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The Rise and Fall (?) of the Opioid Epidemic Michael Saxe, M.D. Chairman Emeritus Dept. of Emergency Medicine Middlesex Hospital. Goals. Review history of opium and opioids Learn the causes of today’s opioid epidemic Understand the role of prescribers and patients

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  1. The Rise and Fall (?) of the Opioid EpidemicMichael Saxe, M.D.Chairman EmeritusDept. of Emergency MedicineMiddlesex Hospital

  2. Goals • Review history of opium and opioids • Learn the causes of today’s opioid epidemic • Understand the role of prescribers and patients • Learn how you can help to end the opioid epidemic

  3. What’s Your Experience? • Who has personally known someone (not just a patient) with an opioid problem? • Abuse • Dependence • Addiction • Rehab • Death

  4. Deaths in CT in 2016 • MVA deaths 306 • Drug overdose deaths 917 • Increase since 2012150% • % involving opioids 85- 90% • % heroin +/-- fentanyl65% • 78% white, 75% male

  5. History of Opium • Opium poppy: Dried opium latex ~12% morphine • 4,000 B.C.: First known cultivation and use • Variety of medical uses over the ages • Treatment of pain • Calming irritable infants • Cough suppressant • Diarrhea treatment • Tranquilizer

  6. Recreational Uses • 1300’s in Ottoman Empire • 1600’s in China • Opium mixed with tobacco, then smoked • Much stronger smoked than taken orally • Addiction first recognized and described • 1729: Opium outlawed in China • 1800’s: Two Opium Wars over Indian opium imports into China • British vs. Chinese: British won • Result: Unrestricted importing of Indian opium into China

  7. Result: Chinese Opium Use • Widespread opium use by Chinese (opium dens) • 1905: 25% of Chinese males regular opium users

  8. Opioids in U.S. • Civil War: Morphine widely used for injuries • Morphine addiction: ”The soldier’s disease” • Late 1800’s: Chinese immigrants came to U.S. • First opium dens in San Francisco and New York • 1870’s: Opium dens outlawed, went underground, persisted until WWII

  9. Opioid Derivatives • Developed by pharmaceutical companies in U.S. and Europe • Morphine (1804) • Codeine (1832) • Diacetylmorphine (Heroin) 1898 • Hydrocodone (1920) • Hydromorphone (1924) • Oxycodone (1927) • Methadone (1937)

  10. Heroin • Generic name: Diacetylmorphine • Patented by Bayer as “Heroin” in 1898 • Marketed as “non-addicting, treatment for morphine addiction” • 1906: Approved by AMA as replacement for Morphine • 1914: 200,000 heroin addicts in NYC • 1914: Harrison Narcotics Act: Outlawed non-medical use of Heroin • 1924: Heroin outlawed for medical use

  11. 1900’s to 1980’s • Opioids prescribed only for acute, severe pain • Not used for chronic pain • Vast majority of opioid addicts: Heroin addicts primarily in inner cities • No “opioid epidemic”

  12. Origins of Today’s Opioid Epidemic • FDA approvals for Purdue Pharmaceuticals • 1984 MS Contin for terminal cancer pain • 1990 OxyContin for terminal cancer pain • 1994 OxyContin for non-cancer pain • Purdue marketing to doctors: “Pain is undertreated: • Marketed as “under 1% addicting” • No good published studies • 2007: Purdue pleaded guilty of false marketing, $600 million fine paid

  13. The Under Treated Pain Movement • 1994 Under treatment of pain in U.S.? • 2000 JCAHO pain scale: • 0 to 10 scale • The 5th vital sign • JCAHO: Must address any pain over 0 • 2000’s Patient satisfaction surveys • “Did the provider adequately control your pain?” • Provider compensation affected by patient satisfaction surveys 2016 Patient satisfaction become Core Measures ($$) for hospitals

  14. Opioid Prescriptions and Deaths

  15. U.S. Way Off the Bell Curve • 5% of world’s population • 80% of world’s prescribed opioids • The Opioid Epidemic is an American epidemic.

  16. Where do Patients Get Their First Opioids?

  17. Who Prescribes Opioids? (In decreasing total volumes) • Primary care providers (over 50% of total volume) • Orthopedists • Physiatrists • Pain specialists • Emergency physicians • General Surgeons • Neurologists • Dentists

  18. Dramatic Increases in Heroin and Fentanyl Deaths • Chronic opioid therapy causes: • Hyperaesthesia (Increased pain sensitivity) • Need for increasing doses for same pain relief or euphoria • Results: • Patient requests for increasing doses/frequency • Prescribers tapering, cutting patients off • Patients “doctor shopping” or buying opioids illegally • Cheapest opioids per strength: Heroin +/- Fentanyl • Dramatic increase in Heroin and Fentanyl deaths

  19. Increasing Heroin Deaths

  20. Fentanyl Deaths Surging

  21. Stronger, More Dangerous Opioids • Buyers don’t know what they’re buying. • Old heroin Columbian, ~10% purity • New heroin Mexican, ~40% purity • Fentanyl: • Synthetic opioid made in chemistry labs • Smuggled from Mexico and China • 20 to 30 times strength of Heroin • Sometimes added to Heroin or stamped into pills • Unknown amounts mixed in heroin or pills, so high risk of overdoses

  22. Morphine Milligram Equivalents (MME’s) • Morphine recognized as “gold standard” for Rx of moderate to severe pain. • One MME = Analgesic effect of 1 mg. of Morphine • Strength of other analgesics can be compared to Morphine via MME’s

  23. MME’s of Some Opioids • Tramadol 1 mg 0.1 MME • Codeine 1 mg 0.15 MME • Morphine 1 mg 1.0 MME • Hydrocodone 1 mg 1.0 MME • Oxycodone 1 mg. 1.5 MME • Hydromorphone 1 mg. 3.0 MME • Heroin 1 mg. 3 – 4 MME • Fentanyl 1 mg 50 – 100 MME

  24. MME’s/day ~ Addiction Risk • Increased MME’s/day = Increased addiction risk • < 30 MME’s per day: Fairly low risk • > 60 MME’s per day: Higher risk • > 90 MME’s per day: Much higher risk • Any MME’s per day, acute or chronic, have some risk of leading to addiction.

  25. How Many MME’s Per Day Are Prescribed? • Vicodin 1 q6 20 MME’s/day • Percocet 1 q6 30 MME’s/day • Vicodin 2 q4 60 MME’s/day • Dilaudid4 mg q4 72 MME’s/day • Percocet 2 q4 90 MME’s/day • Oxycodone 10 q4 90 MME’s/day • Oxycontin 60 bid 180 MME’s/day

  26. Opioid Epidemic’s 3 Phases • Initial phase: Short-term (2-7 days) • Middle phase: One week to several months • Chronic pain or desire for Euphoria leads to repeated and chronic use • Typically, patient requests for increasing MME’s/day • Late phase: Several months and beyond • Dependent or addicted patients • Prescription drug seeking, doctor-shopping • Buying opioids illegally • Escalating overdose deaths from prescription opioids and illegal opioids

  27. Lots of Attention Given to Late Phase • Patients already dependent or addicted • Why? Addiction and deaths are headline-grabbers. • Results: • Lots of media, government, healthcare org’s attention • More funding for treatment of addicts • Prescribers taperingor cutting off opioids • Lots of Suboxone prescribed • Rehab programs • Jails

  28. But Insufficient Attention to First and Middle Phases • First phase: Short-term (2 to 7 days) opioid prescriptions • Middle phase: One week to several months of opioids • Where future opioid addicts are made.

  29. Mopping the Floor vs. Turning off the Faucet

  30. Need to Turn Off the Faucet • 80 – 90% of new heroin/fentanyl addicts start on prescription opioids. • 69% of first-time users get prescription opioids from a friend or relative (leftover pills in medicine cabinets). • Every opioid prescription (even for a few days) has some risk of leading to addiction. • Education of providers and public needed to minimize ALL opioids whenever possible.

  31. Dramatic Reductions in Opioid Prescribing Needed • To return to 1994 levels of opioid prescribing (before today’s Opioid Crisis), a 75% reduction in prescribed opioids per patient will be needed. • Without dramatic reductions in prescribing of opioids, we will create more NEW opioid addicts than we have resources to treat. • The “Opioid Faucet” is prescription opioids. We all can control it

  32. Opioids for Acute Pain • First try non-opioids meds or therapy. • If opioids needed for SEVERE pain, low doses of hydrocodone have lower risk than oxycodone or Dilaudid. • Prescribe 10 to 12 pills (not 20 or more) for just 2-3 days • Educate patients of risks of addiction. • We must discard leftover pills. • State law: Must check PMP for any new opioids over 3 days. • State law: Must obtain written permission from DPH for opioid prescriptions > 7 days

  33. Opioids for Chronic Pain • No good studies show improved pain scores with chronic opioids. • Minimize MME’s per day. (Higher MME’s = Higher Addiction Risk) • Use pain contracts: One prescriber only, compliance with Rx. • Random urine tox screens to confirm compliance • State law: Must check PMP every 90 days • Taper MME’s if possible • CDC guidelines for tapering MME’s/day • Consider referrals to pain specialists if >90 MME’s/day and unable to taper.

  34. The Solution is You • Always start with non-opioid alternatives • Tylenol and/or NSAID’s • Gabapentin, Antidepressants • Physical therapy • If using opioids, educate re addiction risk. • Low dose Hydocodone first, not Oxycodone or Dilaudid • 3 days max. If more, PMP look-up required • Transition off opioids ASAP • Remember: No good studies show that opioids are effective for chronic pain (Hyperaesthesia)

  35. Can Opioids be Reduced? • Middlesex ED’s 48% reduction in last five years • Hartford ED ~50% reduction in last five years • YOU control the faucet. The Solution to the Opioid epidemic is YOU. • We’re in this together. To end the opioid epidemic, all prescribers and patients need to know that we must dramatically reduce opioid prescribing.

  36. The Solution is You: Let’s Turn off the Faucet

  37. Thank you Michael Saxe, M.D. MSaxe@midhosp.org

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