Lynam presentation

Engaging the Medical Community:Opiate Prescribing

Edward Lynam, MDMedical Director

Quest Counseling, Reno, NV

Remembering History“Those who cannot remember the past are

doomed to repeat it.”George Santayana

Commercialization of Opiates 1British East India CompanyTea from ChinaBoston Tea Party!Silver to ChinaSilver shortagesOpium from Bengal/India to ChinaQing DynastyOpium War(s)Silver and Tea from China, Opium to China

ChinaBy 1940: 40 million opium addicts, 10% of

populationA century of corruption, decline, and defeatMao and Communists: solved addiction

problem

Commercialization of Opiates 2Purdue Pharma, 1990’sOxycontin: sustained release oxycodoneMarketing drove it from $48 million in 1996

to $1 billion in 2001$200 million in marketing in 2001 aloneFree 7 to 30 day suppliesBonuses to sales staff more than base salary5000 health professionals given all expense

paid stays at fancy resorts to become speakers

Medical Use of Oral OpiatesDysentery and Diarrhea (historical)Cough Suppression (rare)Pain Management

Acute Pre-op Op Post-op

Chronic Cancer, end of life: palliative Non-cancer

Effects of Opiates CNS and PNS opiate receptors (therapeutic):

Decreased pain perception: analgesiaDecreased reaction to pain: psychologicalIncreased tolerance to pain: more functional

activityMild to severe neurocognitive impairmentNausea and/or ConstipationItching and miosisImmune/Reproductive hormone changesAccidents and delayed return to employment

Effects of Opiates in AddictionAbove therapeutic dosage

Euphoria: false sense of exaggerated well being

Accelerated development of toleranceRespiratory depression leading to hypoxic

death Cuts the normal response to carbon dioxide Lungs can fill with fluid Tolerance to this effect not predictable at high

doses Half of deaths had used another respiratory

depressant

Misuse of Prescription Opiates30 to 40% of prescribed doses are not used properly

Engaging PrescribersFederal Efforts: starting 2011

Office of National Drug Control Policy (ONDCP)

Food and Drug Administration (FDA)

Drug Enforcement Administration (DEA) 

Strategy Expand awareness and education to

physicians, researchers, and the publicExpand efforts to monitor the prescribing

of these drugs, including calling upon every state to set up a program (43 so far)

Make it easier for consumers to dispose of drugs

Shut down “pill mills” and reduce doctor shopping

Educating PrescribersTraining: substance abuse in general

curriculumDEA licensure: requiring specific educational

content Manufacturers: requiring “re”-educational

funding

Opioid Risk Evaluation and Mitigation Strategy (REMS)

Physicians for Responsible Opioid Prescribing (PROP)

Best Practices for Emergency Medicine

Washington StateAgency Medical Directors Group

Published guidelinesOpiate dosing calculator (web and app)Free patient assessment toolsFree 4 hour CME activitySearchable Directory of Pain Management

SpecialistsOther resources

What do prescribers need to do?Establish a clear upper limit on dosingWritten care agreements

No early refills or replacement of lost or stolenRefills only on clinic visitsRandom urine screening

Red flags: end accessState monitoring systemEngage family in safety education

ConclusionHistorically Opiate Addiction is linked to

commercializationPrescription Opiates have legitimate medical

roleA large percentage end up being misused or

abusedUnintentional deaths have skyrocketedPublic education is importantPrescribers need greater educationStates can help with monitoring, disposal

programs, shutting down pill mills, and doctor shopping