NoRxAbuse Kick-off Safe Prescribing Saves Lives

February 4, 2016

Housekeeping

Sign-in sheets

Action team sign-up

Restroom locations

Electronic devices

Begin and end on time

Presentation Material Online: www.norxabuse.org

SAFE PRESCRIBING SAVES LIVES Ivan Petrzelka, PharmD, JD, MBA February 4, 2016

www.NoRxAbuse.org 3

OUR MISSION

Improvement of patient safety and prevention of prescription drug abuse.

4

DRUG ABUSE TRENDS

Paradigm shift in pain management

Shift from illicit drugs to Rx drugs

Accessibility Perception of safety Social acceptability

Rx Drug overdose deaths tripled since 1990 Rx Opioids are most abused – fastest growing

cause of death in US

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WHAT IS RX DRUG ABUSE?

Use without a prescription Use in a manner other than prescribed Use to induce certain experience or feeling

Up to 30% of opioid users may be abusing Rx meds

CDC & NIDA

6

7

US RX OVERDOSE DEATHS

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EVERY

WEEK

9

MAGNITUDE OF RX ABUSE

10

25K >3 MM

>20 MM

HOW DID WE GET HERE?

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HOW DID WE GET HERE?

11

OxyContin® introduced in 1996 Pain as 5th Vital Sign initiative (VA 1999) Decade of Pain Control & Research 2001-2010 (HR3244)

PATHS TO RX DRUG ABUSE

Injury – overmedication

Well-meaning family member or friend

Peer pressure – teens Direct to consumer advertising

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No. 1 Drug Dealer in USA

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SOLUTIONS

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EDUCATION

TREATMENT

REGULATION

ENFORCEMENT

ROLE OF OUR COALITION

Coalition for responsible prescribing and dispensing Bring together key stakeholders

Prescribers Dispensers Health Plans Educators Law enforcement Local businesses Public officials, etc.

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CALL TO ACTION Prescribers – drive the change in prescribing patterns, use

CURES, random testing, use alternative treatment mods. Prescribers and dispensers – educate patients on risks of

using controlled substances Heath plans - expand coverage for

alternative treatment modalities Public officials – expand access to

treatment for dependence & addiction Patients – secure your prescriptions

and dispose of unused drugs

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CHCF GRANT NoRxAbuse received one of twelve grants provided by

California HealthCare Foundation for opioid safety coalitions

Grant funds will support: Education of prescribers & patients Expansion of access to Mediation Assisted Treatment Expansion of access to Naloxone for treatment of opioid

overdose Safe disposal of Rx Drugs Better communication between law enforcement and providers

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JOIN OUR COALITION

We welcome all interested parties to join our efforts to improve patient safety

Many opportunities to help: Subscribe to our updates Attend meetings Join task force Professional expertise Financial or organizational support

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THANK YOU

www.NoRxAbuse.org ipetrzelka@charter.net

Rx Opiates In Shasta County

Andrew Deckert, MD, MPH, Health Officer,

Shasta County HHSA—Public Health February 4, 2016

WHAT ARE OPIOIDS? Illegal Drugs: Heroin

Prescription (Rx) medications used to treat pain: Morphine Codeine (eg Tylenol #3) Methadone Oxycodone (OxyContin, Percodan, Percocet) Hydrocodone (Vicodin, Lortab, Norco) Fentanyl (Duragesic, Fentora) Hydromorphone (Dilaudid) Buprenorphine (Subutex, Suboxone) Illegal Use of Rx Drugs RX opiates not prescribed to user RX drugs not used as prescribed, e.g. diversion (sold)

Opiates are a new epidemic

• 4x more pain meds sold since 1999 in US • No reported increase in population’s pain • Rx opiates questionable help for chronic pain • 44 people die every day in US fm Rx opiates CDC.gov/DrugOverdose/epidemic/index.html

The Story of A Pill Culture

US Drug Related Deaths

CDC, National Center for Health Statistics, National Vital Statistics System

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Rx Opioids

Cocaine

Heroin

Opioid Prescriptions per 1,000 residents, 2013

1,313

572

0

200

400

600

800

1,000

1,200

1,400

Shasta County California

Source: Brandeis PDMP Center of Excellence, analysis of CURES data, 2013

Source: CDPH EpiCenter, ER Visits with Primary Diagnosis/Ecode of Opioid Drug Poisoning, 2006-2014

27.4

45.5

39.1

27.7

32.7

40.4 39.2 40.9

56.9

10.5 11.3 12.9 14.2 14.1 16.0 16.5 17.4 18.4

0

10

20

30

40

50

60

2006 2007 2008 2009 2010 2011 2012 2013 2014

Rate

per

100

,000

Res

iden

ts

Shasta vs CA Rate of Emergency Department Visits Related to All Opioids (Poisonings)

Shasta County California

Source: OSHPD ER and Hosp data. Any dx or E-code ICD9- Heroin: 965.01, E850.0; All Opioids: 304.0, 304.7, 305.5, 965.00, 965.01, 965.02, 965.09, E850.0, E850.1, E850.2

Opioid Related ER Visits, Shasta Co, 2008-2013

4 6 4 7 11 26 44

421 363 386

440 480 474

854

0

100

200

300

400

500

600

700

800

900

2008 2009 2010 2011 2012 2013 2014

Num

ber o

f ER

Visit

s Shasta County Opioid Related ER Visits, 2008-2014

Heroin All Opioids

“Did you know that narcotic prescription-related ER visits

have more than doubled in Shasta?

We’re coming together to fix this, and your voice is

important. Come join our coalition.”

Source: OSHPD ER and Hosp data. Any dx or E-code ICD9- Heroin: 965.01, E850.0; All Opioids: 304.0, 304.7, 305.5, 965.00, 965.01, 965.02, 965.09, E850.0, E850.1, E850.2

Opioid Related Hospitalizations, Shasta Co, 2008-2013

4 3 2 1 4 9 9

321 298

387 390

548

631 609

0

100

200

300

400

500

600

700

2008 2009 2010 2011 2012 2013 2014

Num

ber o

f Hos

pita

lizat

ions

Shasta County Opioid Related Hospitalizations, 2008-2014

Heroin All Opioids

5.7

10.8

15.3 15.8

13.5

9.5

13.4

11.7

4.1 4.5 4.8 5.3 5.1 5.1 4.5

5.1

0

2

4

6

8

10

12

14

16

18

2006 2007 2008 2009 2010 2011 2012 2013

Rate

per

100,

00

Crude Rate of Opioid Pharmaceuticals Deaths

Shasta County California

Source: CDPH EpiCenter, Drug Poisoning Deaths, 2006-2013

“Did you know that someone dies every 2-3 weeks in

Shasta from drug overdose?

We’re coming together to fix this, and your voice is

important. Come join our coalition.”

In the VA, 50% of opioid OD deaths are on concurrent benzodiazepines2

– Among opioid users, risk of death goes up with benzodiazepines in a dose-response fashion

After opioids, benzodiazepines (anti-anxiety meds) are drug class most commonly involved in pharmaceutical OD deaths (30%) 1

1. Jones CM, et al. JAMA 2013;309 (70):657-659. 2. Park TW, et al. BMJ. 2015;350:h2698.

Benzodiazepines and Overdose Deaths

596.3

1,249.0

1,210.7

922.3

596.8

435.6

223.8

32.3

0 200 400 600 800 1,000 1,200 1,400

Rate per 1,000 CA Residents

Age

Gro

up

Opioid Prescribing Rates by Age group

<18

18-24

25-34

35-44

45-54

55-64

>= 65

Total

27% 25%

21%

0%

10%

20%

30%

40%

50%

2006-2007 2008-2009 2009-2011

Percent of Shasta County 11th graders who have ever used prescription pain killers to “get high”

Source: OSHPD Hospitalizations ICD 9: 7795 (Drug Withdrawal in Newborn) or 76072 (Narcotics affecting fetus or newborn via placenta or breast milk)

8.8 7.1 7.3

4.9 4.2 4.1

13.5

18.3

24.6 22.9

14.8

23.2 23.8

0

5

10

15

20

25

30

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Rate

per

1,0

00 Li

ve B

irths

Rate of Shasta County Newborns with Narcotics

62.4%

13.6%

4.9%

17.3%

0% 10% 20% 30% 40% 50% 60% 70%Percent of Prescriptions

Paye

r Sou

rce

Payment Source for Opioids California 2013

Cash

Medicaid

Medicare

Private insurance

Totals do not add to 100% because other

payment types are not shown.

Changing Face of Heroin Use in U.S.

• 80% of heroin users, who were mostly young city dwellers, initiated heroin first

1960s

• 75% of heroin users started using heroin after getting into opioid painkillers first… Older, more suburban/rural

Recent Years

T. Cicero et al JAMA Psychiatry. 2014;71(7):821-826. doi:10.1001/jamapsychiatry.2014.366

What’s happening now…

10 Drug Take Back events with 4500 pounds of meds

4 permanent pill Medication Disposal kiosks

Syringe Exchange Program has removed 250,000 dirty needles over 7 years

16 Sharps kiosks collecting 21,000 pounds of needles and syringes since 2006

www.thinkagainshasta.com website for parents

What’s happening now (continued)… Shasta HHSA active participant on the No Rx Abuse coalition, and helped secure grant funding

NO Rx Abuse applied for and will receive 50 naloxone autoinjectors (~$700 retail each)

HHSA has opiate treatment programs for all ages and contracts with AOD service providers

Upcoming medication assisted treatment trainings (eg Suboxone) for law enforcement, public and medical providers

Rx opiates and heroin both

Evidence -- Rx opiates significant local issue

To decrease heroin here, decrease Rx opiate abuse Other substances, polypharmacy (eg alcohol, meth, marijuana)

Prevention

Treatment

“Did you know that one in four Shasta 11th graders have

taken prescription painkillers that aren’t prescribed to

them?

We’re coming together to fix this, and your voice is

important. Come join our coalition.”

Managing Pain Safely: Progress on Reducing Opioid Overuse in the PHC Service Area

Michael Vovakes, MD Northern Region Medical Director Partnership HealthPlan of California February 4, 2016

Accomplishments: Review of PHC Opioid Prescription Data

MPS Data – Total Prescriptions

2013 2014 2015

0.00

10.00

20.00

30.00

Rx

22.8

10.5

27.7

13.7

MPS Lunched

Formulary Change

TAR Process Change

Opioid Prescriptions P100MPM

Overall

RegionNorthern

Southern

52% Decrease Jan 2014 – November 2015

2013 2014 2015

0.00

5.00

10.00

15.00

20.00

New

9.99

2.18

2.253.61

2.14

19.66

Initial Opiate Fills P100MPM

Region (copy) (group)

Overall

Region

Northern

Southern

MPS Data – Initial Prescriptions

39% Decrease Feb 2014 – November 2015

Project Launch

Formulary Change, MPS Forum I

Enhanced Benefits Implemented, TAR Process Change

2013 2014 2015

0%

5%

10%

15%

% o

7.5%

15.4%

8.3%

11.3%

6.2%

% Opioid Users on Unsafe Dose (>120 MED)

Region (copy) (group)Overall

Northern

Southern

MPS Data – Unsafe Dose

40% Decrease Jan 2014 – November 2015

Project Launch

Formulary Change, MPS Forum I

Enhanced Benefits Implemented, TAR Process Change

Percent Decrease of Unsafe Dose

52 Moore R. CMO Report on Quality. Dec. 2015

63 64 63 58

47 49

22

46 42

46 47 48

66

48

0

10

20

30

40

50

60

70

80

90

100

% Decrease Unsafe Dose December 2013-November 2015

Accomplishments: Health Plan Activities

MPS Workgroups

Pharmacy

Provider Network

Care Coordination/Utilization Management/ Member Services

Legislative Policy/Regulation/Communication

Community Support MPS

Tec

hnic

al S

uppo

rt Data Management

MPS

Ste

erin

g Co

mm

ittee

Education Health plan pharmacy prior authorization changes Additional options for treating pain (chiropractic, acupuncture) Community activation Aligned incentives Additional resources

Interventions

Accomplishments: Community Coalitions

PHC Counties Participating in CHCF Regional Opioid Safety Coalition Grant Program

10 PHC Counties are participating in CHCF’s Regional Opioid Safety Coalition Grant Program

CHCF Opioid Safety Coalition County

Community Coalition Status

58

1

5

3

2

5

2 2

4 4

1

3

4

1

2

PHC COUNTY COALITION STATUS

Key

1 Little or No Effort (Yet)

2 Initial Meetings, Beginning of Framework Formation

3 Framework Formation, Action Teams Initiating

4 Strong Effort- Framework Implemented, Regular Meetings, Active Action Teams, Working towards Milestones

5 Robust Effort- Active Action Teams, Accomplishing Milestones, Measurable Results

Accomplishments: Primary Care Providers

Opioid Oversight Committees Setting up Health Center-wide policies (like Safe Prescribing Committee at SCHC) Tapering Integrated Behavioral Health Talking to patients, one by one

Interventions

Progress Towards Goal

By December 31, 2016, we will improve the health of PHC members by ensuring that prescribed opioids are for appropriate indications, at safe doses, and in conjunction with other treatment modalities as measured by a:

• Decrease in total number of initial prescriptions by 75% • Decrease in total number of prescription escalations by 90% • Decrease in total number of patients on high-dose opioids* by 75%

Managing Pain Safely – Aim Statement

*Defined as greater than 120 mg. MED

Achieving Our Goal: I Health Plan Activities for 2016

Provision of tele-consult services for complex patients on high-dose opioids Education and coordination around addiction screening and treatment Partner with CHCF for continued support in developing and sustaining local efforts targeted at reducing improper use of opioids Planning process for creating integrated clinics for high utilizers Pharmacy academic detailing MPS provider level data sharing Tapering guide/ toolkit Naloxone Pilot

Looking Ahead in 2016: Health Plan Activities

Achieving Our Goal: II State Wide Activities

Support for Community Coalitions Planning for Integrated Approach to Patients on High Doses of Chronic Opioids CDC Guidelines CURES 2.0

Looking Ahead in 2016: State Wide Activities

Achieving Our Goal: III Prescriber Activities

• Sign up for tele-consult services for complex patients on high-dose opioids

• Make local opioid oversight committees more robust • Participate in regional coalitions • Give feedback on draft plan for integrating chronic pain

treatment with Medication Assisted Therapy • Ask your PHC Regional Medical Director to meet with

you and/or your clinicians to review their individual PHC opioid data and to review MPS

• Tapering guide/ toolkit • Distribute Naloxone and educate patients/families on how to use it.

Looking Ahead in 2016: Prescriber Activities

CHRONIC PAIN MANAGEMENT IN FAMILY PRACTICE

Candy Stockton, MD

Medical Director, Shingletown Medical Center

Pharmacist's perspective on Chronic Pain Management William A. Ranker, PharmD MBA

Corresponding Responsibility

A prescription for a controlled substance shall only be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his or her professional practice.

The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription.

Even after conferring with the prescriber, a pharmacist shall not compound or dispense a controlled substance prescription where the pharmacist knows or has objective reason to know that said prescription was not issued for a legitimate medical purpose.

The community pharmacist's perpetual awkward position Healthcare's "Bad-guy" ?

Prescriber-pharmacist relationship Strained colleagues?

Pharmacist-patient relationship Often "displeased"

Pharmacist-Pharmacy relationship We are mostly employees.

Pharmacist-regulator relationship Get out your ticket book!

Pharmacy Quantity Restrictions

Pharmacies in our county are restricted in the quantity of narcotics they can purchase from drug wholesalers for dispensing each month

Utilitarianism presides

A pharmacist's determining factors in narcotic Rx acceptance Monthly quantity

Established patient at pharmacy?

Getting all medications at your pharmacy (i.e. maintenance meds)

Is the prescriber (and office) a good communicator?

Is the prescriber following established pain management guidelines?

Is the prescriber utilizing monitoring tools?

Does the prescriber have ample documentation procedures in place?

CURES/PDMP

A valuable resource often untapped

Rx Drug abuse and the Workplace

Indiana's Rx Abuse Task Force Survey

Respondents consisted of 200+ companies with 50+ employees

80% Reported problems related to workers misusing Rx drugs

33% Reported accidents tied to Rx drug misuse

Driving under the influence of Prescription drugs Benzodiazepines affect motor reflexes without regard to length of use

(tolerance)

Lack of counseling by prescribers and pharmacists about risks

Duty to report

Inaction is no longer an option No more intentional walks

LAW ENFORCEMENT PERSPECTIVE ON ABUSE OF PRESCRIPTION DRUGS

Eric Magrini

Undersheriff, Shasta County

CALL TO ACTION

Ivan Petrzelka, PharmD, JD, MBA

www.NoRxAbuse.org

QUESTIONS

85

THANK YOU

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