Interventional/Medical Pain Management

The Dark Side of
Opioids
Chris Burnett, MD, FIPP, ABIPP
Baylor Scott & White
Department of Anesthesiology
Pain Management Division
Objectives
•
Review the evolution of opioid prescribing practices in
the United States in recent decades
•
Identify the scope of the opioid epidemic in our country
•

National Scope

Dimensions of Opioid Profit
Review responsible opioid prescribing guidelines and
recent CDC recommendations for opioid prescribing
Evolution of Opioid
Prescribing Practices
Evolution of Opioid
Prescribing
•
In 1986, Dr. Russell Portenoy, a New York Pain Specialist,
published a paper in the Journal of Pain advocating the
use of long-term opioids in patients with chronic nonmalignant pain1
•
He concluded that “opioid medications can be safely
and effectively prescribed to selected patients with
relatively little risk of producing the maladaptive
behaviors which define opioid abuse”2
•
The article reviewed only 38 patients in a practice of
thousands and the methods section gave no indication
of how the patients were selected for inclusion
1Portenoy
2A
RK, Foley KM. Chronic use of opioid analgesics in non-malignant pain: Report of 38 cases. Pain. 1986; 25(2): 171-186
Pain-Drug Champion Has Second Thoughts. http://www.wsj.com/articles/SB10001424127887324478304578173342657044604
Evolution of Opioid
Prescribing
•
Dr. Portenoy widely lectured against opiophobia
among doctors and often quoted that the risk of
opioid addiction was <1%2
•
Concurrently, pharmaceutical companies increased
the number of available products and aggressively
marketed them

2A
In 1996, Purdue Pharma released Oxycontin and
marketed it as less addictive than other pain
medications2
Pain-Drug Champion Has Second Thoughts. http://www.wsj.com/articles/SB10001424127887324478304578173342657044604
Evolution of Opioid
Prescribing
•
To improve pain management, the VA launched the
“pain as the fifth vital sign” initiative in 1999, requiring
a pain intensity rating at all clinical encounters3
•
In 2001, JCAHO mandated that hospitals focus on
monitoring and treating patients’ pain

They released a guidebook that stated “there is no
evidence that addiction is a significant issue when
persons are given opioids for pain control”2
o
3
(Paid for by Purdue Pharma)
Pain as the Fifth Vital Sign Toolkit. http://www.va.gov/painmanagement/docs/toolkit.pdf
Pain-Drug Champion Has Second Thoughts. http://www.wsj.com/articles/SB10001424127887324478304578173342657044604
2A
Evolution of Opioid
Prescribing
• Regulatory organizations were
recruited to forward the
movement—the Federation of State
Medical Boards urged that State
Boards punish physicians and
hospitals for not treating pain
adequately2
 The FSMB has since admitted to receiving
$2 million in funding from opioid
manufacturers from 1997-20042
2Canton
T, Perez E. Pain-Drug Champion Has Second Thoughts. http://www.wsj.com/articles/SB10001424127887324478304578173342657044604
Evolution of Opioid
Prescribing
•
It has since been reported that Dr. Portenoy had received
millions of dollars in funding from opioid manufacturers

In an interview with the Wall Street Journal in December 2012,
Portenoy said: "Clearly, if I had an inkling of what I know now then, I
wouldn't have spoken in the way that I spoke. It was clearly the
wrong thing to do,”2
•
In 2007, Purdue Pharma and 3 executives pled guilty to
“misbranding” of Oxycontin as less addictive with less abuse
potential leading to $635 million in fines2
•
Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS), Press Ganey Scores and Pain as the Fifth Vital
Sign=Pressure to prescribe
2Canton
T, Perez E. Pain-Drug Champion Has Second Thoughts. http://www.wsj.com/articles/SB10001424127887324478304578173342657044604
National Scope of
the Opioid Epidemic
Abundance of Opioids
Buprenorphine
Buprenex
Butrans transdermal patch
Duocet
Hycomed
Hycocet
Hydrogesci
HY-PHEN
Panacet 5/500
Panlor
Stagesic
T-Gesic
Ugesic
Zydone
Detuss
Dexbrompheniramine/hydrocodone/phenylep
hrine
Histussin HC Syrup
Cytuss-HC NR
H-C Tussive-NR
Ru-Tuss with Hydrocodone
Vetuss HC Syrup
Hydrocodone/phenylephrine
Phenylephrine HD
Lortuss HC
Tusdec-HC
Nalex-DH
Dexchlorpheniramine/hydrocodone/phenyleph Hydrocodone/phenylephrine/pyrilamine
rine
PhendaCof Plus
Zotex HC
Hycomal DH
Butalbital/aspirin/caffeine
Codimal DH
Dicomal-DH
Fiorinal
Aspirin/Hydrocodone
Notuss PD
Hyco-DH
Lortab ASA
EndaCof-Plus
Butorphanol
Damason-P
Hydrocodone/phenylpropanolamine
Stadol
Azdone
Diphenhydramine/hydrocodone/phenylephrine Hycomine
Alor 5/500
Hydro-DP
Hycomine Pediatric
Codeine
Panasal 5/500
Rindal HPD
Codamine
Acetaminophen/codeine
Endal HD
Codamine Pediatric
Capital with Codeine
Bromphenirarmine/guaifenesin/hydrocodone Tussinate
Margesic #3
Tusnel-HC
Hydrocodone/potassium guaiacolsulfonate
Phenaphen with Codeine
Guaifenesin/hydrocodone
Prolex DH
Tylenol with Codeine
Brompherirarmine/hydrocodone/phenylephrine Narcof
Protuss
VasoTuss HC
Hycotuss Expectorant
Marcof Expectorant
Aspirin/codeine
BPM PE HC
Vortex
Entuss Expectorant
Empirin with Codeine
Canges-HC NR
Obredon
Butalbital/acetaminophen/caffeine/codeine
FluTuss HC
Hydrocodone/potassium
Fioricet with Codeine
Guaifenesin/hydrocodone/pheniramine/phenyl guaiacolsulfonate/pseudoephedrine
Brompheriamine/hydrocodone/pseudoephedri ephrine/phenylpropanolamine
Protuss-D
Dihydrocodeine
ne
Procof D
Dihydrocodeine/Acetaminophen/Caffeine
M-END
Guaifenesin/hydrocodone/pheniramine/phenyl
DHCplus
Visvex
propanolamine/pyrilamine
Hydrocodone/pseudoephedrine
Brovex HC
Rezira
Aspirin/Caffeine/dihydrocodeine
Drocon-CS
Guaifenesin/hydrocodone/phenylephrine
Tussafin
Synalgos-DC
Tussgen
Carbinoxamine/hydrocodone/phenylephrine Ambi 5/15/100
P-V-Tussin
Fentanyl
Excof
Mintuss G
Fentanyl Transdermal System
Donatussin MAX
Atuss G
Hydrocodone/pseudophedrine/triprolidine
Duragesic
Excof-SF
Tussafed-HC
Zymine HC
Actiq
Max HC
Abstral
Guaifenesin/hydrocodone/pseudoephedrine
Hydromorphone
Carbinoxamine/hydrocodone/pseudoephedrin Poly-Tussin XP
Hydrocodone
e
Hydrotussin HD
Dilaudid
Hysingla ER
Tri-Vent HC
Hycofenix
Dilaudid-5
Zohydro ER
Histex HC
Entuss-D JR
Dilaudid-HP
Mintex HC
Hydrostat IR
Acetaminophen/caffeine/chlorpheniramine/hy
Homatropine/hydrocodone
Exalgo ER
drocodone/phenylephrine
Chlorpheniramine/guaifenesin/hydrocodone/p Hydromet
Hycomine Compound
seudophedrine
Hycodan
Methadone
Z-Tuss 2
Tussigon
Dolophine
Acetaminophen/hydrocodone
Hydropane
Methadose
Chlopheniramine/hydrocodone
Methadose Sugar-Free
Norco
Tussionex Pennkinetic
Hydrocodone/ibuprofen
Diskets
Vicodin
TussiCaps
Vicoprofen
Lortab
Novasus
Reprexain
Morphine
Lorcet 10/650
Vituz
Ibudone
Avinza
Lorcet-HD
Xylon
Kadian
Allay
Chlorpheniramine/hydrocodone/pseudoephed Hydrostal IR
MS Contin
Anexsia 5/500
rine
Oramorph SR
Anexsia 7.5/650
Zutripro
Hydrocodone/pheniramine/phenylephrine/phe Roxanol-T
Dolacet
Notuss-Forte
nylpropanolamine/pyrilamine
Dolagesic
Notuss
Rolatuss with Hydrocodone
Butalbital
Butalbital/acetaminophen/caffeine
Femcet
Fioricet
Esgic
Esgic-Plus
Morphine/Naltrexon
Embeda
Nalbuphine
Nubain
Oxycodone
OxyContin
Roxicodone
OxyIR
Percolone
Acetaminophen/oxycodone
Percocet
Percocet 5/325
Percocet 10/325
Endocet
Roxicet
Roxilox
Tylox
Xartemis XR
Aspirin/oxycodone
Percodan
Roxiprin
Endodan
Percodan-Demi
Ibuprofen/oxycodone
Combunox
Nalozone/oxycodone
Targiniq ER
Oxymorphone
Opana
Opana ER
Numorphan
Numorphan HCl
Pentazocine
Pentazocine/Naloxone
Talwin NX
Pentazocine/Acetaminophen
Talacen
Pentazocine/Aspirin
Talwin
Propoxyphene
Propoxyphene/Acetaminophen
Darvocet-N50
Darvocet-N 100
E-Lor
Propacet 100
Propoxyphene/Aspirin/Caffeine
Darvon Compound-65
PC-Cap
Propoxyphene Compound-65
Tapentadol
Nucynta
Nucynta ER
Nationwide Scope of
Opioid Epidemic
•
Opioids are the most frequently prescribed drug class
in the US today
•
76 million opioid prescriptions were dispensed in 1991
compared to 219 million opioid prescriptions dispensed
in 20114
•
Health care providers wrote 259 million prescriptions for
painkillers in 2012…enough for every American adult to
have a bottle of pills5
4The
Societal and Economic Burden of Chronic Pain and Opioid Abuse: The Role of Abuse-Deterrence Technology.
http://www.managedcaremag.com/sites/default/files/graphics/DiseaseStateReport-PAIN.pdf
5Opioid Painkiller Prescribing. http://www.cdc.gov/vitalsigns/opioid-prescribing/
Nationwide Scope of
Opioid Epidemic
• We now annually prescribe enough pain pills to
give every man, woman and child one pill every
four hours, around the clock, for three weeks6
• The United States makes up 5% of the world’s
population and consumes 75% of the world’s
prescription drugs 7
• There are twice as many painkiller prescriptions
per person in the US as in Canada5
6 Let's
end the prescription drug death epidemic. http://www.cnn.com/2012/11/14/health/gupta-accidental-overdose/
Prescription Drug Abuse Statistics You Need to Know. https://talbottcampus.com/index.php/resources/disease-info/2015-prescription-drug-abuse-statistics/
5Opioid Painkiller Prescribing. http://www.cdc.gov/vitalsigns/opioid-prescribing/
72015
Nationwide Scope of
Opioid Epidemic
•
In 2011, 52 million people in the US age 12+ had
used prescription drugs non-medically at least once
in their lifetime, 6.2 million in the past month 8
•
2.1 million Americans have a substance abuse
disorder involving prescription opioids9
8Popping
9Health
Pills: Prescription Drug Use in America. https://www.drugabuse.gov/related-topics/trends-statistics/infographics/popping-pills-prescription-drug-abuse-in-america#1
Care Costs from Opioid Abuse: A State-by-State Analysis. http://www.drugfree.org/wp-content/uploads/2015/04/Matrix_OpioidAbuse_040415.pdf
Nationwide Scope of
Opioid Epidemic
•
24% of high school students -- more than 5 million
kids -- have abused prescription medications 10
•
27% of teens mistakenly believe that prescription
drug abuse is safer than illegal drugs 10
•
3 in 10 teens believe that prescription pain relievers
are not addictive 10
10Prescription
Drug Abuse Up Among Teens: Survey. http://www.webmd.com/parenting/news/20130423/prescription-drug-abuse-up-among-us-teens-survey
Nationwide Scope of
Opioid Epidemic
•
Prescription drugs are responsible for more overdose
deaths than “street drugs” such as cocaine, heroin, and
amphetamines COMBINED
•
Drug overdose deaths continue to increase in the United
States and are now the leading cause of death from
injury nationwide 1
•
In 36 states and Washington, DC, overdose deaths now
exceed motor vehicle–related deaths1
•
46 Americans die each day from overdosing on
prescription painkillers5
11Drug
Overdose Now Leading Cause of Injury-Related Deaths. http://www.medscape.com/viewarticle/846636
Painkiller Prescribing. http://www.cdc.gov/vitalsigns/opioid-prescribing/
5Opioid
Nationwide Scope of
Opioid Epidemic
•
Every 19 minutes someone dies of
an opioid overdose (75/day)12
•
For each opioid-related overdose
death there are:
 10 people admitted for
substance abuse treatment
 32 visits to the emergency
department for non-lethal
overdose
 130 people report drug abuse
or dependency
 825 individual reports of nonmedical use of opioids13
Kounang N. Obamam announces new moves to fight opioid and heroin abuse epidemic. http://www.cnn.com/2016/03/29/health/obama-war-on-drug-abuse/index.html
Societal and Economic Burden of Chronic Pain and Opioid Abuse: The Role of Abuse-Deterrence Technology.
http://www.managedcaremag.com/sites/default/files/graphics/DiseaseStateReport-PAIN.pdf
12
13The
Nationwide Scope of
Opioid Epidemic
1999: 4,000 Opioid Deaths14 2008: 28,647 Opioid Deaths14
6
• The prescription drug epidemic is contributing to an increase in heroin use 10, 15
14 Increases
in Drug and Opioid Overdose Deaths — United States, 2000–2014. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm
Overdose Now Leading Cause of Injury-Related Deaths. http://www.medscape.com/viewarticle/846636
15Prescription Drug Abuse https://www.justice.gov/usao/priority-areas/prescription-drug-abuse
11Drug
Nationwide Scope of
Opioid Epidemic
•
Economic Impact
$72.5 billion in heath care costs to manage these
patients16
 Opioid abusers generate, on average, annual direct
heath care costs 8.7 times higher than non-abusers17

16 Strassels
SA. Economic burden of prescription opioid misuse and abuse. J Manag Care Pharm. 2009;15:556–62.
White AG, Birnbaum, HG, Mareva MN, et al. Direct Costs of Opioid Abuse in an Insured Population in the United
States. J Manag Care Pharm. 11(6):469-479. 2005
17
Dimensions of
Opioid Profit
Dimensions
of Opioid Profit
Professional Drug Seeker
•
Why would someone sell pain medication on the
street?

Street dealer selling illicit drugs
o
Example:
•
Purchases $500 of cocaine
•
Adds baking soda, etc. to increase product
•
Sells total content for ~$1,000
OR….
Professional Drug Seeker
Potential Profit for Prescription Dealers
•

5 visits a day
o
o
o
18
Upfront Costs
•
$100 (Cost for pain clinic visit) = $500
•
~$25(cost for hydrocodone/APAP 10/325 Rx, quantity 12018) = $125
•
Total amount expended = $625
Cash Flow
•
Street value of hydrocodone pill = $6
•
Typical Rx = 120 pills x $6 = $720
•
Street value of five Rx = $3,600
Net Profit
•
$3,600-$625 = $2,975 profit/day
•
If “working” 5 days/week: $59,500 per month or $714,000 per year
http://www.goodrx.com/hydrocodone-acetaminophen?form=tablet&dosage=10mg-325mg&quantity=120&days_supply=&label_override=hydrocodone%20/%20acetaminophen
Street Value of Rx Drugs
Prescription
Retail Value *
Street Value*
Oxycontin
$2.20
$10-$60
Oxycodone
$.37
$5-$20
Lortab
$.27
$3-$10
Percocet
$.85
$5-$20
Vicoden
$.27
$3-$10
*Prices were taken from www.goodrx.com and www.streetrx.com on March 27, 2016.
Who is your preferred
supplier?
VS
Professional Drug Seeker
•
Makes a living selling prescription drugs
•
Not desperate
•
Looks at the job as a challenge
•
Willing to invest money and time to accomplish objective
•
Patient, deliberate, and methodical
•
Is looking for a reputable physician, not a pill mill
•
Will research your practice from existing patients
Professional Drug Seeker
•
Typical Behaviors






Will be on time for each appointment
Will NOT call in early for refills
Will go along with the treatment plan
Will present themselves as other patients do
Will NOT draw attention to themselves
Will plan on staying in the practice for years
Professional Drug Seeker
•
Methods to Obtain Narcotic

The Insurance Fraud Tactic
o
Locate someone desperate for money who has health
insurance
o
Pay for the use of their insurance card
o
Obtain fake ID or Driver’s License and “become” the
insured party
o
Use a different fake name and insurance card at each
clinic- This makes them UNTRACEABLE
Professional Drug Seeker

The Recruiter Tactic
o
o

Identify people who have health insurance and who want to
make extra money
Pay the recruited person for the full bottle of medication to sell on
the street
The Doctor Shopper Tactic
o
o
Use a fake ID or Driver’s License (no insurance); cash pay patient
Claim to have lost insurance and cannot obtain insurance due to
cost or pre-existing condition
*All of the above Professional Drug Seeking methods are felony offences in the state of Texas
Safeguards
for the Clinician
•
Verify the authenticity of the patient’s ID or Driver’s License
•
Verify all medical records that are delivered or faxed
•
Verify all referrals
•
Utilize an abuse assessment and a diversion assessment
during new patient intake
•
Utilize and ENFORCE a comprehensive patient agreement
•
Provide eye-to-eye conversation with your patients
•
Take a digital photograph of all patients during new patient
intake
Pill Mills
• A doctor’s office, clinic, or health care facility
that routinely colludes in the prescribing and
dispensing of controlled substances outside the
scope of the prevailing standards of medical
practice in the community19
19
http://www.flpdmpfoundation.com/documents/Office%20of%20Drug%20Control%20Definition%20of%20a%20Pill%20Mill.pdf
Pill Mills
•
Tip-Offs

A sign that says: “Wellness Clinic,” “Rehabilitation Center,” “Treatment Center,”
“________Medical Group,” “_________ Medical Clinic”

Long lines

Vehicles with out-of-state license plates

Security guards, cameras, and/or steel bars

Posted signs referring to patients paying cash only

Medical staff providing a list of specific pharmacies
Potential Pill Mill Profit
•
A Pill Mill in Houston, Texas on average sees 40 patients per
day at $100 per patient. The clinic is open 6 days per week.




•
40 patients x $100 = $4,000 per day
$4,000 X 6 days = $24,000 per week
$24,000 x 4 weeks = $96,000 per month
$96,000 x 12 month = $1,152,000 per year
A Pill Mill related pharmacy in Houston fills 30 hydrocodone
prescriptions per day at ~$200 per Rx.




30 Rx X $200 = $6,000 per day
$6,000 x 6 days = $36,000 per week
$36,000 x 4 weeks = $144,000 per month
$144,000 x 12 months = $1,728,000 per year
Pharmacies
•
Recently, a pharmacist in New York City and her
husband were arrested for flooding the streets of
Brooklyn & Queens with 700,000 oxycodone pills
worth as much as $15 million21
•
They distributed 430,000 oxycodone pills without a
prescription21
•
The couple faces a litany of drug charges and could
serve 20 years in prison21
21Shapiro
R, Brown SR. Couple made millions running crooked NYC pharmacies, flooding streets with $10M worth of oxycodone pills: prosecutors.
http://www.nydailynews.com/new-york/nyc-crime/couple-made-millions-running-nyc-pill-mills-prosecutors-article-1.2415980
Pill Mill
•
In June of 2015, a New York doctor and his officemanager wife were indicted for operating a pill mill,
dispensing more than $77 million worth of pill
prescriptions20
•
Dr. Rogelio Lucus allegedly worked with several
major drug rings to write for more than 23,600
prescriptions for oxycodone since January 2, 200920
20Rosenber
R, Culliton K, Golding B. Elderly doctor, wife charged in $77M ‘pill mill’ http://nypost.com/2015/06/09/doctor-wife-accused-of-running-77m-prescription-pill-mill/
Responsible Opioid
Prescribing Guidelines
& CDC Guidelines for Prescribing Opioids for
Chronic Pain
Responsible Opioid
Prescribing
•
CDC Guidelines for determining when to initiate or
continue opioids for chronic pain:22
Opioids are not first-line or routine therapy for chronic
pain
 Establish and measure goals for pain and function
 Discuss realistic benefits and risks, as well as the
availability of non-opioid therapies with patients

22Guidelines
for Prescribing Opioids for Chronic Pain. http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf
Responsible Opioid
Prescribing
•
CDC Guidelines for opioid selection, dosage,
duration, follow-up, and discontinuation22
Use immediate-release opioids when starting
 When opioids are needed for acute pain, prescribe no
more than needed

Three days or less will often be sufficient
o More than seven days will rarely be needed
o

Start low and go slow
Reassess individual risk vs. benefit when increasing the
dosage ≥50 MME/day
o Avoid increasing dosage to ≥90 MME/day
o
22Guidelines
for Prescribing Opioids for Chronic Pain. http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf
Responsible Opioid
Prescribing
23http://paindr.com/wp-content/uploads/2012/08/2012-07-25_FDA-letter-from-physicians-for-responsible-opioid-prescribing.pdf
Responsible Opioid
Prescribing
•
Some Interesting Study Findings on Dose Limits





24Alturi
5 studies showed that the rate of overdose was directly
proportional to the prescribed opioid dose24
Patients taking higher doses reported significantly greater
catastrophizing and greater pain severity than the non-opioid
group24
All the available literature correlates increasing mortality with
increasing doses24
Several studies have demonstrated that for patients with severe
pain on high opioid doses, tapering resulted in reduced pain
and improved mood24
Patients receiving 100mg or more MME/day had a 9-fold
increase in overdose risk with 12% fatal overdoses and most
overdoses being medically serious24
S, Akbik H, Sudarshan G. Prevntion of Opioid Abuse in Chronic Non-Cancer Pain: An Algorithmic, Evidence Based Approach. Pain Physician 2012; 15: 177-179
Responsible Opioid
Prescribing
•
CDC Guidelines for opioid selection, dosage,
duration, follow-up, and discontinuation22
Do NOT prescribe extended release/long acting
opioids for acute pain
 Follow-up and re-evaluate risk of harm; reduce dose or
taper and discontinue if needed

o
22Guidelines
Evaluate benefits and harms of continued therapy at
least every three months
for Prescribing Opioids for Chronic Pain. http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf
Responsible Opioid
Prescribing
•
CDC Guidelines for assessing risk and addressing
harms of opioid use22

Check the state’s prescription drug monitoring
program (PDMP) for high dosages and prescriptions
from other providers upon initiation of opioid therapy
and at least every three months
o
22Guidelines
*Be aware…patients are not the only ones being
monitored by prescription monitoring programs*
for Prescribing Opioids for Chronic Pain. http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf
Responsible Opioid
Prescribing
•
CDC Guidelines for assessing risk and addressing
harm of opioid use22

22Guidelines
Evaluate risk factors for opioid-related harm
o
History of overdose
o
History of substance use disorder
o
Opioid doses ≥50 MME/day
o
Concurrent benzodiazepine use
for Prescribing Opioids for Chronic Pain. http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf
Responsible Opioid
Prescribing
•
CDC Guidelines for assessing risk and addressing
harm of opioid use22

22Guidelines
Use urine drug testing to identify prescribed substances
and undisclosed use
o
Before starting opioid therapy
o
At least annually thereafter
for Prescribing Opioids for Chronic Pain. http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf
Urine Drug Screen
•
It is difficult to correlate urine drug concentration
with the patient’s dose
•
BS&W “Basic Urine Drug Screen”–tests primarily for
illicit drug use

•
Has the opioid concentration cutoff set extremely high
(>2,000ng/ml)
Quantitative testing can detect the parent drug
and its metabolites to demonstrate recent use of
prescribed medications (most opioids are
detectable for 1-2 days)
Responsible Opioid
Prescribing
•
CDC Guidelines for assessing risk and addressing
harm of opioid use22
Avoid concurrent benzodiazepine and opioid
prescribing
 Arrange treatment for opioid use disorder if needed

o
22Guidelines
Usually medication-assisted treatment with buprenorphine
or methadone in combination with behavioral therapies
for Prescribing Opioids for Chronic Pain. http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf
Responsible Opioid
Prescribing
•
PROP recommends no more than 90 days of opioid
use23
•
Identify secondary gain issues up front (addiction,
diversion, desire for disability, lawsuits)
•
Monitor hospital admissions and ER visits

One recent study of 3,000 patients who experienced a
nonfatal overdose showed that 90% of patients continued
to receive prescription opioids. More than half received
the prescription from the same doctor 25
23http://paindr.com/wp-content/uploads/2012/08/2012-07-25_FDA-letter-from-physicians-for-responsible-opioid-prescribing.pdf
25
Doyle K. Many continue to receive opioid prescription after overdose. http://www.reuters.com/article/us-health-painkillers-overdoses-idUSKBN0UB1NF20151229
Responsible Opioid
Prescribing
• Strongly Consider a Care Agreement

Single prescriber

Single pharmacy

No early refills

No refills over the phone

Lost or stolen meds or scripts will not be refilled

Subject to random UDS

Subject to 24 hour random pill counts
Helpful
Resources
Initial Treatment
26Manchikant
L, et. al. American Society of Interventional Pain Physicians (ASIPP) Guidelines for Responsible Opioid Prescribing in Chronic Non-Caner Pain: Part 2-Guidance. Pain
Physician. 2012; 15:67-116
Potency Conversion
Drug
IM/IV
PO
Morphine
10
30
Hydromorphone
1.5
7.5
Methadone
10
10-20
Oxycodone
NA
20
Hydrocone
NA
30-45
1
10
Codeine
120
200
Meperidine
75
300
Oxymorphone
Duragesic Conversion
Oral 24 Morphine
Equivalent (mg/day)
Transdermal Fentanyl
Dose (ࣆg/day)
45-60
12.5
60-134
25
135-224
50
225-314
75
315-404
100
405-494
125
405-584
150
585-674
175
675-764
200
765-854
225
855-944
250
945-1034
275
1035-1124
300
Treatment Algorithm
24Alturi
S, Akbik H, Sudarshan G. Prevntion of Opioid Abuse in Chronic Non-Cancer Pain: An Algorithmic, Evidence Based Approach. Pain Physician 2012; 15:177-189
Questions?
References
1.
Portenoy RK, Foley KM. Chronic use of opioid analgesics in non-malignant pain: Report of 38 cases. Pain. 1986; 25(2): 171-186
2.
A Pain-Drug Champion Has Second Thoughts. http://www.wsj.com/articles/SB10001424127887324478304578173342657044604
3.
Pain as the Fifth Vital Sign Toolkit. http://www.va.gov/painmanagement/docs/toolkit.pdf
4.
The Societal and Economic Burden of Chronic Pain and Opioid Abuse: The Role of Abuse-Deterrence Technology.
http://www.managedcaremag.com/sites/default/files/graphics/DiseaseStateReport-PAIN.pdf
5.
Opioid Painkiller Prescribing. http://www.cdc.gov/vitalsigns/opioid-prescribing/
6.
Let's end the prescription drug death epidemic. http://www.cnn.com/2012/11/14/health/gupta-accidental-overdose/
7.
2015 Prescription Drug Abuse Statistics You Need to Know. https://talbottcampus.com/index.php/resources/diseaseinfo/2015-prescription-drug-abuse-statistics/
8.
Popping Pills: Prescription Drug Use in America. https://www.drugabuse.gov/related-topics/trendsstatistics/infographics/popping-pills-prescription-drug-abuse-in-america#1
9.
Health Care Costs from Opioid Abuse: A State-by-State Analysis. http://www.drugfree.org/wpcontent/uploads/2015/04/Matrix_OpioidAbuse_040415.pdf
10.
Prescription Drug Abuse Up Among Teens: Survey. http://www.webmd.com/parenting/news/20130423/prescription-drugabuse-up-among-us-teens-survey
11.
Drug Overdose Now Leading Cause of Injury-Related Deaths. http://www.medscape.com/viewarticle/846636
12. Kounang N. Obamam announces new moves to fight opioid and heroin abuse epidemic.
http://www.cnn.com/2016/03/29/health/obama-war-on-drug-abuse/index.html
13. The Societal and Economic Burden of Chronic Pain and Opioid Abuse: The Role of Abuse-Deterrence Technology.
http://www.managedcaremag.com/sites/default/files/graphics/DiseaseStateReport-PAIN.pdf
14. Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm
15. Prescription Drug Abuse https://www.justice.gov/usao/priority-areas/prescription-drug-abuse
16. Strassels SA. Economic burden of prescription opioid misuse and abuse. J Manag Care Pharm. 2009;15:556–62.
17. White AG, Birnbaum, HG, Mareva MN, et al. Direct Costs of Opioid Abuse in an Insured Population in the United States. J Manag Care
Pharm. 11(6):469-479. 2005
18.
http://www.goodrx.com/hydrocodone-acetaminophen?form=tablet&dosage=10mg325mg&quantity=120&days_supply=&label_override=hydrocodone%20/%20acetaminophen
19.
http://www.flpdmpfoundation.com/documents/Office%20of%20Drug%20Control%20Definition%20of%20a%20Pill%20Mill.pdf
20.
20Rosenber
21.
Shapiro R, Brown SR. Couple made millions running crooked NYC pharmacies, flooding streets with $10M worth of oxycodone pills:
prosecutors. http://www.nydailynews.com/new-york/nyc-crime/couple-made-millions-running-nyc-pill-mills-prosecutors-article-1.2415980
22.
Guidelines for Prescribing Opioids for Chronic Pain. http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf
23.
http://paindr.com/wp-content/uploads/2012/08/2012-07-25_FDA-letter-from-physicians-for-responsible-opioid-prescribing.pdf
R, Culliton K, Golding B. Elderly doctor, wife charged in $77M ‘pill mill’ http://nypost.com/2015/06/09/doctor-wife-accused-ofrunning-77m-prescription-pill-mill/
24.
Alturi S, Akbik H, Sudarshan G. Prevntion of Opioid Abuse in Chronic Non-Cancer Pain: An Algorithmic, Evidence Based
Approach. Pain Physician 2012; 15: 177-189
25.
Doyle K. Many continue to receive opioid prescription after overdose. http://www.reuters.com/article/us-health-painkillersoverdoses-idUSKBN0UB1NF20151229
26.
Manchikant L, et. al. American Society of Interventional Pain Physicians (ASIPP) Guidelines for Responsible Opioid Prescribing
in Chronic Non-Caner Pain: Part 2-Guidance. Pain Physician. 2012; 15:67-116