1. Prescription Opioid Use and Abuse Joseph Merrill M.D., M.P.H. University of Washington July 21, 2009

2. Prescription Opioid Use and Abuse Trends in prescription opioid use Trends in problems related to prescription opioids Addiction in patients prescribed opioids HMC efforts to improve opioid management

4. Opioid Management for Chronic Pain: HMC Adult Medicine Clinic Trends in prescribing of opioids and related problems The AMC Opioid Registry Opioid Review Committee Addiction treatment options

5. Opioids for Pain Treatment Highly effective for post-op and cancer pain Effective for chronic pain conditions, but… –Benefit clearer for pain level than function –Only short term use has been well studied –Trials have generally excluded patients with psychiatric problems, especially addiction

6. Opioids Prescribing Trends for Non-Cancer Pain TROUP: AK Medicaid and WellPoint –Small increase in % prescribed opioids 2002-5 –Substantial increase in dose per member –Largest increases: long-term treatment (>180 d) CONSORT: GHC and Kaiser N. CA –Opioid prescribing episodes analyzed 1997-2005 –Acute ( 20mg/d) TROUP study NIDA DA 022560 M. Sullivan PI

7. Supported by NIDR grant DA-022557, Michael Von Korff & Connie Weisner PI’s Provisional Results Prevalence of opioid use episodes per 1,000 adults: chronic non-cancer pain at Group Health Cooperative* *population of approximately 300,000 adults

8. Prevalence of Long-Term Opioid Use: Group Health 0 1 2 3 4 5 6 7 8 9 199719981999200020012002200320042005 Prevelance (%) of Long Term Use Women (18-44) Women (45-64) Women (65+) Men (18-44) Men (45-64) Men (65+) 1 2 3 4 5 6

9. What Predicts Regular Opioid Use? Health Care for Communities Survey (2 waves: 1997-1998, 2000-2001) –Opioids “at least several times a week for a month or more” in the past 12 months? –Predictors of later opioid use: OR (95% CI) High Pain Interference2.37 (1.51, 3.71) Common health diagnosis1.96 (1.47, 2.62) Alcohol problem0.63 (0.35, 1.15) Drug problem2.98 (1.68, 5.30) Sullivan MD et al. Arch Intern Med 2006

10. Opioids for Pain Treatment: Summary Increasing use nationally for non-cancer pain Longer duration and higher dose use growing fastest Patients with co-morbid mental health and addiction diagnoses are more likely to be prescribed opioids

11. New Non-medical Users of Pain Relievers Aged 12 or Older Source: Office of Applied Studies. (2003). Results from the 2002 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 03–3836, NHSDA Series H– 22). Rockville, MD: Substance Abuse and Mental Health Services Administration. Nonmedical Use of Prescription Pain Relievers May 21, 2004 Millions

12. Healthy Youth Survey 2006 10 th Grade, Any past 30 day use 2006 WA DOH Healthy Youth Survey

13. 36% from a friend or acquaintance 21% from their own prescriptions 15% taken from their own or someone else’s home without permission 11% from a family member 11% other sources 6% from a drug dealer Healthy Youth Survey 2008 Opioid Source for 10 th Graders

16. Switching from Prescription Opioids to Heroin 2009 Syringe Exchange Survey (N=477) 91% reported heroin use 39% of heroin users said they were “hooked on prescription opiates” before they began using heroin 50% used sedatives or alcohol within 2 hours of use 30% were in jail >5 days in the last year

19. Addiction During Opioid Treatment DSM-IV criteria are limited in pain treatment Opioid Dependence Criteria (≥ 3 in last 12 months) –Tolerance –Withdrawal –Persistent desire to cut down or quit –Spends time taking, obtaining, recovering –Takes more than intended –Given up important activities due to opioids –Use in spite of physical or psychological problems caused by opioids

20. Prescription Opioid “Misuse” Multiple efforts to develop better criteria –History of or current substance abuse –Take more than prescribed, ask for more, lost meds –Patient, family, MD concerns about addiction –Preoccupation with opioids –Opioids given to or received from others –Opioids used to calm nerves No measure is well validated or guides treatment

21. STOMP Study design Retrospective cohort study of GHC patients on long term opioids (10 or more fills or >120 days supply) Single phone survey with trained interviewers Items included: –Prescription Drug Use Questionnaire (misuse) –DSM-IV Opioid Dependence diagnosis using CIDI –PHQ-2 depression, PHQ Anxiety –Graded Chronic Pain Scale (Von Korff) –AOD abuse screens (WHO ASSIST) –Opioid beliefs

22. STOMP Analyses PDUQ reliability poor in this sample (alpha 0.56) Factor analysis to determine reliable domains of interest in this population Latent Class Analysis to categorize patients into different types based on –Opioid-related domains from factor analysis –Also included pain, function, depression, anxiety Exploratory regression analyses to find variables that might help identify patients who are having problems

23. STOMP Respondents (n=704)

24. STOMP factor analysis To determine reliable domains in this setting PDUQ found to have 3 factors: –Addictive behaviors & history –Addiction concerns –Dose escalation and frustration with medical providers DSM Abuse and Dependence loaded as a single, distinct factor

25. Factors used to develop types (4 opioid use factors just described) 5.PHQ- 2 depression 6.PHQ anxiety 7.Graded Chronic Pain Scale

26. STOMP Latent Class Analysis: 3 Types of Patients 82% Typical –Moderate pain, depression & anxiety, low opioid addiction issues 12% Addictive Behaviors (Abuse ) –Elevated Mental Health and Addiction & Addictive behaviors 6% Pain Dysfunction –Elevated Mental Health and Addiction & Pain interference

27. Factor scores by Patient Type -0.2 0 0.2 0.4 0.6 0.8 1 1.2 1.4 BehaviorsConcernsDose Esc/Frus Abuse/DepPainAnxietyDepression Facor Score NormalAbusePain dysfunction Difference between abuse and pain groups 0.03 0.06 0.003

28. STOMP Regression Analysis To find variables that may identify patients who are doing poorly on opioids Opioid dose much higher in Addictive Behaviors and Pain Dysfunction groups Addictive Behaviors group younger and more likely male

29. Clinical Challenges with Opioids for Chronic Non-Cancer Pain Making expectations clear Providing reliable dispensing Responding to problematic behaviors Distinguishing addiction from other problems Treating co-morbid pain and addiction Engaging patients in non-opioid pain treatments

30. AMC Opioid Agreement Crucial to have expectations clear up front Renewed with changes in Primary Care MD Outlines patient and provider responsibilities Clarifies problematic opioid use behaviors –Multiple providers, early refills, illicit drug use, etc –Increasing dose without consultation Allows for periodic urine toxicology testing

31. AMC Opioid Registry Initially developed to assist with timely refills Allows patients to phone in refill requests Tracks initiation of opioid prescribing agreements Ongoing registry-related projects: –Tracking opioid indication –Tracking pain and function (CHAMMP) –Registry survey to develop an intervention for problem patients (CHAMMP)

32. AMC Opioid Registry: Demographic Information N = 557

33. Indication for Chronic Opioid Therapy

34. AMC Registry: Opioid Type Long-acting only25% (135/557) Short acting only 28% (161/557) Long and short acting 47% (261/557)

35. Long-Acting Agents Prescribed

36. Short-Acting (PRN) Agents Prescribed

37. AMC Registry Population HMC Service Utilization in 2008 –20% with HMC admission (range 1-10) –39% with ED visit (range 0-15) –Mean # outpatient visits: 10.5 Addiction Diagnoses (ICD codes 2007-8) –Alcohol only: 5.8% –Drug only: 20.0% –Both alcohol and drug: 8.9% –Neither: 65.3%

38. Opioid Review Committee Established in 2008 Assists providers with difficult opioid management cases Inter-disciplinary committee (MDs, mid-levels, CD counselors, pharmacy, chief resident) Monthly meetings to review cases and develop opioid management policies –Prescribing guidelines –Educational materials –Urine toxicology testing policy –Coordination with HMC Acute Pain Service

39. Options for Addiction Management On-site Chemical Dependency Counseling –Co-management and coordination of care –Useful when not clear if prescribing is safe HMC Addictions Program Suboxone Track –Provides buprenorphine/naloxone treatment –Group and 1 on 1 counseling –Medical and psychiatric expertise on site Collaboration with methadone maintenance programs

40. Opioid Management: The Adult Medicine Clinic Chronic opioid use for pain has increased Substantial clinical challenges Requires a coordinated response at multiple levels (clinic, medical center, health care system, State) AMC is developing a collaborative care model for opioid pain management

41. Questions or Comments?

42. Washington State Guideline on Opioid Dosing for Chronic Pain Developed through interagency process involving pain experts Educational resource for primary care providers Emphasizes need to balance risks of over- and under-treatment of pain Advocates expert consultation for doses above 120mg morphine per day or equivalent http://www.agencymeddirectors.wa.gov/opioiddosing.asp

43. Washington State Guideline on Opioid Dosing for Chronic Pain Strengths –Highlights concerning trends –Focuses on functional assessment and monitoring Criticisms –Lack of empirical support for dose limitations –Access to pain experts limited –May inhibit effective pain management in primary care Alternatives –Focus on problem patients –Prescription monitoring programs