Transcript A Community Approach – Shames

Jim Shames MD
Medical Director Jackson County
Health and Human Services
Jackson County Oregon
Population 206,412
(Jackson County averages over 250,000 opioid
prescriptions per year)
As the dose increases, so does mortality
Opioid Overdose
Risk (fatal
non-f:atal) byEquivalent
Average Dose (MED)
Mortality
risk compared
to &Morphine
Daily Dose of Medically Prescribed Opioids
10
9
8
7
6
5
4
3
2
1
0
**
9-fold
increase
in risk
relative
to low-dose
patients
**
** Significant
increment in
risk p<0.05
Non-user 1-19 mg. 20-49 mg. 50-99 mg. 100+ mg.
Dunn et al., Annals Int Med, 2010
Overdose deaths in US compared to motor
vehicle accidents
The 3 legged stool for community engagement:
The 3 Ps
• Prescribers (Health Professionals): Need
to learn about current best practices
concerning the treatment of Chronic
Complex Non-Cancer Pain (CCNP)
• Patients: Need behavioral and other
supports to learn to manage their chronic
pain without reliance on opioids
• Public: Need to understand the changes in
scientific understanding of pain
management so they can support their
loved ones. Need to learn about naloxone.
Prescribers
The abundance of prescription opioids is the
result of prescriptions!
If we don’t solve this problem as a
community, we are only passing it on to
the next provider.
Oregon Pain Guidance
(formerly Opioid Prescribers Group)
Attendees: Physicians, Mid-level providers, Nurses, Substance Abuse Counselors,
CCOs, Therapists, Pharmacists, Medical specialty (Pain Medicine, ED), Dental,
Community Justice Partners
Oregon Pain Guidance (OPG)
• Public Health initiative to reduce opioid overdoses by addressing the problem
at its core: medical providers
• CME and dinner provided
• OPG evolution:
Brainstormed >
Created guidelines >
guideline acceptance
• Topics for discussion:
–
–
–
–
–
–
Trauma Informed Care
Benzodiazepines
Challenging conversations
Oregon Medical Board
120 MED policy
Best practices
• OPG Steering Committee:
– Meet every 2 weeks
– Handle the work of the OPG
Summary of guidelines:
• Assess prior to prescribing!
• Encourage non opioid treatments
(They really work).
• Measure functional improvement.
• Compassionately say “No.”
• Keep MED below 120
and methadone below 40 mg.
• Assess for aberrant behaviors
(UDS, PDMP, pill counts, call backs)
• Don’t combine benzodiazepines and opioids
• Collaborate with community partners
(analysis of 112 JaCo and JoCo
prescribers: OPG survey)
Disagree
6%
Neutral
12%
Agree 24%
Completely
Agree 58%
We do need to provide compassionate care to
those with certain painful conditions
We don’t want to throw the
baby out with the bathwater
Opioids have a role to play
• In the treatment of acute
and post surgical pain
• In cancer and other
deteriorating painful
conditions
• In some chronic conditions,
when utilized at safe doses
•
•
•
•
Provider resources
Patient resources
Public resources
Supported by
Medicaid insurance
plans and Public
Health
• Please link us to your
websites.
www.oregonpainguidance.org
The Dissemination concept
• Critical mass: If enough providers understand
the guidelines, word of mouth and peer
pressure will lead to adoption.
• Information is transmitted via the pilot’s
providers, OPG, KOBI messaging, website,
consults, conferences,
Educating the
Public
through TV spots
Patients
Help from the CCOs
• They help support the OPG
• Pay for behavioral health consultants to assist
primary care providers
• Support the Website, the Pain Conference, the
Guidelines
• They both have a 120 MED policy for their
members
• Are thought leaders at the Steering
Committee meetings
Providing local alternatives to opioids
• Pain Resiliency Program
• By referral from Primary
Care
• Support by CCOs
• Curriculum:
–
–
–
–
–
–
Evaluation, orientation
“Pain School”
Peer to Peer support
Movement therapy
Behavioral support
Feedback to Medical Home
Help from others
•
•
•
•
Jefferson Regional Health Alliance
Federal Harold Rogers Grant (see next slide)
Jackson County Health and Human Services
In kind contributions from many local non
profits
Interdisciplinary Action Committee:
IDAC
• Problem focused monthly meetings
• Participants:
– District Attorney
– Sheriff, Police
– Drug Court
– Public Health
– Substance Abuse treatment
– Southern Oregon University
– Parole and probation
Naloxone
• Oregon allows
bystander use
• Medford Police were
one of the first in the
State to initiate
naloxone use by
their officers.
• Plans for broader
community use
Jackson County accidental overdose data for the past
3 years:
25
20
15
2011
2012
2013
10
5
0
All Rx opioids
methadone alone
Heroin
Thank You
[email protected]