Opioid Use and Misuse: Current Perspectives

John Sorboro, MD, ABPNDiplomat, American Society of Addiction Medicine

Chief Medical Officer Behavioral Health, HSAGJune 13, 2019

Transition SlideUsed for changing topics

How Drug Overdose Mortality Has Changed

3

How Drug Overdose Mortality Has Changed

4

Deaths in 2017

NOTES: Deaths are classified using the International Classification of Diseases, 10th Revision. Drug-poisoning (overdose) deaths are identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14.

Source: NCHS, National Vital Statistics System, Mortality.5

Prescription Opioid Deaths

6

Heroin Has Not Gone Away

7

It’s Not Just Opioids!

8

Amphetamine Deaths

9

A Deadly Combination

10

Not So Antidepressant

11

The Top 10

1) Fentanyl2) Heroin3) Cocaine4) Methamphetamine5) Alprazolam6) Oxycodone7) Morphine8) Methadone9) Hydrocodone10) Diazepam

https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf

12

Where Are We Heading With Benzos?

13

Changes in Benzodiazepine Prescribing

• National Ambulatory Medical Care Survey (NAMCS) from January 1, 2003, through December 31, 2015.

• Looked at eight commonly prescribed Benzodiazepines• The benzodiazepine visit rate increased from 3.8% to 7.4%.• 127% increase in the absolute number of benzodiazepine

visits occurred.• The unadjusted benzodiazepine visit rate did not change

among visits to psychiatrists, but increased among visits to primary care, surgeons and medical specialists.

• Largest increase: back and chronic pain and instances in which we were unable to attribute the benzodiazepine to a particular indication.

14

Benzodiazepine and Opioid Prescriptions, 2015

• Benzodiazepines and opioids co-prescribed • 19.2% of opioid visits got a BNZ• 26.4% of BNZ visits got an opioid• Rate at which benzodiazepine and opioid

prescriptions were noted in a single visit quadrupled from 0.5% to 2.0%

15 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2722576

Prescribe?BNZ?

16

Opioid?Muscle

Relaxer?

Benzodiazepines Over Time

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/201995517

Why Is This Happening?

18

Such a Pretty Flower!

19

To This…

20

U.S. and Europe Total Opioid Consumption: 1980–2015

21

Opioid Prescribing

Source: National Prescription Audit (NPATM), 2012. Data from IMS. Accessed on: September 28, 2018. Available at: https://www.cdc.gov/vitalsigns/opioid-prescribing/infographic.html

This color-coded U.S. map shows the number of painkiller prescriptions per 100 people in each of the fifty states plus the District of Columbia in 2012.

22

State Ranking of Fatal Overdoses/100,000

1. West Virginia — 49.62. Ohio — 39.23. District of Columbia — 34.74. New Hampshire — 345. Maryland — 32.217. Tennessee — 19.323. Florida — 16.329. Arizona — 13.530. Nevada — 13.331. Oklahoma — 10.2

CDC's National Center for Health Statistics23

State Ranking of Opioid Sales: 2017

1) Tennessee 44.3kg (*17)2) Oklahoma 43.1kg (*31)3) Nevada 40.5kg (*30)8) Arizona 32.9kg (*29)14) West Virginia 30.7kg (*1)17) Florida 29.4kg (*23)31) Ohio 23.1kg (*2)51) District of Columbia 10.6kg (*3)

24

Largest Reductions in Opioid Sales: 2010–2017

1) Florida 61%4) West Virginia 42%5) Nevada 38%6) Ohio 37%8) Tennessee 36%18) District of Columbia 25%

25

Number of Opioid-Related Deaths Grew 2.8 Times from 2002–2015

26 Source: National Institute on Drug Abuse. Overdose Death Rates. National Drug Overdose Deaths (Figure 1). Accessed on April 15, 2019. Available at https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/national_drug_overdose_deaths_through_2017.pdf.

What Is Killing People? Pt.1

Fatalities at 42,000 in 2016 (CDC)

Nearly double casualties in 2010; >5x 1999 figures

False narrative?

Patients addicted to doctor-prescribed opioids

Nonmedical use of prescription opioids peaked in 2012

CDC = The Centers for Disease Control & Prevention

27Source: National Institute on Drug Abuse. The National Survey on Drug Use in Health. Accessed on April 15, 2019. Available at https://www.drugabuse.gov/national-survey-drug-use-health.

What Is Killing People? Pt.2

1. Minozzi, S., Amato, L. Development of dependence following treatment with opioid analgesics for pain relief: a systematic review. Addiction 2012 . Accessed on April 15, 2019. Available at https://onlinelibrary.wiley.com/doi/full/10.1111/j.1360-0443.2012.04005.x.

2. Volkow, N.D., McLellan, A.T. Opioid Abuse in Chronic Pain—Misconceptions and Mitigation Strategies. N Engl J Med 2016; 374:1253–1263. Accessed on April 15, 2019. Available at https://www.nejm.org/doi/full/10.1056/NEJMra1507771.

Minority of those prescribed opioids develop opioid use disorder

Diversion of many drugs is common and difficult to prevent

28

What Is Killing People? Pt.3

Of 136K patients in ERs treated for opioid overdoses, 13% were chronic pain patients (JAMA, 2014)

Heroin and fentanyl use increases are strongly correlated with increased opioid deaths1

95% of overdose deaths are related to polypharmacy2

JAMA = Journal of the American Medical Association

291. CDC. National Vital Statistics Reports Vol. 65, No.10, December 20, 2016. Available at: https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_10.pdf

Accessed on: September 28, 20182. Richard M. Fairbanks School of Public Health. Polypharmacy Among Prescription Drug Users. August 2017 Accessed on April 16, 2019. Available at

https://fsph.iupui.edu/doc/research-centers/polypharmacy-among-prescription-drug-users.pdf

Novel Synthetic Opioids

• AH-7921• U-47700• MT-45• Butyryl-fentanyl• ???

30

How Did We Get Here?

31

America: The Farewell Tour…

32

What Can We Do?

33

“That hurts! You got 2 vital signs?”

Is Your Pain a 1 or a 75?

35

Movement to a Multi-Dimensional Tool

36

Better Measurement Tools

https://www.sciencedirect.com/science/article/pii/S235264671500109X37

You have 7 days to live and your

7 minutes are up.

Huh?

38

Why Do We Consume so Many Prescription Drugs?

*Includes Africa, Asia, and Australia39

How Many Should We Give? (5mg Oxycodone)

• Partial mastectomy: 5 pills• Partial mastectomy with sentinel lymph node

biopsy: 10 pills• Laparoscopic cholecystectomy: 15 pills• Laparoscopic inguinal hernia repair: 15 pills• Open inguinal hernia repair: 15 pills

https://www.uptodate.com/contents/prescription-of-opioids-for-acute-pain-in-opioid-naive-patients/abstract/1840

Leftovers Are Not Good

• Patients used 27% of the opioids prescribed to them.

• Prescription size had the strongest association with opioid consumption after surgery

• Patients using an additional 5 pills for every 10 extra pills prescribed.

• Significant disparities between the quantity of opioids prescribed and consumed after surgery.

41

What Is Opioid Stewardship?

• Leadership Commitment and Culture• Organizational Policies• Clinical Knowledge, Expertise and Practice• Patient and Family Education & Engagement• Tracking, Monitoring & Reporting • Accountability• Community

42

Different Patient/Different Needs

• Opioid Naïve: Not been exposed to opioids in the past 30 days

• Opioid Exposed: History of chronic pain who have been prescribed opioids daily for long periods of time (months to years), opioid tolerant

• Opioid Use Disorder: Individuals with a history of escalating patterns of opioid use despite negative consequences in health, family work and other areas of their life.

43

Opioid Prescriber Education

• One-hour mandatory narcotics-prescribing education program

• Postoperative opioid-prescribing guidelines(hand, sports, and foot and ankle services)

• The decrease in pills prescribed in the post-intervention group (6 procedures) amounted to 30,000 fewer opioid pills prescribed per year

• Knee arthroscopy (6), Shoulder arthroscopy (6), Hip arthroscopy (16), Hand (13–21)

44

We Still Have Work!

https://www.cdc.gov/drugoverdose/images/vitalsigns/VS_MME-Prescribing-Graphic_508.pdf45

Have We Evolved To Be Self-Destructive?

46

Thank you!John Sorboro, MD, ABPN

Diplomat, American Society of Addiction MedicineChief Medical Officer Behavioral Health, HSAG

June 13, 2019

This material was prepared by Health Services Advisory Group, Inc., the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the

U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-11SOW-C.3-05282019-14.

CMS Disclaimer