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Madelyn Atol, PharmD, BCACPTammy Chambers BS, RN

April 12, 2019

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Objectives

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Identify 3 unique characteristics of the senior population that increase their risk for opioid-related adverse events

Understand how the New Chronic User measure supports quality improvement in the prevention of chronic opioid use

Identify at least 2 opioid safetyprotocols that can be implemented

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Opioid Crisis

5https://www.cdc.gov/nchs/products/databriefs/db329.htm

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A growing problem in older adults

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Opioid-related inpatient stays

Non-opioid related inpatient stays

34%

17%

www.hcup-us.ahrq.gov/reports/statbriefs/sb244-Opioid-Inpatient-Stays-ED-Visits-Older-Adults.pdf.

Slide Title

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Age 25-44 years

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Slide Title

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Age 65+ years

More than a statistic

10https://www.strathcona.ca/community-families/well-being-and-mental-health/opioids/

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Risks for opioid-related adverse events in older adults

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Age-related changes and opioid risks

Kidney function declines

Liver mass and blood flow is reduced

Central nervous system (CNS) is more sensitive to opioids and other CNS

medicines https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884408/pdf/bcp0057-0006.pdfhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5139620/#S3title

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Additional complexities in older adults

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High prevalence of chronic conditions and chronic pain

14Dahlhamer J, Lucas J, Zelaya C, Nahin R, Mackey S, DeBar L, Kerns R, Von Korff M, Porter L, Helmick C. Prevalence of chronic pain and high impact chronic pain among adults – United States, 2016. MMWR.

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Agency for Healthcare Research and Quality Statistics

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https://meps.ahrq.gov/data_files/publications/st515/stat515.shtmlSTATISTICAL BRIEF #515 Any Use and Frequent Use of Opioids among Elderly Adults in 2015-2016, by socioeconomic Characteristics Asako S. Morlya, PhD and G. Edward Miller, PhD, Published online: September 2018

Patterns of Opioid Prescribing in MN: 2012 and 2015

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https://www.mathematica-mpr.com/our-publications-and-findings/publications/patterns-of-opioid-prescribing-in-minnesota-2012-and-2015Issue Brief April 2018

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Po

lyp

har

mac

y

17https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657172/

Opioids and polypharmacy

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Sedation

Falls

Fractures

Cognitive impairment

Delirium

Overdose

www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mccchartbook.pdf.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657172/

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Moving Upstream

Reducing New Chronic Opioid Use

Minnesota Response

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Why Prevention?

2012-2014 Established comprehensive multi-agency plan

• Focus on prevention, treatment, recovery• Formation of State Opioid Oversight Project (SOOP)

2015-Opioid Prescribing ImprovementProgram (OPIP)

• Goal to reduce opioid dependency and substance use

2015-Opioid Prescribing Workgroup (OPWG)

• Group of experts that developed recommendations on opioid prescribing and use

2017 New Chronic User Measure

• Early intervention measure to evaluate opioid utilization and support quality improvement

2018-Opioid Prescribing Guidelines

• Tool for clinicians who manage pain in primary care and specialty outpatient settings

2018-Opioid Action Plan

• Goal to save lives and reduce harm

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Where does chronic opioid use start?

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Why Prevention?

• DHS identified that if a person is on opioids for days, they are more likely to become a long term user.

• FINDINGS:enrollees transitioned to new chronic opioid users in

each year analyzedof those enrollees had a previous diagnosis of substance

use, mental health or bothof enrollees who received a 45 day supply of opioids

over the 90 day period continued opioid use at 3 years

*Opioid naïve enrollees that became new chronic users

New Chronic User Measure

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Why Prevention?

Opioid Naïve User

Patient new to taking opioids. At least 90-days without an opioid prescription.

New Chronic User

An opioid naïve user who has been prescribed a 45 day’s supply or more over a consecutive 90 day period.

Eligible Population

Medicaid enrollees (PMAP, MNCare, Fee-for-Service, MSHO and MSC+).

Age 12 years old and older.

Exclusions Cancer Hospice

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Minnesota Opioid Prescribing Guidelines

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Why Prevention?

Patient Safety Recommendations

Biopsychosocial and Risk Assessment

Non-Opioid and Non-pharmacologic Pain Management

Opioid Prescribing for Acute Pain

Opioid Prescribing for Post-Acute Pain

Opioid Prescribing for Chronic Pain

Tapering or Discontinuing

Women of Childbearing Age

Visit mn.gov/dhs/opioid-guidelines to access all this helpful content

24Visit mn.gov/dhs/opioid-guidelines to access all this helpful content

Acute: Pain occurring first 4-7 days after an acute event.

Post-Acute: Pain occurring up to 45 days following an acute event.

Chronic: Pain lasting >45 days after an acute even; or beyond the normal expected time of tissue healing.

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Why Prevention?

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Why Prevention?

Risks of Taking day of

Opioids for Acute Pain

Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66:265–269. DOI: http://dx.doi.org/10.15585/mmwr.mm6610a1.Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504

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6% at 1 year

3% at 3 years

Impact of Refills

26https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm

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What is the strongest predictor of misuse?

27https://www.clinicalpainadvisor.com/home/topics/opioid-addiction/opioid-prescriptions-after-surgery-parameters-to-blame-for-misuse/

Chronic opioid use in HealthPartners members

0.00

10.00

20.00

30.00

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80.00

90.00

1Q16

2Q16

3Q16

4Q16

1Q17

2Q17

3Q17

4Q17

1Q18

2Q18

3Q18

4Q18

CHRONIC OPIOID >=90 DAYS MEMBER PER/1000

Commercial Medicaid Medicare MSHO HealthPlan Overall

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Chronic high dose opioid use in HealthPartners members

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3Q17

4Q17

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2Q18

3Q18

4Q18

CHRONIC OPIOID HIGH DOSE MEMBER PER/1000

Commercial Medicaid Medicare HealthPlan Overall

How do we plan to helpreduce new chronic opioid use?

Collaborative Provider

Education

Hosting Webinars

Creating a Toolkit

Promoting the MN Guidelines

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Overview of Provider Toolkit

A Provider Toolkit

Meeting the Challenges of Opioids and PAIN:

PATIENT EDUCATION ON PAIN AND OPIOID PRESCRIPTIONS

ADDRESSING OPIOID PRESCRIPTION PRACTICES

IDENTIFYING SAFE AND EFFECTIVE PAIN MANAGEMENT PROTOCOLS

NONPHARMACOLOGIC AND NON-OPIOID PHARMACOTHERAPY ALTERNATIVES

Go toStratisHealth.org/PIP/Opioids.html to

access the Provider Toolkit

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Table of Contents

Introduction to the issue................................................................................................................. 2Shared Decision Making ................................................................................................................. 4

Resources for Shared Decision Making ......................................................................................... 5Resources for Patient Education about Pain and Opioids .............................................................. 7

Identifying Opioid Use Disorder or Drug Seeking Behavior ............................................................ 8Resources for Opioid Use Disorder .............................................................................................. 9

Prescription Monitoring Programs ............................................................................................... 10Effective Screening for Risk Factors .............................................................................................. 10Continuing Medical Education and Training Opportunities ........................................................... 12Non-Pharmacological Alternative Pain Management Therapies ................................................... 14

Resources for Non-Pharmacologic Interventions ........................................................................ 15Tools for Pharmacists ................................................................................................................... 16

Patient Education ...................................................................................................................... 16Proper Disposal ......................................................................................................................... 17

Considerations for the Elderly/Seniors ........................................................................................ 17Considerations for Adolescents and Young Adults ........................................................................ 18Safe Storage and Disposal of Prescription Opioids …..................................................................... 20Pet Connection: Opioids Prescribed for Animals ........................................................................... 21Appendix A ................................................................................................................................... 23Resources from Other States and Related Topic Areas: ................................................................. 23Bibliography ................................................................................................................................. 24

Resources for 55 years and older

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The

A brochure titled

A series of

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Safety Protocols

Minnesota Opioid Prescribing Guidelines

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Prescribe the lowest effective dose and duration

Halt the progression to chronic opioid use during the post-acute pain period

Avoid initiating chronic opioid therapy

mn.gov/dhs/opioid-guidelines

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Minnesota Prescription Monitoring Programpmp.pharmacy.state.mn.us

The MN PMP is a tool that pharmacies and prescribers submit prescription data for all Schedules II, III, IV and V controlled substances, butalbital and gabapentin dispensed in or into Minnesota. Minnesota licensed prescribers and pharmacists, and their delegated staff may be authorized to access information from the PMP database.

Check the MN PMP to help determine if a patient exhibits signs of opioid misuse or abuse.

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Screening for Risk Factors (ABCDPQRS)

Factors that may affect the prescriber’s decision to prescribe opioids are:

• Alcohol Use

• Benzodiazepines and Other Drug Use

• Clearance and Metabolism of the Drug

• Delirium, Dementia and Falls Risk

• Psychiatric Comorbidities

• Query the Prescription Monitoring Program

• Respiratory Insufficiency and Sleep Apnea

• Safe Driving, Work, Storage and Disposal

Resources are listed in the Tool Kit; the Drug Abuse Screen Test (DAST-10); The Alcohol Use Disorders Identification Test (AUDIT); The Patient Health Questionnaire (PHQ-9). 38

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Alternative PainManagement Therapies

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• Techniques such as cognitive behavioral therapy (CBT), mindfulness-based stress reduction, behavioral operant therapies and other modalities may be included during the assessment/session with a licensed behavioral health professional

Cognitive and Behavioral Therapies

• Includes strategies such as physical therapy treatment modalities (e.g., TENS, exercise programs, hydrotherapy, hot-cold treatments), chiropractic treatments, acupressure, exercise and massage.

Physical Rehabilitation and Peripheral Therapies

• Includes techniques such as specialty pain care/pain management, acupuncture, Tai Chi, yoga, meditation and biofeedback.

Complementary and Integrative Medicine

opioid storage and disposal

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Keep in a safe, locked place, out of reach of family, children, visitors, and pets

DoseOfReality.mn.gov/drug-takeback

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Naloxone access

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in Minnesota may get naloxone at a pharmacy without a prescription from their doctor

Recap

• Older adults have several risk factors for opioid-related adverse events

• The New Chronic User measure supports efforts to move upstream to prevent chronic opioid use

• The Provider Toolkit contains several resources to promote opioid safety

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Everyone has a role!

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PrescribingGuidelines

Screening for risk/age

considerations

MN Prescription Monitoring

Program

Avoid unnecessary prescriptions

Consider alternative pain

therapies

Patient Education/Safe

Storage Disposal

Questions?

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Appendix

Resource Links

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DHS link to Opioid Prescribing Guidelines 2018:

• https://mn.gov/dhs/opioid-guidelines/

CDC Guideline for Prescribing Opioids for Chronic Pain-2016:

• https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

Stratis Link:

• http://www.stratishealth.org/pip/opioids.html

Substance Abuse and Mental Health Services Administration

• https://www.samhsa.gov/

• Contact Information for Tammy Chambers tammy.j.chambers2@healthpartners.com

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The Opioid Provider Toolkit includes a benefit grid to assist providers in recommending Alternative Pain Management Therapies for Medicaid patients.

Go to StratisHealth.org/PIP/Opioids.html and under resources you can access the Alternative Pain

Management Therapies – Minnesota Medicaid Benefit Coverage grid

Tools for Pharmacistsand prescribers are partners in ensuring patient safety

• The MN Pharmacists Association (MPhA) has compiled an MPhA Opioid Toolkit with tools and information specific to pharmacists.

• Prescription Drug Monitoring Programs (PMP) are electronic databases and are used to collect, maintain and distribute controlled substance prescription information.

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Go to StratisHealth.org/PIP/Opioids.htmlto access the Provider Toolkit which

provides links to several resources on pages 16-17.

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Member Brochure

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UNDERSTANDINGPAIN

Pain is a normal part of the healing process.

TALKINGWITH

YOURDOCTOR

Be prepared to give information and ask questions about the cause of your pain. Make sure you discuss the type of pain you are feeling. This will help your doctor recommend the best treatment options available to you.

OTHERTREATMENT

OPTIONS FORPAIN

Acute pain may be managed success-fully with non-opioid medications and/or alternative treatments.

This list provides examples of some of the most commonly used and effectivealternative treatments. Talk to your doctor about options that may help you.

Please check with your health planfor benefit coverage.Ask your doctor about all of your

treatment options so that together, you can decide the best possible plan for managing your pain.

Questions to ask:

• What options are available for treating my pain?

• Could any of these treatment options cause a bad reaction with other medical conditions or medications?

If you and your doctor decide that an opioid medication is the best treatment option, ask the following questions:

• What are the risks and side effects of taking opioid medications?

• How many days should I take the opioid medication?

• If I feel better can I stop taking the medication?

Pain is an unpleasant feeling and emotional experience due to illness, injury, disease or a medical condition.

How you feel and react to pain depends on what is causing the pain and several personal factors such as:

• Your genetic makeup and how sensitive your body is to pain

• Gender (biological, psychological and social factors)

• Eating habits, activities, getting enough rest and sleep

• History of health problems

• Stress, anxiety, job status

• Past experiences with pain

• Coping strategies for recognizing and managing pain

An injury or illness that may be very painful for one person may be only slightly painful for another.

People experience and react to pain differently.

FIND OUT YOUROPTIONS

• Non-opioid pain relief medications such as acetaminophen (Tylenol®), aspirin, naproxen (Aleve®, Naprosyn®) and ibuprofen (Advil®, Motrin®)

• Self-Care (ice, heat, rest)

• Exercise (walking, swimming, stretching, yoga, Tai Chi)

• PhysicalTherapy

• Occupational Therapy

• Chiropractic or Osteopathic Care (spinal adjustment)

• Acupuncture

• TENS Unit (Transcutaneous Electrical Nerve Stimulation)

• Biofeedback

• Cognitive BehavioralTherapy

SAFE STORAGE

OFMEDICATIONS

• Opioid medications need to be stored in a secure and safe place.

• Choose a place in your house that is up and away and out of sight of children and visitors.

• Return medication to your secure location after every use.

• When traveling, keep medications in a locked carrying case.

SAFE DISPOSAL

OFMEDICATIONS

• Once you are finished taking the pain medication, promptly dispose of all remaining pills, tablets or patches.

• Minnesota has take-back programs for unused and outdated medication. Ask your doctor or contact your pharmacy, local police station or county law enforcement center to find the nearest location to you.

• Some pharmacies offer mail-back programs where you can pick up a drug disposal envelope.

• If a take-back or pharmacy mail-back program is not available where you live, you can go on the internet to learn how to safely dispose of unused medications at https://www.pca.state.mn.us/living-green/managing-unwanted-medications

• Avoid throwing prescription medicationin the garbage, flushing them down thetoilet or pouring them down a sink.

Referenced Materials

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Slide 5: https://www.cdc.gov/nchs/products/databriefs/db329.htmSlide 7: Weiss AJ (IBM Watson Health), Heslin KC (AHRQ), Barrett ML (M.L. Barrett, Inc.), Izar R, Bierman AS (AHRQ). Opioid-Related Inpatient Stays and Emergency Department Visits Among Patients Aged 65 Years and Older, 2010 and 2015. HCUP Statistical Brief #244. September 2018. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/reports/statbriefs/sb244-Opioid-Inpatient-Stays-ED-Visits-Older-Adults.pdf. Accessed January 15, 2019.Slide 10: https://www.strathcona.ca/community-families/well-being-and-mental-health/opioids/Slide 12: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884408/pdf/bcp0057-0006.pdfhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5139620/#S3title

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Referenced Materials

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Slide 14: Dahlhamer J, Lucas J, Zelaya C, Nahin R, Mackey S, DeBar L, Kerns R, Von Korff M, Porter L, Helmick C. Prevalence of chronic pain and high impact chronic pain among adults – United States, 2016. MMWR.Slide 15: https://meps.ahrq.gov/data_files/publications/st515/stat515.shtmlSlide 16: https://www.mathematica-mpr.com/our-publications-and-findings/publications/patterns-of-opioid-prescribing-in-minnesota-2012-and-2015Slide 17: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657172/Slide 18: Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, et al. Multiple Chronic Conditions Chartbook: 2010 Medical Expenditure Panel Survey Data. Rockville, MD: Agency for Healthcare Research and Quality; 2014. www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mccchartbook.pdf.Accessed February 17, 2019. Polypharmacy is defined simply as the use of multiple medications by a patienthttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657172/

Referenced Materials

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Slide 25: Suggested citation for this article: Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR MorbMortal Wkly Rep 2017;66:265–269. DOI: http://dx.doi.org/10.15585/mmwr.mm6610a1.Downloaded From: https://jamanetwork.com/ by a Healthpartners-Arneson Methodist Lib & Regions Med Lib User on 03/11/2019Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg.2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504Slide 26: https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htmSlide 27: https://www.clinicalpainadvisor.com/home/topics/opioid-addiction/opioid-prescriptions-after-surgery-parameters-to-blame-for-misuse/Slide 40: https://www.fda.gov/downloads/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/understandingover-the-countermedicines/ucm107163.pdf