Transcript CDC Guideline for Prescribing Opioids for Chronic Pain

National Center for Injury Prevention and Control
IPOP Opioid Overdose Training Academy
The Basics of Opioid Overdose:
A Public Health Perspective
Joann Yoon Kang, JD
Policy and Partnerships Team Lead
Division of Unintentional Injury Prevention
October 17, 2016
CDC PRIORITIES: Unintentional Injury Prevention
Motor Vehicle Safety
Prescription Drug Overdose
Older Adult Falls
Traumatic Brain Injury
Public Health Model
Assess the
Problem
Implement
& Disseminate
Effective
interventions
Identify the
Causes
Develop &
Evaluate
Programs
& Policies
Changing Landscape of
Prescription Drug Overdoses –
Rise of an Epidemic
Unintentional drug poisoning mortality by
drug, United States, 1979-1998
Opioids/Heroin
Cocaine
Age-adjusted rate per 100,000
1.2
1
0.8
0.6
0.4
0.2
0
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98
Slide developed by Dr. Lenard Paulozzi
Source: CDC WONDER
States Waving Red Flags, 1999-2004
• Maine medical examiner report (2002) finds “a rising problem
with prescription drug abuse.”
• North Carolina epi aid (2002) finds that “prescription
narcotics” accounted for 90% of the increase in drug deaths,
1997-2001
• 11-state MMWR (2004) uses new ICD10 coding, finds rx
opioid deaths outnumber heroin deaths during 1999-2000.
Slide developed by Dr. Lenard Paulozzi
Sources: CDC Epidemiological Assistance to North Carolina, 2002 (K. Sanford, M. Ballesteros, D. Budnitz, G.
Agyekum)
MMWR, 2004, vol 53, no 11 (M. Davies, V. Coronado)
CDC Involvement Begins, 2004
• Tools then available to study the issue
– Mortality data from National Vital Statistics System
– Drug sales data from DEA
– Datasets from the Drug Abuse Warning Network of
SAMHSA
Slide developed by Dr. Lenard Paulozzi
First DUIP Publication on Rise of Opioid
Overdose
• “Increasing deaths from opioid analgesics in the United
States”
• Published in Pharmacoepidemiology and Drug Safety in 2006
• Paulozzi, Budnitz, and Xi
• First use national data coded to ICD-10
– Distinguishes heroin from opioid analgesics for first time
Slide developed by Dr. Lenard Paulozzi
Confirmation
• Study using a different source, DAWN medical examiner data,
confirmed deaths were attributed to specific opioids (2006)
• Epi Aid to West Virginia confirmed that opioid analgesics were
causing deaths in the absence of alcohol or illicit drugs (2008)
Slide developed by Dr. Lenard Paulozzi
Sources: AJPH 2005; 96:1755-57 (L. Paulozzi)
CDC Epidemiological Assistance to West Virginia, 2008 (A. Hall, J. Logan, R. Toblin, et al.)
Changing Landscape of
Prescription Drug Overdoses –
Current Burden
Sharp Increase in Opioid Prescriptions
Increase in Deaths
Role of Prescribing Opioids and Overdose Deaths
Prescription opioid misuse is a major risk factor
for heroin use
3 out of 4 people
who used heroin in the
past year misused
opioids first
7 out of 10 people
who used heroin in the
past year also misused
opioids in the past year
Jones, C.M., Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002–2004 and 2008–
2010. Drug Alcohol Depend. (2013).
Rise in Rx overdose deaths since 2000
and recent increase in heroin & fentanyl deaths
Deaths per 100,000 population
5
Commonly Prescribed Opioids
like oxycodone or hydrocodone
4
Heroin
3
2
Methadone
1
Synthetic opioids
like fentanyl
0
2000
2002
SOURCE: National Vital Statistics System Mortality File.
2004
2006
2008
2010
2012
2014
Overview of CDC’s Response
HHS Secretary’s Opioid Initiative
Focus on three priority areas that tackle the opioid crisis and significantly
impact those struggling with substance use disorders to help save lives
1
Providing training and educational resources to
assist health professionals in making informed
prescribing decisions
2
Increasing use of Naloxone
3
Expanding the use of Medication-Assisted Treatment
3 Pillars of CDC’s
Opioid Prevention Work

Improve data quality and track trends

Strengthen state efforts by scaling up effective public
health interventions

Supply healthcare providers with resources to improve
patient safety
Improving Data Quality and Tracking Trends:
Recommendations from Ohio EpiAid
• Use multiple data sources for comprehensive analysis
– Vital Statistics
– Coroner/Medical Examiner Reports and Toxicology
• Utilized unintentional drug overdose module in the
National Violent Death and Reporting System (NVDRS)
– Prescription drug monitoring programs
– Emergency Dept. chief complaint and triage notes
– Emergency Medical Services
• Naloxone administration data
– DEA data on heroin and fentanyl drug seizures
Law enforcement seizures (dark blue) and
fentanyl-involved overdoses (light blue), Ohio,
Jan 2013- June 2015
250
200
Number
150
100
50
2013
2014
2015
June
May
April
March
Feb.
Jan.
Dec.
Nov.
Oct.
Sept.
Aug.
July
June
May
April
March
Feb.
Jan.
Dec.
Nov.
Oct.
Sept.
Aug.
July
June
May
April
March
Feb.
Jan.
0
Improving Tracking and Monitoring
• CDC is working to maximize capabilities and use of
Prescription Drug Monitoring Programs (PDMPs):
– Statewide databases that track controlled prescription
drugs
• Contain critical clinical data that helps:
– Identify patients at risk for opioid-related overdoses
– Inform providers of other medications the patient is
receiving that may interact with those prescribed
– Identify patients struggling with substance-use disorder
Strengthening States’ Efforts
Overdose Prevention in State Awardees
50
45
45
40
Funded States
35
30
25
20
16
15
10
5
5
0
0
FY 2013
FY 2014
FY 2015
FY 2016
CDC’s Overdose Prevention in States Effort
• Prevention for States Program
– 29 States
– 4 Key Strategies:
• Enhancing and maximizing PDMPs
• Community, insurer, and health systems interventions
• Policy evaluation
• Rapid response projects
• Data-Driven Prevention Initiative
– 14 States
– Two levels of funding:
• Planning and Data
• Prevention in Action
CDC’s Overdose Prevention in States Effort
• Enhanced State Surveillance of Opioid-Involved Morbidity
and Mortality
– Support to enhance states’ data capacity
– 12 states funded to:
• Monitor illicit opioid use risk factors
• Improve the timeliness and quality of opioid overdose
data
– Improved quality and timeliness of surveillance data will
support and inform prevention and response efforts
Pillar 3: Providing Resources to Healthcare
Providers

Primary care

Patients > 18 Years
with chronic pain

Outpatient settings

Outside of active
cancer, palliative, and
end of life care
THE EVIDENCE
Opioids treat pain
Lack of evidence that opioids control pain effectively long term.
effectively long-term.
Risk
ofisserious
harm increases with opioid dose.
There
no unsafe
opioid dose.
Up to a quarter of patients receiving opioids long-term in a
Addiction
risksetting
is low. struggles with addiction.
primary care
First, do no harm. Opioids are not first-line
or routine therapy for chronic pain.
When opioids are used, prescribe the
lowest effective dosage.
Exercise caution when prescribing opioids
and monitor all patients closely.
CDC Guideline Implementation
Translation and Communication
Clinical Training
Health System Implementation
Insurer/Pharmacy Benefit Manager
Implementation
Educational Resources
Patient materials
• Graphics and messages
• Fact sheets
• Posters
• Podcasts
• Infographics
Training Resources: Webinars
COCA webinar series
1. Overview
2. Nonopioid Treatments for
Chronic Pain
3. Assessing Benefits and
Harms of Opioid Therapy
4. Dosing and Titration of
Opioids
Additional webinars coming soon!
Health Systems
• Quality Improvement (QI) Initiative
• Clinical Decision Supports
– Create sharable EHR code/artifacts
– Clinical sites to implement guideline & track
outcomes
• Coordinated Care Plan
– Create the Chronic Pain Care Involving Opioids: A
Coordinated Care Plan for Safer Practice
• State-led efforts through CDC-funded states
– EHR and PDMP (prescription drug monitoring
program) integration
Insurer Interventions
Coverage for non-pharmacologic therapies
Improve ease of prescribing non-opioid pain medications
Reimbursement for patient counseling, care coordination, &
checking PDMP
Promote more judicious use of high dosages of opioids outside of palliative care, active
cancer or end-of-life care, using mechanisms such as drug utilization review
Remove barriers to evidence-based treatment of opioid use
disorder, such as eliminate lifetime limits on buprenorphine
Collaboration with Partners
•
•
•
•
•
•
•
Federal Agencies
Law Enforcement and DEA
Medical and Pharmacy Associations
Academic Institutions
Insurers and health systems
Partner organizations
States and local health departments
For more information please contact Centers for Disease
Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: [email protected]
Web: www.cdc.gov
Special thanks to Kristen Sanderson, MPH for her assistance with this presentation.
Please note that the findings and conclusions in this report are those of the authors
and do not necessarily represent the official position of the Centers for Disease
Control and Prevention.