Ohio Department of Health RESPONSE TO OHIO’S PRESCRIPTION DRUG OVERDOSE EPIDEMIC: PRESCRIBING GUIDELINES 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 2 Ohio Department of Health
OHIO DEATHS AND DEATH RATES PER 100,000 DUE TO UNINTENTIONAL DRUG OVERDOSE BY YEAR, 1999-2011 1 1,765 1800 16 Number of drug overdose deaths Death Rate per 100,000 1,544 14 1,475 1,423 1500 Death rate per 100,000 Number of Deaths 1,351 1,261 12 ~5 1200 deaths 10 1,020 per day 904 900 8 702 658 6 555 600 411 The number of drug overdose 4 327 deaths in Ohio increased 300 2 440% from 1999-2011. ~1 per day 0 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year 3 1 Source: ODH Office of Vital Statistics,
Unintentional drug overdose deaths of Ohio residents by specific drug(s) involved, by year, 2000-2011 1,2 Still more deaths from prescription opioids than from cocaine, heroin, and marijuana combined. 900 789 cocaine 800 694 benzodiazepines 700 Number of deaths heroin 600 508 546 550 prescription opioids 462 500 388 400 319 257 221 300 199 200 138 100 - 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year 2 Multiple substances are usually involved in one death. 4 Ohio Department of Health
OHIO DATA CONTRIBUTING FACTORS: There is a strong relationship between increases in exposure to prescription opioids and fatal unintentional overdose rates. Unintentional drug overdose death rates and distribution rates of prescription opioids in grams per 100,000 population by year, Ohio, 1997-2011 1-3 100,000 16 opioids distributed in grams 14 per 100,000 population death rate per 100,000 80,000 12 10 60,000 8 Total Rx Opioid Grams (MME) 40,000 6 per 100,000 4 Unintentional overdose death 20,000 rate Drugs distributed – 643% increase 2 Death rate – 365% increase - - 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year 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 other than fentanyl are taken orally; fentanyl is applied transdermally. 2) These doses are approximately equianalgesic: morphine: 30 mg; codeine 200 mg; oxycodone 5 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- Ohio Department of Health 2007; 5. preliminary data for 2007
STATE RESPONSE TO EPIDEMIC 6 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) Link to Bill Analysis: http://www.lsc.state.oh.us/analyses129/11-hb93-129.pdf 7
GOVERNOR’S CABINET OPIATE ACTION TEAM (GCOAT) Professional Education Workgroup 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 8
GCOAT PROFESSIONAL EDUCATION WORKGROUP 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 9
PROFESSIONAL EDUCATION Professional Education Workgroup WORKGROUP: INITIATIVE #1 O HIO E MERGENCY AND A CUTE C ARE F ACILITY O PIOID AND O THER C ONTROLLED S UBSTANCES P RESCRIBING G UIDELINES (ED G UIDELINES ) 10 Ohio Department of Health
OPIOID PRESCRIBING GUIDELINES FOR E.D.s & URGENT CARE FACILITIES Professional Education Workgroup Oh Ohio io Pr Process ss o 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. o Active ED Physicians brought this issue to the PEW and requested action. o Based project on Washington State ED Guidelines. 11
OPIOID PRESCRIBING GUIDELINES FOR E.D.s & URGENT CARE FACILITIES Professional Education Workgroup Ohio Process Consensus-based process developed in partnership with key medical/health care organizations as members of the work group: o Ohio ACEP o Ohio ENA o Ohio State Medical Assn. o Ohio BWC o Ohio Hospital Assn. o Ohio Medicaid o Urgent Care Facilities o Ohio Assn. of Health Plans o Ohio Pharmacists Assn. o State Medical Board o Ohio Osteopathic Assn. o Board of Pharmacy o Ohio Association of PAs 12
OPIOID PRESCRIBING GUIDELINES FOR ED’S & ACUTE CARE FACILITIES Professional Education Workgroup GUIDELINES PATIENT HANDOUT 13 Ohio Opiate Action Team – Public Education Work Group
OPIOID PRESCRIBING GUIDELINES FOR E.D.’S & ACUTE CARE FACILITIES POCKET CARDS Professional Education Workgroup Distributed in partnership with the Ohio Hospital Association and the Ohio Chapter, American College of Emergency Physicians, and upon request. 14
ED GUIDELINES: SUPPORTING MATERIALS Professional Education Workgroup Background document Frequently Asked Questions Patient Handout Promotional materials: • Introductory Letter for Pocket Cards Professional Organizations Sample Tools • Facebook Posts • Discharge Instructions • Website Content • SBIRT resources • Press Release template • Pain Agreement • Newsletter Article 15
DISSEMINATION & PROMOTION… Professional Education Workgroup o Pubic announcement and press conference in May 2012 at Ohio Opiate Summit o Promotion through: o Endorsing organizations and committee members o Health care association communications (e.g., websites, newsletters, webinars, etc.) o Pocket card mailing o Continuing education courses o Media and social networking sites o Organization press releases o April 16, 2013 Webinar on Lessons Learned in Implementing EDGs . 16
SOME OF THE OHIO HOSPITAL SYSTEMS ADOPTING THE ED GUIDELINES Professional Education Workgroup 17 Ohio Opiate Action Team – Public Education Work Group
EVALUATION OF GUIDELINES Professional Education Workgroup • 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) 18 Ohio Department of Health
PROFESSIONAL EDUCATION Professional Education Workgroup WORKGROUP: INITIATIVE #2 80MG MED OPIOID “TRIGGER POINT” GUIDELINES 19 Ohio Department of Health
REFORMING PRESCRIBING PRACTICES COMMITTEE THE GOALS 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 opioids for chronic, non-terminal pain. • Actively promote registration and use of OARRS. 20
REFORMING PRESCRIBING PRACTICES COMMITTEE Professional Education Workgroup 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 21 Ohio Department of Health
REFORMING PRESCRIBING PRACTICES COMMITTEE Professional Education Workgroup • 80mg morphine equivalent daily dose (MED) for 3 consecutive months established as “trigger point” based on 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. 22 Ohio Department of Health
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