ve B
irths
Rate of Shasta County Newborns with Narcotics
62.4%
13.6%
4.9%
17.3%
0% 10% 20% 30% 40% 50% 60% 70%Percent of Prescriptions
Paye
r Sou
rce
Payment Source for Opioids California 2013
Cash
Medicaid
Medicare
Private insurance
Totals do not add to 100% because other
payment types are not shown.
Changing Face of Heroin Use in U.S.
• 80% of heroin users, who were mostly young city dwellers, initiated heroin first
1960s
• 75% of heroin users started using heroin after getting into opioid painkillers first… Older, more suburban/rural
Recent Years
T. Cicero et al JAMA Psychiatry. 2014;71(7):821-826. doi:10.1001/jamapsychiatry.2014.366
What’s happening now…
10 Drug Take Back events with 4500 pounds of meds
4 permanent pill Medication Disposal kiosks
Syringe Exchange Program has removed 250,000 dirty needles over 7 years
16 Sharps kiosks collecting 21,000 pounds of needles and syringes since 2006
www.thinkagainshasta.com website for parents
What’s happening now (continued)… Shasta HHSA active participant on the No Rx Abuse coalition, and helped secure grant funding
NO Rx Abuse applied for and will receive 50 naloxone autoinjectors (~$700 retail each)
HHSA has opiate treatment programs for all ages and contracts with AOD service providers
Upcoming medication assisted treatment trainings (eg Suboxone) for law enforcement, public and medical providers
Rx opiates and heroin both
Evidence -- Rx opiates significant local issue
To decrease heroin here, decrease Rx opiate abuse Other substances, polypharmacy (eg alcohol, meth, marijuana)
Prevention
Treatment
“Did you know that one in four Shasta 11th graders have
taken prescription painkillers that aren’t prescribed to
them?
We’re coming together to fix this, and your voice is
important. Come join our coalition.”
Managing Pain Safely: Progress on Reducing Opioid Overuse in the PHC Service Area
Michael Vovakes, MD Northern Region Medical Director Partnership HealthPlan of California February 4, 2016
Accomplishments: Review of PHC Opioid Prescription Data
MPS Data – Total Prescriptions
2013 2014 2015
0.00
10.00
20.00
30.00
Rx
22.8
10.5
27.7
13.7
MPS Lunched
Formulary Change
TAR Process Change
Opioid Prescriptions P100MPM
Overall
RegionNorthern
Southern
52% Decrease Jan 2014 – November 2015
2013 2014 2015
0.00
5.00
10.00
15.00
20.00
New
9.99
2.18
2.253.61
2.14
19.66
Initial Opiate Fills P100MPM
Region (copy) (group)
Overall
Region
Northern
Southern
MPS Data – Initial Prescriptions
39% Decrease Feb 2014 – November 2015
Project Launch
Formulary Change, MPS Forum I
Enhanced Benefits Implemented, TAR Process Change
2013 2014 2015
0%
5%
10%
15%
% o
7.5%
15.4%
8.3%
11.3%
6.2%
% Opioid Users on Unsafe Dose (>120 MED)
Region (copy) (group)Overall
Northern
Southern
MPS Data – Unsafe Dose
40% Decrease Jan 2014 – November 2015
Project Launch
Formulary Change, MPS Forum I
Enhanced Benefits Implemented, TAR Process Change
Percent Decrease of Unsafe Dose
52 Moore R. CMO Report on Quality. Dec. 2015
63 64 63 58
47 49
22
46 42
46 47 48
66
48
0
10
20
30
40
50
60
70
80
90
100
% Decrease Unsafe Dose December 2013-November 2015
Accomplishments: Health Plan Activities
MPS Workgroups
Pharmacy
Provider Network
Care Coordination/Utilization Management/ Member Services
Legislative Policy/Regulation/Communication
Community Support MPS
Tec
hnic
al S
uppo
rt Data Management
MPS
Ste
erin
g Co
mm
ittee
Education Health plan pharmacy prior authorization changes Additional options for treating pain (chiropractic, acupuncture) Community activation Aligned incentives Additional resources
Interventions
Accomplishments: Community Coalitions
PHC Counties Participating in CHCF Regional Opioid Safety Coalition Grant Program
10 PHC Counties are participating in CHCF’s Regional Opioid Safety Coalition Grant Program
CHCF Opioid Safety Coalition County
Community Coalition Status
58
1
5
3
2
5
2 2
4 4
1
3
4
1
2
PHC COUNTY COALITION STATUS
Key
1 Little or No Effort (Yet)
2 Initial Meetings, Beginning of Framework Formation
3 Framework Formation, Action Teams Initiating
4 Strong Effort- Framework Implemented, Regular Meetings, Active Action Teams, Working towards Milestones
5 Robust Effort- Active Action Teams, Accomplishing Milestones, Measurable Results
Accomplishments: Primary Care Providers
Opioid Oversight Committees Setting up Health Center-wide policies (like Safe Prescribing Committee at SCHC) Tapering Integrated Behavioral Health Talking to patients, one by one
Interventions
Progress Towards Goal
By December 31, 2016, we will improve the health of PHC members by ensuring that prescribed opioids are for appropriate indications, at safe doses, and in conjunction with other treatment modalities as measured by a:
• Decrease in total number of initial prescriptions by 75% • Decrease in total number of prescription escalations by 90% • Decrease in total number of patients on high-dose opioids* by 75%
Managing Pain Safely – Aim Statement
*Defined as greater than 120 mg. MED
Achieving Our Goal: I Health Plan Activities for 2016
Provision of tele-consult services for complex patients on high-dose opioids Education and coordination around addiction screening and treatment Partner with CHCF for continued support in developing and sustaining local efforts targeted at reducing improper use of opioids Planning process for creating integrated clinics for high utilizers Pharmacy academic detailing MPS provider level data sharing Tapering guide/ toolkit Naloxone Pilot
Looking Ahead in 2016: Health Plan Activities
Achieving Our Goal: II State Wide Activities
Support for Community Coalitions Planning for Integrated Approach to Patients on High Doses of Chronic Opioids CDC Guidelines CURES 2.0
Looking Ahead in 2016: State Wide Activities
Achieving Our Goal: III Prescriber Activities
• Sign up for tele-consult services for complex patients on high-dose opioids
• Make local opioid oversight committees more robust • Participate in regional coalitions • Give feedback on draft plan for integrating chronic pain
treatment with Medication Assisted Therapy • Ask your PHC Regional Medical Director to meet with
you and/or your clinicians to review their individual PHC opioid data and to review MPS
• Tapering guide/ toolkit • Distribute Naloxone and educate patients/families on how to use it.
Looking Ahead in 2016: Prescriber Activities
CHRONIC PAIN MANAGEMENT IN FAMILY PRACTICE
Candy Stockton, MD
Medical Director, Shingletown Medical Center
Pharmacist's perspective on Chronic Pain Management William A. Ranker, PharmD MBA
Corresponding Responsibility
A prescription for a controlled substance shall only be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his or her professional practice.
The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription.
Even after conferring with the prescriber, a pharmacist shall not compound or dispense a controlled substance prescription where the pharmacist knows or has objective reason to know that said prescription was not issued for a legitimate medical purpose.
The community pharmacist's perpetual awkward position Healthcare's "Bad-guy" ?
Prescriber-pharmacist relationship Strained colleagues?
Pharmacist-patient relationship Often "displeased"
Pharmacist-Pharmacy relationship We are mostly employees.
Pharmacist-regulator relationship Get out your ticket book!
Pharmacy Quantity Restrictions
Pharmacies in our county are restricted in the quantity of narcotics they can purchase from drug wholesalers for dispensing each month
Utilitarianism presides
A pharmacist's determining factors in narcotic Rx acceptance Monthly quantity
Established patient at pharmacy?
Getting all medications at your pharmacy (i.e. maintenance meds)
Is the prescriber (and office) a good communicator?
Is the prescriber following established pain management guidelines?
Is the prescriber utilizing monitoring tools?
Does the prescriber have ample documentation procedures in place?
CURES/PDMP
A valuable resource often untapped
Rx Drug abuse and the Workplace
Indiana's Rx Abuse Task Force Survey
Respondents consisted of 200+ companies with 50+ employees
80% Reported problems related to workers misusing Rx drugs
33% Reported accidents tied to Rx drug misuse
Driving under the influence of Prescription drugs Benzodiazepines affect motor reflexes without regard to length of use
(tolerance)
Lack of counseling by prescribers and pharmacists about risks
Duty to report
Inaction is no longer an option No more intentional walks
LAW ENFORCEMENT PERSPECTIVE ON ABUSE OF PRESCRIPTION DRUGS
Eric Magrini
Undersheriff, Shasta County
CALL TO ACTION
Ivan Petrzelka, PharmD, JD, MBA
www.NoRxAbuse.org
QUESTIONS
85
THANK YOU
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