4/12/2018 Opioid Addiction and Prescribing Mitchell Mutter, MD - - PDF document

4/12/2018 1 Opioid Addiction and Prescribing

Mitchell Mutter, MD Director of Special Projects

Nashville, TN | April 12, 2018

Disclosure Statement of Financial Interest I, Mitchell Mutter, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context

• f the subject of this presentation.

Key Findings in 2017

Source: CSMD 2018 Legislative Report

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T h T he Op Op i

• i
• i

d d C r C ri s i s i s s by by t h t he Nu Numbers

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Chronic Pain Guidelines Expert Panel Public Chapter 430

• Requires the development of the TN Chronic Pain Guidelines

– 1st edition 2014 – 2nd edition 2017 – Annual review

Ri Ri s k s k P roof

• of

Yo Your P r P rac t i c e c e

• How many patients on greater than 120 MEDD?
• How many patients drive a far distance to practice site?
• How many patients are on combinations?
• Resources available in office

– Naloxone handouts – Education on near misses – Education on street drugs

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Public Chapter 1033

• Pain Management Clinics transitions from certificate system to licensure

system

– Medical director holds license – Non-transferable – Only a pain specialist is eligible to be medical director – > 50% of patients being treated for pain qualifies as a pain clinic and must be registered – No pharmacy – Clinic can be suspended based on specific violation

• No new patients
• Monitored

– Went into effect on July 1, 2017

TN Pain Management Clinics per County, 7/3/2017

Annual NAS Trends

Source: Neonatal Abstinence Surveillance System. TN Dept. of Health

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Neonatal Abstinence Syndrome Surveillance Summary Week 09: February 25 – March 03, 2018

NAS Rate per 1,000 Live Births, 2016

Source: Neonatal Abstinence Surveillance System. TN Dept. of Health

NAS Rates by Region

Source: Neonatal Abstinence Surveillance System. TN Dept. of Health 2016 Data are provisional.

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Consequences of Opioid Epidemic

Source: Clinical Infectious Diseases, December 7, 2017

• Tennessee in-state variability assessment for a “Rapid Dissemination of

HIV or HCV Infection Event” utilizing data about the opioid epidemic.

• More granular data improved insights into county-level HIV/HCV outbreak

vulnerability compared to national models.

Scott County, Indiana Outbreak

• 220 U.S. counties had highest vulnerability
• 41 small counties located in TN
• 25 overlapped with more granular TN data
• CDC – acquired HIV 2016

Source: Clinical Infectious Diseases, December 7, 2017

75 Predictors Used to Compute each County Risk Score

• MME/Capita
• Death from Heroin/Opioids
• Socioeconomic
• IV Drug Use
• Mental Health Services
• Uninsured Percentage
• Other, see December 7, 2017 Clinical Infectious Diseases

Source: Clinical Infectious Diseases, December 7, 2017

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Risk Ranking

Source: Clinical Infectious Disease, December 7, 2017

Public Chapter 476

• Currently, the top 50 prescribers of controlled substances in the state are

annually identified and sent a letter notifying them of their inclusion on this list and asked to respond with a justification for their prescribing patterns.

• Public Chapter 476 adds the top 10 prescribers from all of the combined

counties having populations of fewer than 50,000

• Effective/Signed May 18, 2015

MMEs Prescribed by Top 50 Prescribers and Dispensed in 2013 ‐ 2017

Source: CSMD 2018 Legislative Report

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Why do Prescribers and Dispensers Check the CSMD?

Source: CSMD 2018 Legislative Report

Prescription Drug Overdose Dashboard

Source: https://www.tn.gov/health/health-program-areas/pdo/pdo/data-dashboard.html

Tennessee Drug Overdose Data

Source: https://www.tn.gov/health/health-program-areas/pdo/pdo/data-dashboard.html

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Tennessee Drug Overdose Data

Source: https://www.tn.gov/health/health-program-areas/pdo/pdo/data-dashboard.html

Ag Age- ad adjus t ed drug ug

• v
• verdos

e de deat h ra rat es , by by s t s t at e, Un Uni t e t ed S t S t at es , 20 201 6

NOTES: Deaths are classified using the International Classification of Diseases, Tenth Revision. Drug-poisoning (overdose) deaths are identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14.. SOURCE: NCHS, National Vital Statistics System, Mortality.

T h T he Op Op i

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• i

d d C r C ri s i s i s s by by t h t he Nu Numbers

24.5

Tennessee

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Drug ug

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• verdos

e de deat h ra rat es , by by s e s elec t c t ed ag age gr group : Un Uni t e t ed S t S t at es , 1 999- 999- 20 201 6

1Significant increasing trend from 1999 to 2016 with different rates of change over time, p < 0.05. 22016 rate was significantly higher than for the rate for age groups 15–24, 55–64, and 65 and over, p < 0.05.

NOTES: Deaths are classified using the International Classification of Diseases, Tenth Revision. Drug-poisoning (overdose) deaths are identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14. SOURCE: NCHS, National Vital Statistics System, Mortality.

Age‐Adjusted Rates for All Drug Overdose Deaths and by Sex and Race in TN by Year Tennessee Overdose Deaths where patient did not have prescriptions in CSMD 60 days prior to death

0% 10% 20% 30% 40% 50% 60% 2013 2014 2015 2016 All Drug

Source: TN Dept. of Health, Office of Informatics and Analytics

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All Drug Deaths by Age Distribution, 2012‐2016

50 100 150 200 250 300 350 400 450 500 5‐14 years 15‐24 years 25‐34 years 35‐44 years 45‐54 years 55‐64 years 65‐74 years 75‐84 years 85+ years

2012 2013 2014 2015 2016

Number of Deaths

Source: TN Dept. of Health, Office of Informatics and Analytics

All Fentanyl Deaths by Age Distribution, 2012‐2016

20 40 60 80 100 120 5‐14 years 15‐24 years 25‐34 years 35‐44 years 45‐54 years 55‐64 years 65‐74 years 75‐84 years 85+ years

2012 2013 2014 2015 2016

Number of Deaths

Source: TN Dept. of Health, Office of Informatics and Analytics

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Opioids Present in Overdose Deaths in TN by Year

64.7 68.2 71.3 72.7 4.6 5.5 12.0 18.0 5.4 11.6 14.1 15.9 2.0 3.7 3.4 4.1

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 2013 2014 2015 2016 Opioid Fentanyl Heroin Buprenorphine

* Percentages for fentanyl, heroin, buprenorphine are included in the opioid category and are broken out for clarity.

Percentage of Overdose Death

Source: TN Dept. of Health, Office of Informatics and Analytics

Access to Documents

2018 C CSMD L MD Legi gislat ative Repo e Report

https://www.tn.gov/health/health-program-areas/health-professional-boards/csmd- board/csmd-board/reports.html

TDH Pa H Pain in M Management C nt Clinic ic S Statut utes es, Ru , Rule les, a and Guid idelin lines es

https://www.tn.gov/health/health-program-areas/health-professional-boards/pm- board/pm-board/statute-rules-and-guidelines.html

Pres escr cription

• n D

Drug O ug Over erdo dose (P (PDO DO)

https://www.tn.gov/health/health-program-areas/pdo.html

Access to Documents

Tenness essee’s ee’s I In-St

• State

te V Vulne lnerab abil ility ity A Assess ssment f nt for a r a ‘Rapid D Dissemin inatio ation n of HIV o V or HCV In V Infect fection’ E n’ Event ent U Utili ilizi zing ng D Data about

• ut the

the Opioid E Epidem emic

https://academic.oup.com/cid/advance-article/doi/10.1093/cid/cix1079/4706246

Neonat natal al A Abstin inence S Syndrome ( (NAS)

https://www.tn.gov/health/nas.html

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Contact Me

Mit Mitchell Mut Mutter, M.D M.D. Dir Director o

• f Spe

Special Pr Projects

615-532-3541

Mitc Mitchell hell.Mut .Mutter@tn.g tn.gov

Tennessee Department of Health Health Related Boards 665 Mainstream Drive, 2nd Floor Nashville, TN 37243

Thank You!