Lewis Nelson, MDRutgers New Jersey Med School

Reducing the Risk of Opioid Harm

Lewis S. Nelson, MDRutgers New Jersey Medical School

Consequences of opioid use

HyperalgesiaAddiction

Abuse

Overdose/Death

“Long term use”

Opioid use disorderDependence

Tolerance

Prescription Drugs• Addiction, Abuse• Overdose• Deaths >19,000/yr• $500B annually

Three Inextricable Concurrent Epidemics

Chronic Pain• >100 million pts• $635 billion (APS)

• CV ($309 billion)• Cancer ($243 billion)• Diabetes ($188 billion)

Illicit Opioids• Addiction, Abuse• Overdose• Death (>25,000/yr )• Cost (uncountable)

3280

20,100

15,40014,400

Cocaine: 10,600

NCHS Data Brief, Dec 2017

An Epidemic of Iatrogenic Addiction

The Best Way To Treat Opioid Addiction Is To Prevent It

You Cannot Develop Opioid Addiction Without Exposure To An Opioid

Keep Opioid Naïve Patients Opioid Naïve

(as best as possible)

Limit opioid initiation Pain management

guidelines Alternatives to opioids Prescribing guidelines

Safe opioid use Default prescribing EHR

Regulatory limits Order sets

Nudge prescribers Patient education

Prescription Monitoring Program

Addiction management Mediation-assisted

therapy Reduce barriers to

treatment Linkage to care/warm

handoff Recovery support

Three things we CAN do about it?

Harm reduction Naloxone

distribution/prescribing Public health

interventions Recovery coaches Family engagement

Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.

July 15, 2016

New York City Department of Health and Mental Hygiene

Neurology 2014;83:1277-1284

www.solvethecrisis.org/best-practices

Improve consistency (reduce variability) of pain management and limit opioid use

(Multimodal analgesia)

Reduce harm of opioid prescribing, while maintaining appropriate use

(Safe opioid use)

Keep Opioid Naïve Patients Opioid Naïve(as long as possible)

Why Use Guidelines

Presenter

Presentation Notes

They may be wrong: Evidence is limited or subjective Guideline developers may be conflicted They may be misapplied: May not apply to all patients Interpreted as rules vs guidelines Be careful reading guidelines in which you don’t know the integrity of the source . You may die of a conflict of interest. Get your facts first, then you can distort them as you please If you don’t read the newspaper you are uninformed. If you do read the newspaper, you are misinformed.

Strategies to Curb the Opioid Epidemic: Mandatory Education

newjersey.pmpaware.net

• Provider decides when to search • PDMP found • PDMP searched (~52 clicks)

Best practice (and the law) is to review the NJ PMP prior to prescribing an opioid.`

Pull

Push

Analgesic Order Sets

Morphine sulfate immediate release

J Gen Intern Med. 2018;33(4):409–11

ED Opioid Prescribing

Baseline Performance relative to group, blinded

Performance relative to group, unblinded

West J Emerg Med. 2016 ;17(3):258-63

Pres

crib

ing

rate

Limit opioid initiation Pain management

guidelines Alternatives to opioids Prescribing guidelines

Safe opioid use Default prescribing EHR

Regulatory limits Order sets

Nudge prescribers Patient education

Prescription Monitoring Program

Addiction management Mediation-assisted

therapy Reduce barriers to

treatment Linkage to care/warm

handoff Recovery support

Opioid stewardship program

Harm reduction Naloxone

distribution/prescribing Public health

interventions Recovery coaches Family engagement

Lewis.Nelson@Rutgers.edu@LNelsonMD