1. { Bay Area Prescription Drug Abuse Summit: Pharmacist Perspective Lori Reisner, Pharm.D. Health Sciences Professor of Clinical Pharmacy University of California Medical Center, San Francisco May 7, 2014

2. Opioid use in primary care:  300% increase in opioid analgesic prescriptions between 1999 -2010  Painkiller overdose deaths among women increased 5-fold and 3.6 times among men increased  Similar increases occurred in opioid-related ED visits and hospitalizations  Mean annual direct health care costs for patients who abuse opioids are 8.7-times higher than for non-abusers  Chronic pain may be present in up 20-50% of primary care physicians’ patients, and opioids are an essential component of their armamentarium  Regulatory responsibilities and scrutiny of opioid prescribing are increasing Background CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008. MMWR 2011; 60: 1-6

3.  Prescription drug-related deaths now outnumber those from illicit substances  CDC reported 14,800 deaths from opiate overdose in 2008  Sedative combinations contribute to a significant percentage of deaths  Benzodiazepines  Non-benzodiazepine sedatives (e.g., carisoprodol, zolpidem)  Alcohol and other sedatives Background CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008. MMWR 2011; 60: 1-6

4. Overdose rates by state rate, Nebraska. 4 Drug Overdose Rates by State, 2008 4

5.   209 drug-related deaths, up from 41 the year prior   Oxycodone was detected in 53 of the total   25 percent of accidental drug-related deaths in San Francisco involved oxycodone   Dr. Nikolas Lemos, chief forensic toxicologist at the Office of the San Francisco Medical Examiner, quoted by SF Weekly   Contrast with 29 deaths due to motor vehicle accidents during that period San Francisco San Francisco 2009 and 2010

6.  Underlying comorbidities  Sleep apnea/respiratory disease  Cardiovascular diseases  Obesity/metabolic diseases  Reimbursement systems  Less face-to-face patient time  More reliance on medications/prescribing options  Limited options (insurance restrictions)  HCAHPS Scores  Reimbursement determined by percentiles  Reliance on pain scores may pressure prescribers to use more opioids  Prescriber Education  Lack of knowledge about non-opioid options  Inadequate trial periods/Inadequate dosing  Drug-drug interactions  Pharmacokinetics: Frequency of long-acting meds/Dose adjustments  Regulatory  Intensifying scrutiny of less offensive agents, e.g., tramadol Influences on Morbidity/Mortality

7.  Retail Pharmacist have little experience with appropriate pain regimens  May lack information regarding combination therapies (multiple prescribers/pharmacies)  Fear of challenging physician prescribing  Cannot reliably confirm misuse/abuse or counterfeits  Integrating non-pharmacological interventions and modalities  Prescribers subscribing to “harm reduction” philosophies  Developing safer medications: abuse-limiting modifications Challenges

8. Example Multimodal Regimen UCSF Arthroplasty (Joint replacement) Service:  Acetaminophen 1000 mg PO Q6H  Celecoxib 200 mg PO BID*  Gabapentin 300 mg PO TID*  Oxycodone 10 mg PO Q4H PRN moderate pain  Morphine 2 mg IV Q2H PRN severe pain  Epidural catheter w/ ropivacaine & fentanyl  +/- peripheral nerve infusion (local anesthetic) *may be omitted or dose-adjusted depending on comorbidities or meds prior to admission

9.  Improved Prescriber Education  Limited utility and persistence  Mandated curriculum?  Mandated re-certification?  Prescription pattern audits ( CURES)  Prescription pattern audits (Controlled Substance Utilization Review and Evaluation System, CURES)  Development of Pain Management Specialist/Consultant Certification across Professional Domains  Will require accepted certification/accreditation standards  Pharmacist Empowerment  Retail, hospital and ambulatory practices  Patient Education  Balancing portrayal in popular media, e.g., television  Instruction in proper use and risks  Reimbursement: adequate for appropriate patient care Recommendations