Harms and Opportunities for Intervention Roy Purssell, MD Emilie - - PowerPoint PPT Presentation

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Harms and Opportunities for Intervention Roy Purssell, MD Emilie - - PowerPoint PPT Presentation

Apr 28, 2023 246 likes •540 views

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

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SLIDE 1

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

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SLIDE 2

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
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SLIDE 3

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.

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SLIDE 4

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.

Ontario

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SLIDE 5

10 20 30 40 2004 2005 2006 2007 2008 2009 2010 2011

Year

British Columbia

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SLIDE 6

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
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SLIDE 7

50 100 150 2 4 2 5 2 6 2 7 2 8 2 9 2 1 2 1 1 2 4 2 5 2 6 2 7 2 8 2 9 2 1 2 1 1

Women Men

Prescription opioid (non-methadone) Prescription opioid and methadone Methadone

Prescription opioid deaths by sex in BC

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SLIDE 8

Potential causes

Changes in prescribing

  • Treatment of chronic pain
  • Pharmaceutical marketing
  • Shift to stronger opioids

Trends in opioid prescriptions in BC

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SLIDE 9

No opioid prescription in the past year 38% No opioid prescription in the past 60 days 21% Opioid prescription in past 60 days 41%

Men All opioid-related deaths in 2011 (N=86)

No opioid prescription in the past year 23% No opioid prescription in the past 60 days 27% Opioid Prescription in past 60 days 50%

Women All opioid-related deaths in 2011 (N=48)

Potential causes: Diversion from medical and non-medical sources

Prescription opioid dispensations prior to prescription opioid-related death in BC

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SLIDE 10

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
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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

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SLIDE 12

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.

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SLIDE 13

Geo eographical variation in n opio

  • pioid

pr prescribing an and

  • p
  • pioid-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.

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SLIDE 14

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.

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SLIDE 15

Men Women 2 4 6 8 10 40 million 80 million 120 million

Unintentional deaths

Men Women 2 4 6 8 10 40 million 80 million 120 million

Suicide deaths

Total morphine equivalents dispensed per year per 100,000 population

The relationship between average yearly opioid dispensations and average yearly prescription opioid-related deaths in BC LHAs from 2004 to 2011

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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
  • n 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
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SLIDE 17

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

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SLIDE 18

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

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SLIDE 19

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.

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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
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SLIDE 21

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.

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In Interv rvention an and pr prevention:

Physician, pharmacist, and patient education

1.

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
  • f 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.

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SLIDE 23

Physicians Opioid Prescribing – Effect of course and medical regulation

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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/

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Where are we now (26 months)?

57 sites

25

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SLIDE 26

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
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SLIDE 27

Questions?

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SLIDE 28

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