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THE OPIOID CRISIS

THE OPIOID CRISIS. It’s not a choice, it’s a disease. It’s a crisis we helped create. It’s a crisis we propagate by our attitudes about the addict. It is a crisis that will affect each one of us in time.

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THE OPIOID CRISIS

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  1. THE OPIOID CRISIS It’s not a choice, it’s a disease

  2. It’s a crisis we helped create. It’s a crisis we propagate by our attitudes about the addict. It is a crisis that will affect each one of us in time.

  3. How did we get here? • 1890s: Sears and Roebuck offered a syringe and a small amount of cocaine for sale for $1.50 • 1890: First congressional act passed to levy taxes on morphine and opium • 1909: Smoking Opium Exclusion Act banned possession, importation and use of opium, but just for smoking • 1914: Harrison Act regulated and taxed production, importation and distribution of opiates and cocaine • 1919: 18th amendment banned alcohol; 1933: overturned by 21st amendment • 1937: Marijuana Tax act placed tax on sale of marijuana • Bureau of Narcotics Drug Division (BNDD) created • 1970: Controlled Substances Act (Nixon) regulated certain drugs and developed our current narcotic schedules I-V • 1973: DEA created • 1977: Making good on his platform, Carter decriminalized possession of up to 1 oz marijuana • 1980s: “Just Say No’ was born (Reagan) • 1986: Anti-drug Abuse Act created

  4. The Role the Medical Profession Played: 1986: Dr. Russell Portenoy pens a paper espousing the use of opium derived painkillers for chronic non-cancerous pain. “ …little risk of addiction or overdose among pain patients…less than 1%”. 1996: American Pain Society trademarks the slogan, “Pain. The 5th Vital Sign.” 1988: Veterans Health Admin and JCAHO adopt pain as 5th vital sign 1990s: American Pain Society continues to educate physicians that risk of addiction minimal 1998: Federation of State Medical Boards releases a policy reassuring physicians that they will not face regulatory action for prescribing large amounts of narcotics 2001: JCAHO standard released requiring hospitals to ask about pain and treat it as a priority 2004: The Federation of State Medical Boards called on state boards to make undertreatment of pain punishable for the first time. 2007: Purdue Pharma pleads guilty to “misbranding” of the drug as less addictive and less subject to abuse than other pain medications; $635 million paid in fines 2012: 259 million scripts written for Opioids, totaling over 9 billion dollars 2013: Opioid deaths surpass car accidents as leading cause of accidental death; 1999-2013 sees 4x increase in Opioid deaths

  5. Wave 1: 1991 Physicians begin prescribing opioids for non cancer pain, reassured by pharma that addiction risk minimal Wave 2: 2010 Heroin deaths increase as opioids scripts harder to get; heroin cheaper and more available Wave 3: 2013 Synthetic opioid, Fentanyl, hits drug market WHERE WE ARE

  6. 4 out of 5 heroin users started out using opioid based pain pills

  7. Most Prescribed Opioids 2013, total scripts Hydrocodone-combination (Vicodin) 127,859,000 Oxycodone w/acetaminophen (generic Percocet) 32,962,000 Oxycodone HCL ( generic OxyContin) 16,440,000 Acetaminophen w/codeine 11,225,000 Morphine sulfate 9,658,000 Fentanyl 6,468,000 OxyContin (brand) 5,659,000 Methadone 3,860,000 Hydromorphone HCL (generic Dilaudid) 3,587,000 Oxymorphone HCL, ER(Opana ER) 756,000 https://mississippigrouphealth.com/mississippi-opioid-epidemic/

  8. THE SCOPE OF THE PROBLEM National Institute of Drug Abuse Survey: 2015-16 Illicit Drug Use 2-17 years old 18-25 years old 26 years and older 2015: 25.3 57.5% 50.1% 2016: 23% 56.3% 50.2%

  9. THE ANATOMY OF ADDICTION “Because essential portions of the circuit are below the area of the neocortex and consciousness (subcortical), drug dependence develops without conscious recognition. The effects of drugs on projections to the frontal lobes are what eventually lead to the impaired control over drug use, through a reduction of cortical decision-making functions.” p.53, The Science of Addiction, 2007 Carlton K Erickson

  10. RED- High dopamine; normal pleasure and interest YELLOW- Medium dopamine availability; difficulty feeling pleasure GREEN- Low dopamine availability; lack of pleasure Opioids block opiate receptors> block pain messengers>trigger dopamine release> produces euphoria

  11. DRUG ADDICTION IS A CHRONIC, RELASPING DISEASE. IF THE LIPS OF AN ADDICT ARE MOVING, THEY ARE LYING. • “I’ll allergic to everything, but Oxycontin” • “I’ve tried that, it doesn’t work” • Faking headaches, faking kidney stones, faking chronic pain • Sketchy about their past medical history • Reluctant to do drug testing • Requesting Demerol in ER (clinical analgesia fir 2-3 hrs, CNS excitation for 15-30 hrs; 67% more drug high than equivalent doses of morphine; generally banned for use by Cedars- Sinai in LA)

  12. PRINCIPLES OF TREATMENT • Behavioral Therapy • Medication • Treatment of Co-occurring Mental Health Issues • Long Term Follow Up WITHDRAWAL DETOX- usually inpatient; 30 days recommended by addictionologist, but rarely approved by insurance Medication often useful Newer devices coming onto market to stimulate certain nerves RELAPSE PREVENTION Therapy, Therapy and more Therapy Family services Vocational/educational services Legal services Medical services to treat HIV/AIDS/Hep C/Hep B, etc 12 Step Programs Medication- Methadone and buprenorphine (Suboxone) to block cravings Naltrexone to block opioid receptors Long term residential treatment, sober living

  13. I get all that, but they are in my office NOW

  14. Compassionate Refusal to Prescribe • Show compassion for their pain, but turn the tables and reinforce • that the medication they request may be harmful to them • Attempt to discuss psychological and physical addiction with the patient • Pull and review the PDMP with the patient to make your concern visible in black and white • Have a pre-printed list of local addiction treatment facilities, both inpatient and outpatient, including NA and AA, to share with patient. They may not seek help then and there, but will have it. • If treatment is absolutely necessary, … “methadone and long acting morphine… are less likely to reinforce drug-seeking behavior .” EMCNA, vol 23, 2005, p349-365 • Drug screen periodically • If treated with narcotics give, insist on drug use contract, where patient is “locked in” to one pharmacy, one prescriber (YOU), will have no trips to ER for medication. Put in print that if the contract is violated, discharge from clinic is automatic.

  15. The Catch 22 Are they in real pain? Are you assuming they are drug seeking? Have you done due diligence to R/O a real reason for pain, THIS TIME? • In an article by Jonathan Reisman, MD, an ER physician at Schuylkill Medical Center in PA, • we see why each and every presentation to ER/office MUST be considered individually. • Stereotypical drug seeker with track marks, reeks of cigarettes and alcohol presents • to ER every Friday afternoon, 5 pm. • Well known to ER; history of abuse, addiction and suicide in family • Asking for strongest IV narcotic made. • Work up always negative; why even bother. • Except…

  16. Cleveland Journal of Medicine Volume 83 Number 3 March 2016

  17. Cleveland Journal of Medicine Volume 83 Number 3 March 2016

  18. Cleveland Journal of Medicine Volume 83 Number 3 March 2016

  19. I, _________________________________________________, agree to undergo pain management by Dr. _____________________________. My diagnosis is __________________________________________________________________. I agree to the following statements: I will not accept any narcotic prescriptions from another doctor.I will be responsible for making sure that I do not run out of my medications on weekends and holidays, because abrupt discontinuation of these medications can cause severe withdrawal syndrome.I understand that I must keep my medications in a safe place.I understand that Dr. _______________________________ will not supply additional refills for the prescriptions of medications that I may lose.If my medications are stolen, Dr. _______________________________ will refill the prescription one time only if a copy of the police report of the theft is submitted to the physician's office.I will not give my prescriptions to anyone else.I will only use one pharmacy.I will keep my scheduled appointments with Dr. ________________________ unless I give notice of cancellation 24 hours in advance.I agree to refrain from all mind/mood altering/illicit/addicting drugs including alcohol unless authorized by Dr. ______________________. Sample Pain TreatmentContract from Web MD The doctor may terminate this agreement at any time if he/she has cause to believe that I am not complying with the terms of this agreement, or to believe that I have made a misrepresentation or false statement concerning my pain or my compliance with the terms of this agreement. B. I understand that I may terminate this agreement at any time. If the agreement is terminated, I will not be a patient of Dr. _____________________ and would strongly consider treatment for chemical dependency if clinically indicated. ______________________________ ______________ Patient Date ______________________________ ______________ Provider Date ______________________________ ______________ Witness Date

  20. BE COGNIZANT OF FAILURE TRIGGERS Negotiation: You gave it to me before, why not now? Ethics: Your my doctor, help me! It’s your job! Guilt: This is the only thing that helps; you are ruining my life! Accusation: The only reason I drink or use is because you won’t give me the Percocet I need to control my pain. Threats:I am going to the press (my Senator, your boss, the state medical board, my lawyer, insert others here). Doubt: Are we trained to treat pain in the office long term? Do I refill? Do I stop/decrease? REFER

  21. DRUG USE ON A LOCAL LEVEL

  22. https://mississippigrouphealth.com/mississippi-opioid-epidemic/https://mississippigrouphealth.com/mississippi-opioid-epidemic/

  23. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/mississippi-opioid-summaryhttps://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/mississippi-opioid-summary

  24. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/mississippi-opioid-summaryhttps://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/mississippi-opioid-summary

  25. RECOMMENSATIONS OF GOVERNOR’S OPIOID AND HEROIN STUDY TASK FORCE 8/2017 Healthcare All UMMC physicians in MS have their own unique DEA number; all scheduled drugs reported to MPMP daily All VA facilities in MS assure scheduled drugs reported to MPMP daily Improved mechanism in investigating and reporting overdoses Providers shall not provide > 7 day supply for acute non-cancer pain (3 encouraged) Benzo scripts limited to 1 month with no more than 2 refills POS drug testing done every time schedule II script written (chronic non-cancer pain); POS drug testing for benzos q 90 days Providers and pharmacists need to work together on these efforts Include dentists in MPMP and require 5hrs CDE on opioids q 2 yrs Any prescribing provider in MS needs 5hrs CME on opioids q 2 yrs MPMP checked q schedule II script and q90 days for benzo script Increase funding for treatment Surcharge on pharma selling schedule II/III to state and used for treatment/education Methadone not to be used to treat acute or chronic non-cancer pain Discourage long acting opioids for acute non-cancer pain Requirements of hospice for disposal of meds at patient’s death Strongly discourage use of benzos and opioids concomitantly Avoid morphine doses > 50 meq daily All schedule II-V meds shipping into MS reported to MPMP

  26. Law Enforcement Increase criminal punishment for sale or intent to sell of heroin/fentanyl ; 40 years to life if results in death Exclude those charged of selling controlled drugs from Drug Court Healthcare providers, coroners. Law enforcement mandated to report overdoses EMTs and law enforcement trained on Narcan use and dangers of contact with fentanyl Expand drop box program throughout state All medical examiners/coroners must us Mississippi crime lab Upon a person’s death, MEs/coroners must hand over any drugs to law enforcement for disposal Expand MS crime lab staff Additional recommendations on education, prevention and treatment

  27. TREATMENT CENTERS https://www.treatment-centers.net/directory/mississippi.html

  28. Works Cited 1. Erickson, Carlton K., The Science of Addiction: from Neurobiology to Treatment, 2007 2. Cleveland Clinic Journal of Medicine; Volume 83, Number 3, March 2016. Prescribing Opioids in primary Care: Safely starting, monitoring and stopping; Tobin, D.G, Andrews, R. and Becker, W.C. 3. Emergency Medicine Clinics of North America; The Drug-Seeking Patient in the Emergency Room; Hanson, G.R; volume 23 (2005) pp349-365 4. http://www.webmd.com/pain-management/pain-management-pain-treatment- agreement#1 5. Clinical Pain Advisor; A Psychologist’s Advice for Dealing With Difficult Patients; Chaverneff, F., 2017; https://www.clinicalpainadvisor.com 6. Todays Hospitalist; Strategies doe dealing with drug-seeking patients; Fitzgibbons, S., June 2010; https://todayshospitalist.com 7. Opioid and Heroin Task Force, State of Mississippi, August 2017 8. https://drugabuse.gov 9. https://mississippigrouphealth.com

  29. THANK YOU!!!!

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