Prescription Opioid-Related Harms and Opportunities for Intervention Roy Purssell, MD Emilie Gladstone, MPH *Please note BC data presented here are not final results and should not be distributed
Ou Outline • Burden of prescription opioid deaths in North America • Trends in prescription opioid death rates the United States and Canada • Demographics of the crisis • Potential causes of the crisis • Changes in opioid availability • Changes in prescribing • Shift to stronger opioids • Treatment of chronic pain • Pharmaceutical marketing • Diversion and non-medical sources • Heroin substitution • The relationship between dose and harm • Co-prescribing and drug interactions • Geographical Variation in opioid related harm • Small area variation in prescribing practices • Intervention and Prevention • Tamper resistant technology • Packaging • Best practices for prescription drug monitoring • Harm-reduction • Physician and Patient Education
United States Paulozzi LJ, Jones CM, Mack KA, Rudd RA. Vital Signs: overdoses of prescription opioid pain relievers--United States, 1999--2008. MMWR 2011;60(43):1487-92.
Ontario Gomes T, Mamdani MM, Dhalla IA, Cornish S, Paterson JM, Juurlink DN. The burden of premature opioid-related mortality. Addiction. 2014;109(9):1482-8.
30 10 20 40 0 2004 British Columbia 2005 2006 2007 Year 2008 2009 2010 2011
Who is impacted? Demographics of the crisis • Men • 45-54 years of age • White and Native American/First Nations • History of drug abuse • Low education • Low income 1. Okie S. A flood of opioids, a rising tide of deaths. N Engl J Med. 2010;363(21):1981-5. 2. http://umanitoba.ca/outreach/evidencenetwork/archives/19635
Prescription opioid deaths by sex in BC Women Men 150 100 50 0 4 5 6 7 8 9 0 1 4 5 6 7 8 9 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Prescription opioid (non-methadone) Methadone Prescription opioid and methadone
Potential causes Changes in prescribing o Treatment of chronic pain o Pharmaceutical marketing o Shift to stronger opioids Trends in opioid prescriptions in BC
Potential causes: Diversion from medical and non-medical sources Prescription opioid dispensations prior to prescription opioid-related death in BC Men Women All opioid-related deaths in 2011 (N=86) All opioid-related deaths in 2011 (N=48) No opioid prescription in the past year 23% Opioid No opioid prescription in prescription in Opioid past 60 days the past year Prescription in 41% 38% past 60 days 50% No opioid prescription in the past 60 days No opioid 27% prescription in the past 60 days 21%
He Heroin substitution 1. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-6. 2. http://www.economist.com/news/united-states/21633819-old-sickness-has-returned-haunt-new-generation-great-american-relapse
The relationship between dose and harm • Current guidelines: no maximum dose but watchful dose is 200mg • Dose-response relationship http://oceanservice.noaa.gov/education/lessons/the_seeds.html
Co-prescribing and drug interactions • Counterindications • Benzodiazepines and antidepressants • Alcohol Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2006. NCHS data brief. 2009(22):1-8.
Geo eographical variation in n opio opioid pr prescribing an and op opioid-related ha harms Paulozzi LJ, Jones CM, Mack KA, Rudd RA. Vital Signs: overdoses of prescription opioid pain relievers--United States, 1999--2008. MMWR 2011;60(43):1487-92.
Gomes T, Juurlink D, MoineddinR, Gozdyra P, Dhalla I, Paterson M, et al. Geographical variation in opioid prescribing and opioid-related mortality in Ontario. Healthc Q. 2010;14(1):22-4.
The relationship between average yearly opioid dispensations and average yearly prescription opioid-related deaths in BC LHAs from 2004 to 2011 Unintentional deaths Suicide deaths 10 10 8 8 Men 6 6 4 4 Women 2 2 Women Men 0 0 0 40 million 80 million 120 million 0 40 million 80 million 120 million Total morphine equivalents dispensed per year per 100,000 population
First Do No Harm: Responding to Canada’s Prescription Drug Crisis • National Advisory Council on Prescription Drug Misuse • Led by the Canadian Centre on Substance Abuse (CCSA), the Coalition on Prescription Drug Misuse (Alberta) and the Nova Scotia Department of Health and Wellness, in partnership with Health Canada’s First Nations and Inuit Health Branch’s Prescription Drug Abuse Coordinating Committee • Strategy developed around five streams of action: Prevention, Education, Treatment, Monitoring and Surveillance • Fifty eight recommendations
In Interv rvention an and pr prevention: Tamper resistant technology and packaging http://seekingalpha.com/article/255543-pharmaceutical-companies-reformulate-pain-products-how-investors-can-benefit
Tamper resistant technology • Information on ways to defeat formulation’s tamper resistant properties is readily available • 24% of patients who abused oxycodone found a way to defeat the formulation’s tamper resistant properties • 66% of patients who abused oxycodone switched opioids - most commonly switching to heroin Cicero TJ, Ellis MS. Effect of Abuse-Deterrent Formulation of OxyContin NEJM 2012;367: 187-189
The Growing Impact of Pediatric Pharmaceutical Poisoning Calls to poison centres for unintentional exposures of a single pharmaceutical product by a child <6 years (2001 to 2008) • 43% increase in the number of moderate of serious injuries • 36% increase in the number of admissions • 28% increase in ED visits • Greatest morbidity followed ingestion of opioids, sedative-hypnotic and cardiovascular agents • Prevention efforts have proved to be inadequate in the face of rising availability of prescription medications, particularly more dangerous medications Bond GR, Woodward RW, Ho M. The Growing Impact of Pediatric Pharmaceutical Poisoning. Journal of Pediatrics 2012;160:265-270.
In Interv rvention an and pr prevention: Prescription drug monitoring programs 1. Dormuth CR, Miller TA, Huang A, Mamdani MM, Juurlink DN. Effect of a centralized prescription network on inappropriate prescriptions for opioid analgesics and benzodiazepines. Can Med Assoc J. 2012;184(16):E852-E6. 2. http://www.health.gov.bc.ca/pharmacare/pharmanet/netindex.html
Ideal Prescription-Drug Monitoring Program • Ease of Access • Standardized Content • Real-Time Updates • Mandatory pharmacy reporting • Monitoring of prescribing of drugs in DEA Schedules 2-5 • Interstate accessibility • Confidentiality and security • Support for public health initiative and research • Capability for strictly monitored access by nonprescribers Perrone J, Nelson LS. NEJM 2012 ;366:2341-2343.
In Interv rvention an and pr prevention: Physician, pharmacist, and patient education Effect of a course-based intervention and effect of medical regulation on physician’s opioid prescribing • Among physicians referred by the College of Physicians and Surgeons of Ontario, the rate of opioid prescribing decreased dramatically in the year before course completion • The course had no added effect on the rate of physicians’ opioid prescribing in the subsequent 2 years Kahan M, Gomes T, Juurlink DN et al. Can Fam Phys 2013;59:e231-e239. 1.
Physicians Opioid Prescribing – Effect of course and medical regulation
In Interv rvention an and pr prevention: Harm reduction http://towardtheheart.com/ezine/3/take-home-naloxone-program http://www.canadiandesignresource.ca/fashiontextiles/insite-t-shirt/
Where are we now (26 months) ? 57 sites 25
World Health Organization Recommendation • People likely to witness an opioid overdose should have access to naloxone and be instructed in its administration to enable them to use it for the emergency management of opioid overdose • Strength of recommendation – Strong
Questions?
Conclusions • Drug Overdose is a leading cause of injury mortality and morbidity in Canada • More research is needed to evaluate the extent of prescription drug misuse • More research is needed to optimize prevention, screening and treatment programs
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