Transcript What began with cocaine and heroin……

The Prescription
Opioid Epidemic
A QUESTION OF BALANCE
P. Tennent Slack, MD
Departmental Chair
Interventional Pain Medicine Division
Northeast Georgia Physicians Group
Disclosure
I do not have (nor does any immediate family member
have) actual or potential conflict of interest, within the
last twelve months; a vested interest in or affiliation
with any corporate organization offering financial
support or grant monies for this continuing education
activity; or any affiliation with an organization whose
philosophy could potentially bias my presentation.
Lecture Outline
1. Overview of the Problem
2. How We Got Here
3. The Perfect Storm
4. The Prescriber’s World
5. Reforms
Opioids
OPIATES
Morphine ~1804
Codeine ~1832
Semi-synthetic
hydrocodone (1920) - Lortab; Vicodin; Norco
oxycodone (1916) - OxyContin; Percocet; Roxicodone
Synthetic
methadone (1937)
fentanyl (1960)
hydromorphone (1924) - Dilaudid
oxymorphone (1914) - Opana
What began with cocaine and
heroin……
What began with cocaine and
heroin……
MMWR / January 1, 2016 / Vol. 64 / Nos. 50 & 51
Circa 2000
The Tipping Point
Further increases in annual prescription volume began
to associate with overdose deaths
Major Outlier Statistically
Push For More Aggressive
Treatment Of Pain
• Perception that pain undertreated
• Opioid addiction rates low
Multiple Contributing
Elements
•
Annual volume of opioid prescriptions steadily on the rise
throughout the 1990's
•
Aggressive marketing by opioid manufacturers

Purdue Pharma fined $600 M in 2007
•
Rise of internet sales
•
Rise of PILL MILLS
•
Low prescriber awareness / low public awarness
•
Initially weak regulatory environment
What Make Prescription
Opioids Different?
•
•
•
•
Efficient distribution mechanism
Prescribed = not dangerous
Easily ingested
DEADLY SIDE EFFECT PROFILE
 ESPECIALLY WHEN MIXED WITH
OTHER CNS DEPRESSANTS
Alcohol
Xanax
Soma
Gold
standard
drug =
opioids
Monetary
Gain
Pain as a
complex
mind-body
phenomenon
Variations in
insurance
coverage for
pain
treatment
High
demand
for opioids
in the US
THE PRESCRIBER’S WORLD
distrust
compassion
THE PRESCIBER’S WORLD
Inumerable Troublesome Presentations
• Elderly forgetful patient presents with grandchild
distrust
• Young patient presents with parent
compassion
• Patient has abuse history but clearly definable source of pain
• Patient in flare up requesting early refill
• Patient in upward titration and/or search for best drug response phase
• Patient’s urine drug fails to show presence of prescribed drug
Opioid use - misuse spectrum
Ability to
downregulate use
More
control
Less control
“Legitimate” use
“Chemical coping”
Addiction
1.
2.
3.
4.
4 C’s
Loss of control
Compulsive
use
Continued use
despite harm
Craving
Reforms
•
STATE level
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State Medical Board rules and regulations – Feb 2012
PDMP – May 2013
Tramadol scheduled as CS IV
“Pill Mill” legislation – May 2013
9-1-1 Medical Amnesty Law
Medical Cannabis
NATIONAL level
•
•
•
REMS training
ADT formulations
Hydrocodone rescheduled from CS III to CS II
MAG Foundation
Think About It campaign
6 Point Opioid Prescribing Platform
Project DAN
P. Tennent Slack, MD
E-mail: [email protected]
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