Download Opiate Abuse 2011

Opiate Abuse 2011
Dr. Stephen H. Anderson MD
Goals & Objectives
• How did we get here & where ARE we
• Understand “What’s the harm?”
• Whose to “blame” & what are some
solutions?
• The Washington State Opioid
Prescription Guidelines for Treating
Chronic Pain
• The “Script”
• How can I help?
Historical Opium
• First used Medicinally in the Stone Age
•
•
•
•
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Sumerian, Assyrian, Egyptian, Indian, Minoan, Greek,
Roman, Persian, & Arab Empires all report medicinal
use.
Fifteenth Century China first reported recreational use
Opium Wars in 1839 & 1858
International Opium Commission of 1914, followed by
the International Narcotics Control Board
DEA
Historical Opiates
• 1804 Friedrich Serturner isolated
Morphine
• Morphine first marketed by Heinrich
Merck
• Codeine isolated in 1832
• Heroin synthesized in 1874 by the
Bayer Pharmaceutical Company
Opium in Society
QuickTime™ and a
GIF decompressor
are needed to see this picture.
It’s the Damned
Taliban
Joint Commission Standard
• Joint Commission Standard - PC.01.02.07 :
The hospital assesses and manages the
patient's pain.
Pre Pain
Standard
Post Pain
Standard
Patient satisfaction with pain
control
4.13 ± 0.16
4.38 ± 0.08*
Opioid adverse drug reactions per
100,000 inpatient hospital
days
11.0
24.5*
* P<0.001
Source: Vila et al., 2005
Prescription Opiate
Analgesics
and
Relative
Potency
• Demerol
4
•
•
•
•
•
•
•
Hydrocodone 5
5-7
Oxycodone
7
Oxycontin 40
8.5
Fentanyl
9
MS Contin 30
10
Hydromorphone 2
11
Oxymorphone 5
???
Acute Overdose
Presentation
•
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Decreased level of consciousness
Decreased respiration
Pinpoint pupils
Vomiting
Loss of muscle tone & airway control
Seizure
Cardiopulmonary Arrest (PEA-VF-Asystole)
Treatment of Acute
Overdose
• Protection from harm (rhabdomyolysis,
etc)
• Airway control
• IV/IO access, blood pressure control
• Naloxone SQ/IM/IV 0.4- ???
Anything Else?
• Tylenol Overdose? Acetylcysteine
• Poly Drug Overdose?....
NO Flumazenil
!!!
Are Overdoses a
Problem?
FEEL MY PAIN
Dramatic Increase in Emergency Department Visits
Resulting From Prescription Opioid Use Deborah Brauser
From Medscape Medical News
June 29, 2010
The estimated number of emergency department (ED) visits involving nonmedical use of prescription opioids increased by 111% during a 5-year period, according to a new study by
researchers from the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA).
Oxycodone, hydrocodone, and methadone products were the opioid pain relievers most frequently involved in these visits, with increases of 152%, 123%, and 73%,
respectively.
"These alarming findings provide 1 more example of how the misuse of prescription pain relievers is impacting lives and our health care system," said Pamela S. Hyde, JD,
administrator of SAMSHA, Rockville, Maryland, in a statement. "This public health threat requires an all-out effort to raise awareness of the public about proper use, storage, and
disposal of these powerful drugs.“
"We urgently need to take action," echoed Thomas R. Frieden, MD, MPH, director of the CDC in Atlanta, Georgia, in the same statement. "[ED] visits involving non-medical use of
these prescription drugs are now as common as [ED] visits for use of illicit drugs. These prescription medicines help many people, but we need to be sure they are used properly and
safely.“
The findings were reported jointly in a SAMHSA survey report and in the CDC's Morbidity and Mortality Weekly Report, published online June 17.
Dramatic Increases
Results showed that the nonmedical use of prescription opioids rose significantly from 144,600 ED visits in 2004 to 305,900 visits in 2008 (P < .001). It also
increased by 29% just between the years 2007 and 2008.
In addition, ED visits during the 5-year period involving nonmedical oxycodone use rose significantly from 41,700 to 105,214 visits a year (P < .001).
Hydrocodone involvement rose from 39,844 to 89,051 visits, and methadone product involvement rose from 36,806 to 63,629 visits.
These increases "reflect, in part, substantial increases in the prescribing of these classes of drugs," the investigators write.
"These findings indicate substantial, increasing morbidity associated with the nonmedical use of prescription drugs...despite recent efforts to
control the problem," write the study authors. "Stronger measures to reduce the diversion of prescription drugs to nonmedical purposes are
warranted.“
"The abuse of prescription drugs is our nation's fastest-growing drug problem. And this new study shows it is a problem that affects men and
women, people under 21, and those over 21," said R. Gil Kerlikowske, director of the Office of National Drug Control Policy in Rockville,
Maryland, in a statement.
8
So, What’s the
Problem?
It’s Not Like People
Are Dying....
Unintentional Injury Deaths
Washington State, 1999-2008
Source: Washington State Department of Health, Death Certificates
23
•
Wednesday, July 14, 2010
Last updated 11:26 a.m. PT
• Prescription drugs more deadly than car crashes, state report says
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•
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•
•
•
•
By GERRY SPRATT
SEATTLEPI.COM STAFF
Prescription drug overdoses have replaced car accidents as the leading cause of injury-related death for 3554-year-olds in Washington, according to a report from the state Department of Health.
The rate of death from prescription overdoses increased 90 percent between 2003 and 2008, the report said.
In 2008, the last year for which numbers are available, 505 people in the state died from prescription drug
overdoses and 646 people were hospitalized.
Stevens, Clallam, Spokane, Grant and Snohomish counties led the way in 2008 death rates from prescription
medications. In Stevens County, the rate was 18.6 per 100,000 population. King County's rate was 6.8 per
100,000.
"Too many people treat these powerful drugs as casual medications," state health officer Dr. Maxine Hayes
said in a news release. "This stuff isn't aspirin, and it should be handled with care."
More information on proper use of prescription drugs can be found at the Department of Health website.
Gerry Spratt can be reached at 206-448-8012 or [email protected]. Follow Gerry on Twitter at
twitter.com/gspratt76.
6
Drug overdose death rates in the United States have
never been higher
12
Epidemics of unintentional drug overdose deaths
in the United States, 1970-2006
Prescription drugs
Crack cocaine
Heroin
•
Source: National Vital Statistics System
14
Prescription for Tragedy | A Journal Sentinel Watchdog Update
Role of prescription drugs in area overdose deaths rising
In first half of year, prescription medications were involved in 78%
fatal overdoses By Tom Kertscher of the Journal Sentinel July 31, 2010
The role of prescription drugs in fatal overdoses is rising in the four-county Milwaukee area, a Journal
Sentinel analysis has found. During the first six months of 2010, prescription drugs - either alone or mixed
with illegal drugs - were involved in 78% of the fatal overdoses. That's up from 70% from 2002 through
2009. When you look at deaths caused by prescription drugs alone, the increase is even sharper.
From 2002 through 2009, prescription medicines by themselves caused just over half of the more
than 1,200 overdose deaths, according to a Journal Sentinel analysis published in February.
But during the first six months of 2010, nearly two out of every three fatal overdoses were caused by
prescription drugs alone, the new figures show. Those totals do not include suicides.
Among those who died: Jason Oddsen, 24, of Oconomowoc.
He lived with his mother, Carolyn Oddsen, and died in the emergency room at Oconomowoc Memorial
Hospital, where his mother works as an emergency room nurse and emergency medical technician
instructor.
Oddsen said her son had developed an addiction to the prescription painkiller oxycodone before graduating,
with honors, from the University of Wisconsin-Milwaukee in May 2009.
On the night before his death, while with friends in Hartland, he overdosed after taking oxycodone, two other
pharmaceuticals and heroin, according to a medical examiner's report.
Like 15-year-old Madison Kiefer, a Whitefish Bay prescription drug overdose victim, Oddsen was left dead or
nearly dead in a driveway on a cold winter morning. Kiefer's death in March 2009 raised alarms about
prescription drug abuse in the community.
The Oddsen case remains under investigation by Hartland police,but no decision has been made on
whether criminal charges will be filed.
Oddsen wasn't pronounced dead until after being taken to the hospital emergency room.
"Every day I go to work I get to walk into the place where my son died and try to help people," his mother
said.
9
Where Are All These
Drugs Coming From?
Overdose Death Rate correlates directly with Opioid sales
(Prescription) rate
Unintentional drug overdose death rates & sales of Rx painkillers in US:
Source: National Vital
Statistics System & Drug
Enforcement Administration,
ARCOS
18
Prescription Opioids (oxycodone, methadone
and hydrocodone)
• The increase in drug overdose death rates is largely because of prescription
opioid painkillers.
• Among deaths attributed to drugs, the most common drug categories are cocaine,
heroin, and a type of prescription drug called opioid painkillers.
• “Opioids” are synthetic versions of opium. They have the ability to reduce pain but
can also suppress breathing to a fatal degree when taken in excess. Examples of
opioids are oxycodone (OxyContin® ), hydrocodone (Vicodin® ), and methadone.
• In 2006, the number of deaths involving opioid analgesics was 1.63 times
the number involving cocaine and 5.88 times the number involving heroin.
• There has been at least a 10-fold increase in the medical use of opioid painkillers
during the last 15 years because of a movement toward more aggressive
management of pain.
• Because opioids cause euphoria, they have been associated increasingly with
nonmedical, recreational use. Opioids are now widely available in illicit markets in
the United States.
• By 2006, opioids were involved in more overdose deaths than heroin and
cocaine combined.
16
That’s Not Around
Here!
Availability correlates with poisoning rate:
Opioid Analgesics and Rates of Fatal Drug Poisoning in the United States
American Journal of Preventive Medicine, Volume 31, Issue 6 , Pages 506-511, December 2006
Leonard J. Paulozzi, MD, George W. Ryan, PhD
•
Objective: To determine whether the variability in rate of sale of prescription opioid analgesics is related to the
variability in rates of drug poisoning mortality among states in the United States in 2002.
•
Methods: Drug poisoning deaths were defined as unintentional deaths or those of undetermined intent whose
underlying cause was coded to “narcotics” (X42) or “other and unspecified” drugs (X44) in the National Vital Statistics
System. Per capita sales of ten opioid analgesics from the Drug Enforcement Administration and combined sales in
morphine equivalents were correlated with drug poisoning mortality rates by state using multivariate linear regression.
Regression coefficients between mortality rates and sales rates were adjusted for race (percent white, percent black)
and age (percent aged 24 years or younger, and percent aged 65 years and older).
•
Results: There was over a ten-fold variability in sales of some opioid analgesics. Combined sales ranged 3.7-fold,
from 218 mg per person in South Dakota to 798 mg per person in Maine. Drug poisoning mortality varied 7.9-fold,
from 1.6/100,000 in Iowa to 12.4/100,000 in New Mexico. Drug poisoning mortality correlated most strongly with
non-OxyContin® oxycodone (r=0.73, p<0.0001), total oxycodone (r=0.68, p<0.0001), and total methadone
(r=0.66, p<0.0001) in the multivariate analysis. A scatterplot demonstrated a linear relationship between total opioid
analgesic sales and drug poisoning mortality.ConclusionsThe extent of opioid analgesics use varies widely in the
United States. Variation in the availability of opioid analgesics is related to the spatial distribution of drug poisoning
mortality by state.
•
Conclusions: The extent of opioid analgesics use varies widely in the United States. Variation in the availability of
opioid analgesics is related to the spatial distribution of drug poisoning mortality by state.
20
Overall drug overdose death rates in the United
States vary by state and region.
•
21
Unintentional Opioid Overdose Related Deaths &
Sales of Rx Opioid Painkillers in WA
Source: Washington State
Department of Health,
Death Certificates
& Drug Enforcement
Administration, ARCOS
19
Washington
• Data Summary
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•
•
Overdose deaths and hospitalizations involving prescription pain medicine have increased in
Washington State from 1995 to 2008:
17 times more deaths.
7 times more hospitalizations.
Since 2003, four times more people are receiving addiction treatment for prescription pain medicine.
According to the Health Youth Survey, Washington teens are using prescription pain medicine to get high.
This includes:
four percent of 8th graders
10 % of 10th graders
12% of 12th graders
•
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•
•
22
26
Unintentional Injury Deaths
Washington State, 1999-2008
Source: Washington State Department of Health, Death Certificates
23
Not in My
Patients!
Pain Physician. 2008 Mar;11(2 Suppl):S63-88.
Therapeutic opioids: a ten-year perspective on the complexities and complications of
the escalating use, abuse, and nonmedical use of opioids. Manchikanti L, Singh A.
•
Abstract: Therapeutic opioid use and abuse coupled with the nonmedical use of other psychotherapeutic drugs has
shown an explosive growth in recent years and has been a topic of great concern and controversy. Americans,
constituting only 4.6% of the world's population, have been consuming 80% of the global opioid supply, and
99% of the global hydrocodone supply, as well as two-thirds of the world's illegal drugs. With the increasing
therapeutic use of opioids, the supply and retail sales of opioids are mirrored by increasing abuse in patients
receiving opioids, nonmedical use of other psychotherapeutic drugs (in this article the category of psychotherapeutics
includes pain relievers, tranquilizers, stimulants, and sedatives, but does not include over-the-counter drugs),
emergency department visits for prescription controlled drugs, exploding costs, increasing incidence of side effects, and
unintentional deaths. However, all these ills of illicit drug use and opioid use, abuse, and non-medical use do not
stop with adults. It has been shown that 80% of America's high school students, or 11 million teens, and 44% of middle
school students, or 5 million teens, have personally witnessed, on the grounds of their schools, illegal drug use, illegal
drug dealing, illegal drug possession, and other activities related to drug abuse. The results of the 2006 National Survey
on Drug Use and Health showed that 7.0 million or 2.8% of all persons aged 12 or older had used prescription
type psychotherapeutic drugs nonmedically in the past month, 16.387 million, or 6.6% of the population, had
used in the past year, and 20.3%, or almost 49.8 million, had used prescription psychotherapeutic drugs
nonmedically during their lifetime. Sadly, the initiates of psychotherapeutic drugs used for
nonmedical purposes were highest for opioids. Therapeutic opioid use has increased
substantially, specifically of Schedule II drugs. Apart from lack of effectiveness (except for shortterm, acute pain) there are multiple adverse consequences including hormonal and immune system effects,
abuse and addiction, tolerance, and hyperalgesia. Patients on long-term opioid use have been shown to
increase the overall cost of healthcare, disability, rates of surgery, and late opioid use.
31
Non-medical Use of Pain Relievers
12 or Older, 2005 & 2006
Source: National Survey on Drug Use & Health, SAMSHA
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Overdose Deaths Involving Prescription Opioids
among Medicaid Enrollees—Washington, 2004–2007
From Morbidity & Mortality Weekly Report 2009;58(42):1171-1175. © 2009 Centers for Disease Control and
Prevention (CDC)
P Coolen, MN; S Best; A Lima; J Sabel, PhD; L Paulozzi, MD
During 1999–2006, the number of poisoning deaths in the United States nearly doubled, from approximately 20,000 to 37,000, largely
because of overdose deaths involving prescription opioid painkillers.[1] This increase coincided with a nearly fourfold increase in the use of
prescription opioids nationally.[2] In Washington, in 2006, the rate of poisoning involving opioid painkillers was significantly higher
than the national rate.[1] To better characterize the prescription opioids associated with these deaths and to reexamine previously
published results indicating higher drug overdose rates in lower-income populations,[3] health and human services agencies in Washington
analyzed overdose deaths involving prescription opioids during 2004–2007. This report describes the results of that analysis, which found
that 1,668 persons died from prescription opioid-related overdoses during the period (6.4 deaths per 100,000 per year); 58.9% of
decedents were male, the highest percentage of deaths (34.4%) was among persons aged 45–54 years, and 45.4% of deaths were
among persons enrolled in Medicaid. The
age-adjusted rate of death was 30.8 per 100,000 in the
Medicaid-enrolled population, compared with 4.0 per 100,000 in the non-Medicaid
population, an age-adjusted relative risk of 5.7. Methadone, oxycodone, and hydrocodone were involved in 64.0%, 22.9%, and
13.9% of deaths, respectively. These findings highlight the prominence of methadone in prescription opioid–related overdose
deaths and indicate that the Medicaid population is at high risk. Efforts to minimize this risk should focus on assessing the patterns of
opioid prescribing to Medicaid enrollees and intervening with Medicaid enrollees who appear to be misusing these drugs.
During 2004–2007, approximately 90% of clients in the Washington PRC program misused prescription opioids by doctor
shopping, frequent cycling through emergency departments, and prescription forgery. WSHRSA attempted to limit such misuse
by restricting PRC clients to one primary-care provider, one narcotics prescriber, one pharmacy, and one hospital for
nonemergency care. In addition, WSHRSA could require prior authorization for all opioid prescriptions.
Methadone's use as a painkiller increased more than twelvefold in the United States and Washington during 1997–2006 driven in part by
its low cost. Washington ranked fourth among states in the per-capita cosumption of methadone in 2005 and 2006.
25
Yes, But....
Don’t Do It......
Sources of Narcotic Analgesics
Setting Type
% Distribution
Emergency department
39%
Primary care office
31%
Medical specialty office
13%
Surgical specialty office
10%
Hospital outpatient department
7%
Source: National Center for Health Statistics. Medication therapy in ambulatory medical
care: United States, 2003-04
37
Where do they get prescription opiates
that are used ‘non-medically’?
 56% get free from friend or family member
 19% from a doctor
 9% bought them from friend or family
 4% from a drug dealer
 0.1% purchasing them from the internet
Source: National Survey on Drug Use & Health, 2006
38
OK, So
What.
Their Dead!
“No Skin Off My
$$$$$
Teeth”
State-Funded Substance Abuse Treatment Admissions for
Rx Opioids - Adults
Source: WA Department of Social & Health Services, TARGET, 2009
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State-Funded Substance Abuse Treatment Admissions for Rx Opioids -Teens
Source: WA Department of Social & Health Services, TARGET, 2009
34
Anesthesiology:
April 2010 - Volume 112 - Issue 4 - pp 777-778
Opioid Medication Management: Clinician Beware!
Jamison, Robert N. Ph.D.; Clark, J. David M.D., Ph.D.
•
Fitzgibbon et al.1 presents summary data of malpractice claims about opioid medication management for
chronic pain between 2005 and 2009. The investigators examined 8,962 closed claims from 35 liability
insurance companies and determined that 295 claims involved chronic pain management. Of these, 17%
(51) directly related to medication management, mostly for prescribing opioids for chronic low-back
pain. Unfortunately, death was the most common outcome involved in these claims. The authors note
that compared with a previous review by their same group,2 the number of claims related to
medication management had increased from 2 to 8%. The primary reasons for medication
management claims, which may surprise some readers, included (1) failure by the prescribing
physician to communicate a care plan, (2) inadequate monitoring and documentation of care, (3)
inappropriately high-prescribed doses of opioids, or (4) unethical or illegal clinical practices.
•
Prescription opioid precautions should include careful patient selection including assessment of pain, mood,
function, and misuse risk factors, a treatment plan accompanied with a patient–physician treatment
agreement, and an appropriate level of monitoring of the patient during opioid therapy based on the level of
risk to assess efficacy, adverse effects, and aberrant drug-taking behavior. Unfortunately, documentation of
patient evaluation, formulation of treatment plans, and follow-up on treatment plans are absent from the
medical records of many patients managed with opioids.8 Implementation of these procedures takes time and
requires thorough documentation but results in reduced opioid misuse. For those patients with high-risk
chronic pain who have a history of abuse but for whom a trial of opioid therapy is still to be undertaken,
structural interventions including frequent urine screen monitoring, self-report compliance checklists, and
individual and group substance abuse counseling, can result in improved compliance with prescription.
30
OK, It’s a Problem.
What’s Getting Done
About It?
Hippocrates
Greek: 460 BC-370
BC
“First... Do No Harm”
ESHB 2876 (Moeller) Pain management
Passed House: 96--‐0
Passed Senate: 37-10
Passed Senate: 36-12
Passed House: 96-1
Governor signed March 25th, 2010, with a partial veto
This legislation seeks to decrease accidental overdoses from opioid
prescriptions. Washington is in the upper third of states for opioid death rate in
the country.
The amended bill directs medical and nursing boards and commissions to write
rules regarding pain management. Boards and commissions are to consider a
number of issues during rule making, including special circumstances when
dosage amounts maybe exceeded without consultation from a pain specialist,
sufficient training and experience to exempt a practitioner from the specialty
consultation requirement, guidance on tracking opioid use among others.
27
Public Response: ESHB 2876
• The public (WA state) perceived the medical community as being
unresponsive and not policing themselves.
• The 2010 legislature passed Engrossed Substitute House Bill 2876 in
response to concerns about the consequences and risks of managing
chronic, long-term pain.
• The bill requires the boards and commissions repeal existing rules
about pain management by June 30, 2011. MQAC, BOMS, and PMB
currently have rules that must be repealed
• The bill requires five boards and commissions to adopt new rules
related to pain management by June 30, 2011. These boards and
commissions have separate disciplining and rulemaking authority. It
does require separate rules for each profession.
• The rules required by the legislation will not apply to treatment of
chronic cancer pain or acute pain caused by an injury or a surgical
procedure. It also does not apply to palliative, hospice and other end
of life care.
28
DOH ED Opioid Abuse Work Group
• A sub work group of:
• Interagency Workgroup to Prevent Prescription Opioid Misuse,
Abuse and Overdose (June 2008)
• Coordinated by Washington Dept of Health
• ED Work Group Started February 2009
• Monthly Conference calls
• Guidelines in progress since April 2009 (18 months)
47
45
Guidelines Adopted For The
Prescribing of Opioid Drugs
for the Treatment of Chronic
(non-cancer) Pain through
the Emergency Department.
Morphed at some institutions into “Guidelines to Prevent
Prescription Drug Abuse From the ED”
21 Point Plan
Guidelines to Prevent Prescription Drug Abuse from the ED
1. One prescriber, not multiple ED physician prescribers.
2. Avoid IV/IM opioids for the treatment of chronic pain in the
ED.
3. Require picture ID to fill opioid prescriptions from the ED.
4. Photograph ED patients without ID.
Guidelines to Prevent Prescription Drug Abuse from the ED
1. Don’t replace lost or stolen prescriptions.
2. Don’t give replacement doses of methadone.
3. Don’t use OxyContin and Fentanyl patches for acute
pain.
4. Share ED visit information with all EDs in WA. “EDIE”
(Emergency Department Information Exchange)
Guidelines to Prevent Prescription Drug Abuse from the ED
9. Have pain agreements accessible to ED physician.
10.ED care coordination programs are encouraged.
11.Keep a list of primary care and chemical dependency
resources.
12.Implement screening and brief intervention programs for
substance abuse.
Guidelines to Prevent Prescription Drug Abuse from the ED
13.Demerol usage is discouraged.
14.Contact the PMD when possible and prescribe only
enough pill to last until PMD office opens.
15.Prescribe no more than 30 pills.
16.Screen for previous addiction when prescribing opioids
from the ED.
17.EMTALA does not require the treatment of pain.
52
51
Tweaks At ARMC and with
Cascade Emergency Physicians
• #2) All other methods of treating acute exacerbation of
chronic pain prior to the use of IV/ IM opioids should be
explored. The use of opioids is discouraged. In the event
opioids are used, such use will be accompanied by a
complete and open discussion of the risks of addiction and
death, as well as the formulation of alternative treatments &
resources in the future. This conversation will be
documented.
• #4) Administration is encouraged to explore the
photographing of patients without ID.
Due to Recent Increase in Prescription Medication Addiction, Overdose and Deaths
the Cherry Hill Emergency Department Follows These Guidelines
to Reduce Prescription Drug Abuse **
•
•
•
•
One provider should provide all opioids to treat a
patient’s chronic pain: We do not prescribe additional
narcotic pain medications after the first visit or when you
are already receiving or have received medications from
another doctor or ED. Any exception will be made only
after a urine tox screen and direct contact with your
regular doctor.
The administration of intravenous and intramuscular
opioids in the emergency department for the relief of
acute exacerbations of chronic pain is discouraged:
We do not give pain medication shots (injections) for
exacerbations of chronic pain.
Prescriptions for controlled substances from the
emergency department should state the patient is
required to provide a government issued picture
identification (ID) to the pharmacy filling the
prescription: You will be asked to show a state ID
(Drivers License or similar) when you get a narcotic
prescription from our ED filled at the pharmacy.
Emergency departments should photograph patients
who present for pain related complaints without a
government issued ID: If you do not have photo ID and
are requesting or prescribed narcotic pain medication we
will take your photograph for the medical record.
•
•
•
•
•
Emergency medical providers should abstain from
providing replacement prescriptions for controlled
substances that were lost, destroyed or stolen: We do
not refill stolen or lost prescriptions for narcotics or
controlled substances.
Emergency medical providers should not provide
replacement doses of methadone for patients in a
methadone treatment program who have missed a
dose: We do not provide missed methadone doses.
Long acting or controlled release opioids (such as
OxyContin, fentanyl patches and methadone) should
not be prescribed for acute pain: we do not prescribe
long acting or controlled release opioids (OxyContin,
MSContin, fentanyl, Duragesic, methadone . .)
Emergency departments should share the ED visit
history of a patient with other emergency physicians
who are treating a patient: Health care laws allow us to
share and request your medical record and visits with
other doctors.
Emergency departments should coordinate the care of
patients who frequently visit the ED using an ED
coordination program: Frequent users of the ED will
often have care plans made to facilitate and optimize their
care including avoidance of use of medications associated
with abuse or addiction.
44
Due to recent increase in prescription drug addiction, overdose and death the
Swedish Emergency Departments Follows These Guidelines
to Reduce Prescription Drug Abuse
1.
2.
3.
4.
One provider should provide all opioids to treat a patient’s
chronic pain: We do not prescribe additional narcotic pain
medications after the first visit or when you are already receiving
or have received medications from another doctor or ED. Any
exception will be done only after a urine tox screen and direct
contact with your regular doctor.
The administration of intravenous and intramuscular opioids
in the emergency department for the relief of acute
exacerbations of chronic pain is discouraged: We do not give
pain medication shots (injections) for exacerbations of chronic
pain.
Prescriptions for controlled substances from the emergency
department should state the patient is required to provide a
government issued picture identification (ID) to the pharmacy
filling the prescription: You will be asked to show a state ID
(Drivers License or similar) when you get a narcotic prescription
from our ED filled at the pharmacy.
Emergency departments should photograph patients who
present for pain related complaints without a government
issued ID: If you do not have photo ID and are requesting or
prescribed narcotic pain medication we will take your photograph
for the medical record.
5.
6.
7.
8.
9.
Emergency medical providers should abstain from providing
replacement prescriptions for controlled substances that
were lost, destroyed or stolen: We do not refill stolen or lost
prescriptions for narcotics or controlled substances.
Emergency medical providers should not provide
replacement doses of methadone for patients in a
methadone treatment program who have missed a dose: We
do not provide missed methadone doses.
Long acting or controlled release opioids (such as
OxyContin, fentanyl patches and methadone) should not be
prescribed for acute pain: we do not prescribe long acting or
controlled release opioids (OxyContin, MSContin, fentanyl,
Duragesic, methadone . .)
Emergency departments should share the ED visit history of
a patient with other emergency physicians who are treating a
patient: Health care laws allow us to share and request your
medical record and visits with other doctors.
Emergency departments should coordinate the care of
patients who frequently visit the ED using an ED
coordination program: Frequent users of the ED will often
have care plans made to facilitate and optimize their care
including avoidance of use of medications associated with abuse
or addiction.
10. The Swedish Emergency Physicians do not prescribe Schedule 2
Controlled Substances --those most associated with abuse or addiction-including oxycodone or oxycodone containing medications (Percocet,
OxyContin), Dilaudid (hydromorphone), Morphine (MSContin) and others.
** from the Washington ED Opioid Abuse Work Group sponsored by the
Washington State DOH
46
Everyone On The Same
Page
“The Script”
“This is a policy the doctors across the state of Washington
have adopted in response to an alarming increase in
complications from prescription narcotics. All situations,
such as yours, are unique. But that doesn’t change the fact
that addiction & overdose deaths are skyrocketing in
Washington. We as doctors in order to create a healthier
state, are taking a decisive step to correct a health epidemic
we have partially helped to create. Now our goals are to
find you solutions, referrals, and answers to your pain
management, not just more drugs. So lets talk about your
long term health plan going forward, and how I can help
you, WITHIN MY GUIDELINES.”
How Can I Help?
• Examine your own prescribing habits
• Reach for a non-opioid first
• Share Practice Plans & Pain
Management Contracts (EDIE & with
Primary Care)
• DON’T give false expectations to
patients about their ED visit (know our
guidelines)
• For Consultants, be available & expect
“the call”
Thank-You.
Questions for the
panel
Disclaimer:
This slide in no way advocates the
substitution of alcohol for opioids,
the over exposure to UV sunshine,
the utilization of non optometrical
supplied eye protection, or the
proximity to open water without a
Coast Guard approved floatation
device...