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Opioid Analgesic Use, Overuse, and Abuse among Patients at University Health Centers

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Opioid Analgesic Use, Overuse, and Abuse among Patients at University Health Centers ACHA Meeting May 31, 2012 David C. Dugdale, MD Director, Hall Health Primary Care ... – PowerPoint PPT presentation

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Title: Opioid Analgesic Use, Overuse, and Abuse among Patients at University Health Centers


1
Opioid Analgesic Use, Overuse, and Abuse among
Patients at University Health Centers
  • ACHA Meeting
  • May 31, 2012
  • David C. Dugdale, MD
  • Director, Hall Health Primary Care Center
  • Division of General Internal Medicine
  • University of Washington
  • dugdaled_at_uw.edu

2
Disclosures/Financial Relationships
  • I have NO actual or potential conflict of
    interest in relation to this educational activity
    or presentation
  • I consult about pt education materials for the
    following companies
  • ADAM Corp
  • Milliman Care Guidelines

3
Acknowledgements
  • Mary Watts, MD
  • Associate Director for Medical Affairs, Hall
    Health
  • Division of General Internal Medicine, UW
  • Alex Cahana, MD
  • Director, UW Pain Center
  • Division of Pain Management, UW

4
OverviewLearning Objectives
  • Describe the scope of opioid use
  • Definitions (5 minutes)
  • Issues concerns (20 minutes)
  • Compare and contrast opioid use for chronic and
    acute pain syndromes (10 minutes)
  • Describe our clinical approach and QI program
    aimed at chronic pain management (20 minutes)
  • Describe our clinical approach and QI program
    aimed at acute pain management (20 minutes)

5
Self-assessment Questions IAll True-False
  • Drug tolerance is defined as a drug-induced loss
    of effect over time
  • In the US, the annual death rate from
    unintentional drug overdose has been about the
    same from 2003 to 2007
  • Pills left over from a valid prescription are a
    common source of opioids diverted for non-medical
    use

6
Self-assessment Questions IIAll True-False
  • In the US, the most commonly prescribed opioid is
    methadone
  • Hydrocodone is about a tenth as strong as
    morphine
  • Chronic pain management emphasizes function over
    complete pain control

7
Scope of Opioid Use Definitions
  • Pain
  • Narcotics
  • Opiates
  • Opioids
  • Drug
  • Dependence
  • Tolerance
  • Abuse
  • Addiction
  • Diversion

8
Scope of Opioid Use Definitions
  • Pain
  • A subjective, unpleasant sensory and emotional
    experience
  • Acute painacute tissue injury
  • Chronic pain
  • Cancer pain
  • Chronic non-malignant pain
  • Pain is usually due to apparent external
    stimulus, but not always
  • Pain intensity is modulated by many physiologic
    and psychosocial factors

9
Scope of Opioid Use Definitions
  • Narcotics
  • This term is widely used to mean something other
    than opiates or opioids
  • Original meaning any substance with
    sleep-inducing properties
  • Its imprecision as a term makes it undesirable

10
Scope of Opioid Use Definitions
  • Opiates vs. opioids
  • Opiate means something naturally derived from
    opium
  • Codeine and morphine are the clinically most
    important opiates

11
Scope of Opioid Use Definitions
  • Opiates vs. opioids
  • Opioids includes opiates plus synthetic or
    semi-synthetic derived substances
  • Fentanyl (Duragesic)
  • Hydrocodone (Vicodin and others)
  • Hydromorphone (Dilaudid)
  • Methadone
  • Oxycodone (Percocet and others)

12
Scope of Opioid Use Definitions
  • Drug Dependence
  • Characterized by the occurrence of withdrawal
    symptoms with the abrupt cessation of a drug
  • Drug Tolerance
  • Drug-induced loss of effect (over time)
  • Often associated with dose escalation

13
Scope of Opioid Use Definitions
  • Drug Abuse
  • Use of a drug in a manner that deviates from
    medical, legal, or social standards
  • Commonly used alternative terms
  • non-medical use
  • illicit use
  • An important concern of all college health
    programs

14
Scope of Opioid Use Definitions
  • Drug Addiction is a disease (UpToDate)
  • With a strong genetic component
  • Affects 10 of people
  • Defined by aberrant drug-taking behavior
  • Craving
  • Loss of control
  • Compulsive use
  • Continued use despite harm

15
Scope of Opioid Use Definitions
  • Drug Diversion (UpToDate)
  • Distribution of a drug into the illicit
    marketplace
  • A strong likelihood that diversion of prescribed
    drugs is occurring MUST stop
    prescribing
  • Suspected abuse or addiction
    prescribing may legally continue if appropriate
    medical actions are being taken to
  • stop the behavior
  • regain control over the prescribing, and
  • manage the medical and psychiatric condition of
    the patient

16
Scope of Opioid Use--Issues
  • Acute pain setting
  • Acute pain management is usually straightforward,
    but using opioids brings a number of possible
    issues and complications
  • Although there are well established typical
    doses, significant variations in response occur
  • Sedation can be profound, and
  • Inadvertent overdoses are possible in the acute
    pain management setting

17
Scope of Opioid Use--Issues
  • Longer term opioid use can be associated with
  • physical dependence
  • tolerance and dose escalation
  • addiction with pervasive psychological, social,
    and physical harm
  • harms that can be accidental!

18
Scope of Opioid Use--Issues
  • Opioids can be drugs of abuseeuphoriaand if
    overused can lead to excess sedation, coma, and
    death
  • Fatal overdoses can be accidental or intentional
  • Opioids are controlled substancestherefore there
    are legal and regulatory issues related to their
    use

19
Scope of Opioid Use--Issues
  • Chronic pain mgmt is far more complex than acute
    pain management
  • Application of the principles of acute pain
    management or cancer pain management has created
    a clinical morass
  • This started in the late 1980s
  • The field of Chronic Non-Cancer Pain has
    developed to address this
  • The role of opioids in this domain has generated
    intense controversy

20
Scope of Opioid Use--Issues
  • Relevance to college health settings
  • There are rising concerns about use, overuse, and
    abuse of opioid analgesics in all people in the
    US
  • There are special concerns about adolescents and
    young adults
  • Nonmedical use of opioids by young adults is
    one of the most common forms of drug abuse

21
Drug Overdose and Opioid use in the US
Statistical Overview
22
US Deaths in 2008
  • Drug overdose 36,450
  • Motor vehicle accidents 39,973

MMWR 2011431487-1492
23
Washington State Deaths
  • Accidental death from poisoning recently
    surpassed death from motor vehicle accidents as
    the 1 cause of death of young adults in
    Washington State
  • Of deaths by drug overdose, 55 were due to
    prescription drugs
  • Opioids were implicated in 74 of these

24
US Drug Overdosesan Epidemic
Okie S. NEJM 2010363(21)1981-1985
25
US Drug Overdoses by Agent
Okie S. NEJM 2010363(21)1981-1985
26
Drug Overdose Death Rates (US, 2008 per 100,000
people)
Intent All drugs Prescription drugs Opioids Illicit drugs
Overall 11.9 6.5 4.8 2.8
Unintentional 9.2 4.8 3.9 2.6
Undetermined 1.1 0.6 0.5 0.2
Suicide 1.6 1.1 0.5 0.1
MMWR 2011431487-1492
27
Drug Overdose Death Rates(US, 2008 per 100,000
people)
Gender All drugs Prescription drugs Opioids Illicit drugs
Overall 11.9 6.5 4.8 2.8
Men 14.8 7.7 5.9 4.3
Women 9.0 5.3 3.7 1.4
MMWR 2011431487-1492
28
Drug Overdose Death Rates (US, 2008 per 100,000
people)
Age (yrs) All drugs Prescript drugs Opioids Illicit drugs
Overall 11.9 6.5 4.8 2.8
15-24 8.2 4.5 3.7 2.2
25-34 16.5 8.8 7.1 4.4
35-44 20.9 11.0 8.3 5.3
45-54 25.3 13.8 10.4 6.0
MMWR 2011431487-1492
29
US Opioid Usealso an Epidemic
  • 100 million prescriptions for hydrocodone per
    year
  • Top drug by of prescriptions dispensed
  • US has 4 of the worlds population
  • Uses 99 of worlds supply of hydrocodone
  • Uses 80 of worlds supply of opioids
  • 3 of the US population without cancer (8
    million people) are regular users of opioids

http//www.rxlist.com (accessed
1/5/2012) Sullivan, et al. Pain 200511995-103.
30
US Opioid Sales
  • Sales of opioids
  • 2010 7.1 kg per 10,000 people (710 mg per person
    per year)
  • Thats 142 Vicodins per person per year!!
  • 2010 sales were 4 fold greater than 1999 sales

MMWR 2011431487-1492
31
US Opioid Overdose and Sales Rates
Kuehn BM. JAMA 2012(1)19-21
32
US Opioid Prescribing Patterns
  • 3 of physicians accounted for 62 of opioids
    prescribed

MMWR 2011431487-1492
33
Association between Drug Overdose Deaths Sales
of Opioids
  • Range of annual sales (kg per 10,000 people)
  • 3.7 kg (IL) 12.6 kg (FL)
  • Among the 27 states with OD rates above national
    mean
  • 21 had rates of opioid sales above the national
    mean
  • Among the 24 states with OD rates at or below
    national mean
  • 5 had rates of opioid sales above the national
    mean

MMWR 2011431487-1492
34
Nonmedical Use of Opioids
  • Range of prevalence of nonmedical use of opioids
  • 3.6 (NEB) 8.1 (OK)

MMWR 2011431487-1492
35
Association between Drug Overdose Deaths
Nonmedical Use of Opioids
  • Among the 27 states with OD rates above national
    mean
  • 21 had rates of nonmedical use above the national
    mean
  • Among the 24 states with OD rates at or below
    national mean
  • 6 had rates of nonmedical use above the national
    mean

MMWR 2011431487-1492
36
2012 National Drug Control Strategy
  • Has 7 core areas of focus
  • Prevention, early intervention, treatment,
    disruption of distribution
  • Identifies 13 important steps forward
  • Step 4 is responding to the prescription drug
    abuse epidemic
  • The Administrations Prescription Drug Abuse
    Prevention Plan, focusing on education,
    monitoring, proper disposal, and enforcement

http//www.whitehouse.gov/ondcp/2012-national-drug
-control-strategy, accessed May, 2012
37
Drug Abuse and Overdoses in the US Summary
  • A serious problem, especially among younger
    adults as a portion of cause of death
  • A growing problem
  • It seems virtually certain that the rising
    prevalence of prescribed opioids has contributed
    to this

38
Opioid Prescriptions and Non-medical Use or
AbuseSome Data
39
Opioid Prescription Trends in Adolescents 2001
2005
  • 20-40 of adolescent patients with common pain
    syndromes received opioid prescriptions

Richardson, et al. Gen Hosp Psych 201133423-428
40
Drug Abuse Rates
  • For adults age 18-25, rate of drug abuse in
    previous month (excluding alcohol)
  • All drugs 21.5
  • Marijuana 18.5
  • Nonmedical use of psychotherapeutic agents 5.9
  • Hallucinogens 2.0
  • Cocaine 1.5

National Survey on Drug Use and Health (2010)
41
Drug Abuse Rates
  • Nonmedical use of psychotherapeutic agents
  • Pain relievers 49
  • Tranquilizers 36
  • Stimulants 15

National Survey on Drug Use and Health (2010)
42
Drug Diversion
  • Sources of diverted opioids include
  • Relative or friend
  • 55 for free
  • 11 bought
  • 5 took without asking
  • Use or sharing of leftover prescribed opioids
  • Illicit drug purchases (5)

National Survey on Drug Use and Health (2010)
43
Frequency () of Non-prescribed Use of
Prescription Drugs in past 12 Months College
Students
Drug Class Male Female All
Antidepressant 2.9 3.3 3.2
ED drugs 1.4 0.8 1.0
Pain killers 8.6 6.8 7.5
Sedatives 4.4 4.1 4.3
Stimulants 8.7 7.2 7.8
1 or more of the above 15.5 14.0 14.6
NCHA-II, spring, 2011
44
Risk Factors among College Students for
Non-medical Prescription Drug Use
  • 2008 survey of 599 undergrads at SE university
  • Assessed substance use in previous year
  • Males, Greeks, and freshmen more likely to use
    non-medical prescription drugs
  • Multivariate analysis found that the MOST
    influential factors were
  • Excessive alcohol use
  • Other illicit drug use

Lanier, et al. JACH 201159(8)721-727
45
Characteristics of Prescription Drug Use among
Adolescents
  • Classroom based survey (2008) at mid-Atlantic
    urban university
  • Asked about drug use since entering high school
  • Paper survey, distributed through one of several
    introductory classes

Rozenbroek, et al. JACH 201159(5)358-363
46
Characteristics of Prescription Drug Use among
Adolescents
  • No significant gender difference
  • Age 20 or more associated had slightly higher
    rates of use (medical and non-medical)
  • Whites more likely to use than Asians or
    African-Americans

Rozenbroek, et al. JACH 201159(5)358-363
47
Characteristics of Prescription Drug Use among
Adolescents
Type of use Opioids CNS depressants Stimulants
Medical 27.9 4.4 5.3
Non-medical 4.4 2.9 7.8
Both 4.8 1.7 1.9
Non-user 62.9 91.0 85.0
Rozenbroek, et al. JACH 201159(5)358-363
48
Most Common Reasons for Non-medical Use of
Prescription Drugs
Reason Opioids CNS depressants Stimulants
Makes me feel good 49.1 37.9 15.1
Just to try it 32.0 24.3 20.0
Help me study 3.8 21.6 53.8
Help manage sleep 0 10.8 9.2
Rozenbroek, et al. JACH 201159(5)358-363
49
Reasons for Prescription Drug Misuse among
College Students Rx for a Party
  • Survey of 91 current students at a public SW
    university
  • 55 reported at least one episode of
    sociorecreational prescription drug use in the
    previous year
  • Manage highs drug substitution (for alcohol)
  • Participate in social use (as distinguished from
    independent drug seeking)
  • 42 had no concerns about dangers of what they
    were doing

Quintero G. JACH 201058(1)64-70
50
Clinical Approach to Pain
  • Acute pain
  • Chronic pain

51
Acute Pain
  • One of the most common reasons that people
    consult a medical provider
  • Only a small fraction of people with acute pain
    go on to develop chronic pain

52
Chronic Pain--Definitions
  • International Association for the Study of Pain
  • Pain without apparent biologic value that has
    persisted beyond the normal tissue healing time
    (usually assumed to be 3 months)
  • American College of Rheumatology
  • Widespread or regional pain for at least 3 months

53
Chronic Pain--Definitions
  • American Society of Anesthesiologists
  • Pain not due to neoplastic involvement extending
    beyond the expected temporal boundary of tissue
    injury and normal healing and adversely affecting
    the function or well-being of the individual
  • DSM-4
  • Persistent pain for 6 months

54
Chronic Non-cancer Pain--Overview
  • A prevalent condition data from NHANES
  • Back pain 10
  • Leg/foot pain 7
  • Arm/hand pain 4
  • Headache 3
  • Complex regional pain 11
  • Widespread pain 4
  • Much less prevalent in the college-age
    population reliable data difficult to find

55
Chronic Non-cancer Pain--Overview
  • A complex syndrome with historically highly
    variable clinical approaches
  • Most aggressive approaches attempted to directly
    apply principles of cancer pain treatment
  • Pain as the 5th vital sign
  • Most now agree that was/is inappropriate

56
Chronic Pain Management General Principles
  • Establish treatment goals, with measures as
    objective as possible
  • Treat all established diagnoses
  • Low threshold for mental health referral
  • Distinguish between pain treatment and opioid
    treatment
  • E.g., pain Rx has many options other than opioids

57
Chronic Pain Management, contd
  • Emphasize function over pain control
  • Exercise and other physical modalities
    prioritized
  • Medication management
  • Non opioid
  • Opioid

58
Chronic Pain Management, contd
  • Medication managementnon-opioids
  • Acetaminophen
  • NSAIDs
  • Tricyclic agents

59
Chronic Pain Management, contd
  • Medication managementnon-opioids and neuropathic
    pain
  • Some syndromes have specific agents that are FDA
    approved
  • Postherpetic neuralgia gabapentin, pregabalin,
    capsaicin
  • Pregabalindiabetic neuropathy, post herpetic
    neuralgia, fibromyalgia
  • Others have clinical trial data
  • Tricyclics and diabetic neuropathy
  • Carbamazepine or oxcarbazepine and trigeminal
    neuralgia

60
Chronic Pain Management, contd
  • Non-opioid neuropathic pain agents
  • Tricyclic agents
  • Other antidepressants duloxetine, venlafaxine
  • Anticonvulsants gabapentin, pregabalin,
    carbamazepine, oxcarbazepine
  • Topical lidocaine
  • Topical capsaicin

61
Chronic Opioid Management
  • Opioid management has its own set of specific
    needs
  • Realistic expectations 30 drop in pain score is
    typical7/10 to 5/10 for example
  • Monitor for effectiveness
  • Monitor for complications
  • Monitor for deviations from expected treatment
    process

62
Chronic Opioid Management, contd
  • Opioid management has its own set of specific
    needs
  • Informed consent
  • Treatment agreements or contracts
  • These reduce risk of opioid misuse by 7-23
  • Urine drug testing

Starrels JL, et al. Ann Intern Med
2010152(11)172
63
Chronic Opioid Management, contd
  • Overdose risk is highly correlated with
    prescribed dose
  • Dunn, et al examined morphine equivalent doses in
    an HMO
  • 1-20 mg per day 0.2 annual OD rate
  • 50-99 mg per day 0.7 annual OD rate
  • 100 mg per day 1.8 annual OD rate

Dunn KM, et al. Ann Intern Med 2010152(2)85
64
Chronic Opioid Management, contd
  • Fatal overdose risk is highly correlated with
    prescribed dose
  • Bohnert, et al examined morphine equivalent doses
    in the VA
  • Identified 100 mg per day as having markedly
    increased risk compared to 1-20 mg per day
  • Chronic pain RR 7.2
  • Cancer pain RR 12.0
  • Acute pain RR 6.6

Bohnert, et al. JAMA 2011305(13)1315-1321
65
Chronic Opioid Management, contd
  • Urine drug testing
  • Examines for adherence to regimen
  • Examines for drugs of abuse that might preclude
    opioid therapy
  • Interpretation can be difficult
  • Overall added value is controversialbut it is
    widely recommended

66
Urine Drug Testing
Drug Duration of Detectability False Positive Causes
Amphetamines 2-3 days Pseudoephedrine, phenylephrine, bupropion, desipramine, methylphenidate, Adderall more
Cocaine 2-3 days Topical anesthetics containing cocaine
Marijuana 1-7 days (light) 1 month (heavy) Ibuprofen, naproxen, hemp seed oil
Opiates 1-3 days Rifampin, fluoroquinolones, quinine
Phencyclidine 7-14 days Dextromethorphan
67
Urine Drug Testing--Pearls
  • At UW Medicine lab
  • Standard drug screen is starting point
  • Oxycodone is not detected by this (it is a
    semisynthetic opioidbut hydrocodone and
    hydromorphone are)
  • Methadone and fentanyl (synthetic opioids) are
    not detected by this
  • Amphetamine by gas chromatography is highly
    specific

68
Chronic Pain QI Project at Hall Health
  • Motivated by evolving care and legal standards in
    Washington State and delivery system issues in
    Seattle
  • Develop a standardized approach to assessment and
    follow-up
  • Distinguish between pain management and use of
    chronic opioid therapy to manage pain
  • Still a work in progress in our health system

69
Chronic Pain Assessment
  • Standard HP
  • Mandatory review of prior records
  • Standard questionnaire and metrics for clinical
    status
  • Pain intensity scale
  • Anxiety and depression status
  • Functional status

70
Chronic Pain Assessment, contd
  • Mandatory screening for substance abuse, family
    history of substance abuse, and psychiatric
    disorders (depression and anxiety most common)
  • These are most predictive of aberrant drug
    related behavior
  • Use standard charting tools in the Electronic
    Health Record (EpicCare Smart tools)

71
Chronic Pain Assessment, contd
  • Careful assessment of functional status social,
    recreational, occupational
  • Establish a diagnosis!
  • Especially neuropathic pain
  • Urine toxicology screening if indicated based on
    current treatment plan

72
Chronic Pain Management
  • Establish treatment goals, with measures as
    objective as possible
  • Treat all established diagnoses
  • Low threshold for mental health referral
  • Distinguish between pain treatment and opioid
    treatment
  • E.g., pain Rx has many options other than opioids

73
Chronic Pain Management, contd
  • Emphasize function over pain control
  • Exercise and other physical modalities
    prioritized
  • Medication management
  • Non opioid
  • Opioid

74
Opioids Implicated in Drug Overdoses
  • Chronic pain meds usually morphine, methadone,
    or fentanyl
  • Acute pain meds most often codeine,
    hydrocodone, and oxycodone

75
Morphine Equivalence of Opioids
  • Morphine equivalence calculator available at
    http//www.agencymeddirectors.wa.gov/Files/DosingC
    alc.xls
  • Each of the below equals 20 mg morphine
  • 135 mg codeine
  • 20 mg hydrocodone
  • 13 mg oxycodone

76
Morphine equivalence calculator
77
Morphine equivalence calculator
  • The dose calculator is NOT designed to determine
    doses for medication transition
  • Only an approximation
  • Does not account for incomplete cross-tolerance
    and pharmocokinetics
  • Especially difficult for methadone and fentanyl

78
Chronic Pain Management, contd
  • Criteria for referral to pain specialist
  • Mainly based on severity of disability
  • BEFORE pain behaviors have coalesced or
    maladaptive coping strategies have emerged
  • In Washington Stateif opioid dose is gt120
    mg/day morphine equivalents
  • This is now a lawJanuary, 2012!

79
Chronic Pain Management, contd
  • Criteria for referral to substance use treatment
  • Careful history taking important here
  • Objective tools
  • Pharmacy dispensing records (from WA state
    prescription management program)
  • Urine toxicology testing

80
Washington State Regulatory Changes
  • Recently passed legislation (HB 2876)
  • Regulates the use of chronic opioid therapy
  • Creates information about best practices as a way
    of reducing drug diversion and the potential for
    overdose
  • http//www.agencymeddirectors.wa.gov/Files/OpioidG
    dline.pdf

81
Washington State Regulatory Changes
  • Recently passed legislation
  • Requires practitioner training program
  • About 2 hours, on-line option available
  • Creates prescription management program to allow
    prescribers on-line access to pharmacy dispensing
    records

82
Washington State Regulatory Changes
  • Recently passed legislation
  • Requires pain specialty consultation in specified
    circumstancestied to dose and other factors
  • Greater than 120 mg daily morphine equivalent
    dose
  • http//www.doh.wa.gov/hsqa/professions/painmanagem
    ent/files/mdpapainmgmt.pdf

83
Chronic Pain Management Summary
  • Complicated biopsychosocial problem
  • Not very common at student health centers
  • But there is a need to understand the state of
    the art
  • Proliferation of opioids has multiple
    implications
  • Regulatory agencies paying more attention
  • Search for best practices ongoing
  • At Hall Health, our practice guideline reduced
    provider stress created better practice

84
Acute Pain Management QI Project at Hall Health
  • Addressing chronic pain issues was important to
    our center and provider group
  • Opportunities for improvement in the area of
    acute pain management were not on the radar of
    providers

85
Acute Pain Management QI Project at Hall Health
  • However, opioid scripts for acute pain
    outnumbered chronic pain 301 (or more)
  • Data about accidental OD potential of opioids
    usually used for acute pain became known
  • A parent complained that her son received 28
    Vicodins for a self-limited illness

86
Project Goals
  • We sought to optimize the indications for and
    size of opioid prescriptions
  • We expected this to reduce the amount of opioids
    available through on campus sources

87
Methods
  • We had already conducted a pilot study to assess
    opioid prescriptions for chronic vs. acute pain
  • Based on this review, we identified a small
    cohort of patients under management for chronic
    pain
  • This was typically less than 10 patients at any
    time

88
Methods
  • Using our EHR, we identified all patients who
    received an opioid prescription from October 1,
    2010 to December 31, 2010the baseline period
  • We excluded patients who were under management
    for chronic pain

89
Methods
  • We collected patient demographic and prescriber
    data, as well as data about specific
    medication(s), amount of pills prescribed, and
    directions for use
  • We focused on codeine, hydrocodone, and oxycodone

90
Intervention
  • 2010
  • Educational modules about chronic non-cancer pain
  • CME program on same subject
  • Practice guideline for assessment and management
    of chronic non-cancer pain developed and
    implemented by mid-2010

91
Intervention
  • In late 2010 we designed several interventions
    for implementation in early January, 2011
  • Educational module for acute pain including
    practice guideline for prescription size
  • Prescribing tools revised, with 10 being the
    default prescription size (previously 28)
  • Educational module repeated in April, 2011

92
Intervention
  • We collected follow-up data for 2 time periods
  • January 1, 2011 to March 31, 2011
  • April 1, 2011 to June 30, 2011

93
Results
Oct-Dec, 2010 Jan-Mar, 2011 Apr-Jun, 2011
visits 7785 8965 8624
opioid scripts 260 372 299
of visits with opioid script 3.34 4.15 3.47
94
Results
of total scripts Oct-Dec, 2010 Jan-Mar, 2011 Apr-Jun, 2011
Codeine 24 16 17
Hydro-codone 65 74 63
Oxycodone 8 9 19
95
Results
Oct-Dec, 2010 Jan-Mar, 2011 Apr-Jun, 2011
opioid scripts, all 253 364 295
Mean pills per script (95 CI) 19.8 (1.0) 15.6 (1.0) 16.2 (1.1)
plt0.001 (Jan vs. Oct) p0.94 (Apr vs. Jan)
96
Results
of scripts for 10 pills or less Oct-Dec, 2010 Jan-Mar, 2011 Apr-Jun, 2011
Codeine 44 45 38
Hydrocodone 20 56 57
Oxycodone 5 28 46
All 25 52 52
plt0.001 plt0.05
97
Limitations
  • Data were limited to prescriptions from the
    student health center
  • Patients of the center may access other sources
    of care
  • Limited ability to assess clinical
    appropriateness of prescriptions

98
Conclusions
  • Using a combination of educational programs and
    prescribing tools we were able to decrease pills
    per script of hydrocodone, oxycodone, and all
    opioids
  • This did not occur with codeine
  • This led to 1000-1500 fewer opioid pills being
    prescribed per quarter
  • There was no evidence of increased return visits
    for poorly controlled pain

99
Discussion Questions
100
References--1
  • Ballantyne JC, Mao J. Opioid therapy for chronic
    pain. N Eng J Med 20033491943-1953.
  • Becker WC, et al. Nonmedical use of opioid
    analgesics obtained directly from physicians
    prevalence and correlates. Arch Int Med
    2011171(11)1034-1036.
  • Bohnert ASB, et al. Association between opioid
    prescribing patterns and opioid overdose-related
    deaths. JAMA 2011305(13)1315-1321.
  • Christo PJ, et al. Urine drug testing in chronic
    pain. Pain Physician. 201114(2)123-143.
  • CDC. Overdoses of prescription opioid pain
    relieversUS, 1999-2008. MMWR 2011431487-1492.

101
References--2
  • Dunn KM, et al. Opioid prescriptions for chronic
    pain and overdose a cohort study. Ann Intern
    Med. 2010152(2)85-92.
  • Lanier, et al. What matters most? Assessing the
    influence of demographic characteristics,
    college-specific risk factors, and poly-drug use
    on nonmedical prescription drug use. JACH
    201159(8)721-727.
  • McCabe SE, et al. Medical use, illicit use, and
    diversion of abusable prescription drugs. JACH
    200654(5)269-278.
  • National Survey on Drug Use and Health, 2010
    (available at samhsa.gov)

102
References--3
  • Paulozzi LJ, et al. A national epidemic of
    unintentional prescription opioid overdose
    deaths how physicians can help control it. J
    Clin Psych 201172(5)589-592.
  • Quintero G. Rx for a party A qualitative
    analysis of recreational pharmaceutical use in a
    collegiate setting. JACH 201058(1)64-70.
  • Richardson LP. Trends in the prescription of
    opioids for adolescents with non-cancer pain. Gen
    Hosp Psych 201133423-428.
  • Rozenbroek, et al. Medical and nonmedical users
    of prescription drugs among college students.
    JACH 201159(5)358-363.

103
New patient chronic pain template
  • Fred L Zz Frederickson is an 67 year old male who
    presents for initial evaluation for management of
    chronic pain. Pt is already on chronic pain
    medications.
  • Brief history of chronic pain syndrome
  • How long have you been on medications for pain?
  • Who has been prescribing your medications?
  • 1. Where do you feel your pain? PAIN
    LOCATION104450
  • 2. Which word best describes your pain? PAIN
    QUALITY104449
  • 3. On a scale of 0 to 10, which best describes
    your pain at its WORST in the last month PAIN
    SCALE104448"0 (No Pain)"
  • 4. On a scale of 0 to 10, which best describes
    your pain at its LEAST in the last month PAIN
    SCALE104448"0 (No Pain)"
  • 5. On a scale of 0 to 10, which best describes
    your pain at ON AVERAGE in the last month PAIN
    SCALE104448"0 (No Pain)"
  • 6. On a scale of 0 to 10, which best describes
    your pain RIGHT NOW PAIN SCALE104448"0 (No
    Pain)"

104
New patient chronic pain template
  • 7. Previous use of opioids to control pain? YES
    ADDL DEFAULT NO104995"Yes, "
  • 8. Prior history or current alcohol or illicit
    substance use? YES ADDL DEFAULT NO104995"Yes,
    "
  • 9. Have you ever been diagnosed or treated for
    depression? YES ADDL DEFAULT NO104995"Yes,
    "
  • 10. Do you think you are suffering from
    depression now? YES ADDL DEFAULT
    NO104995"Yes, "
  • 11. What side effects are you having
  • a. Nausea PAIN SIDE EFFECT SCALE104452
  • b. Constipation PAIN SIDE EFFECT
    SCALE104452
  • c. Trouble Thinking PAIN SIDE EFFECT
    SCALE104452
  • 12. On a scale of 0 to 10, which best describes
    how, DURING THE PAST WEEK, the pain has
    INTERFERED with your
  • a. General Activity PAIN INTERFERENCE
    SCALE104453
  • b. Mood PAIN INTERFERENCE SCALE104453
  • c. Normal Work PAIN INTERFERENCE
    SCALE104453
  • d. Sleep PAIN INTERFERENCE SCALE104453
  • e. Enjoyment of life PAIN INTERFERENCE
    SCALE104453
  • f. Ability to concentrate PAIN INTERFERENCE
    SCALE104453
  • g. Relations with Others PAIN INTERFERENCE
    SCALE104453

105
New patient chronic pain template
  • 13. Goals of therapy
  • What does your pain keep you from doing that you
    most want to do?
  • If it is not possible to get you back to 100
    what percent improvement would make a significant
    difference in your quality of life?
  • Objective
  • GENERAL APPEARANCE50"healthy","alert","no
    distress"
  • AFFECT103406
  • Go to "forms" to fill out PHQ 9 if appropriate
  • ASSESSMENT
  • Candidate for ongoing management of chronic pain
    YES NO (HH)104741"YES"
  • Patient agrees to provide a copy of medical
    records YES NO (HH)104741"YES"
  • Pain Contract reviewed and signed by patient
    copy provided to patient YES NO
    (HH)104741"YES"
  • Consent for chronic opioid treatment signed and
    copy given to the patient Use "special consent
    for medical care" U2224 YES NO
    (HH)104741"YES"
  • Urine tox screen recommended at the first visit.
    Document when last dose of medication was taken.
    See "clinical pearls" about ordering urine tox
    screen

106
Return patient chronic pain template
  • SUBJECTIVE
  • Patient reports taking medications as prescribed
    YES NO (HH)104741"YES"
  • The next 3 questions have to do with pain
    intensity 1 is no pain and 10 is unbearable
    pain)
  • 1. Average pain level this week NUMBERS
    0-10102198
  • 2. Worst pain level this week NUMBERS
    0-10102198
  • 3. Today's pain level NUMBERS 0-10102198
  • 4. On a scale of 0 to 10, which best describes
    how, DURING THE PAST WEEK, the pain has
    INTERFERED with your
  • a. General Activity PAIN INTERFERENCE
    SCALE104453
  • b. Mood PAIN INTERFERENCE SCALE104453
  • c. Normal Work PAIN INTERFERENCE
    SCALE104453
  • d. Enjoyment of life PAIN INTERFERENCE
    SCALE104453
  • 5. Are you experiencing any other symptoms or
    have you had any illnesses since your last visit?
  • Update social history. Type .soch to bring in
    brief social history
  • type .phq9 to bring in phQ9 depression survey
  • Objective
  • Appears well, in no apparent distress. Vital
    signs There were no vitals taken for this
    visit..
  • AFFECT103406

107
Pain management agreement
  • The purpose of this Agreement is to prevent
    misunderstandings about certain medicines you
    will be taking for pain management. This is to
    help both you and your doctor comply with the
    laws regarding controlled medications.
  • I understand that if I break this Agreement, my
    doctor will stop prescribing these pain-control
    medicines.
  • I will not share, sell, or trade my medication
    with anyone. This is against the law.
  • I agree that I will submit to random urine drug
    testing.
  • I understand the reason for this random urine
    drug testing.
  • I agree that I will use my medicine only as it is
    prescribed.
  • I understand that I will not receive early
    refills on my narcotic pain medications
  • I will not attempt to obtain any controlled
    medicines, including but not limited to opioid
    pain medicines, controlled stimulants, or
    antianxiety medications from any other doctor.
  • I will not use any illegal substances, including
    but not limited to marijuana, cocaine,
    amphetamine, and heroin.
  • I will safeguard my pain medicine from loss or
    theft.
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