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Bay Area Prescription Drug Abuse Summit: Pharmacist Perspective

Bay Area Prescription Drug Abuse Summit: Pharmacist Perspective. Lori Reisner, Pharm.D. Health Sciences Professor of Clinical Pharmacy University of California Medical Center, San Francisco May 7, 2014. Background. Opioid use in primary care:

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Bay Area Prescription Drug Abuse Summit: Pharmacist Perspective

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  1. Bay Area Prescription Drug Abuse Summit:Pharmacist Perspective Lori Reisner, Pharm.D. Health Sciences Professor of Clinical Pharmacy University of California Medical Center, San Francisco May 7, 2014

  2. Background Opioid use in primary care: • 300% increase in opioid analgesic prescriptions between 1999 -2010 • Painkiller overdose deaths among women increased 5-fold and 3.6 times among men increased • Similar increases occurred in opioid-related ED visits and hospitalizations • Mean annual direct health care costs for patients who abuse opioids are 8.7-times higher than for non-abusers • Chronic pain may be present in up 20-50% of primary care physicians’ patients, and opioids are an essential component of their armamentarium • Regulatory responsibilities and scrutiny of opioid prescribing are increasing CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008. MMWR 2011; 60: 1-6

  3. Background • Prescription drug-related deaths now outnumber those from illicit substances • CDC reported 14,800 deaths from opiate overdose in 2008 • Sedative combinations contribute to a significant percentage of deaths • Benzodiazepines • Non-benzodiazepine sedatives (e.g., carisoprodol, zolpidem) • Alcohol and other sedatives CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008. MMWR 2011; 60: 1-6

  4. rate, Nebraska.4 Drug Overdose Rates by State, 20084 Overdose rates by state

  5. San Francisco 2009 and 2010 • 209 drug-related deaths, up from 41 the year prior • Oxycodone was detected in 53 of the total • 25 percent of accidental drug-related deaths in San Francisco involved oxycodone • Dr. Nikolas Lemos, chief forensic toxicologist at the Office of the San Francisco Medical Examiner, quoted by SF Weekly • Contrast with 29 deaths due to motor vehicle accidents during that period

  6. Influences on Morbidity/Mortality • Underlying comorbidities • Sleep apnea/respiratory disease • Cardiovascular diseases • Obesity/metabolic diseases • Reimbursement systems • Less face-to-face patient time • More reliance on medications/prescribing options • Limited options (insurance restrictions) • HCAHPS Scores • Reimbursement determined by percentiles • Reliance on pain scores may pressure prescribers to use more opioids • Prescriber Education • Lack of knowledge about non-opioid options • Inadequate trial periods/Inadequate dosing • Drug-drug interactions • Pharmacokinetics: Frequency of long-acting meds/Dose adjustments • Regulatory • Intensifying scrutiny of less offensive agents, e.g., tramadol

  7. Challenges • Retail Pharmacist have little experience with appropriate pain regimens • May lack information regarding combination therapies (multiple prescribers/pharmacies) • Fear of challenging physician prescribing • Cannot reliably confirm misuse/abuse or counterfeits • Integrating non-pharmacological interventions and modalities • Prescribers subscribing to “harm reduction” philosophies • Developing safer medications: abuse-limiting modifications

  8. Example Multimodal Regimen UCSF Arthroplasty (Joint replacement) Service: • Acetaminophen 1000 mg PO Q6H • Celecoxib 200 mg PO BID* • Gabapentin 300 mg PO TID* • Oxycodone 10 mg PO Q4H PRN moderate pain • Morphine 2 mg IV Q2H PRN severe pain • Epidural catheter w/ ropivacaine & fentanyl • +/- peripheral nerve infusion (local anesthetic) *may be omitted or dose-adjusted depending on comorbidities or meds prior to admission

  9. Recommendations • Improved Prescriber Education • Limited utility and persistence • Mandated curriculum? • Mandated re-certification? • Prescription pattern audits (Controlled Substance Utilization Review and Evaluation System, CURES) • Development of Pain Management Specialist/Consultant Certification across Professional Domains • Will require accepted certification/accreditation standards • Pharmacist Empowerment • Retail, hospital and ambulatory practices • Patient Education • Balancing portrayal in popular media, e.g., television • Instruction in proper use and risks • Reimbursement: adequate for appropriate patient care

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