24
Opioids and Butte County Community Goal and Voluntary Community Prescribing Guidelines ANDY MILLER M.D. BUTTE COUNTY PUBLIC HEALTH OFFICER
Opioids and Butte County
Community Goal and Voluntary Community Prescribing
Guidelines
ANDY MILLER M.D.
BUTTE COUNTY PUBLIC HEALTH OFFICER
Opioid Deaths
“Nationally, corrected opioid and heroin involved mortality rates
were 24% and 22% greater than reported rates”
American Journal of Preventative Medicine August 7 2017
The United States
Americans are 4.6% of the world population
Americans use 80% of the world’s painkillers
Americans use 99% of the world’s hydrocodone
“A government survey found that the number of people who
reported using heroin in the previous year rose from 373,000 in 2007
to 620,000 in 2011. Eighty percent of them had used a prescription
painkiller first”.
Dreamland
Opioid Deaths
National Vital Statistics System. United States Department of Health and Human Services. Centers for Disease Control and Prevention, NationalCenter for Health Statistics. Multiple Cause of Death on CDC WONDER Online Database. wonder.cdc.gov Accessed Mar 2017.
Any Substance-Affected Diagnosis for Still- or Live-Born Infants Age 0 to 89 Days, per 1,000 hospital Still- or Live-Births Butte compared to California
• Numerator: Any hospitalization with a substance-affected diagnosis for still- or live-born infants age 0 to 89 days, by place of residence in one calendar year
• Denominator: The total number of hospital still- or live-births, by place of residence in one calendar year
• Data Source: Office of Statewide Health Planning and Development (OSHPD). Hospital discharge data.
26.0 27.5
21.7
31.9 32.0
23.2
27.8
22.7 21.3
25.3
19.9
37.3
11.5 12.8 14.2 14.4 14.7 13.4
15.8 18.6
21.0 20.2 22.5 23.4
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Butte Lower Upper California
MMWR July 7, 2017
MMWR July 7, 2017
Butte County MME per resident
The national average is 640 MME/resident/year (2015).
Butte county:
1880.6 MME/resident/year without MAT (2015, CDC)
2140 MME/resident/year with MAT (2016, CURES)
A lethal dose of morphine is 200 mg
This equates to about 200 Norco for each resident of Butte County
each year
Reduces mortality
Cost effective
Intra nasal and injectable
Is safe
Is not a controlled substance
Can be dispensed without a Rx
Low potential for misuse
Safe during pregnancy
Is a long-term medication
Reduces mortality
Requires training and a waiver
Often co-formulated with naloxone
A Community Goal
A measurable metric that we agree as the primary goal.
MME/resident/year
“Our goal is to decrease the MME/resident/year in
Butte County to the most recent national
average”.
Present National Average is 640 MME/res/yr.
Butte County Voluntary Prescribing
Guidelines General Guidelines for all Prescribers
Strongly consider not starting opioids for chronic conditions. The evidence that
chronic opioid use improves pain or quality of life is weak and the evidence for
individual and community harm is strong.
If you choose to use opioids, use the smallest dose for the shortest amount of
time. Discuss the duration of treatment prior to starting an opioid.
Every person on daily 50 MME dose or higher will be prescribed naloxone.
Check CURES with each new controlled substance prescription and at least every 4 months for on-going prescriptions. This is the law in California.
Patients may take an opioid or a benzodiazepine, but not both.
We do not recommend using soma for any reason.
Butte County Voluntary Prescribing
Guidelines
Primary Care
The maximum daily MME dose that primary care will support is 90mg. We suggest that
doses above this require specialty care to manage the higher risk. If patients are seen
by a specialist who recommends a higher MME, that medication dose will be
maintained by the specialist.
The health care community supports primary care providers who choose not to
prescribe chronic opioids to their patients.
Butte County Voluntary Prescribing
Guidelines Emergency Care
Every person seen for an overdose that includes opioids will receive naloxone or a prescription for naloxone upon discharge.
Emergency rooms will not provide temporary or replacement doses for chronic pain patients. This includes lost, stolen or destroyed medications. It also includes those missing
methadone doses.
Emergency rooms will check CURES for each patient receiving any opioid medication.
Nothing stronger than Percocet will be prescribed from an ER
All opioid prescriptions should be limited to 20 or less pills.
No refills for opioids should be given.
Opioid prescriptions should not be dispensed more frequently than every thirty days. Regardless of chief complaint.
The Plan for these Guidelines
Endorsed by:
1. Butte Glenn Medical Society
2. Sunrise Rotary Club
3. Butte County District Attorney
4. Butte County Public Health
Hoping for endorsements from:
1. All four area hospitals
2. Organized Outpatient Clinics
3. Butte County Sheriff’s office
4. City Councils
5. Area Universities
6. Butte County Board of Supervisors
1. Present and refine the
Guidelines
2. Receive endorsements
from the Community
3. Create posters and
distribute
4. Add additional guidelines
and continue refining Pain management, Pharmacies, Surgeons,
Dentists, etc.
What else are we doing to address
opioids in Butte County?1. All area hospitals and organized outpatient clinics are working
internally to address opioids.
2. Butte Substance Abuse Prevention Task Force – meets monthly
3. Trying to add a opioid education lesson to county high school
health classes. Join effort with local colleges to build a panel of
speakers.
4. Butte County Behavioral Health of Butte County Office of
Education are doing primary prevention work related to all
substance use.
5. Chico State and Butte College are both working to address their
student populations.
Thank you!
Risk / Benefit
CDC Guidelines
In summary, evidence on long-term opioid therapy for chronic pain outside of end-of-life care remains limited, with insufficient evidence to determinelong-term benefits versus no opioid therapy, though evidence suggests risk for serious harms that appears to be dose-dependent”
No evidence shows a long-term benefit of opioids in pain and function versus no opioids for chronic pain with outcomes examined at least 1 year later. Extensive evidence shows possible harms of opioids.”
Washington State Guidelines
“Because there is little evidence to support long term efficacy of COAT in improving function and pain, and there is ample evidence of its risk for harm, prescribers should proceed with caution when considering whether to initiate opioids or transition to COAT.”
Opioid medications continue to injure and kill too many Butte County Residents. The rate of opioid
prescriptions in Butte County is twice that of our state. The amount of opioids prescribed to Butte
County residents is three times the national average. The Butte County Substance Abuse Task Force,
working with a coalition of concerned physicians, have created the following Butte County Chronic
Opioid Prescribing Guidelines.
General Guidelines for all Prescribers
1. Strongly consider not starting opioids for chronic conditions. The evidence that chronic opioid
use improves pain or quality of life is weak and the evidence for individual and community harm
is strong.
2. If you choose to use opioids, use the smallest dose for the shortest amount of time. Discuss the
duration of treatment prior to starting an opioid.
3. Every person on daily 50 MME dose or higher for more than two weeks will be prescribed
naloxone.
4. Check CURES with each new controlled substance prescription and at least every 4 months for
on-going prescriptions. This is the law in California.
5. Patients may take an opioid or a benzodiazepine, but not both.
6. We do not recommend using soma for any reason.
Primary Care
1. The maximum daily MME dose that primary care will support is 90mg. We suggest that doses
above this require specialty care to manage the higher risk. If patients are seen by a specialist
who recommends a higher MME, that medication dose will be maintained by the specialist.
2. The health care community supports primary care providers who choose not to prescribe chronic opioids to their patients.
Emergency Care
1. Every person seen for an overdose that includes opioids will receive naloxone or a prescription
for naloxone upon discharge.
2. Emergency rooms will not provide temporary or replacement doses for chronic pain patients.
This includes lost, stolen or destroyed medications. It also includes those missing methadone
doses.
3. Emergency rooms will check CURES for each patient receiving any opioid medication.
4. Nothing stronger than Percocet will be prescribed from an ER
5. All opioid prescriptions should be limited to 20 or less pills.
6. No refills for opioids should be given.
7. Opioid prescriptions should not be dispensed more frequently than every thirty days. Regardless
of chief complaint.
