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REVIEWING THE CORONERS’ REPORTS. PRACTICE CHANGING FINDINGS.

Cathy D. Trame M.S., C.N.S., RN-BC

CONFLICT OF INTEREST DISCLOSURE

Authors Conflicts of Interest Cathy D. Trame MS, CNS, RN-BC

Clinical Consultant for I-Flow Corporation (Division of Kimberly Clark)

Cadence Pharmaceuticals/Mallinckrodt – Speaker’s Bureau

Any views or opinions in this presentation are solely those of the author/presenter and do not necessarily represent the views or opinions of the American Society for Pain Management Nursing®.

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THE PROBLEM

100 people a day die from drug overdoses in the U.S.; nearly half of these (46) are from prescription painkillers.

259 million prescriptions for opioids were written in 2012 in the U.S.

$8.5 Billion worth of narcotic painkillers were sold in the U.S., ordered as prescriptions in 2010

This is enough medication “to medicate every American adult around the clock for one month”

(CDC, 2011; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

OPIOID EXPOSURE AND OVERUSE DISORDERS

Edlund MJ, Martin BC, Russo JE, et al. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of

opioid prescription. Clin J Pain. 2014 Jul;30(7):557-64.

HealthCore Database, (n=568,540); no opioid use in previous 6 months. Concluded “prescription opioid exposure was a strong risk factor for incident OUDs”. Duration of use, vs dose, was strongest predictor; Low dose acute odds ratio(OR) 3.44 vs. high dose acute OR 3.10 vs high dose long term OR 122.45.

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PREDICTORS OF RISK OF OPIOID ABUSE Cochran, BN, Flentje, A., Heck, NC, Van Den Bos J, Perlman, D, Torres, J, Valuck, R, & Carter, J.

Factors predicting development of opioid use disorders among individuals who receive an initial opioid prescription: mathematical modeling using a database of commercially-insured individuals. Drug Alcohol Depend. 2014 May 1;138:202-8.

Derived from U.S. commercial insurance claims database: Male (59.9% vs. 44.2% for non-OUDs)

Younger (M=37.9 vs. 47.7)

Rx history of more opioids (1.7 vs. 1.2), and more days supply of opioids (M=272.5, vs. M=33.2

Prescriptions filled at more pharmacies (M=3.3 per year vs. M=1.3)

Higher rates of psychiatric disorders

Utilize more medical and psychiatric services

Prescribed more concomitant medications

HOSPITAL INPATIENT UTILIZATION RELATED TO OPIOIDOVERUSE AMONG ADULTS, 1993-2012 (AHRQ.GOV)

Hospital stays involving opioid overuse among adults increased more than 150 percent

By 2012, opioid related hospital stays represented a rate of 295.6 stays per 100,000 population

Highest increases in women, people aged 85 years and older, and people living in the Midwest

The proportion of inpatient stays for opioid overuse billed to Medicaid decreased over time, while

the proportion billed to Medicare more than doubled

CDC STATSWWW.CDC.GOV/VITALSIGNS/PRESCRIPTIONPAINKILLEROVERDOSES/

Drug overdose was the leading cause of injury death in 2010. Among people 25 to 64 years old, drug overdose caused more deaths than motor vehicle traffic crashes.

Drug overdose death rates have been rising steadily since 1992 with a 102% increase from 1999 to 2010 alone.

OHIO has increased 440% 1999-2011 Source: ODH, Office of Vital Statistics, Analysis by Injury Prevention Program

Of the 22,134 deaths relating to prescription drug overdose in 2010, 16,652 (75%) involved opioid analgesics and 6,497 (30%) involved benzodiazepines.

In 2011, drug misuse and abuse caused about 2.5 million emergency department (ED) visits. Of these, more than 1.4 million ED visits were related to pharmaceuticals.

DA1

Slide 9

DA1 why ohio onlyDine, Alan, 7/16/2014

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“More than three out of four people who misuse prescription painkillers use drugs prescribed to someone else.”

http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

Drug Overdose Rates by State, 2008

DRUG OVERDOSE RATES BY STATE in 2010

STATE DEMOGRAPHICS

Correlation between the number of opioid prescriptions written and the number of opioid-related deaths

Three top prescribing states in U.S. per person –Alabama, Tennessee, West Virginia (CDC calculated from retail pharmacy records in 2012)

Most long-acting opioids/person – Maine, New Hampshire

PAINKILLER PRESCRIPTIONS BY STATE2012

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OPIOID RELATED DEATHS OHIO STATISTICS

SOURCE: ODH, OFFICE OF VITAL STATISTICS, ANALYSIS BY INJURY PREVENTION PROGRAM

Ohio has been experiencing epidemic proportions of deaths related to prescription opioids.

5 people/day die in Ohio from prescription opioid overdoses nearly 1 person every 5 hours(2011).

In 2007, these deaths surpassed motor vehicle accidents as the #1 cause of accidental death in Ohio.

On-Q Take A.C.T.I.O.N

DA2

2007-2012OHIO DRUG OVERDOSEDEATH RATES BY COUNTY

http://www.healthyohioprogram.org/vipp/drug/dpoison.aspx

OHIO EARLY ACTIONS IN RESPONSE TO THE CRISIS

Poison Action Group (PAG) assigned to investigate and report on prescription opioid overdoses (division of ODH) – 2009 – 4 people/day dying from prescription opioid overdoses.

In 2010, Wright State University received a grant to determine injury prevention action steps to report back to the Governor. (WSU Center for Interventions, Treatment & Addictions Research -CITAR)

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DA2 do you these same data for other states?Dine, Alan, 7/16/2014

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REVIEWING THE CORONERS’ REPORTS - OHIO

Most common age group – 35-44 years old 57% Male, 43% Female 90% White, 10% Black Education - <High School 20%, HS graduate 76%,

College graduate 2%, Post‐graduate 1% Marital Status - Single 41%, Married 29%, Divorced

26%, Separated 2%, Widowed 2% Ever in US Armed Forces - 13%

REVIEWING THE CORONERS’ REPORTS - OHIO

HEALTH DATA – extracted from case synopsis and postmortem report Physical Disability/Illness – 79%Heart Disease – 65%Mental Disability/Illness – 27%History of Any Substance Abuse – 75%

BREAKDOWN OF SUBSTANCE ABUSE HISTORY

Any history 75% Alcohol 13% Cocaine 12% Marijuana 5% Heroin 26% Prescription opioids 27% Benzodiazepines 15% Other Prescription Medications 3% Over‐the‐Counter Medications 0%

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OTHER DEMOGRAPHICS

Location of deathDecendent’s home 68% Friend’s home 14%Hospital 9%Relative’s home 2%Other 6%

911 called – 96% Reported by

EMS/Police 82%Hospital Physician 17% Coroner 1%

MOST PROFOUND FINDINGS Verifiable Valid Prescription for Controlled Drugs in

Toxicology Report = 33% Types of Drugs in Toxicology Report

Any prescription opioid -74% (Most common: methadone, 32% hydrocodone 24%, oxycodone 23%)

Heroin – 31% ETOH – 23% Antidepressants – 38% Sedative/Benzodiazepine – 76% Other Prescription – 39%

Two or more of the following CNS depressants: alcohol, heroin, prescription opioids, and/or sedatives - 85%

UNINTENTIONAL DRUG POISONING COALITIONNOW: MONTGOMERY COUNTY OPIATE TASK FORCE

The goal of the project was and is to help reduce the rate of unintentional prescription drug overdose deaths in Montgomery County with the following objectives: Participate in the Montgomery County Opiate Task Force Maintain the Poison Death Review process Implement the Coalition’s recommendations Educate prescribers about OAARS Offer training about the unintentional OD problem to heath care

professionals Develop a social marketing strategy to reduce unintentional Rx

overdoses.

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CHANGING TRENDS IN OHIO DEMOGRAPHICS 2011-2013 Majority was still white, 35-44 years old, 67% male 87% of the 226 deaths were from Montgomery

County 78% had physical disability or illness – 58% had heart

disease as most common illness Per family interviews, 78% had a history of substance

abuse, while 20% had a reported mental illness Most common rx. opioids were oxycodone,

hydrocodone, methadone, morphine, & fentanyl –heroin in ½ of opioid combinations

FACTORS CONTRIBUTING TO THE CRISIS

“Americans, constituting only 4.6% of the world's population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply, as well as two-thirds of the world's illegal drugs.”

“Retail sales of commonly used opioid medications from 1997 t0 2007 have increased 149%, with increases ranging from 222% for morphine, 280% for hydrocodone, 319% for hydromorphone, 525% for fentanyl base, 866% for oxycodone, to 1,293% for methadone. Average sales of opioids per person have increased from 74 milligrams in 1997 to 369 milligrams in 2007, a 402% increase.”

http://www.ncbi.nlm.nih.gov/pubmed/20859312

CONTRIBUTING FACTORS CONT’D.

Pain as the Fifth Vital Sign? Did we go too far? Pill mills – human greed Previous lack of prescription monitoring systems Current lack of interstate communication for

prescription monitoring systems Lack of naloxone access Drug availability

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RESPONSIBILITIES OF GOVERNMENT

Discussion Laws

Drug dealer consequences

State monitoring programs Public education Access to treatment CDCDEA

RESPONSIBILITIES OF PUBLIC SERVANTS Police

Drug take-back eventsNaloxoneResources to address

EMSNaloxoneRepercussions to friends around the scene

Schools – Teachers Education Screening? Family interventions

RATES AND RISK FACTORS FOR PROLONGED OPIOID USE AFTER MAJOR SURGERY: POPULATION BASED COHORT STUDYBMJ2014;348DOI: HTTP://DX.DOI.ORG/10.1136/BMJ.G1251(PUBLISHED 11 FEBRUARY 2014)CITE THIS AS:BMJ2014;348:G1251

According to the study >3% of the opioid naïve, surgical patients continued long term use of opioids after surgery and over 49% of the patients went home with a prescription.

Risk factors like age, comorbidities and surgical type influenced increased risks of long term use.

They included younger age, lower fifth of neighborhood income, specific comorbidities (diabetes, heart failure,pulmonary disease), and use of specific drugs preoperatively (benzodiazepines, SSRIs, ACE inhibitors). Intrathoracic procedures, even minimally invasive, had highest risk of long term use.

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SOCIAL RESPONSIBILITIES OF HEALTHCARE PROVIDERS AND FACILITIES

Discussion Certifying organizations Physicians – education, prescription volumeNurses - educationHospitals – multi-modal focus, opioid reduction programs,

incorporation of other modalities ie. regional block, epidural, adjuvant therapies

ASCs/Short staysResearch on treatment Access

SUCCESSFUL MODELS - FLORIDA Noted 28% increase in death rates from 2006-2010 Death rate from prescription opioid overdoses

decreased 23% from 2010-2012 “Operation Pill Nation”Mandated Pain Clinics prescribing scheduled substances

to register with state and began statewide raids – 250 pain clinics closed; 98 high opioid prescribers decreased to 13.

Prohibited physician dispensing of Schedule II & III substances from offices

Heroin overdose rates increased from 0.3/100,000 to 0.6/100,000 but reflected a decrease of 668 deaths from opioids compared to 60 heroin deaths.

CALL TO ACTION!!!

THANK YOU!ctrame@cfl.rr.com

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REFERENCES

Centers for Disease Control: http://www.cdc.gov/homeandrecreationalsafety/rxbrief/ http://www.cdc.gov/media/releases/2014/p0701-opioid-painkiller.html

Cochran, BN, Flentje, A., Heck, NC, Van Den Bos J, Perlman, D, Torres, J, Valuck, R, & Carter, J. Factors predicting development of opioid use disorders among individuals who receive an initial opioid prescription: mathematical modeling using a database of commercially-insured individuals. Drug Alcohol Depend. 2014 May 1;138:202-8.

Drug Abuse Warning Network (DAWN): http://www.samhsa.gov/data/2k13/DAWN106/sr106-buprenorphine.htm

Edlund MJ, Martin BC, Russo JE, et al. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. Clin J Pain. 2014 Jul;30(7):557-64.

NIH: http://www.ncbi.nlm.nih.gov/pubmed/20859312 Ohio Department of Health: http://www.healthy.ohio.gov/vipp/drug/dpoison.aspx

http://www.healthy.ohio.gov/vipp/data/~/media/94e95f2e821e407e8f1583636f8f8db1.ashx Wright State University Taskforce with links to yearly death reviews:

http://www.med.wright.edu/citar/prescriptiondrugs WSU Summary of Death Review: http://www.med.wright.edu/sites/default/files/citar/NR%20-

%20draft%20death%20review%20report%20052714%20final.pdf