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Engaging the Medical Community:Opiate Prescribing
Edward Lynam, MDMedical Director
Quest Counseling, Reno, NV
Remembering History“Those who cannot remember the past are
doomed to repeat it.”George Santayana
Commercialization of Opiates 1British East India CompanyTea from ChinaBoston Tea Party!Silver to ChinaSilver shortagesOpium from Bengal/India to ChinaQing DynastyOpium War(s)Silver and Tea from China, Opium to China
ChinaBy 1940: 40 million opium addicts, 10% of
populationA century of corruption, decline, and defeatMao and Communists: solved addiction
problem
Commercialization of Opiates 2Purdue Pharma, 1990’sOxycontin: sustained release oxycodoneMarketing drove it from $48 million in 1996
to $1 billion in 2001$200 million in marketing in 2001 aloneFree 7 to 30 day suppliesBonuses to sales staff more than base salary5000 health professionals given all expense
paid stays at fancy resorts to become speakers
Medical Use of Oral OpiatesDysentery and Diarrhea (historical)Cough Suppression (rare)Pain Management
Acute Pre-op Op Post-op
Chronic Cancer, end of life: palliative Non-cancer
Effects of Opiates CNS and PNS opiate receptors (therapeutic):
Decreased pain perception: analgesiaDecreased reaction to pain: psychologicalIncreased tolerance to pain: more functional
activityMild to severe neurocognitive impairmentNausea and/or ConstipationItching and miosisImmune/Reproductive hormone changesAccidents and delayed return to employment
Effects of Opiates in AddictionAbove therapeutic dosage
Euphoria: false sense of exaggerated well being
Accelerated development of toleranceRespiratory depression leading to hypoxic
death Cuts the normal response to carbon dioxide Lungs can fill with fluid Tolerance to this effect not predictable at high
doses Half of deaths had used another respiratory
depressant
Misuse of Prescription Opiates30 to 40% of prescribed doses are not used properly
Engaging PrescribersFederal Efforts: starting 2011
Office of National Drug Control Policy (ONDCP)
Food and Drug Administration (FDA)
Drug Enforcement Administration (DEA)
Strategy Expand awareness and education to
physicians, researchers, and the publicExpand efforts to monitor the prescribing
of these drugs, including calling upon every state to set up a program (43 so far)
Make it easier for consumers to dispose of drugs
Shut down “pill mills” and reduce doctor shopping
Educating PrescribersTraining: substance abuse in general
curriculumDEA licensure: requiring specific educational
content Manufacturers: requiring “re”-educational
funding
Opioid Risk Evaluation and Mitigation Strategy (REMS)
Physicians for Responsible Opioid Prescribing (PROP)
Best Practices for Emergency Medicine
Washington StateAgency Medical Directors Group
Published guidelinesOpiate dosing calculator (web and app)Free patient assessment toolsFree 4 hour CME activitySearchable Directory of Pain Management
SpecialistsOther resources
What do prescribers need to do?Establish a clear upper limit on dosingWritten care agreements
No early refills or replacement of lost or stolenRefills only on clinic visitsRandom urine screening
Red flags: end accessState monitoring systemEngage family in safety education
ConclusionHistorically Opiate Addiction is linked to
commercializationPrescription Opiates have legitimate medical
roleA large percentage end up being misused or
abusedUnintentional deaths have skyrocketedPublic education is importantPrescribers need greater educationStates can help with monitoring, disposal
programs, shutting down pill mills, and doctor shopping