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@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. Overview—Learning 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 pain—acute 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 abuse—euphoria—and if overused can lead to excess sedation, coma, and death • Fatal overdoses can be accidental or intentional • Opioids are controlled substances—therefore 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 2011;43:1487-1492

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 Overdoses—an “Epidemic” Okie S. NEJM 2010;363(21):1981-1985

25. US Drug Overdoses by Agent Okie S. NEJM 2010;363(21):1981-1985

26. Drug Overdose Death Rates (US, 2008 per 100,000 people) MMWR 2011;43:1487-1492

27. Drug Overdose Death Rates(US, 2008 per 100,000 people) MMWR 2011;43:1487-1492

28. Drug Overdose Death Rates (US, 2008 per 100,000 people) MMWR 2011;43:1487-1492

29. US Opioid Use—also an “Epidemic” • 100 million prescriptions for hydrocodone per year • Top drug by # of prescriptions dispensed* • US has 4% of the world’s population • Uses 99% of world’s supply of hydrocodone • Uses 80% of world’s 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 2005;119:95-103.

30. US Opioid Sales • Sales of opioids • 2010: 7.1 kg per 10,000 people (710 mg per person per year) • That’s 142 Vicodins per person per year!! • 2010 sales were 4 fold greater than 1999 sales MMWR 2011;43:1487-1492

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 2011;43:1487-1492

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 2011;43:1487-1492

34. Nonmedical Use of Opioids • Range of prevalence of nonmedical use of opioids: • 3.6% (NEB) – 8.1% (OK) MMWR 2011;43:1487-1492

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 2011;43:1487-1492

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 Administration’s 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 Abuse:Some 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 2011;33:423-428

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 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 2011;59(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 2011;59(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 2011;59(5):358-363

47. Characteristics of Prescription Drug Use among Adolescents Rozenbroek, et al. JACH 2011;59(5):358-363

48. Most Common Reasons for Non-medical Use of Prescription Drugs Rozenbroek, et al. JACH 2011;59(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 2010;58(1):64-70

50. Clinical Approach to Pain • Acute pain • Chronic pain