OVERDOSE EPIDEMIC: PRESCRIBING GUIDELINES MIPA CONFERENCE - - PowerPoint PPT Presentation

RESPONSE TO OHIO’S PRESCRIPTION DRUG OVERDOSE EPIDEMIC: PRESCRIBING GUIDELINES

Ohio Department of Health

MIPA CONFERENCE PREVENTING INJURY: FROM RESEARCH TO PRACTICE TO PEOPLE SEPTEMBER 30, 2013

Christy Beeghly, MPH

Program Administrator Violence and Injury Prevention Program Ohio Department of Health

OVERVIEW

• Ohio Emergency and Acute Care

Facility Opioid and Other Controlled Substances Prescribing Guidelines

• 80 MED “Trigger Point” Opioid

Prescribing Guidelines

Ohio Department of Health

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327 411 555 702 658 904 1,020 1,261 1,351 1,475 1,423 1,544 1,765

2 4 6 8 10 12 14 16 300 600 900 1200 1500 1800

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Death rate per 100,000 Number of drug overdose deaths Year Death Rate per 100,000 Number of Deaths

OHIO DEATHS AND DEATH RATES PER 100,000 DUE TO UNINTENTIONAL DRUG OVERDOSE BY YEAR, 1999-20111

1Source: ODH Office of Vital Statistics,

3

The number of drug overdose deaths in Ohio increased 440% from 1999-2011.

~5 deaths per day ~1 per day

Unintentional drug overdose deaths of Ohio residents by specific drug(s) involved, by year, 2000-20111,2 4

2Multiple substances are usually involved in one death.

Still more deaths from prescription opioids than from cocaine, heroin, and marijuana combined.

138 199 257 221 319 388 462 508 546 550 694 789

• 100

200 300 400 500 600 700 800 900

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Number of deaths Year cocaine benzodiazepines heroin prescription opioids

Ohio Department of Health

OHIO DATA

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There is a strong relationship between increases in exposure to prescription opioids and fatal unintentional overdose rates.

Sources: 1. Ohio Vital Statistics; 2. DEA, ARCOS Reports, Retail Drug Summary Reports by State, Cumulative Distribution Reports (Report 4) Ohio, 1997-2007 http://www.deadiversion.usdoj.gov/arcos/retail_drug_summary/index.html; 3. Calculation of oral morphine equivalents used the following assumptions: (1) All drugs

• ther than fentanyl are taken orally; fentanyl is applied transdermally. 2) These doses are approximately equianalgesic: morphine: 30 mg; codeine 200 mg; oxycodone

and hydrocodone: 30 mg; hydromorphone; 7.5 mg; methadone: 4 mg; fentanyl: 0.4 mg; meperidine: 300 mg ; 4. US Census Bureau, Ohio population estimates 1997- 2007; 5. preliminary data for 2007

Drugs distributed – 643% increase Death rate – 365% increase

CONTRIBUTING FACTORS:

• 2

4 6 8 10 12 14 16

• 20,000

40,000 60,000 80,000 100,000 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 death rate per 100,000

• pioids distributed in grams

per 100,000 population Year

Unintentional drug overdose death rates and distribution rates of prescription opioids in grams per 100,000 population by year, Ohio, 1997-20111-3

Total Rx Opioid Grams (MME) per 100,000 Unintentional overdose death rate

Ohio Department of Health

STATE RESPONSE TO EPIDEMIC

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Ohio Department of Health

STATE LEGISLATION

HB 93 addresses (Became law April 2011):

• Pain management clinic licensure (i.e., Pill mills)

and related changes

• Sets In-office physician dispensing limits
• Medicaid and Bureau of Workers’ Comp Lock-in

Programs

• Required changes to OARRS rules (Ohio’s PMP)

7 Link to Bill Analysis: http://www.lsc.state.oh.us/analyses129/11-hb93-129.pdf

GOVERNOR’S CABINET OPIATE ACTION TEAM (GCOAT)

Established fall of 2011 to address the continuing epidemic of misuse, abuse and overdose from prescription opioids. Five work groups:

• 1. Treatment – includes Medication Assisted Treatment
• 2. Professional Education
• 3. Public Education
• 4. Enforcement
• 5. Recovery Supports

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Professional Education Workgroup

GCOAT PROFESSIONAL EDUCATION WORKGROUP

Co-Chaired by

• Ted Wymyslo, M.D., Director, Ohio Department of Health
• Bonnie Kantor-Burman, Director, Ohio Department of Aging

Two subcommittees formed:

• Opioid Prescribing Guidelines for Ohio Emergency/Acute

Care Facilities - Lead: Director Wymyslo

• Reforming Prescribing Practices in Ohio– Lead: Director

Kantor-Burman

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Professional Education Workgroup

OHIO EMERGENCY AND ACUTE CARE FACILITY OPIOID AND OTHER CONTROLLED SUBSTANCES PRESCRIBING GUIDELINES (ED GUIDELINES)

PROFESSIONAL EDUCATION WORKGROUP: INITIATIVE #1 10

Ohio Department of Health

Professional Education Workgroup

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Professional Education Workgroup

Oh Ohio io Pr Process ss

• ED treatment of pain is frequently indicated without the benefit of an

established doctor-patient relationship and often in an environment of limited resources. Closure of pill mills may lead to increased doctor shopping in EDs.

• Active ED Physicians brought this issue to the PEW and requested

action.

• Based project on Washington State ED Guidelines.

OPIOID PRESCRIBING GUIDELINES FOR E.D.s & URGENT CARE FACILITIES

• Ohio ACEP
• Ohio State Medical Assn.
• Ohio Hospital Assn.
• Urgent Care Facilities
• Ohio Pharmacists Assn.
• Ohio Osteopathic Assn.
• Ohio Association of PAs
• Ohio ENA
• Ohio BWC
• Ohio Medicaid
• Ohio Assn. of Health Plans
• State Medical Board
• Board of Pharmacy

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Professional Education Workgroup

Consensus-based process developed in partnership with key medical/health care organizations as members of the work group:

OPIOID PRESCRIBING GUIDELINES FOR E.D.s & URGENT CARE FACILITIES

Ohio Process

OPIOID PRESCRIBING

GUIDELINES FOR ED’S & ACUTE CARE FACILITIES

GUIDELINES PATIENT HANDOUT

Ohio Opiate Action Team – Public Education Work Group

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Professional Education Workgroup

OPIOID PRESCRIBING GUIDELINES FOR E.D.’S & ACUTE CARE FACILITIES POCKET CARDS 14

Professional Education Workgroup

Distributed in partnership with the Ohio Hospital Association and the Ohio Chapter, American College of Emergency Physicians, and upon request.

ED GUIDELINES: SUPPORTING MATERIALS

Background document Patient Handout Pocket Cards Sample Tools

• Discharge Instructions
• SBIRT resources
• Pain Agreement

Frequently Asked Questions Promotional materials:

• Introductory Letter for

Professional Organizations

• Facebook Posts
• Website Content
• Press Release template
• Newsletter Article

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Professional Education Workgroup

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Professional Education Workgroup

• Pubic announcement and press

conference in May 2012 at Ohio Opiate Summit

• Promotion through:
• Endorsing organizations and committee

members

• Health care association communications

(e.g., websites, newsletters, webinars, etc.)

• Pocket card mailing
• Continuing education courses
• Media and social networking sites
• Organization press releases
• April 16, 2013 Webinar on Lessons

Learned in Implementing EDGs.

DISSEMINATION & PROMOTION…

SOME OF THE OHIO HOSPITAL SYSTEMS ADOPTING THE ED GUIDELINES

Ohio Opiate Action Team – Public Education Work Group

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Professional Education Workgroup

EVALUATION OF GUIDELINES

• Follow-up evaluation survey on implementation and

impact of the ED Guidelines planned:

• Process evaluation among ED administrators and ED physicians.
• Assess implementation, use and any reported prescribing

behavior change based on guidelines.

• Assess any changes made to ED Guidelines when implementing.
• Surveys developed and to be implemented in conjunction

with OHA and Ohio ACEP.

• Tracking OARRS (Ohio PMP data)

Ohio Department of Health

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Professional Education Workgroup

80MG MED OPIOID “TRIGGER POINT” GUIDELINES

PROFESSIONAL EDUCATION WORKGROUP: INITIATIVE #2 19

Ohio Department of Health

Professional Education Workgroup

THE GOALS

• Reduce the misuse and abuse of prescription opioids

in Ohio by:

• Establishing a “trigger point” for re-assessment and “pressing

pause” in opioid prescribing.

• Develop and implement guidelines for all prescribers of
• pioids for chronic, non-terminal pain.
• Actively promote registration and use of OARRS.

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REFORMING PRESCRIBING PRACTICES COMMITTEE

Professional Education Workgroup

THE GOALS

REFORMING PRESCRIBING PRACTICES COMMITTEE

Consensus Process with Key Stakeholders:

• Professional licensing boards
• State agencies (ODH, OhioMHAS, ODA, Medicaid,

BWC etc.)

• State professional associations
• Practicing pain and palliative care professionals
• State and federal public health agencies

Ohio Department of Health

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Professional Education Workgroup

REFORMING PRESCRIBING PRACTICES COMMITTEE

• 80mg morphine equivalent daily dose (MED) for 3

consecutive months established as “trigger point” based

• n CDC expertise and research studies finding:
• Increased mortality rates at 50-100+mg morphine

equivalent daily dose (MED).

• Other adverse effects for long-term use of high MEDs

for chronic, non-terminal (CNT) pain.

• Limited evidence on effectiveness of opioids for long-

term treatment of CNT pain.

• In 2011, over 50% of Ohio prescribers saw a patient with

an MED >80mg.

Ohio Department of Health

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Professional Education Workgroup

80 MED TRIGGER POINT ACTION STEPS:

• 80 MED for 3 months is established “trigger point” at which

prescriber should “press pause” and consider the following action steps:

• Re-establish informed consent
• Review patient’s functional status
• Review progress toward treatment objectives to determine

benefit of opioid therapy

• Re-check OARRS
• Consider a patient pain agreement
• Consider referral to a pain or other appropriate specialist
• OARRS data needed to determine MEDs.

Ohio Department of Health

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Professional Education Workgroup

CHANGES TO OARRS REPORTS

OHIO OPIOID TRIGGER GUIDELINES

Officially Approved by:

• State Medical Board of Ohio
• Ohio State Dental Board
• Ohio Board of Nursing
• Ohio State Board of

Optometry

• Ohio Board of Pharmacy

http://www.med.ohio.gov/pdf/NEWS /Prescribing%20Opioids%20Guidlin es.pdf

Ohio Department of Health

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SUPPORTIVE MATERIALS

• Education committee created a 1-hour CME training video

which will be available online:

• Scope of the problem – Director of Health
• Clinical guidelines – State Medical Board Representative
• Action steps – Pain Management Specialist
• Metrics & conclusion – Addiction Medicine Specialist
• Letter to describe guideline and changes to OARRS report for:
• Prescribers
• Pharmacists
• Patients

Ohio Department of Health

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Professional Education Workgroup

EDUCATIONAL PACKET

OHIO STATE BOARD OF PHARMACY

77 South High Street, Room 1702; Columbus, Ohio 43215-6126

• Equal Opportunity Employer and Service Provider-

September 12, 2013

Attention Pharmacists: Major change in the O.A.R.R.S. report to address the “M.E.D.” Ohio initiative This letter is intended to educate you on the “M.E.D.” initiative which was created to curtail the prescription drug epidemic and rising overdose death rates from opiates and combinations therein. M.E.D. stands for morphine equivalency dosing. This is essentially a system to equate different opiates and potencies into a standard morphine equivalent value via a conversion chart created by the Centers for Disease Control (CDC). This chart will be located on the last page of the new O.A.R.R.S. report. Each active opiate prescription (identified by having days supply remaining), will have a daily M.E.D. value. All active (concurrent) prescription values are then combined into one daily “M.E.D.” value, which will be bolded and located on the upper right portion of the O.A.R.R.S report. It is important to note that this value is a snapshot of the day when you run the report. It is not a “90 day average”. This could mean that something may not show up on the report (due to lag in report time to O.A.R.R.S versus the fill date) or that tomorrow the score may lower due to “active” prescriptions running out the next day. These are scenarios that you should understand when viewing this M.E.D. value. Where did the “80” M.E.D. threshold recommendation come from? The threshold of equal to or greater than 80 M.E.D. was identified by a team of pain management physicians and specialists that were convened by the Governor’s office. For a specific example, #16, 5mg Hydrocodone tablets taken in one day would equate to a M.E.D. value of exactly 80. However, be aware that normal dosing (Oxycontin 40mg twice daily) may also generate a value of 80 M.E.D. for that prescription. At 80 M.E.D., it was deemed that prescribers should “press pause” before prescribing the

• piate. This includes a number of clinical considerations that the prescriber should take

into account prior to issuing the prescription, as specified in the Medical Board’s statement

• n

this issue. This can be viewed via the link at http://www.med.ohio.gov/pdf/NEWS/Prescribing%20Opioids%20Guidlines.pdf. That is all that is required. If a patient’s M.E.D. value is greater than 80, it does NOT preclude the prescriber from issuing or the pharmacist from filling the prescription, just that you should “press pause”, making sure that your patient absolutely requires this

• treatment. For pharmacists, things to consider when pressing pause may include: review
• f the O.A.R.R.S. report, review of the drug profile in your system, prior knowledge of this

patient and physician, and professional judgement. Remember that this is a tool, not a definitive number to determine whether you fill or do not fill the prescription. However, if after review of the OARRS report you suspect a legitimacy issue, do not fill the prescription and notify us of your concern. There are a number of nice additions to the O.A.R.R.S. report that have been added to assist you. Please see the following O.A.R.R.S. report example with explanations for each section. Kyle Parker, M.B.A, R.Ph Executive Director Ohio State Board of Pharmacy

TIMELINE

Rollout and education period October 1 – December 31, 2013 Evaluation period January 1 – December 31, 2014

Ohio Department of Health

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Professional Education Workgroup

METRICS

1. Percentage of prescribers of controlled substances registered in OARRS. 2. Percentage of registered prescribers of controlled substances using OARRS. 3. Proportion of patients at 80mg MED and above who have at least one OARRS inquiry over specified time period. 4. Number and percentage of patients prescribed both

• pioids and sedative/hypnotics.

5. Percentage of prescriptions filled with a quantity of 120 or more capsules or pills per prescription. 6. Average MED per prescription.

Ohio Department of Health

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Professional Education Workgroup

BENEFITS OF GUIDELINES TO DATE

• Metrics committee established to review how

guidelines’ impact would be measured.

• Additional resources provided by state to bring in an

evaluation expert.

• Increased collaboration and critical use of PMP data

as a public health tool for state level analysis.

• Functional changes to the OARRS report to serve

as a more useful clinical tool to help curtail over- or inappropriate opioid prescribing.

• Increased education about OARRS to prescribers

and pharmacists.

Ohio Department of Health

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CONTACT ODH

Christy Beeghly, MPH, Program Administrator Violence and Injury Prevention Program Ohio Department of Health (614) 728-4116 Christy.beeghly@odh.ohio.gov