Welcome to our 2018 Critical Issues Seminar Underwriting Opioid Use & Abuse

1. Welcome to our 2018 Critical Issues SeminarUnderwriting Opioid Use & Abuse

2. Seminar Program Opioids: Dimensions of the Dilemma Opioid Epidemic: Racing to the Top of the Leaderboard RED FLAGS for Opioid Abuse Using Rx Records in Opioid Underwriting Opioid Testing Strategies Benzodiazepines and Insurability Please hold your questions until the end of each presentation. We will also have an open forum discussion following the final presentation

3. OPIOIDSDimensions of the Dilemma Hank George, FALU

4. “The United States remains gripped by the opioid crisis. It has affected people of every race, sex and age across the country.”Kevin P. Hill, MDHarvard Medical SchoolJAMA Internal Medicine178(2018):6769[editorial]Kroenke argues that “epidemic” should not be used here because: “…the reality is that most patients receiving an initial opioid prescription do not proceed to chronic use and among the subset that do not use long-term opioids, the majority neither misuse nor experience an overdose.”Kroenke. JAMA. 212(2017):2355[editorial]

5. Straight Talk • Cholera epidemic • Ebola epidemic • War epidemic Trash Talk Obesity “epidemic” Diabetes “epidemic” Autism “epidemic”

6. “More than 115 individuals die in the United States every day from opioid overdoses.”Jerome M. Adams, MD, MPJU.S. Public Heath ServiceJAMA319(2018):2073[editorial] 2016: 63,632 OD deaths, with 66.4% (42,249) due to opioids This is a 28% increase in opioid OD deaths compared to 2015 (33,091)

7. What catalyzed and drovethe current opioid crisis?

8. “A cultural shift in the prescribing habits of physicians from being opioid phobic to prescribing opioids liberally, spurred by alleged evidence of under-treatment of pain, availability of newer long-acting opioid formulations…aggressive marketing techniques by drug manufacturers, disregard for the lack of long-term effectiveness, biased guidelines developed by authorities, physician ignorance (of) abuse potentials, and promulgations of reassuring implicit messages by well-meaning ‘pain experts’ that abuse, addiction and diversion were not key issues in the practice of pain medicine, lead to an exponential increase in thenumber of patients who were treated with opioids” Alan D. Kaye, MD, PhDLouisiana State University Medical SchoolPain Physician20(2017):S93

9. “Talk to any busy full-time primary care physician, and it becomes evident that writing an opioid prescription is much easier than exploring other options for addressing chronic pain in the course of a 15-minute visit.”Karen E. Lasser, MD, MPHBoston University School of MedicineAnnals of Internal Medicine167(2017):351[editorial]

10. “Drug Harms” Ranking(Based on Global Study) # 1 – Opiates # 2 – Opioids # 3 – Cocaine # 4 – Alcohol # 5 – Tobacco # 6 – Benzodiazepines … and last place – Pot! Morgan. Journal of Psychopharmacology, 27(2013):497

11. All opiates are opioids…but not all opioids are opiates  Opiates = natural products of the opium poppy (opium, codeine, morphine) Heroin (diacetylmorphine) = semisynthetic, usually lumped in as an opiate; Schedule I drug of abuse Opioids = other semisynthetic (hydromorphone, hydrocodone, oxycodone) and all fully synthetic (methadone, fentanyl, tramadol) drugs that are chemically more or less similar to opiates All prescription opioids are Schedule II except tramadol (Schedule IV). Meanwhile, marijuana is Schedule I (?) Narcotic = opiates and opioids(despite term misused for cocaine, meth, etc.)

12. Moeller. Mayo Clinic Proceedings. 92(2017):774 Pergolizzi. Pain Therapy. 6(2017):1 Vosburg. Journal of Pain. 19(2018):439 Tramadol Weak opioid commonly used for mild pain Not well-liked by abusers Tapentadol Entirely new analgesic with weak opioid-like effects, but often listed with opioids Rarely sold for abuse purposes (despite WHO allegations to the contrary)

13. Short-Acting Opioid Immediate release, rapid onset of action Short duration of action (2-4 hours) Typically used for breakthrough acute pain Long-Acting Opioid Extended release, slower onset of action Long duration of action (4-72 hours) Typically used for chronic pain Nuckols. Annals of Internal Medicine. 160(2014):38

14. 96% of event risk based on relative drug potency * Most widely abused opioids

15. “The Internet is virtually awash in illegal narcotics” Scott GottliebFDA Commissioner Illicitly manufactured fentanyl and related compounds including ocfentanil and carfentanil (used in veterinary medicine; 10,000 times more potent than fentanyl) Sold as heroin or used to cutheroin because they are cheaper Involved in a rapidly-growing % of OD cases

16. Social Media Opioid Drug Slang Sizzurp Hard Candy SipLean Oil Mobb Double Cup Qualitest Wockhardt Texas Tea Purple Drank Screw Juice

17. Opioid Epidemiology Most widely prescribed class of drugs 62 million had at least 1 opioid prescription filled in 2016 Most scripts written by non-pain specialty physicians with inadequate training in opioid prescribing 11.5 million misused opioids 1.9 million met criteria for opioid use disorder (OUD) Opioids dispensed by # of scripts: hydrocodone, tramadol, oxycodone, morphine, hydromorphone, oxymorphone, tapentadol

18. What is Considered Long-term (Chronic) Opioid Use? Prevailing definitions: 1. ≥ 180 days in 12 month period after care visit excluding 1st 30 days 2. > 90 consecutive days 3-4% of Americans are currently on long-term opioid therapy Getting a 2nd prescription immediately after 1st one doubles likelihood of escalation to long-term use.

19. Comorbidities in Long-term Users 4% of 1.1 million VA patients Chui. Circulation: CV Quality and Outcomes. 11, Supplement(2018):A24

20. Medicinal and recreational marijuana use decreases the incidence of opioid use, as demonstrated by a growing number of studies. This excludes pot use consistent with marijuana use disorder(which is a risk factor for opioid abuse).Bradford. JAMA Internal Medicine. 178(2018):667Powell. Journal of Health Economics. 30(2018):29Wen. JAMA Internal Medicine. 178(2018):673

21. The “Pain Epidemic” is the Root of the Opioid Crisis Chronic pain affects 100 million Americans 20% of outpatient visits are for non-cancer pain 39.5 million Americans have pain on all/nearly all days 47% of OUD patients initially exposed via opioid pain Rx Opioids are effective in acute nociceptive and (sometimes) neurogenic pain but ineffective (or worse) in chronic pain Malpractice claims due to pain management have increased 6-fold in last decade

22. Achilles Heel: Post-Surgical Opioid Rx Cervical spine – 47% refill opioids > 1 year Hand surgery – 13% chronic use in opioid-naïve patients Total Knee arthroplasty – 53% chronic use Total Hip arthroplasty – 35% chronic use #1 Risk factor for chronic (long-term) postsurgical opioid use = duration of presurgical opioid use: O.R. 25.3 if 23-250 days presurgical use O.R. 219.95 if > 250 days presurgical use

23. “Opioid use is perceived by many (but not all) individuals as pleasant, enjoyable and even stimulating”Joseph V. Pergolizzi, Jr. PhDNEMA Research; Naples, FloridaPain Therapy6(2017):1

24. Physiologic Effects Physical Dependence – a natural, expected consequence of therapeutic opioid use, occurs within a short time after initiating use and results in withdrawal symptoms Tolerance– need for greater opioid dose to achieve same effect Pseudo-addiction– medication seeking due to distress from inadequate treatment (hence “pseudo-”)

25. Consequences Misuse–broad and blurry term for use outside prescription parameters (e.g., taking too much/too often, sharing, borrowing, self-medicating anxiety) and for nonmedical use. % of misuse increasing: millennials (21.5%), Gen X (15.3%) and Boomers (12%) Abuse–more serious than misuse (e.g., diversion to get high) with risks of accidents, injuries, legal problems, etc.; occurs in 10-20% of LT users Addiction/Opioid Use Disorder (OUD) in DSM-5

26. Opioid Use Disorder (OUD) – DSM -5 “Problematic pattern” of use leading to “clinically significant impairment or distress” manifesting with 2 or more of 12 criteria Take larger amounts or use over longer period than intended Persistent desire/unsuccessful efforts to cut down/gain control over use Great deal of time spent procuring opioids Craving or strong desire to use Recurrent use problems at work, school, home, interpersonal/legal issues Recurrent use in hazardous scenarios Tolerance defined as need for “markedly increased amounts” or “markedly diminished effect” from same amount Withdrawal syndrome Severity: mild (2-3 symptoms), moderate (4-5), severe (≥ 6) Bottom line = very easy for patient with modest adverse opioid impact to be diagnosed with “Mild OUD” and thus stigmatized as drug abuser

27. “The clinical course of opioid use disorders involves periods of exacerbation and remission, but the underlying vulnerability never disappears…Although persons with opioid problems are likely to have extended periods of abstinence from opioids and often do well, the risk of early death, primarily from an accidental overdose, trauma, suicide, or an infectious disease (e.g. HIV) is increased by a factor of 20.”Marc A. Schuckit, MDUniversity of California – San DiegoNew England Journal of Medicine375(2016):357

28. OUD is a chronic relapsing disorder 2 million American cases 35-40% of the risk is genetic 85% chronic pain, 55% psychiatric comorbidity, 40%+ comorbid substance use disorder, 60% nicotine dependent 10% receive treatment Treatment of physicians with OUD differs because no opioid agonist Rx (methadone, buprenorphine, etc.) is used Lifetime management commonly needed

29. Abuse Methods Inexperienced Abusers Ingestion (chewing, swallowing whole) More Experienced Recreational Abusers Insufflation Inhalation Hard Core Addicts Smoking Intravenous, intramuscular and subcutaneous injection

30. Heroin Use 75% of today’s heroin users started on prescription opioids Prescription opioid abuse increases risk of heroin use 40-fold Increasingly common for progression directly from prescription opioid misuse to initiating heroin use Today’s heroin crisis crosses all socioeconomic and geographic boundaries Typical new patient is suburban or rural, often college-educated and with regular access to health care and health insurance Greatest heroin use prevalence increase at ages 30-45

31. Opioids and Driving Risk Opioid Rx doubles crash risk Opioid Rx increases odds of severe crash injury 7.4-fold Commercial truckers on opioid Rx are 2.4 times more likely to have “at fault” accidents 30% of opioid users in fatal crashes have elevated BAC and 67% test positive for other drugs of abuse Opioid Use = MVR

32. Thank you for your attentionNow, please welcome Dr. Elyssa Del Valle!