Opioids in Butte County Andy Miller M.D. Butte County Public Health

The Past and Present

“Nationally, corrected opioid and heroin involved mortality rates were 24% and 22% greater than reported rates” American Journal of Preventative Medicine August 7 2017

The Future?

Opioid Sales, Deaths, and Treatment Admissions

MMWR July 7, 2017

Death Rate 2016 MME per resident 2015 California Opioid Dashboard MMWR July 7, 2017

Reduce Supply Reduce Demand Decrease Overdose

Reduce Supply Safe Prescribing Guidelines Decision Support Tools Policies and Protocols Provider Support/ Academic Detailing Drug Disposal and Take back Law Enforcement

A Community Goal “Our goal is to decrease the MME/resident/year in Butte County to the most recent national average”. Present National Average is 640 MME/res/yr.

Voluntary Community Prescribing Guidelines

A Community Goal

A Community Goal

Safe Prescribing Guidelines Reduce Supply Safe Prescribing Guidelines Consider not prescribing opioids for chronic pain (A1) Consider non-opioid options, when appropriate, to treat acute pain (A2) If you choose to use opioids for acute pain: least amount for the shortest period of time (A3) Consider opioid Prescribing Guidelines for Hospitalists, Dentists and Surgeons

The First Prescription – Why limit the number of days? FIGURE 1. One- and 3-year probabilities of continued opioid use among opioid-naïve patients, by number of days’ supply* of the first opioid prescription — United States, 2006–2015 MMWR March 17. 2017

The First Prescription – Why limit the number of refills? FIGURE 2. One- and 3-year probabilities of continued opioid use among opioid-naïve patients, by number of prescriptions* in the first episode of opioid use — United States, 2006–2015 MMWR March 17, 2017

Decision Support Tools Reduce Supply Decision Support Tools Consider adding flags to EHR to identify high risk situations Use CURES Have non-opioid pain options as the default in order sets and algorithms

Policies and Protocols Reduce Supply Policies and Protocols Consider a Discharge algorithm using the last day Implement surgeons providing pain control for first 6 weeks Consider removing Soma from medications dispensed Consider removing Xanax from medications dispensed Consider limiting opioid and benzo co-prescribing

Prescribe buprenorphine Reduce Demand Prescribe buprenorphine Consider having X-waivered providers for those patients who have: Have been admitted with an overdose which includes opioids Have a history of , or show signs of, an opioid use disorder

Prescribe naloxone Adopt a policy of providing naloxone for every patient admitted with an overdose or use disorder Consider prescribing naloxone to all patient discharged on >50 MME/day Consider prescribing naloxone to all patients on an opioid and a benzo (or other CNS depressant) Decrease Overdose

Thank you!

Optional Slides for Question and Answer Period

Intra nasal and injectable Reduces mortality Cost effective Intra nasal and injectable Is safe Is not a controlled substance Can be dispensed without a Rx

Low potential for misuse Safe during pregnancy Reduces mortality Requires training and a waiver Often co-formulated with naloxone Low potential for misuse Safe during pregnancy Is a long-term medication

Risk / Benefit CDC Guidelines In summary, evidence on long-term opioid therapy for chronic pain outside of end-of-life care remains limited, with insufficient evidence to determinelong-term benefits versus no opioid therapy, though evidence suggests risk for serious harms that appears to be dose-dependent” No evidence shows a long-term benefit of opioids in pain and function versus no opioids for chronic pain with outcomes examined at least 1 year later. Extensive evidence shows possible harms of opioids.” Washington State Guidelines “Because there is little evidence to support long term efficacy of COAT in improving function and pain, and there is ample evidence of its risk for harm, prescribers should proceed with caution when considering whether to initiate opioids or transition to COAT.”