Opioids: Colorados Response Robert Valuck, PhD, RPh, FNAP - - PowerPoint PPT Presentation

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Opioids: Colorados Response Robert Valuck, PhD, RPh, FNAP - - PowerPoint PPT Presentation

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Opioids: Colorados Response Robert Valuck, PhD, RPh, FNAP Departments of Clinical Pharmacy, Epidemiology, and Family Medicine Director, Colorado Consortium for Prescription Drug Abuse Prevention May 18, 2018 Office of the Governor

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SLIDE 1

Office of the Governor

Opioids: Colorado’s Response

Robert Valuck, PhD, RPh, FNAP

Departments of Clinical Pharmacy, Epidemiology, and Family Medicine Director, Colorado Consortium for Prescription Drug Abuse Prevention

May 18, 2018

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SLIDE 2

Office of the Governor

Objectives

  • Describe the efforts of the Colorado Consortium for

Prescription Drug Abuse Prevention to reduce misuse/abuse

  • Understand the many strategies being implemented across

Colorado to reduce prescription drug abuse

  • Identify strategies that can be implemented in medical

practices to reduce prescription drug abuse

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SLIDE 3

Office of the Governor

What are the current data?

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SLIDE 4

Office of the Governor

Drug Overdose Mortality

  • In 2016, over 63,000 people died from drug overdoses in the

United States

– One every 10 minutes (6 more during this session) – Nearly 2/3 of those deaths involved prescription drugs – Opioids (Rx or illicit) were involved in 75% of those deaths

  • In Colorado, there were 912 drug overdose deaths in 2016
  • Of these 912, 504 were opioid involved (Rx or illicit, combined)

– Good news: Rx opioid deaths down slightly (329 in 2015, 300 in 2016) – Bad news: Heroin deaths (160 in 2015, 228 in 2016), Fentanyl deaths (41 in 2015, 49 in 2016) and Methadone deaths (34 in 2015, 56 in 2016) are all up sharply [Net Gain for all Opioids: 472 in 2015, 504 in 2016]

  • The problem knows no regional, gender, age, income, or other

bounds: it is truly an epidemic (CDC: top four)

CDC/MMWR Jan 13, 2012; 61(01):10-13. Colorado Rx Abuse Task Force data SAMSHA/NSDUH 2009 survey .

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SLIDE 5

Office of the Governor

Drug Overdose Mortality

  • In 2016, over 63,000 people died from drug overdoses in the

United States

– One every 10 minutes (6 more during this session) – Nearly 2/3 of those deaths involved prescription drugs – Opioids (Rx or illicit) were involved in 75% of those deaths

  • In Colorado, there were 912 drug overdose deaths in 2016
  • Of these 912, 504 were opioid involved (Rx or illicit, combined)

– Good news: Rx opioid deaths down slightly (329 in 2015, 300 in 2016) – Bad news: Heroin deaths (160 in 2015, 228 in 2016), Fentanyl deaths (41 in 2015, 49 in 2016) and Methadone deaths (34 in 2015, 56 in 2016) are all up sharply [Net Gain for all Opioids: 472 in 2015, 504 in 2016]

  • The problem knows no regional, gender, age, income, or other

bounds: it is truly an epidemic (CDC: top four)

CDC/MMWR Jan 13, 2012; 61(01):10-13. Colorado Rx Abuse Task Force data SAMSHA/NSDUH 2009 survey .

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SLIDE 6

Office of the Governor

Drug Overdose Mortality

  • In 2016, over 63,000 people died from drug overdoses in the

United States

– One every 10 minutes (6 more during this session) – Nearly 2/3 of those deaths involved prescription drugs – Opioids (Rx or illicit) were involved in 75% of those deaths

  • In Colorado, there were 912 drug overdose deaths in 2016
  • Of these 912, 504 were opioid involved (Rx or illicit, combined)

– Good news: Rx opioid deaths down slightly (329 in 2015, 300 in 2016) – Bad news: Heroin deaths (160 in 2015, 228 in 2016), Fentanyl deaths (41 in 2015, 49 in 2016) and Methadone deaths (34 in 2015, 56 in 2016) are all up sharply [Net Gain for all Opioids: 472 in 2015, 504 in 2016]

  • The problem knows no regional, gender, age, income, or other

bounds: it is truly an epidemic (CDC: top four)

CDC/MMWR Jan 13, 2012; 61(01):10-13. Colorado Rx Abuse Task Force data SAMSHA/NSDUH 2009 survey .

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SLIDE 7

Office of the Governor

Drug Overdose Mortality

  • In 2016, over 63,000 people died from drug overdoses in the United

States

– One every 10 minutes (6 more during this session) – Nearly 2/3 of those deaths involved prescription drugs – Opioids (Rx or illicit) were involved in 75% of those deaths

  • In Colorado, there were 912 drug overdose deaths in 2016
  • Of these 912, 504 were opioid involved (Rx or illicit, combined)
  • In 2017 (provisional), 536 were opioid involved (5% increase)

– Rx opioid deaths rising again (329 in 2015, 300 in 2016, 357 in 2017) – Heroin deaths (160 in 2015, 228 in 2016, 213 in 2017) – Fentanyl deaths (41 in 2015, 49 in 2016, 74 in 2017) – Methadone deaths (34 in 2015, 56 in 2016, 58 in 2017)

  • The problem knows no regional, gender, age, income, or other

bounds: it is truly an epidemic (CDC: top four)

CDC/MMWR Jan 13, 2012; 61(01):10-13. Colorado Rx Abuse Task Force data SAMSHA/NSDUH 2009 survey .

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SLIDE 8

Office of the Governor

Drug Overdose Mortality in Colorado

CDC/NCHS National Vital Statistics System, CDC Wonder. Updated 2010..

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SLIDE 9

Office of the Governor

Drug Overdose Mortality in Colorado

CDC/NCHS National Vital Statistics System, CDC Wonder. Updated 2010..

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Office of the Governor

Drug Overdose Mortality in Colorado

CDC/NCHS National Vital Statistics System, CDC Wonder. Updated 2010..

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SLIDE 11

Office of the Governor

Drug Overdose Death Rates in the US

CDC WONDER data file, Nov 21, 2014; 63(46);1095.

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SLIDE 12

Office of the Governor

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Prescription Drugs: primary driver of Overdose Deaths in United States

Jones et al. JAMA 2013; and CDC/NCHS 2010.

2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 Number of Deaths Drug or Drug Class

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SLIDE 13

Office of the Governor

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Deaths are the Tip of the Iceberg

For every opioid overdose death in 2014 there were…

SAMHSA NSDUH, DAWN, TEDS data sets Coalition Against Insurance Fraud. Prescription for Peril. http://www.insurancefraud.org/downloads/drugDiversion.pdf 2007.

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SLIDE 14

Office of the Governor

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Deaths are the Tip of the Iceberg

For every opioid overdose death in 2014 there were…

SAMHSA NSDUH, DAWN, TEDS data sets Coalition Against Insurance Fraud. Prescription for Peril. http://www.insurancefraud.org/downloads/drugDiversion.pdf 2007.

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SLIDE 15

Office of the Governor

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Deaths are the Tip of the Iceberg

For every opioid overdose death in 2014 there were…

SAMHSA NSDUH, DAWN, TEDS data sets Coalition Against Insurance Fraud. Prescription for Peril. http://www.insurancefraud.org/downloads/drugDiversion.pdf 2007.

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SLIDE 16

Office of the Governor

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Deaths are the Tip of the Iceberg

For every opioid overdose death in 2014 there were…

SAMHSA NSDUH, DAWN, TEDS data sets Coalition Against Insurance Fraud. Prescription for Peril. http://www.insurancefraud.org/downloads/drugDiversion.pdf 2007.

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SLIDE 17

Office of the Governor

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Deaths are the Tip of the Iceberg

For every opioid overdose death in 2014 there were…

SAMHSA NSDUH, DAWN, TEDS data sets Coalition Against Insurance Fraud. Prescription for Peril. http://www.insurancefraud.org/downloads/drugDiversion.pdf 2007.

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SLIDE 18

Office of the Governor

Altarum Research Institute. Economic Toll of Opioid Crisis in U.S. Exceeded $1 Trillion Since 2001. Feb 13, 2018. Viewed at: www.altarum.org/about/news-and-events/

Costs of the Epidemic: Past and Projected

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SLIDE 19

Office of the Governor

Substance Abuse Treatment Gap: 90%

SAMHSA/NSDUH 2011 survey

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Office of the Governor

Access to Medication Assisted Treatment (MAT) in Colorado: April 2017

Colorado Health Institute. Miles Away from Help: The Opioid Epidemic and Medication-Assisted Treatment in Colorado. May 2017. Accessed at: www.coloradohealthinstitute.org

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Office of the Governor

How did we get here?

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Office of the Governor

The Ubiquity and Impact of Opioid Prescription Drugs on the US Population

  • 1. Volkow ND et al. N Engl J Med. 2014;370:2063-2066.
  • 2. CDC Vital Signs. http://www.cdc.gov.

2 4 6 8

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

  • No. per US Population

Year

Kg of Opioids Sold (per 10,000)

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SLIDE 23

Office of the Governor

The Ubiquity and Impact of Opioid Prescription Drugs on the US Population

  • 1. Volkow ND et al. N Engl J Med. 2014;370:2063-2066.
  • 2. CDC Vital Signs. http://www.cdc.gov.

2 4 6 8

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

  • No. per US Population

Year

sold

3.9-fold increase in quantity of opioids sold1

Kg of Opioids Sold (per 10,000)

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SLIDE 24

Office of the Governor

The Ubiquity and Impact of Opioid Prescription Drugs on the US Population

  • 1. Volkow ND et al. N Engl J Med. 2014;370:2063-2066.
  • 2. CDC Vital Signs. http://www.cdc.gov.

2 4 6 8

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

  • No. per US Population

Year

sold

3.9-fold increase in quantity of opioids sold1

Kg of Opioids Sold (per 10,000)

259 million opioid prescriptions were dispensed at retail in 20132

…enough for every American adult to have a bottle of pills…every year!

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SLIDE 25

Office of the Governor

The Ubiquity and Impact of Opioid Prescription Drugs on the US Population

  • 1. Volkow ND et al. N Engl J Med. 2014;370:2063-2066.
  • 2. CDC Vital Signs. http://www.cdc.gov.

2 4 6 8

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

  • No. per US Population

Year 3.9-fold increase in quantity of opioids sold1

Kg of Opioids Sold (per 10,000) Treatment Admission (per 100,000) Overdose Deaths (per 10,000)

259 million opioid prescriptions were dispensed at retail in 20132

…enough for every American adult to have a bottle of pills…every year

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SLIDE 26

Office of the Governor

The “Perfect Storm” of Opioids

  • Rapid increase in amount of opioids being prescribed and

dispensed (prior slides)

  • Causes of the increase?

– Increased recognition of pain, under-treatment of pain – Pain as the “fifth vital sign”, JCAHO and CAHPS measures, etc. – Drug company advertising and promotion – Practitioners not well trained in opioid pharmacology, addiction, medication assisted treatment (MAT) – Drugs are very powerful, highly addictive if not used properly – Scamming, doctor/pharmacy shopping, black market for opioids

CDC/MMWR Jan 13, 2012; 61(01):10-13. SAMHSA/NSDUH 2009 survey . CDC/MMWR Jan 13, 2012; 61(01):10-13. SAMHSA/NSDUH 2009 survey .

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Office of the Governor

How does this problem start?

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SLIDE 28

Office of the Governor

Sales of Opioid Pain Relievers and Nonmedical Opioid Use (2010-11)

#37 in U.S.

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SLIDE 29

Office of the Governor

Sales of Opioid Pain Relievers and Nonmedical Opioid Use (2010-11)

#2 in U.S.

(Oregon = 6.4)

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Office of the Governor

Sources of Opioids among Nonmedical Users

CDC/MMWR Jan 13, 2012; 61(01):10-13. SAMHSA/NSDUH 2009 survey .

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Office of the Governor

Sources of Opioids among Nonmedical Users

CDC/MMWR Jan 13, 2012; 61(01):10-13. SAMHSA/NSDUH 2009 survey .

Over 70% obtain

  • pioids from friends
  • r relatives…the

“Medicine Cabinet” problem (most common starting point to Nonmedical use and Addiction)

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SLIDE 32

Office of the Governor

Sources of Opioids among Nonmedical Users

CDC/MMWR Jan 13, 2012; 61(01):10-13. SAMHSA/NSDUH 2009 survey .

Also significant: patients who are started on opioids legitimately, but begin nonmedical use with the “leftovers” (after their acute pain has subsided)

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Office of the Governor

New Persistent Opioid Users after Surgery

Brummett et al, JAMA Surg. 2017: 152(6)

After surgery, major or minor, 6% of people started on opioids for post surgical pain are new, persistent users 1 year later

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Office of the Governor

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Majority of Heroin users in past year reported Nonmedical use of Opioids before heroin initiation (US, 2002-2004 and 2008-2010)

Jones, C.M. Drug Alcohol Depend., 2013. 32.8 12.4 10.1 16.9 10.5 11.2 16.8 12.9 2.1 18.4 15.2 6.7 25.4 6.2 16.4 9.7 65.1 69.1 74.7 76.4 64.1 82.6 66.8 77.4

10 20 30 40 50 60 70 80 90 100 2002-2004 2008-2010 2002-2004 2008-2010 2002-2004 2008-2010 2002-2004 2008-2010 1-29 Days PYNMU 30-99 Days PYNMU 100-365 Days PYNMU Any PYNMU Percent Frequency of Past Year Nonmedical Use

Age first use OPR same as heroin Age first use heroin before OPR Age first use OPR before heroin

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Office of the Governor

What is being done?

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Office of the Governor

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President’s Commission

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Office of the Governor

President’s Commission: Recommendations

  • Declare national public health emergency (done)
  • Treatment Expansion: eliminate Medicaid IMD

exclusion, create incentives for delivery of MAT, enforce MHPAEA (mental health/SUD parity)

  • CME: mandatory CME for DEA registered prescribers
  • Naloxone: equip law enforcement, create standing
  • rders laws at state level, require coprescribing for at

risk patients

  • PDMPs: fund interstate data sharing, require federal

facilities to participate/report data

  • Other: Address 42 CFR Part 2 consent issues, develop

fentanyl detection sensors/systems, review rules/regs

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Office of the Governor

Recent Federal Initiatives

  • CDC: named Prescription Drug Abuse as one of the top four

epidemics facing the U.S.; issued Guideline for Prescribing Opioids for Chronic Pain (March 2016)

  • CMS: stated “will adopt” CDC guidelines for Medicare patients
  • FDA: issued Black Box Warning for opioids (risk of addiction, OIRD

and death); guidance for abuse deterrent formulations; and recommended Opana ER be pulled from the market (MFR complied)

  • DEA: tougher scheduling (Tramadol; Hydrocodone combination

products); National Drug Take Back days (most recent was 4/28); new rules allowing pharmacies and law enforcement departments to be “reverse distributors” (collect and take back medications)

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Office of the Governor

Pending Federal Legislation

  • House Energy & Commerce committee sent 25 opioid

related bills to the full house on Weds 5/9

  • Marked up yesterday (Thurs 5/17)
  • Topics range from treatment access, to workforce

development, to incentives for development of non

  • pioid medications, to safe disposal, many others
  • Follow along at:

https://energycommerce.house.gov/opioids/

  • President has pledged ~$13 Billion to opioid crisis
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SLIDE 40

Office of the Governor

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Office of the Governor

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  • Created by Governor John Hickenlooper in the fall of 2013 to establish a

coordinated, statewide response to this major public health problem

  • The Consortium serves as a backbone, which links the many state agencies,
  • rganizations, health professions, associations, task forces, and programs that

are currently addressing the prescription drug abuse problem

  • Seeded with $1M in funding from former AG John Suthers

Colorado Consortium for Prescription Drug Abuse Prevention. About the consortium. http://www.corxconsortium.org.

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SLIDE 42

Office of the Governor

Consortium Organization

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Office of the Governor

Regional Coalitions and Initiatives

  • San Luis Valley AHEC
  • North Colorado Health Alliance
  • Boulder Opioid Advisory Group
  • Pueblo Heroin Task Force
  • Yampa Valley Rx Task Force
  • Tri-County Opioid Overdose Partnership
  • El Paso County Opioid Coalition (CPAR)
  • Mountain Areas Drug Awareness Partnership
  • Other AHECs: Central, Centennial, SE, SW, Western
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SLIDE 44

Office of the Governor

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Office of the Governor

  • Committee met between July and October 2017, drafted 6 bills, 5 passed:
  • Prevention/Education

⦁ Workforce Development

  • Clinical Practice Improvement (SB-22)

⦁ Treatment (Inpatient/Residential)

  • Harm Reduction

⦁ Payment Reform (prior auth)

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SLIDE 46

Office of the Governor

Practice Level Changes to Prevent Abuse

  • Laws, Regs, Guidelines, Incentives: be aware of best

practices, requirements, carrots and sticks

  • Patient Education: safe use, storage, disposal
  • Naloxone coprescribing / education (OpiRescue app)
  • Alternatives to Opioids (ALTO)
  • MAT in primary care (IT-MATTTRs, Hub-and-Spoke)
  • Software to help you implement changes (OpiSafe)
  • Participate in the larger effort (local or state level)
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SLIDE 47

Office of the Governor

Thank You!

Email: robert.valuck@ucdenver.edu Website: www.corxconsortium.org Phone: 303-724-2890