Oregon’s Opioid Initiative: How Hospice & Palliative Care Can Help Oregon Hospice & Palliative Care Association Conference Sept 25, 2018 Katrina Hedberg, MD, MPH State Health Officer Oregon Health Authority

My Background Public Health Physician/ Medical Epidemiologist, not hospice/ palliative care expert Importance of data for decision-making Public health role re: opioids Public health role re: end-of-life care

Objectives To understand: Current data on the opioid overdose epidemic in Oregon. Various strategies being implemented to address this crisis. The role that hospice and palliative care medicine can have helping Oregon address the opioid overdose epidemic.  Slide lead: Katrina Hedberg

Presentation Outline Scope of problem in Oregon Oregon Opioid Initiative Statewide and community strategies Oregon Prescribing Guidelines PDMP Role of hospice & palliative care in opioid crisis Resources Update presentation objectives to match audience and goals of presentation

Prescription Opioids in Oregon Deaths 149 deaths (3.6/100,000 residents) from prescription opioids in 2016 Hospitalizations 330 hospitalizations for overdose; 4300 for opioid use disorder $8 million in hospitalization charges in 2014 Slide lead: Public Health

Death Rates: White middle-aged Americans 2000-2015 Slide lead: Public Health

Drug Overdose Deaths—US 2000-2015 Slide lead: Public Health

Drug Overdose Deaths, Oregon 2000-2016 Pharmaceutical and Synthetic Opioids Rate per 100,000 population Heroin Methamphetamine and stimulants Slide lead: Public Health Source: Oregon Vital Statistics, Death Certificates healthoregon.org/opioids Data dashboard

Age-adjusted drug overdose rates by state – 2010 and 2015 Nationally and in many states, drug overdose deaths increased from 2010 to 2015 Unlike most states, overall drug overdose death rates fell slightly in Oregon from 2010-2015 Slide lead: Public Health CDC MMWR: https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm?s_cid=mm655051e1_w

Drug Overdose Deaths by Age Oregon 2012-2016 Deaths per 100,000 residents Slide lead: Public Health Source: Oregon Vital Statistics, Death Certificates

Scope of the Opioid Epidemic

Drug Overdose Hospitalizations Oregon 2000-2014 Slide lead: Public Health Source: Oregon Hospital Discharge Dataset, Office of Health Analytics. healthoregon.org/opioids Data dashboard

Amount Opioids Prescribed in the US 2015: 226 million prescriptions for opioid pain medications1 Almost enough for every of adult (18+) to have a bottle of pills Opioid dependency 2015: 2 million persons diagnosed with a SUD involving opioids 2 Slide lead: Public Health CDC MMWR: https://www.cdc.gov/mmwr/volumes/66/wr/mm6626a4.htm?s_cid=mm6626a4_w American Society of Addiction Medicine

2015-2017 Oregon Opioid Prescribing: Decreased by 24% Oregon Opioid Fills 2011-2017 Q3 2015: 236 opioid prescriptions per 1,000 residents Q3 2017: 179 opioid prescriptions per 1,000 residents Quarterly Fills per 1,000 Residents *** Data can be updated every quarter – contact Josh Van Otterloo (PH PDMP for most recent data) Slide lead: Public Health Source: Oregon Prescription Drug Monitoring Program healthoregon.org/opioids Data dashboard

Oregon Opioid Prescribing by Age: 2016 Fills Per 1,000 residents Slide lead: Public Health Age group (years) Source: Oregon Prescription Drug Monitoring Program

Oregon Opioid Prescribing by Age Patients receiving a >120 MED opioid fill Age Group Recipients per 1,000 residents Slide lead: Public Health Source: Oregon Prescription Drug Monitoring Program. healthoregon.org/opioids Data dashboard

Unused opioid pills after a prescription Systematic review of orthopedic, thoracic, obstetric and general surgery: 67% – 92% of patients with unused opioids Dental surgery: avg 54% unused Hand surgery: avg 34% used Shoulder surgery: avg 25% unused C-Section: 83% reported taking fewer than half Slide lead: HERC

Oregon Pain Medication Misuse Oregon: Sixth highest state for nonmedical use of prescription painkillers 5.3% of persons 12-17 years of age Slide lead: Public Health Source: SAMHSA- 2013-14 National Survey on Drug Use and Health, state level data

Pain Categories for Treatment Pain lasting > 3 months, or past time of tissue healing Prevalence: ~15% of US adults Acute Pain Chronic non-cancer pain Cancer pain End of life pain Slide lead: Public Health

The Oregon Opioid Initiative Reduce risks to patients by making pain treatment safer and more effective, emphasizing non-opioid and non- pharmacological treatment Reduce harms for people taking opioids and support recovery FROM substance use disorders by making naloxone rescue and medication-assisted treatment (MAT) more accessible and affordable Protect the community by REDUCING THE NUMBER OF PILLS IN CIRCULATION through implementation of safe prescribing, storage, and disposal practices 2 OPTIMIZE OUTCOMES BY MAKING STATE AND LOCAL DATA AVAILABLE for informing, monitoring, and evaluating policies and targeted interventions Aim: Reduce deaths, non-fatal overdoses, and harms to Oregonians from prescription opioids, while expanding use of non-opioid pain care 3 1 Slide lead: Lisa Bui / Katrina Hedberg 4

Oregon Opioid Initiative: Strategies Slide lead: Lisa Bui / Katrina Hedberg

Oregon Health Authority Opioid Initiative Summary Prioritized List Back Condition Benefit Coverage (7/1/2016) Prescription Drug Overdose Grant HB 4124 Naloxone Availability Collaboration with law enforcement and EMT Medication Assisted Treatment (MAT) STR Grant 1 2 Reduce Harms/ Support Recovery Reduce Risk Reduce Harms/ Support Recovery Statewide Prescribing Guidelines Statewide Dental Prescribing Guidelines Statewide Performance Improvement Project (PIP) HB 4124: Prescription Monitoring Interactive opioid dashboard CCO PIP: > 120 MED and > 90 MED tracked Reduce number of pills Slide lead: Lisa Bui Data Availability 3 4

The New Back Care Paradigm: Medicaid Coverage Decreased Coverage: - Surgeries - Opioids - Epidural Steroid Injections Increased Coverage: - Cognitive Behavior Therapy - Spinal Manipulation - Acupuncture - PT/OT - Non-opioid medications - Yoga * - Interdisciplinary Rehab * - Supervised exercise * - Massage Therapy * * If available Slide lead: HERC

Opioid Prescribing Recommendations Published March 2016 Chronic Pain Non-cancer Non-palliative Non-end of life Slide lead: Public Health

Chronic Pain Prescribing Guidelines When to use opioids for chronic pain Non-opioid pain treatment options preferred Treatment goals for pain and function Discuss risks and benefits of opioid treatment Opioid selection, dosage, duration Lowest dose, short acting, minimum time Risk Assessment and addressing harms Using PDMP as part of assessment Limit co-prescribing Slide lead: Public Health

Oregon’s Opioid Prescribing Guidelines Task Force Membership Professional Assn’s, licensing boards, organizations Health systems, hospitals, payers Regional task forces, public health departments Goal Standard for opioid prescribing across the state, including health care systems, practice settings Oregon Health Authority Role Convener No mandate, no specific funding Slide lead: Public Health

Format for Oregon Guidelines One stop shopping for statewide guidelines Overarching foundational principles for opioid prescribing in Oregon Specific focus area “chapters”: Chronic pain (current guideline) Dental guideline Guidelines for pregnant women Acute pain guideline: emergency departments, dental clinics, post-surgical Slide lead: HERC

Chronic Pain Prescribing Guidelines (I) Endorse CDC guideline as foundation for opioid prescribing in Oregon Oregon-specific addenda: marijuana use; chronic (legacy) patients; Naloxone Prescription Drug Monitoring Program OMB Material Risk Notice Finalized November 2016 Slide lead: Public Health

Chronic Pain Prescribing Guidelines (II) Prescribing higher doses of opioids Additional evaluation of benefits and risks, documentation of higher dose justification Obtain pain management consultation Compassionate and non-discriminatory treatment for established patients on higher doses. Slide lead: Public Health

Chronic Pain Prescribing Guidelines (III) Co-prescribing opioids and benzodiazepines Check the PDMP for concurrent medications prescribed by other clinicians Consider involving pharmacists, pain specialists, and/or mental health specialists when opioids are co-prescribed with other CNS depressants. Have informed discussion with patient about serious risks associated with using these medications concurrently. Slide lead: Public Health

Acute Pain Prescribing Guidelines (I) In general, opioids should NOT be considered first line therapy for mild to moderate pain. If opioid is prescribed: Evaluate the Patient Identify cause of acute pain (e.g. medical condition, injury), and whether pain is likely to respond to opioid or non-opioid therapies. Assess pain severity and likely duration / period for recovery Assess age and medical conditions that might affect dose. Document evaluation and justification for prescribing an opioid. Review other medications patient is taking; assess potential drug interactions and toxicity. Slide lead: HERC

Acute Pain Prescribing Guidelines (II) Assess history of long-term opioid use / substance use disorder (SUD) Assess patient for history of long-term opioid treatment, including whether they are on a taper plan. Coordinate with other clinicians/ prescribers for the patient. Assess patient’s use of alcohol or sedative medications. Check Prescription Drug Monitoring Program Note chronic opioid use / concurrent prescriptions for benzodiazepines or sedative hypnotics. Slide lead: HERC

Acute Pain Prescribing Guidelines (III) Provide Patient Education Counsel patient about pain and expected duration. Review risks and side effects of opioids. Counsel on safe storage; disposal of unused medications. Amount and Type Lowest effective dose for shortest duration (usually <3 days). Patient Followup Continue to assess response to therapy, level of pain, patient function Slide lead: HERC

Prescription Drug Monitoring Program (PDMP) Tool to help healthcare providers and pharmacists provide patients better care in managing prescriptions. Provide data on controlled substance prescriptions to improve patient safety and health Patients at risk for: overdose, side effects, increased risk from other drugs, physical dependence, drug abuse Slide lead: Public Health

PDMP: Oregon Prescribing Data 7 million prescriptions annually 4,000 prescribers write 80% of scheduled substance prescriptions Opioids (e.g. hydrocodone, oxycodone) account for ~50% of prescriptions Benzodiazepines 2nd most frequent prescription Slide lead: Public Health

Controlled Substance Prescriptions Oregon, 2016 Slide lead: Public Health / HSD – SOTA (John McIlveen) Source: Oregon Prescription Drug Monitoring Program

Hospice / Palliative Care: Role in Opioid Overdose Crisis Adequate pain & symptom management Risks of opioids Opioid over-dose crisis

Public Health Concerns for Hospice & Palliative Care Population-focus Prevent misuse and diversion Judicious number of pills to manage symptoms Storage to limit access for non-patients Disposal of unused meds

Opioid issues for Hospice/ Palliative Care 1.6 million patients in hospice annually 1/3 of patients admitted to hospice on opioids; increases after enrollment Balance patient comfort & control of pain / symptoms with medication side effects Challenges Patients with history of substance use disorder who develop cancer pain, terminal illness Drug diversion in residential settings Misuse of unused opioids

How can Hospice & Palliative Care help? Experience of pain subjective Physical pain, psychological response to pain, resiliency Patient-focused quality end-of-life care Symptom management Pain relief, anxiety, oxygen hunger, nausea Evidence-based treatments Controlled substances and alternative therapies Balance benefits with side effects Conversation related to: medication type & strength, # pills Ongoing evaluation of patient function/ status Adjust and titrate agressively Emotional & psycho-social support

Range of Strategies (Aligned with Opioid Initiative) Non-pharmaceutical pain/ symptom management Music, humor, heat/ cold, exercise Massage, therapeutic touch, acupuncture biofeedback, cognitive behavioral therapy Psycho-social support of patient and family Substance use disorder in patient & family members Judicious prescribing: lowest amounts necessary, refills rather than larger # pills Plan for disposal of unused medications

Risk Evaluation to promote safe opioid use: Virginia Assoc for Hospice/ Palliative Care All patients receiving opioids: Conduct risk assessment Identify who will control medication Opioid safety education Side effects, use as prescribed, secure storage, driving restrictions, who to call with questions, disposal Sign opioid safety plan Low risk: reconcile opioids at RN visit, review safety plan

Risk Evaluation to promote safe opioid use: Virginia Assoc for Hospice/ Palliative Care Moderate/ high risk: Patients Assess which substances abused, how recent Reconcile opioids at every visit, limit supply (e.g. 1-2 wk), consider anti-depressants rather than benzo’s, treat mental health issues, long-acting with no short-acting breakthrough opioids Emphasize safety Family member (above plus…) Emphasize safety, deny access, install lock box

Hospice Compliance Network Balance opioid risks with need for pain relief Identify and respond to risk of substance abuse, misuse, diversion as compliance and quality concern Meticulous charting, document reason for opioid, and efforts taken to mitigate risk Know SUD resources in area Rotate choice of opioid Consider alternative placement if in-home is problematic Use non-pharmaceutical modalities Address emotional and spiritual needs

Oregon Opioid Initiative Partnerships Federal State & Local Health care & Treatment Community State policy makers and statutes Oregon Health Leadership Council Health Systems Local public health departments Centers for Disease Control & Prevention Substance Abuse & Mental Health Services Administration Department of Justice Public safety/ Law Enforcement OHSU & NW Addictions Technology Transfer Center OR Coalition for the Responsible Use of Meds Needle exchange programs Coordinated Care Organizations Health systems Emergency Departments Pain management clinics Opioid Use Disorder Treatment Programs Pharmacies Slide lead: Lisa Bui / Katrina Hedberg

Balance Needs Use of Opioids Slide lead: Lisa Bui / Katrina Hedberg Protect & promote pain Management Control misuse Inform clinicians Control diversion public policy Public education prevention practice Privacy & Security Slide lead: Lisa Bui / Katrina Hedberg

For More Information Contact: Web resources: Katrina Hedberg, MD, MPH: Katrina.hedberg@state.or.us Web resources: OHA Opioids Website: http://healthoregon.org/opioids Interactive Data Dashboard Community Information Guidelines Oregon Prescription Drug Monitoring Program Website: http://www.orpdmp.com Oregon Pain Management Commission module: https://www.oregon.gov/oha/HPA/CSI-PMC/Pages/module.aspx