Transcript Presentation: Jonathan K. Han, MD

Prescribing
Naloxone and
Promoting Safe
Use of Opioids
in Primary Care
Jonathan Han, MD
Medical Director
UPMC New Kensington Family
Health Center
UPMC St. Margaret Family
Medicine Residency Program
July 30, 2015
Disclosures
 None
Objectives
• Recognize the scope of opioid abuse
in our practice environment
• Understand significance of social
determinants of health in addressing
issues of substance abuse and
dependence
• Demonstrate naloxone prescribing as
a harm reduction strategy in a primary
care environment
Scope of the Problem
• 2 million individuals with opioid
analgesic use disorders
• 4-fold increase in opioid prescriptions
for pain in the last 10 years
• Deaths from prescription opioids have
doubled in the last 10 years: 17,000 in
2010
• 46 Americans die every day from
overdose on prescription opioids
CDC MMWR November 4, 2011 / 60(43);1487-1492
Coffin P, Banta-Green C. The Dueling Obligations of Opioid Stewardship.Ann Intern Med. 2014;160(3):198-200.
Opioid pain reliever-related overdose deaths increasing
at a faster rate than deaths from any major cause
WISQARS, 2000 and 2010; CDC/NCHS, National Vital Statistics System
More Opioid Harms
In 2013…
•
81.1% of overdose deaths were
unintentional
•
52% of overdose deaths were
related to pharmaceuticals
•
Opioids were implicated in 71.3%
of these deaths
http://wkyufm.org
Prescription Drug Overdose in the United States: Fact Sheet. CDC Website.
24 people per 100,000
http://www.overdosefreepa.pitt.edu/overdosedata/
For JS
How did we get here?

Archives Internal Med Vol
165 July 23, 2005

11 Multidisciplinary
members of the APS

Reviewed MEDLINE and
“Cumulative Index to
Nursing and Allied Health
Literature database”

All members of APS gave
input as well
How did we get here?
“All patients should be routinely screened for
pain, and when it is present, pain intensity
should be recorded in highly visible ways
that facilitate regular review by health care
providers.”
How did we get here?
• J GEN INTERN MED 2006; 21:607–612.
• Obj: measure Pain as 5th Vital Sign’s
impact on pain management
• 15 PCP offices; 300 visits before and 300
after implementation
• Results: P value >.05 for every comparison
(provider assessment, pain exam, orders,
analgesics, follow up)
• Conclusions: No change
How did we get here?
Real expert opinion:

“No one ever died from a pain
scale of 10” – Nil Das, MD
PAIN has an element of blank;
It cannot recollect
When it began, or if there were
A day when it was not.
It has no future but itself,
Its infinite realms contain
Its past, enlightened to perceive
New periods of pain.
“Part One: Life, XIX”
Emily Dickinson, 1830-1886
We need to address Root
Causes
 Provide
patients access to an integrated
multidisciplinary primary care team Patient Centered Medical Home
 Intervene
“upstream” – address social
determinants of health care
 Decrease
fragmentation of care
Why are we here?
Why are we here:
ACE Matters
Why are we here?
• Personal History of Substance Abuse
Alcohol
Illegal Drugs
Prescription Drugs
• Age 16-45
Opioid
Risk Tool
• History of Preadolescence Sexual
Abuse
• Psychological Disease:
Attention Deficit Disorder, Bipolar,
Schizophrenia, Obsessive Compulsive
Disorder
Depression
Webster LR, Webster R. Predicting aberrant
behaviors in Opioid-treated patients:
preliminary validation of the Opioid risk
tool. Pain Med. 2005;6(6):432
Responsible opioid prescribing
in pain management
 Follow
evidencebased guidelines
 Use
screening tools
(e.g. DIRE, ORT)
 Follow
protocols
and utilize
agreements
 Urine
 Refer
testing
for nonpharmacologic rx
 Prescription
monitoring
programs
drug
 Treat
comorbid
behavioral health
issues
 Refer
for substance
abuse treatment
Community
Medicine*
Naloxone Project – Outpatient
and Inpatient
Harm reduction is a set of practical
strategies and ideas aimed at reducing
negative consequences associated with drug
use. Harm Reduction is also a movement for
social justice built on a belief in, and respect
for, the rights of people who use drugs.
Defined by the WHO as:
A concept aiming to prevent or reduce negative
health consequences associated with certain
behaviors
 Pragmatism
drug use?
– Are we going to eliminate
 Humanistic
Values – Not approval but not
moral judgment
 Focus
on Harms – Not the use itself
 Balancing
 Priority
Costs and Benefits - Evaluation
of Immediate Goals
IBH Harm
Reduction
Strategies
2011
SBIRT
Universal
Screening
for SUD
2010
SBIRT
curriculum
development
2012
Integrated
Behavioral
Health Team MH/SA
services in
family health
centers
2013
Controlled
Substances
Protocol
revision
2014
Naloxone
Rescue
Project
development
Endorsement, Policy and Legal
Support
www.OverdoseFreePA.org

http://prescribetoprevent.org/medical-legal/
FIGURE 2. Number* and location of local drug overdose
prevention programs providing naloxone to laypersons, as of
June 2014, and age-adjusted rates† of drug overdose
deaths§ in 2013
CDC, National Center for Health Statistics -the number and location, by state, of local drug overdose
prevention programs providing naloxone to laypersons, as of June 2014, as well as the age-adjusted rates
of drug overdose deaths in 2013.
Naloxone is extraordinarily
effective

152,283 naloxone kits
dispensed, with 26,463
reversals (one reversal
in 5.7 kits)

Prostate cancer
screening – more than
1000 men to prevent
one death

164 naloxone scripts =
one prevented death,
at a cost of
$420/quality adjusted
life year gained

Aspirin primary
prevention for MI in
elderly men – 511

Statin prevention in
men with 5 yr risk of
7.5%: stroke 606, MI
186

Recent studies suggest
closer to 36 scripts =
one prevented death.
Naloxone Project
Objectives
1. Educate patients and providers about
naloxone
2. Increase naloxone prescribing to highrisk patients
3. Improve provider satisfaction during
difficult visits
4. Reduce opioid use in high-risk patients
High Risk Criteria





Recent emergency medical care involving opioid
poisoning/intoxication
Suspected history of illicit or nonmedical opioid use
High-dose opioid prescription ( > 50 mg of morphine
equivalence/day)
Methadone prescription to opioid naïve patient
Any opioid prescription AND:
 Smoking/COPD/Emphysema/Asthma or other respiratory
illness
 Renal dysfunction, hepatic disease
 Known or suspected concurrent alcohol use
 Concurrent benzo prescription
 Concurrent SSRI or TCA anti-depressant prescription
 Release from opioid detox or mandatory abstinence
program
 Voluntary request from patient
 Patients in methadone or buprenorphine detox/maintenance
 Patient with difficulty accessing emergency medical services
 Recent release from incarceration
Naloxone Letter Project
• Educates patients about dangers of opioid
overdose
– Motivates patients to accept naloxone
prescriptions
– Encourages patients to ask for help to wean
down opioid use, if appropriate
• Helps providers counsel new patients who request
opioid refills at 1st visit
– Decreases contentious tenor of those visits
– Improves provider satisfaction/feelings of
empowerment
Naloxone Project - Letter
Dear Patient:
We are giving you this letter because we believe you, a family member or friend is safer having Naloxone (Narcan) at
home.
Naloxone is a medication that helps people who are having an overdose. Sadly, overdoses are a very common
cause of death. Most overdoses are accidents caused by Opioid pain medicines.
Examples of Opioid pain medicines are:
Hydrocodone (Vicodin/Norco), Oxycodone (Percocet, Oxycodone), Oxymorphone (Opana), Hydromorphone
(Dilaudid),Fentanyl (Duragesic), Methadone and Morphine.
Other things that increase the risk of an overdose are:
Certain medicines and alcohol can increase the risk of an overdose. Ask a pharmacist or doctor to review the
medications you are taking.
Specific medical conditions increase the risk for an overdose. Please talk to your doctor about this.
The good news is we can:
Give you Naloxone (Narcan) and show you, friend, or family member how to use it. Naloxone reverses the effect of
Opioid pain medicine. Another person has to give it to a person who is having an overdose, but it can save their life.
Give you a Naloxone kit to take home or give you a list of pharmacies that carry Naloxone with a prescription.
You may never need this medication yourself. Please give it to anyone who you think maybe experiencing an
overdose.
We want to help keep you safe and healthy. Please call us at _____________ with any questions.
Thank you,
UPMC St. Margaret Inpatient Family Health Center Team
Helpful Websites:
Prescribe to Prevent: http://prescribetoprevent.org/
Project Lazarus: http://project lazarus.org/
Overdose Prevention Project: http://pppgh.org/html/od_project.html
Pharmacies that carry naloxone: http://www.overdosefreepa.pitt.edu/find-naloxone/
February 2014 through February 2015
Letters sent* = 50
Naloxone dispensed* = 70
Naloxone Project – improves
patient/provider satisfaction
Naloxone Project – saves lives!
Barriers to Naloxone in Primary
Care
• Cost/Insurance Coverage
• Naloxone availability
• Buy-in/ Perceptions
• Availability of substance abuse
treatment
“We’ve been wrong about what our job is in medicine.
We think our job is to ensure health and survival. But
really it is larger than that. It is to enable well-being. And
well-being is about the reasons one wishes to be alive.
Those reasons matter not just at the end of life, or when
debility comes, but all along the way.
Whatever we can offer, our interventions, and the risks
and sacrifices they entail, are justified only if they serve
the larger aims of a person’s life.
I never expected that among the most meaningful
experiences I’d have as a doctor – and really, as a
human being – would come from helping others deal
with what medicine cannot do as well as what it can.”
-- Atul Gawande, “Being Mortal”
Thank you
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Nil Das, MD
Marianne Koenig, PharmD
Lucas Hill, PharmD
Brittany Sphar, MD
Jennie Jarrett, PharmD
Ron O’Neill, PharmD
Matt Diiulio, DO
Mary Popovich RN, Staff and Clinicians at
Family Health Centers
Alice Bell, LCSW Prevention Point PGH
Beth Nolan, PhD, U. Pitt School of Public Health
Gerald Cochran, PhD, U. Pitt School of SW