Transcript Opioid Epidemic Presentation - Department of Medicine, Case

The Opioid Epidemic:
What Every Provider Needs to Know
Christina M. Delos Reyes, MD
Director, Addiction Psychiatry Fellowship
Jeanne Lackamp, MD
Director, Division of Psychiatry & Medicine
Moderator
Marcie Manson, Esq
Associate General Counsel, Legal
Litigation & Claims
Monica Tone, MD, MPH
Fellow, Addiction Psychiatry
Introductions and overview
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Audience response questions:
– How many people here are primarily outpatient?
– How many people here are primarily inpatient?
– How many people here have seen someone with a suspected
opioid use disorder in the last year? Six months? One month?
– How many people here know what OARRS is? And have
access? And have used it in the last one month?
– How many people here feel overwhelmed when faced with
patients who have a suspected opioid use disorder?
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Learning Objectives
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Review common pathways leading patients to opioid
addiction
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Describe methods for assessing and monitoring
patients’ prescription substance use patterns, including
but not limited to OARRS
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Identify the continuum of care for opioid use disorders
including overdose prevention, detoxification, and
treatment
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Outline
1. Case presentation
2. Opioid mechanisms of action, scope of current epidemic, and
pathways into addiction
3. Ohio Physicians Health Program (OPHP) data
4. Opioid use disorders – Continuum of care
5. How to assess & monitor opioid usage, including OARRS
6. Take-home messages for your patients and their families
7. Discussion/Q&A
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Part 1: Case Presentation
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Medical History
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62 yo male was experiencing chronic pain as the result of a serious
work injury that occurred in 1991.
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He began treatment with a non-UH physician (Physician A) at an
outside facility in January 2007, after his PCP passed away.
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The patient’s pain was managed with narcotics and muscle
relaxants [hydrocodone, gabapentin, carisoprodol, and ibuprofen].
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He entered into a narcotic contract.
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Medical History
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In November 2007, the patient was having difficulty making his
hydrocodone last for the full weeks, and he was requesting his
medications earlier each month.
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In March 2008, the patient’s opioid use was escalating
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Physician A recommended tapering his medications, as there was
probably a component of addiction. The patient was hesitant.
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The physician recommended chemical dependency treatment.
There is no documentation if the patient followed through.
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Medical History
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In July and August 2008 the patient presented to urgent care, as he ran
out of pain meds early.
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Physician A did discuss with him the need to decrease hydrocodone; he
started the patient on oxycodone.
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Later in August 2008, patient presented to the ED as he again ran out of
pain meds. The ED physician refused to prescribe any pain meds as
patient received over 300 high dose narcotics pills in the last 3 weeks.
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At this time, the patient’s medications included clonazepam, oxycodone,
carisoprodol, gabapentin, and ibuprofen.
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Medical History
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Patient had an MI in August 2009.
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In January 2010, Physician A was not comfortable with the
prescriptions. The patient was receiving high morphine
equivalence dose of 300 mg per day.
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Two other physicians in the same group saw him, and attempted to
wean him off this dangerous drug combination.
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He was non-compliant with the attempts and was subsequently
discharged from the practice in 2010.
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Treatment with UH PCP
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He spent about a year physician shopping, including at UH Pain
Management where “Dr. Noway” offered him alternative treatment,
which did not involve opiates.
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He ultimately landed with “Dr. Bannister,” a UH primary care physician,
in January 2011. Over the next 31 months, Dr. Bannister prescribed
the same combination and dosages that patient had been receiving.
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When the patient started seeing Dr. Bannister, he was receiving:
clonazepam 1mg PO BID, gabapentin 900mg PO TID, hydrocodone
7.5/750mg PO QID, carisoprodol 350mg PO QID, oxycodone 40mg
PO TID, and zolpidem.
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Treatment with UH PCP
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Oxycodone was increased in March 2011 because pain was not
adequately controlled. Dr. Banniser’s notes indicate that patient
continued to experience chronic pain (he had herniated discs in his
back and had had surgery).
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Dr. Bannister continued to see the patient and refill the
prescriptions as needed.
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The last notation in the record on August 12, 2013, indicated that
the patient was being prescribed: clonazepam 2mg PO BID,
gabapentin 900mg PO TID, hydrocodone 7.5/750mg PO QID,
Soma 350mg PO QID, and oxycodone 60mg PO TID.
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The patient died on August 23, 2013.
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The coroner’s report identified opioid toxicity as the cause of death.
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Areas of Concern
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Dr. Bannister was not prescribing in accordance with the UH Opioid
Prescribing Guidelines, which were introduced in January 2012;
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He combined opioids and benzos, (which our guidelines discourage);
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He did not utilize urine toxicology screens or a pain contract;
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He did not refer to pain management;
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He only checked OARRS once; and
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He did not try to obtain the patient’s records from prior providers.
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Claimant’s Criticisms
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There was no indication that Dr. Bannister obtained the prior treatment
records for the patient, including those within the UH System;
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Dr. Bannister had no background in the treatment of chronic pain;
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The initial history and physical were deficient;
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No definitive source of the patient’s pain was ever conclusively
established;
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There was no cohesive treatment plan;
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There was no referral to a specialist;
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Claimant’s Criticisms
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Dr. Bannister inexplicably increased the patient’s already high dose of
oxycodone to 60mg PO TID while maintaining a dose of hydrocodone
7.5/750mg PO QID which represents a morphine equivalent dose of 300
mg/day and this was in addition to CNS depressants clonazepam and
carisoprodol;
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Only one OARRS report was pulled, 5 months after treatment began;
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There was no pain medicine contract, and there was no drug screen
performed.
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Claimant’s Criticisms
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The patient “predictably overdosed” and died from a combination of
medications prescribed by Dr. Bannister, which included opiates,
benzodiazepines and muscle relaxants.
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Dr. Bannister’s Response
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He renewed the patient’s pain meds as he had heart disease and
acute withdrawal could have precipitated a heart attack;
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His pain issues were real as he had a severe injury and it was not
“curable”;
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He was trying to help the patient and not just discharge him from the
practice - the patient would have had nowhere to go;
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At the time of the patient’s accident in the ‘90’s, treating with
oxycodone was pervasive and what the expert called massive doses
was not that uncommon;
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Dr. Bannister’s Response
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The patient was already under psychiatric care and he was seeing
a chiropractor and having physical therapy;
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The patient had tried pain shots to no avail;
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Dr. Bannister was trying his best to treat a suffering human being;
the patient had lost his job due to the horrific accident, was trying to
get justice through workers comp and had very little money, his car
barely worked, he was caring for a developmentally disabled son,
and was trying to make it one day to the next.
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UH Defense
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The patient had been receiving the “holy trinity” of
opioids, benzodiazepines, and muscle relaxants for
years before he saw Dr. Bannister;
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The patient did not exhibit the typical “red flags” when
seeing Dr. Bannister, such as missing appointments,
calling for early refills, showing up randomly seeking
more prescriptions;
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UH Defense
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Dr. Bannister determined that the patient’s existing medication
regimen was appropriate because after having been seen by
numerous specialists, this was what was finally working for him;
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Dr. Bannister never noticed any adverse effects;
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Dr. Bannister required regular appointments;
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It was his cardiac condition that caused the patient’s death, not the
drugs, and toxicology indicated that all the drugs were in his system
at appropriate levels. He had 2 blocked vessels, but was afraid to
undergo surgery.
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UH Defense
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UH had some strong arguments, however it was difficult to
overcome the lack of urine testing, failure to pull OARRS, failure to
review documents from previous providers.
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Part 2: Opioid mechanisms of action, scope of
current epidemic, and pathways into addiction
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Opioid mechanism of action
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Opioids are natural and synthetic substances that act on the
endogenous opiate system
– Receptors: mu, delta, kappa
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Primary sites of action are CNS, respiratory, and GI
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Indicated primarily for pain; also antitussive effects, anti-diarrheal
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Abused for analgesia and euphoria effects
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Opioid mechanism of action
Obtained from: https://www.uspharmacist.com/article/gastrointestinal-sideeffects-of-opioid-analgesics
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Mechanism of reinforcement
Stahl, 2006. Essential
Psychopharmacology
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The scope of the problem
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More people died of drug overdoses in 2014 than any year on
record, and the majority of these (>60%) involved an opioid
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Rate of overdose deaths involving opioids has nearly quadrupled
since 1999
– Over 165,000 people have died from prescription drug OD
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In the last few years there has been a sharp increase in heroinrelated deaths, and in deaths related to synthetic opioids such as
fentanyl and carfentanil
www.hhs.gov
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Common pathways to opioid addiction
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From non-opioid addictive substances
– Alcohol
– Other illicit drugs
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From opioids
– Prescriptions obtained inappropriately (illicitly, or from
friends/family)
– Prescriptions obtained appropriately! From us!
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Source where pain relievers were obtained for most recent nonmedical
use among past year users aged 12 or older: 2012-2013
Image from SAMHSA, as cited in Tetrault and Butner, 2015.
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Part 3: Ohio Physicians Health Program (OPHP) data
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Physicians are not immune to addiction
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Lifetime prevalence of substance use disorders in physicians is
similar to that of general population
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13-14% or about 1 in 7 people
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The Ohio Physicians Health Program (OPHP) assists
physicians with mental/emotional/physical illness, substance use
disorders, stress/burnout
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OPHP Program Services
Confidential Resource
• Mental, Emotional, & Physical
Illness
• Substance use disorders
• Stress & burnout
• Boundary violations
• Gambling
• Intervention services
• Assessment services
Monitoring & Advocacy
• Recovery documentation
• Mental health & wellness
plans
• Toxicology testing
• Compliance reporting
• Support & advocacy
Educational Outreach
• Substance use disorders in the
healthcare community
• Stress, burnout, & suicide in
healthcare populations
• Statutory guidelines to remain
anonymous to licensing
authorities
Compassionate, Supportive, and Safe
OPHP provides a
compassionate, supportive,
and safe environment for
healthcare professionals to
receive confidential services to
improve their health and wellbeing.
Our goal is to inspire physicians
and other healthcare professionals
to seek treatment and monitoring
for their illnesses in order to
ensure patient care and safety.
WEBSITE: www.ophp.org
*ONE-BITE RULE*
OPHP specializes in
providing assistance to
healthcare professionals
voluntarily seeking
treatment and who qualify
for the One-Bite Rule
allowing for confidential
participation.
OPHP Confidential Resource Data
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OPHP Confidential Resource Data
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Part 4: Opioid use disorders – Continuum of care
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Continuum of care: Overdose prevention
Project DAWN: Deaths Avoided with Naloxone
MetroHealth Hospital dispenses FREE kits to eligible patients in the ED as well as:
The Cuyahoga County Board of Health
5550 Venture Drive, Parma, Ohio 44129
Walk-in hours: Fridays, 9:00 a.m. - 12:00 p.m.
The Free Medical Clinic of Greater Cleveland
12201 Euclid Ave, Cleveland, Ohio 44109
Walk-in hours: Tuesdays, 12:00 p.m. - 4:00 p.m. and Fridays 1:00 p.m. - 5:00 p.m.
Thomas F. McCafferty Health Center
4242 Lorain Ave, Cleveland, Ohio 44113
Walk-in hours: Thursdays 4:00 p.m. - 8:00 p.m.
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Continuum of care: Withdrawal/detoxification
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UH hospitals on AllScripts have inpatient opioid withdrawal order set
– “COWS” monitoring scale for withdrawal symptoms
– Buprenorphine is the main medication
– Methadone option available for pregnant females
– Ancillary agents (“comfort meds”) also available (see handout)
– Currently under revision (9/2016)
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REMINDER: UH is not a drug treatment center! Patients must be
admitted with other medical/surgical issues in order to get
buprenorphine-based withdrawal management
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Patients who ONLY have substance use issues/withdrawal should be
referred preferentially to a specialty drug treatment center
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Continuum of care: Withdrawal/detox units
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There are many specialized inpatient detox units in NE Ohio:
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Rosary Hall at St. Vincent Charity Hospital
Lutheran Hospital
New Vision within UH Geauga Hospital
Laurelwood Hospital
Glenbeigh Hospital
Stella Maris
Harbor Light
Ambulatory detox may be an option for some patients:
– UH Addiction Recovery Services (ARS); University Hospitals
– Veterans Addiction Recovery Center (VARC); Cleveland VAMC
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Continuum of care: Treatment options Inpatient
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Inpatient detoxification/withdrawal management
– Short term treatment
– Purpose = detoxify the patient acutely
– Locations = inpatient treatment centers*
– Estimated length of treatment = 3-5 days
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Inpatient rehabilitation (inpatient hospital versus residential)
– Longer term treatment
– Purpose = treat underlying addiction while establishing sobriety
in a controlled setting
– Locations = inpatient hospital or residential treatment centers
– Estimated length of treatment = 30/60/90 days, up to 1 year
* = this can be done on inpatient med/surg units, if patients are admitted for other medical issues
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Continuum of care: Treatment options Outpatient
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Partial hospitalization programs (PHP)
– Intensity: 20+ hours of service per week
– Services: individual counseling, groups, medication management
– Advantage = highly structured, professionally led setting but allows
for work or child responsibilities; can practice sobriety skills at home
– +/- Ambulatory detoxification
– Locations = ARS at UH, Laurelwood, and others
– Estimated length of treatment = typically 3-4 weeks
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Intensive outpatient programs (IOP)
– Intensity: 9+ hours of service per week
– Services: individual counseling, groups, medication management
– Advantage = highly structured, professionally led setting but allows
for work or child responsibilities; can practice sobriety skills at home
– Locations = many including community agencies, ARS at UH
– Estimated length of treatment = typically 6-12 weeks
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Continuum of care: Treatment options Outpatient
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Outpatient clinics
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Intensity: <9 hours of service per week
Services: individual counseling, groups, medication management
Advantage = more flexibility to allow for work and child care
Disadvantage = may not provide adequate structure and/or
monitoring in all cases
Outpatient medication-assisted treatment (MAT) programs
– Methadone (CTC and CAAA)
– Buprenorphine (multiple office-based providers)
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Continuum of care: Medication-assisted treatment
• Naltrexone = opioid antagonist
– Blocks the effects of opioids
• Methadone = opioid full agonist
– Morphine-like effect
• Buprenorphine = opioid partial agonist
– Maximum effect is less than a full agonist
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Buprenorphine: Special considerations
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When prescribing buprenorphine TO TREAT ADDICTION, physician
must have a DATA 2000 Waiver, also called an “X-DEA number” 
EXCEPTION if using buprenorphine in hospital setting in
accordance with the opiate withdrawal order set
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DATA 2000 Waiver can be obtained by any physician by taking an
8-hour online course
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Allows you to treat 30 patients with buprenorphine in year 1, and 100
patients starting in year 2
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As of 8/2016, specific providers can treat up to 275 patients per year
http://www.samhsa.gov/medication-assisted-treatment
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Continuum of care: Adjunct to treatment 
“12 step” programs
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Alcoholics Anonymous and Narcotics Anonymous
– Focus on building coping ability, relapse prevention, and sober
social support
– Sponsors provide 1:1 support
– Widely available meetings (at least 884 weekly in Cleveland)
– Multiple format options (open vs closed, speaker vs discussion,
women only, etc.)
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Al-Anon, Nar-Anon, Families Anonymous
– Support for family members of addicts
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Part 5: How to assess & monitor opioid usage
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How to assess & monitor opioid usage
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SBIRT
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“Universal Precautions” when prescribing opioids
in chronic non-cancer pain (CNCP)
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ORT = Opioid Risk Tool
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OARRS Report
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UH Opioid Prescribing Guidelines
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S-BI-RT
• Screening: Identification of patients with high-risk or dependent
drinking and/or drug use
• Brief Intervention: Conversation to motivate patients who screen
positive to consider healthier decisions (e.g. cutting back, quitting, or
seeking further assessment)
• Referral to Treatment: Active linkage of patients to resources when
needed
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10 steps of “Universal Precautions” in CNCP
1. Make a diagnosis with appropriate differential.
2. Perform a psychological assessment, including risk of addictive disorders.
3. Obtain informed consent.
4. Use a treatment agreement.
5. Conduct assessments of pain level and function before and after the intervention.
6. Begin an appropriate trial of opioid therapy with or without adjunctive medications
and therapies.
7. Reassess pain score and level of function.
8. Regularly assess the “4As” of pain medication (analgesia, ADLs, adverse events,
aberrant drug-related behaviors).
9. Periodically review pain diagnosis and co-occurring conditions, including addictive
disorders.
10. Document initial evaluation and follow-up visits.
Adapted from Gourlay et al., 2005. (SAMHSA TIP 54, page 49)
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ORT =
Opioid
Risk Tool
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OARRS Report
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See OAC 4731-11-11 for most current rules (updated 12/31/15)
“Standards and procedures for review of "Ohio Automated Rx
Reporting System" (OARRS)
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A physician shall obtain and review an OARRS report:
– before prescribing or personally furnishing an opiate analgesic or
benzodiazepine to a patient, unless an exception is applicable
– when a patient's course of treatment with a reported drug other
than an opioid analgesic or benzodiazepine has lasted more
than ninety days, unless an exception is applicable
– when any of the following (19) red flags pertain to the patient
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A physician shall document receipt and review of the OARRS
report in the patient record
OARRS “Red Flags”
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(a) Selling prescription drugs
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(b) Forging or altering a prescription
(c) Stealing or borrowing reported drugs
(d) Increasing the dosage of reported drugs in
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amounts that exceed the prescribed amount
(e) Suffering an overdose, intentional or
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unintentional
(f) Having a drug screen result that is inconsistent
with the treatment plan or refusing to participate in •
a drug screen
(g) Having been arrested, convicted, or received •
diversion or intervention in lieu of conviction for a
drug related offense while under the physician's •
care
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(h) Receiving reported drugs from multiple
prescribers, without clinical basis
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(i) Traveling with a group of other patients to the •
physician's office where all or most of the patients
request controlled substance prescriptions
(j) Traveling an extended distance or from out of
state to the physician's office
(k) Having a family member, friend, law
enforcement officer, or health care professional
express concern related to the patient's use of
illegal or reported drugs
(l) A known history of chemical abuse or
dependency
(m) Appearing impaired or overly sedated during
an office visit or exam
(n) Requesting reported drugs by street name,
color, or identifying marks
(o) Frequently requesting early refills of reported
drugs
(p) Frequently losing prescriptions for reported
drugs
(q) A history of illegal drug use
(r) Sharing reported drugs with another person
(s) Recurring visits to non-coordinated sites of
care, such as emergency departments, urgent
care facilities, or walk-in clinics to obtain reported
drug
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When to re-check OARRS?
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For opioid analgesic or benzodiazepine used > 90 days:
Recheck at least every 90 days during the course of treatment,
unless an exception is applicable
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For reported drug other than an opioid analgesic or benzodiazepine
used > 90 days:
Recheck at least annually until the course of treatment has
ended, unless an exception is applicable
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OARRS exceptions
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(1) The reported drug is prescribed or personally furnished to a hospice
patient in a hospice care program or any other patient diagnosed as
terminally ill;
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(2) The reported drug is prescribed for administration in a hospital,
nursing home, or residential care facility;
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(3) The reported drug is prescribed or personally furnished in an amount
indicated for a period not to exceed seven days;
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(4) The reported drug is prescribed or personally furnished for the
treatment of cancer or another condition associated with cancer;
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(5) The reported drug is prescribed or personally furnished to treat acute
pain resulting from a surgical or other invasive procedure or a
delivery.
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Other important OARRS information
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If you practice in an Ohio county that adjoins another state, you must
check drug database in the state adjoining that county
– NOTE: Pennsylvania does not share data with Ohio, but Michigan,
Indiana, Kentucky, and West Virginia do share data
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All states except Missouri have a Prescription Drug Monitoring Program
(PDMP)
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VA Hospitals are now allowed to share data, as of 2014
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CAUTION!! Federally funded OTPs (Opioid Treatment Programs, or
“methadone clinics”) do not report to OARRS
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UH Opioid Prescribing Guidelines
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Distributed system-wide as of 9/9/16 to all UH Medical
Staff and Advanced Practice Providers
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Covers the following 5 areas:
– Pain presenting at EDs and ACFs
– Acute pain outside of ED
– Post-surgical pain
– Chronic and palliative care pain
– Hospice Care pain
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See handout for more details
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Part 6: Take-home messages
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Messages for patients & their families
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Opioid overdoses are preventable
 Get a Project DAWN Kit
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Opioid use disorders are treatable brain diseases
 Individuals and their families can benefit from treatment
 Treatment is best when it blends bio-psycho-social approaches
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Opioid guidelines exist for patient health and safety
 There may be alternatives to opioids for treating chronic pain
 Opioids (& other controlled substances) are monitored statewide
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Part 7: Discussion & Q/A
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References
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American Society of Addiction Medicine Opioid Addiction 2016 Facts & Figures
http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-factsfigures.pdf
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Medication Assisted Treatment http://www.samhsa.gov/medication-assistedtreatment
National Institute on Drug Abuse (NIDA) https://www.drugabuse.gov/
Ohio Physicians Health Program www.ophp.org
Schuckit MA. Treatment of Opioid Use Disorders. NEJM (07/28/16) Vol. 375, No. 4,
P. 357 http://www.nejm.org/doi/full/10.1056/NEJMra1604339#t=article
Substance Abuse and Mental Health Services Administration. Managing Chronic
Pain in Adults With or in Recovery From Substance Use Disorders. Treatment
Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011
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