1/29/2020 1 Prisma Health Opioid Symposium February 1, 2020 Opioid Crisis Overview Douglas L Furmanek PharmD BCCCP Director, Clinical Pharmacy Services Prisma Health Upstate Objectives • Review the history of opioid use relative to the current epidemic • Describe the health system impact on the appropriate use of opioids • Understand opioid pharmacology, morphine milligram equivalents (MMEs), and conversion between agents • Discuss adjunctive agents used to treat pain
13
Embed
Opioid Symposium V · Case for Change: Prisma Health Hospital Influence on Opioid Dependency • Studies show: • 10% risk of chronic opioid usage after “cancer” surgery •
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1/29/2020
1
Prisma Health Opioid Symposium
February 1, 2020
Opioid Crisis OverviewDouglas L Furmanek PharmD BCCCP
Director, Clinical Pharmacy ServicesPrisma Health Upstate
Objectives
• Review the history of opioid use relative to the current epidemic
• Describe the health system impact on the appropriate use of opioids
• Understand opioid pharmacology, morphine milligram equivalents (MMEs), and conversion between agents
• Discuss adjunctive agents used to treat pain
1/29/2020
2
History of Opioids
• Opium was first reported in 3400 B.C. in Mesopotamia (Southwest Asia)
History of Opioids
• Morphine• Isolated by a German chemist in 1803-1804
• Roughly 10X more potent than processed opium
• “Miracle Drug” used only for severe war injuries and the mentally ill
History of Opioids
• Morphine molecule’s addictive and dependency quickly escalated
• Then family tragedy hit …
• Heroin synthesized from morphine in 1874• Made commercially available by Bayer in 1898
1/29/2020
3
Opioid Similarities
morphine hydrocodone hydromorphone
codeine oxycodone heroin
Letter to the Editor
Opioid Epidemic !!!
1/29/2020
4
More than 72,000 Americans died from drug
overdoses in 2017.
2017 Opioid Prescribing Rate per 1000 Persons
11
South
Carolina
Rank: 9th
Opioid RXs (> 90 MME) Dispensed per 100 Persons
12
South Carolina
Rank: 20th
MME = Morphine Milligram Equivalents
1/29/2020
5
https://www.scdhec.gov/Health/Opioids/
Case for Change: Prisma Health
Hospital Influence on Opioid Dependency
• Studies show:
• 10% risk of chronic opioid usage after “cancer” surgery
• 5-6% risk of persistent usage of opioids post operatively
• 15-25% of post op prescriptions were consumed
• 50% of opioids used for nonmedical purposes are obtained from friends or relatives
Schedule II,III controlled drugs Not controlled drugs
Notable adverse effects:
sedation, respiratory
depression, constipation
Notable adverse effects: gastric
irritation, bleeding, renal toxicity
No anti‐inflammatory effects Anti‐‐‐‐inflammatory effects
No ceiling effects Ceiling effect
Anesthesia and Pain Medicine. 2010 Apr;112(4):810‐33
1/29/2020
6
Culture Change – Old Practice
Adjuncts (gabapentin / clonidine)
NSAIDs, acetaminophen
Extended Release Opioids
Short-acting or IV Opioids
TR
EA
TM
EN
T
WE
AN
IN
G
Culture Change in Prescribing Practices
Adjuncts (Neurontin / Clonidine)
NSAIDs, Tylenol
Extended Release Opioids
Short-acting or IV Opioids
Non-Pharmacologic Therapies
WE
AN
ING
TR
EA
TM
EN
T
WHO Step Approach
Acetaminophen
• Mild pain
• Ideal for those that should not receive NSAIDs
• Opioid-sparing
• NTE 4 g/day
• (consider all sources)
NSAIDs
• Mild to moderate pain
• Consider ulcerogenicprofile and cardiovascular (CV) risk when selecting agent
• Consider alternative agents in anti-coagulated patients
Opioids
• Severe and breakthrough pain
• Potential for side effects
• Ensure bowel regimen
1/29/2020
7
CultivateWell-being
Reduce Pain
Improve Quality of Life
Restore Function
SELFCARE
Multi-Dimensional Care
Psycho-Behavioral
Cognitive Behavioral TherapyAddress Mental Health
Meditation
Procedural
Nerve blocksSteroid injectionsLocal injections
Physical
ExerciseMassage
Heat / Cold TherapyAcupuncture
Yoga
*Flor H, Fydrich T, Turk DC. Pain. 1992;49:221-230.
*Gatchel RJ, Okifuji A.J Pain. 2006;7:779-793.
Kamper SJ et al. Cochrane Database Syst Rev.
2014:CD000963.
Medication
AcetaminophenNSAIDS
Adjunctive AgentsKetamine Lidocaine
Treatment of Acute Pain
• Chronic opioid use often starts with treatment of acute pain
• 1 of 8 opioid naïve patients who receive narcotics after a procedure become persistent users
• Patients traditionally use less than 15% of total opioid RX
Shortest therapeutic
duration
Immediate-
release
Lowest effective
dose
N Engl J Med 2016; 374:1501-1504
CDC Guideline for Prescribing Opioids for Chronic Pain; 2016.
http://turnthetiderx.org/treatment/
3 days or less will usually
be sufficient…
>7 days rarely needed>7 days rarely needed>7 days rarely needed>7 days rarely needed
3 days or less will usually
be sufficient…
>7 days rarely needed>7 days rarely needed>7 days rarely needed>7 days rarely needed
Practice Changes:
Re-evaluation of patient
Re-engagement in pain
management plan
Opioids
• “… any drug, natural or synthetic, that has actions similar to those of morphine”
• Considered the most effective analgesics• Mimic the action of endogenous opioid peptides (endorphins) primarily at mu receptors and some at kappa receptors
• Opioid-induced sedation / euphoria can complement pain relief
• Leads to high liability for abuse
1/29/2020
8
Opioids
Monitor for Opioid-Induced Side Effects
• Key side effects:• Respiratory depression (#1)
• Reduced respiratory effort
• Reduced respiratory rate
• Low blood pressure
• Slow heart rate
• Confusion or dizziness
• Constipation
• Upset stomach
• Dry mouth
Drug Interactions
Interacting Drugs Outcome of Interaction
CNS Depressants
Benzodiazepines
Alcohol
AntihistaminesPhenothiazines
Increased respiratory depression and sedation
Agonist-antagonist opioids Precipitation of withdrawal reaction
Anticholinergic Drugs
Atropine
Antihistamines
PhenothiazinesTricyclic antidepressants
Increased constipation and urinary retention
Hypotensive agents Increased hypotension
Monoamine oxidase inhibitors Hyperpyrexic coma
1/29/2020
9
2016: The CDC Weighs In
• SPEAK ONE COMMON LANGUAGE for opioids• Morphine Milligram Equivalents (MME)