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

2. The Past and Present

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

4. The Future?

5. Opioid Sales, Deaths, and Treatment Admissions

7. MMWR July 7, 2017

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

9. Reduce Supply
Reduce Demand
Decrease Overdose

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

11. 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.

12. Voluntary Community Prescribing Guidelines

13. A Community Goal

14. A Community Goal

15. 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

16. 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. 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

18. 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

19. 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

20. 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

21. 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

23. Thank you!

24. Optional Slides for Question and Answer Period

26. 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

27. 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

28. 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.”