1. 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

2. 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

3. 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

4. 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

5. 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

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

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

8. 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

9. 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
Slide lead: Public Health
CDC MMWR:

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

11. Scope of the Opioid Epidemic

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

13. 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:
American Society of Addiction Medicine

14. 2015-2017 Oregon Opioid Prescribing: Decreased by 24%
Oregon Opioid Fills
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

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

16. 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

17. 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

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

19. 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

20. 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

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

22. 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

23. 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

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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

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

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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. For More Information Contact: Web resources:
Katrina Hedberg, MD, MPH:
Web resources:
OHA Opioids Website:
Interactive Data Dashboard
Community Information
Guidelines
Oregon Prescription Drug Monitoring Program Website:
Oregon Pain Management Commission module: