Opioid Analgesic Use, Overuse,
and Abuse among Patients at
University Health Centers
ACHA Meeting
May 31, 2012
David C. Dugdale, MD
Director, Hall Health Primary Care Center
Division of General Internal Medicine
University of Washington
dugdaled@uw.edu
Disclosures/Financial
Relationships
I have NO actual or potential conflict of interest in relation to this
educational activity or presentation
I consult about pt education materials for the following companies:
ADAM Corp
Milliman Care Guidelines
Acknowledgements
• Mary Watts, MD
– Associate Director for Medical Affairs, Hall
Health
– Division of General Internal Medicine, UW
• Alex Cahana, MD
– Director, UW Pain Center
– Division of Pain Management, UW
Overview—Learning Objectives
• Describe the scope of opioid use
– Definitions (5 minutes)
– Issues & concerns (20 minutes)
• Compare and contrast opioid use for chronic and
acute pain syndromes (10 minutes)
• Describe our clinical approach and QI program aimed
at chronic pain management (20 minutes)
• Describe our clinical approach and QI program aimed
at acute pain management (20 minutes)
Self-assessment Questions – I
All True-False
• Drug tolerance is defined as a druginduced loss of effect over time
• In the US, the annual death rate from
unintentional drug overdose has been
about the same from 2003 to 2007
• Pills “left over” from a valid prescription
are a common source of opioids
diverted for non-medical use
Self-assessment Questions – II
All True-False
• In the US, the most commonly
prescribed opioid is methadone
• Hydrocodone is about a tenth
as strong as morphine
• Chronic pain management
emphasizes function over
complete pain control
Scope of Opioid Use: Definitions
•
•
•
•
•
Pain
“Narcotics”
Opiates
Opioids
Drug
–
–
–
–
–
Dependence
Tolerance
Abuse
Addiction
Diversion
Scope of Opioid Use: Definitions
• Pain
– A subjective, unpleasant sensory and emotional
experience
– Acute pain—acute tissue injury
– Chronic pain
• Cancer pain
• Chronic non-malignant pain
– Pain is usually due to apparent external stimulus,
but not always
– Pain intensity is modulated by many physiologic
and psychosocial factors
Scope of Opioid Use: Definitions
• “Narcotics”
– This term is widely used to mean
something other than opiates or opioids
• Original meaning: any substance with sleepinducing properties
• Its imprecision as a term makes it undesirable
Scope of Opioid Use: Definitions
• Opiates vs. opioids
– Opiate means something naturally derived
from opium
– Codeine and morphine are the clinically
most important opiates
Scope of Opioid Use: Definitions
• Opiates vs. opioids
– Opioids includes opiates plus synthetic or
semi-synthetic derived substances
•
•
•
•
•
Fentanyl (Duragesic)
Hydrocodone (Vicodin and others)
Hydromorphone (Dilaudid)
Methadone
Oxycodone (Percocet and others)
Scope of Opioid Use: Definitions
• Drug Dependence
– Characterized by the occurrence of
withdrawal symptoms with the abrupt
cessation of a drug
• Drug Tolerance
– Drug-induced loss of effect (over time)
– Often associated with dose escalation
Scope of Opioid Use: Definitions
• Drug Abuse
– Use of a drug in a manner that deviates
from medical, legal, or social standards
– Commonly used alternative terms:
• “non-medical use”
• “illicit use”
– An important concern of all college health
programs
Scope of Opioid Use: Definitions
• Drug Addiction is a disease (UpToDate)
– With a strong genetic component
• Affects ~10% of people
– Defined by aberrant drug-taking behavior:
•
•
•
•
Craving
Loss of control
Compulsive use
Continued use despite harm
Scope of Opioid Use: Definitions
• Drug Diversion (UpToDate)
– Distribution of a drug into the illicit marketplace
– A strong likelihood that diversion of prescribed
drugs is occurring
MUST stop prescribing
– Suspected abuse or addiction
prescribing
may legally continue if appropriate medical actions
are being taken to:
• stop the behavior
• regain control over the prescribing, and
• manage the medical and psychiatric condition of the
patient
Scope of Opioid Use--Issues
• Acute pain setting
– Acute pain management is usually straightforward,
but using opioids brings a number of possible
issues and complications
– Although there are well established typical doses,
significant variations in response occur
– Sedation can be profound, and
– Inadvertent overdoses are possible in the acute
pain management setting
Scope of Opioid Use--Issues
• Longer term opioid use can be associated
with:
– physical dependence
– tolerance and dose escalation
– addiction with pervasive psychological,
social, and physical harm
– harms that can be accidental!
Scope of Opioid Use--Issues
• Opioids can be drugs of abuse—
euphoria—and if overused can lead to
excess sedation, coma, and death
– Fatal overdoses can be accidental or
intentional
• Opioids are controlled substances—
therefore there are legal and regulatory
issues related to their use
Scope of Opioid Use--Issues
• Chronic pain mgmt is far more complex than
acute pain management
– Application of the principles of acute pain
management or cancer pain management has
created a clinical morass
– This started in the late 1980s
• The field of “Chronic Non-Cancer Pain” has
developed to address this
– The role of opioids in this domain has generated
intense controversy
Scope of Opioid Use--Issues
• Relevance to college health settings
– There are rising concerns about use,
overuse, and abuse of opioid analgesics in
all people in the US
– There are special concerns about
adolescents and young adults
– “Nonmedical” use of opioids by young
adults is one of the most common forms of
drug abuse
Drug Overdose and
Opioid use in the US:
Statistical Overview
US Deaths in 2008
• Drug overdose: 36,450
• Motor vehicle accidents: 39,973
MMWR 2011;43:1487-1492
Washington State Deaths
• Accidental death from “poisoning”
recently surpassed death from motor
vehicle accidents as the #1 cause of
death of young adults in Washington
State
• Of deaths by drug overdose, 55% were
due to prescription drugs
– Opioids were implicated in 74% of these
US Drug Overdoses—an “Epidemic”
Okie S. NEJM 2010;363(21):1981-1985
US Drug Overdoses by Agent
Okie S. NEJM 2010;363(21):1981-1985
Drug Overdose Death Rates
(US, 2008 per 100,000 people)
Intent
All drugs
Prescription
drugs
Opioids
Illicit drugs
Overall
11.9
6.5
4.8
2.8
Unintentional
9.2
4.8
3.9
2.6
Undetermined
1.1
0.6
0.5
0.2
Suicide
1.6
1.1
0.5
0.1
MMWR 2011;43:1487-1492
Drug Overdose Death Rates
(US, 2008 per 100,000 people)
Gender
All drugs
Opioids
11.9
Prescripti
on drugs
6.5
4.8
Illicit
drugs
2.8
Overall
Men
14.8
7.7
5.9
4.3
Women
9.0
5.3
3.7
1.4
MMWR 2011;43:1487-1492
Drug Overdose Death Rates
(US, 2008 per 100,000 people)
Age (yrs)
All drugs
Overall
11.9
Prescript
drugs
6.5
15-24
8.2
4.5
3.7
2.2
25-34
16.5
8.8
7.1
4.4
35-44
20.9
11.0
8.3
5.3
45-54
25.3
13.8
10.4
6.0
MMWR 2011;43:1487-1492
Opioids
4.8
Illicit
drugs
2.8
US Opioid Use—also an “Epidemic”
• 100 million prescriptions for hydrocodone per
year
– Top drug by # of prescriptions dispensed*
• US has 4% of the world’s population
– Uses 99% of world’s supply of hydrocodone
– Uses 80% of world’s supply of opioids
• 3% of the US population without cancer (~8
million people) are regular users of opioids**
*http://www.rxlist.com (accessed 1/5/2012)
**Sullivan, et al. Pain 2005;119:95-103.
US Opioid Sales
• Sales of opioids
– 2010: 7.1 kg per 10,000 people (710 mg
per person per year)
• That’s 142 Vicodins per person per year!!
– 2010 sales were 4 fold greater than 1999
sales
MMWR 2011;43:1487-1492
US Opioid Overdose and Sales Rates
Kuehn BM. JAMA 2012(1):19-21
US Opioid Prescribing Patterns
• 3% of physicians accounted for 62% of
opioids prescribed
MMWR 2011;43:1487-1492
Association between Drug Overdose
Deaths & Sales of Opioids
• Range of annual sales (kg per 10,000
people):
– 3.7 kg (IL) – 12.6 kg (FL)
• Among the 27 states with OD rates above
national mean
– 21 had rates of opioid sales above the national
mean
• Among the 24 states with OD rates at or
below national mean
– 5 had rates of opioid sales above the national
mean
MMWR 2011;43:1487-1492
Nonmedical Use of Opioids
• Range of prevalence of nonmedical use
of opioids:
– 3.6% (NEB) – 8.1% (OK)
MMWR 2011;43:1487-1492
Association between Drug Overdose
Deaths & Nonmedical Use of Opioids
• Among the 27 states with OD rates above
national mean
– 21 had rates of nonmedical use above the national
mean
• Among the 24 states with OD rates at or
below national mean
– 6 had rates of nonmedical use above the national
mean
MMWR 2011;43:1487-1492
2012 National Drug Control Strategy
• Has 7 core areas of focus
– Prevention, early intervention, treatment,
disruption of distribution
• Identifies 13 important steps forward
– Step #4 is “responding to the prescription drug
abuse epidemic”
– The Administration’s Prescription Drug Abuse
Prevention Plan, focusing on education,
monitoring, proper disposal, and enforcement
http://www.whitehouse.gov/ondcp/2012-national-drug-control-strategy, accessed May, 2012
Drug Abuse and Overdoses
in the US: Summary
• A serious problem, especially among younger
adults as a portion of cause of death
• A growing problem
• It seems virtually certain that the rising
prevalence of prescribed opioids has
contributed to this
Opioid Prescriptions and
“Non-medical Use” or Abuse:
Some Data…
Opioid Prescription Trends in
Adolescents: 2001 & 2005
• 20-40% of adolescent patients with
common pain syndromes received
opioid prescriptions
Richardson, et al. Gen Hosp Psych 2011;33:423-428
Drug Abuse Rates
• For adults age 18-25, rate of drug abuse in
previous month (excluding alcohol)
– All drugs 21.5%
– Marijuana 18.5%
– Nonmedical use of psychotherapeutic agents
5.9%
– Hallucinogens 2.0%
– Cocaine 1.5%
National Survey on Drug Use and Health (2010)
Drug Abuse Rates
• Nonmedical use of psychotherapeutic
agents
– Pain relievers 49%
– Tranquilizers 36%
– Stimulants 15%
National Survey on Drug Use and Health (2010)
Drug Diversion
• Sources of diverted opioids include
– Relative or friend
• 55% “for free”
• 11% “bought”
• 5% “took without asking”
– Use or sharing of leftover prescribed
opioids
– Illicit drug purchases (5%)
National Survey on Drug Use and Health (2010)
Frequency (%) of “Non-prescribed” Use of Prescription Drugs
in past 12 Months: College Students
Drug Class
Male
Female
All
Antidepressant
2.9
3.3
3.2
ED drugs
1.4
0.8
1.0
Pain killers
8.6
6.8
7.5
Sedatives
4.4
4.1
4.3
Stimulants
8.7
7.2
7.8
1 or more of
the above
15.5
14.0
14.6
NCHA-II, spring, 2011
Risk Factors among College Students for
Non-medical Prescription Drug Use
• 2008 survey of 599 undergrads at SE
university
• Assessed substance use in previous year
• Males, “Greeks”, and freshmen more likely to
use non-medical prescription drugs
• Multivariate analysis found that the MOST
influential factors were:
– Excessive alcohol use
– Other illicit drug use
Lanier, et al. JACH 2011;59(8):721-727
Characteristics of Prescription Drug
Use among Adolescents
• Classroom based survey (2008) at midAtlantic urban university
• Asked about drug use “since entering
high school”
• Paper survey, distributed through one of
several introductory classes
Rozenbroek, et al. JACH 2011;59(5):358-363
Characteristics of Prescription Drug
Use among Adolescents
• No significant gender difference
• Age 20 or more associated had slightly
higher rates of use (medical and nonmedical)
• Whites more likely to use than Asians or
African-Americans
Rozenbroek, et al. JACH 2011;59(5):358-363
Characteristics of Prescription Drug
Use among Adolescents
Type of use
Opioids
Stimulants
27.9%
CNS
depressants
4.4%
Medical
Non-medical
4.4%
2.9%
7.8%
Both
4.8%
1.7%
1.9%
Non-user
62.9%
91.0%
85.0%
Rozenbroek, et al. JACH 2011;59(5):358-363
5.3%
Most Common Reasons for Non-medical
Use of Prescription Drugs
Reason
Opioids
CNS
depressants
Stimulants
Makes me feel
good
49.1%
37.9%
15.1%
Just to try it
32.0%
24.3%
20.0%
Help me study
3.8%
21.6%
53.8%
Help manage
sleep
0%
10.8%
9.2%
Rozenbroek, et al. JACH 2011;59(5):358-363
Reasons for Prescription Drug Misuse among
College Students: “Rx for a Party”
• Survey of 91 current students at a public SW
university
• 55% reported at least one episode of
“sociorecreational” prescription drug use in the
previous year
• Manage highs & drug substitution (for alcohol)
• Participate in social use (as distinguished from
independent “drug seeking”)
• 42% had no concerns about dangers of what they
were doing
Quintero G. JACH 2010;58(1):64-70
Clinical Approach to Pain
• Acute pain
• Chronic pain
Acute Pain
• One of the most common reasons that
people consult a medical provider
• Only a small fraction of people with
acute pain go on to develop chronic
pain
Chronic Pain--Definitions
• International Association for the Study of Pain
– Pain without apparent biologic value that has
persisted beyond the normal tissue healing time
(usually assumed to be 3 months)
• American College of Rheumatology
– Widespread or regional pain for at least 3 months
Chronic Pain--Definitions
• American Society of Anesthesiologists
– Pain not due to neoplastic involvement
extending beyond the expected temporal
boundary of tissue injury and normal
healing and adversely affecting the
function or well-being of the individual
• DSM-4
– Persistent pain for 6 months
Chronic Non-cancer Pain--Overview
• A prevalent condition: data from NHANES:
–
–
–
–
–
–
Back pain 10%
Leg/foot pain 7%
Arm/hand pain 4%
Headache 3%
Complex regional pain 11%
Widespread pain 4%
• Much less prevalent in the college-age
population— reliable data difficult to find
Chronic Non-cancer Pain--Overview
• A complex syndrome with historically highly
variable clinical approaches
• Most aggressive approaches attempted to
directly apply principles of cancer pain
treatment
– Pain as the “5th vital sign”
• Most now agree that was/is inappropriate
Chronic Pain Management:
General Principles
• Establish treatment goals, with
measures as objective as possible
• Treat all established diagnoses
– Low threshold for mental health referral
• Distinguish between pain treatment and
opioid treatment
– E.g., pain Rx has many options other than
opioids
Chronic Pain Management, cont’d
• Emphasize function over pain control
• Exercise and other physical modalities
prioritized
• Medication management
– Non opioid
– Opioid
Chronic Pain Management, cont’d
• Medication management—non-opioids
– Acetaminophen
– NSAIDs
– Tricyclic agents
Chronic Pain Management, cont’d
• Medication management—non-opioids and
neuropathic pain
• Some syndromes have specific agents that
are FDA approved
– Postherpetic neuralgia: gabapentin, pregabalin,
capsaicin
– Pregabalin—diabetic neuropathy, post herpetic
neuralgia, fibromyalgia
• Others have clinical trial data
– Tricyclics and diabetic neuropathy
– Carbamazepine or oxcarbazepine and trigeminal
neuralgia
Chronic Pain Management, cont’d
• Non-opioid neuropathic pain agents
– Tricyclic agents
– Other antidepressants: duloxetine,
venlafaxine
– Anticonvulsants: gabapentin, pregabalin,
carbamazepine, oxcarbazepine
– Topical lidocaine
– Topical capsaicin
Chronic Opioid Management
• Opioid management has its own set of
specific needs
– Realistic expectations: 30% drop in pain
score is typical—7/10 to 5/10 for example
– Monitor for effectiveness
– Monitor for complications
– Monitor for deviations from expected
treatment process
Chronic Opioid Management, cont’d
• Opioid management has its own set of
specific needs
– Informed consent
– Treatment agreements or “contracts”
• These reduce risk of opioid misuse by 7-23%
– Urine drug testing
Starrels JL, et al. Ann Intern Med 2010;152(11):172
Chronic Opioid Management, cont’d
• Overdose risk is highly correlated with
prescribed dose
– Dunn, et al examined morphine equivalent
doses in an HMO
– 1-20 mg per day: 0.2% annual OD rate
– 50-99 mg per day: 0.7% annual OD rate
– 100+ mg per day: 1.8% annual OD rate
Dunn KM, et al. Ann Intern Med 2010;152(2):85
Chronic Opioid Management, cont’d
• Fatal overdose risk is highly correlated with
prescribed dose
– Bohnert, et al examined morphine equivalent
doses in the VA
– Identified 100+ mg per day as having markedly
increased risk compared to 1-20 mg per day
– Chronic pain: RR 7.2
– Cancer pain: RR 12.0
– Acute pain: RR 6.6
Bohnert, et al. JAMA 2011;305(13):1315-1321
Chronic Opioid Management, cont’d
• Urine drug testing
– Examines for adherence to regimen
– Examines for drugs of abuse that might
preclude opioid therapy
– Interpretation can be difficult
– Overall added value is controversial—but it
is widely recommended
Urine Drug Testing
Drug
Duration of
Detectability
False Positive Causes
Amphetamines
2-3 days
Pseudoephedrine,
phenylephrine,
bupropion,
desipramine,
methylphenidate,
Adderall & more
Cocaine
2-3 days
Topical anesthetics
containing cocaine
Marijuana
1-7 days (light)
~1 month (heavy)
Ibuprofen, naproxen,
hemp seed oil
Opiates
1-3 days
Rifampin,
fluoroquinolones,
quinine
Phencyclidine
7-14 days
Dextromethorphan
Urine Drug Testing--Pearls
• At UW Medicine lab:
– “Standard” drug screen is starting point
– Oxycodone is not detected by this (it is a
semisynthetic opioid—but hydrocodone
and hydromorphone are)
– Methadone and fentanyl (synthetic opioids)
are not detected by this
– Amphetamine by gas chromatography is
highly specific
Chronic Pain QI Project
at Hall Health
• Motivated by evolving care and legal
standards in Washington State and delivery
system issues in Seattle
• Develop a standardized approach to
assessment and follow-up
• Distinguish between pain management and
use of chronic opioid therapy to manage pain
• Still a “work in progress” in our health system
Chronic Pain Assessment
• Standard H&P
– Mandatory review of prior records
• Standard questionnaire and metrics for
clinical status
– Pain intensity scale
– Anxiety and depression status
– Functional status
Chronic Pain Assessment, cont’d
• Mandatory screening for substance abuse,
family history of substance abuse, and
psychiatric disorders (depression and anxiety
most common)
– These are most predictive of aberrant drug related
behavior
• Use standard charting tools in the Electronic
Health Record (EpicCare “Smart tools”)
Chronic Pain Assessment, cont’d
• Careful assessment of functional status:
social, recreational, occupational
• Establish a diagnosis!
– Especially neuropathic pain
• Urine toxicology screening if indicated
based on current treatment plan
Chronic Pain Management
• Establish treatment goals, with
measures as objective as possible
• Treat all established diagnoses
– Low threshold for mental health referral
• Distinguish between pain treatment and
opioid treatment
– E.g., pain Rx has many options other than
opioids
Chronic Pain Management, cont’d
• Emphasize function over pain control
• Exercise and other physical modalities
prioritized
• Medication management
– Non opioid
– Opioid
Opioids Implicated in
Drug Overdoses
• “Chronic pain meds”: usually morphine,
methadone, or fentanyl
• “Acute pain meds”: most often codeine,
hydrocodone, and oxycodone
“Morphine Equivalence” of Opioids
• “Morphine equivalence” calculator available at
http://www.agencymeddirectors.wa.gov/Files/D
osingCalc.xls
• Each of the below equals 20 mg morphine
– 135 mg codeine
– 20 mg hydrocodone
– 13 mg oxycodone
“Morphine equivalence” calculator
“Morphine equivalence” calculator
• The dose calculator is NOT designed to
determine doses for medication transition
– Only an approximation
– Does not account for incomplete crosstolerance and pharmocokinetics
– Especially difficult for methadone and
fentanyl
Chronic Pain Management, cont’d
• Criteria for referral to pain specialist
– Mainly based on severity of disability
– BEFORE “pain behaviors” have coalesced
or maladaptive coping strategies have
emerged
– In Washington State—if opioid dose is
>120 mg/day “morphine equivalents”
• This is now a law—January, 2012!
Chronic Pain Management, cont’d
• Criteria for referral to substance use
treatment
– Careful history taking important here
– Objective tools:
• Pharmacy dispensing records (from WA state
prescription management program)
• Urine toxicology testing
Washington State Regulatory Changes
• Recently passed legislation (HB 2876)
– Regulates the use of chronic opioid
therapy
– Creates information about best practices
as a way of reducing drug diversion and
the potential for overdose
– http://www.agencymeddirectors.wa.gov/Fil
es/OpioidGdline.pdf
Washington State Regulatory Changes
• Recently passed legislation
– Requires practitioner training program
– About 2 hours, on-line option available
– Creates prescription management program
to allow prescribers on-line access to
pharmacy dispensing records
Washington State Regulatory Changes
• Recently passed legislation
– Requires pain specialty consultation in
specified circumstances—tied to dose and
other factors
• Greater than 120 mg daily morphine equivalent
dose
• http://www.doh.wa.gov/hsqa/professions/painm
anagement/files/mdpapainmgmt.pdf
Chronic Pain Management: Summary
• Complicated biopsychosocial problem
– Not very common at student health centers
– But there is a need to understand the “state of the
art”
• Proliferation of opioids has multiple
implications
• Regulatory agencies paying more attention
• Search for best practices ongoing
– At Hall Health, our practice guideline reduced
provider stress & created better practice
Acute Pain Management
QI Project at Hall Health
• Addressing chronic pain issues was
important to our center and provider
group
• Opportunities for improvement in the
area of acute pain management were
not “on the radar” of providers
Acute Pain Management
QI Project at Hall Health
• However, opioid scripts for acute pain
outnumbered chronic pain 30:1 (or
more)
• Data about accidental OD potential of
opioids usually used for acute pain
became known
• A parent complained that her son
received 28 Vicodins for a self-limited
illness
Project Goals
• We sought to optimize the indications
for and size of opioid prescriptions
• We expected this to reduce the amount
of opioids available through on campus
sources
Methods
• We had already conducted a pilot study
to assess opioid prescriptions for
chronic vs. acute pain
• Based on this review, we identified a
small cohort of patients under
management for chronic pain
– This was typically less than 10 patients at
any time
Methods
• Using our EHR, we identified all patients
who received an opioid prescription
from October 1, 2010 to December 31,
2010—the “baseline” period
• We excluded patients who were under
management for chronic pain
Methods
• We collected patient demographic and
prescriber data, as well as data about
specific medication(s), amount of pills
prescribed, and directions for use
• We focused on codeine, hydrocodone,
and oxycodone
Intervention
• 2010:
– Educational modules about chronic noncancer pain
– CME program on same subject
– Practice guideline for assessment and
management of chronic non-cancer pain
developed and implemented by mid-2010
Intervention
• In late 2010 we designed several
interventions for implementation in early
January, 2011
• Educational module for acute pain including
practice guideline for prescription size
• Prescribing tools revised, with #10 being the
default prescription size (previously #28)
• Educational module repeated in April, 2011
Intervention
• We collected follow-up data for 2 time
periods:
– January 1, 2011 to March 31, 2011
– April 1, 2011 to June 30, 2011
Results
Oct-Dec,
2010
Jan-Mar,
2011
Apr-Jun,
2011
# visits
7785
8965
8624
# opioid
scripts
260
372
299
3.34 %
4.15 %
3.47 %
% of visits
with opioid
script
Results
% of total
scripts
Oct-Dec,
2010
Jan-Mar,
2011
Apr-Jun,
2011
Codeine
24
16
17
Hydrocodone
65
74
63
Oxycodone
8
9
19
Results
# opioid
scripts, all
Mean # pills
per script
(95% CI)
Oct-Dec,
2010
Jan-Mar,
2011
Apr-Jun,
2011
253
364
295
19.8 (1.0)
15.6 (1.0)
16.2 (1.1)
p<0.001
p=0.94 (Apr
(Jan vs. Oct)
vs. Jan)
Results
% of scripts for
10 pills or less
Oct-Dec, 2010
Jan-Mar, 2011
Apr-Jun, 2011
Codeine
44
45
38
Hydrocodone
20
56*
57
Oxycodone
5
28*
46**
All
25
52*
52
* p<0.001
** p<0.05
Limitations
• Data were limited to prescriptions from
the student health center
– Patients of the center may access other
sources of care
• Limited ability to assess clinical
appropriateness of prescriptions
Conclusions
• Using a combination of educational programs
and prescribing tools we were able to
decrease pills per script of hydrocodone,
oxycodone, and all opioids
– This did not occur with codeine
– This led to 1000-1500 fewer opioid pills being
prescribed per quarter
• There was no evidence of increased return
visits for poorly controlled pain
Discussion &
Questions
References--1
• Ballantyne JC, Mao J. Opioid therapy for chronic
pain. N Eng J Med 2003;349:1943-1953.
• Becker WC, et al. Nonmedical use of opioid
analgesics obtained directly from physicians:
prevalence and correlates. Arch Int Med
2011;171(11):1034-1036.
• Bohnert ASB, et al. Association between opioid
prescribing patterns and opioid overdose-related
deaths. JAMA 2011;305(13):1315-1321.
• Christo PJ, et al. Urine drug testing in chronic pain.
Pain Physician. 2011;14(2):123-143.
• CDC. Overdoses of prescription opioid pain
relievers—US, 1999-2008. MMWR 2011;43:14871492.
References--2
• Dunn KM, et al. Opioid prescriptions for chronic pain
and overdose: a cohort study. Ann Intern Med.
2010;152(2):85-92.
• Lanier, et al. What matters most? Assessing the
influence of demographic characteristics, collegespecific risk factors, and poly-drug use on
nonmedical prescription drug use. JACH
2011;59(8):721-727.
• McCabe SE, et al. Medical use, illicit use, and
diversion of abusable prescription drugs. JACH
2006;54(5):269-278.
• National Survey on Drug Use and Health, 2010
(available at samhsa.gov)
References--3
• Paulozzi LJ, et al. A national epidemic of
unintentional prescription opioid overdose deaths:
how physicians can help control it. J Clin Psych
2011;72(5):589-592.
• Quintero G. Rx for a party: A qualitative analysis of
recreational pharmaceutical use in a collegiate
setting. JACH 2010;58(1):64-70.
• Richardson LP. Trends in the prescription of opioids
for adolescents with non-cancer pain. Gen Hosp
Psych 2011;33:423-428.
• Rozenbroek, et al. Medical and nonmedical users of
prescription drugs among college students. JACH
2011;59(5):358-363.
New patient chronic pain template
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Fred L Zz Frederickson is an 67 year old male who presents for initial
evaluation for management of chronic pain. Pt is already on chronic
pain medications.
Brief history of chronic pain syndrome ***
How long have you been on medications for pain? ***
Who has been prescribing your medications? ***
1. Where do you feel your pain? {PAIN LOCATION:104450}
2. Which word best describes your pain? {PAIN QUALITY:104449}
3. On a scale of 0 to 10, which best describes your pain at its WORST
in the last month: {PAIN SCALE:104448::"0 (No Pain)"}
4. On a scale of 0 to 10, which best describes your pain at its LEAST in
the last month: {PAIN SCALE:104448::"0 (No Pain)"}
5. On a scale of 0 to 10, which best describes your pain at ON
AVERAGE in the last month: {PAIN SCALE:104448::"0 (No Pain)"}
6. On a scale of 0 to 10, which best describes your pain RIGHT NOW:
{PAIN SCALE:104448::"0 (No Pain)"}
New patient chronic pain template
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7. Previous use of opioids to control pain? {YES ADDL DEFAULT
NO:104995::"Yes, ***"}
8. Prior history or current alcohol or illicit substance use? {YES ADDL
DEFAULT NO:104995::"Yes, ***"}
9. Have you ever been diagnosed or treated for depression? {YES ADDL
DEFAULT NO:104995::"Yes, ***"}
10. Do you think you are suffering from depression now? {YES ADDL
DEFAULT NO:104995::"Yes, ***"}
11. What side effects are you having:
a. Nausea: {PAIN SIDE EFFECT SCALE:104452}
b. Constipation: {PAIN SIDE EFFECT SCALE:104452}
c. Trouble Thinking: {PAIN SIDE EFFECT SCALE:104452}
12. On a scale of 0 to 10, which best describes how, DURING THE PAST
WEEK, the pain has INTERFERED with your:
a. General Activity: {PAIN INTERFERENCE SCALE:104453}
b. Mood: {PAIN INTERFERENCE SCALE:104453}
c. Normal Work: {PAIN INTERFERENCE SCALE:104453}
d. Sleep: {PAIN INTERFERENCE SCALE:104453}
e. Enjoyment of life: {PAIN INTERFERENCE SCALE:104453}
f. Ability to concentrate: {PAIN INTERFERENCE SCALE:104453}
g. Relations with Others: {PAIN INTERFERENCE SCALE:104453}
New patient chronic pain template
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13. Goals of therapy:
What does your pain keep you from doing that you most want to do? ***
If it is not possible to get you back to 100% what percent improvement
would make a significant difference in your quality of life? ***
Objective:
{GENERAL APPEARANCE:50::"healthy","alert","no distress"}
{AFFECT:103406}
{Go to "forms" to fill out PHQ 9 if appropriate}
ASSESSMENT:
Candidate for ongoing management of chronic pain {YES NO
(HH):104741::"YES"}
Patient agrees to provide a copy of medical records {YES NO
(HH):104741::"YES"}
Pain Contract reviewed and signed by patient; copy provided to patient:
{YES NO (HH):104741::"YES"}
Consent for chronic opioid treatment signed and copy given to the patient
{Use "special consent for medical care" U2224}: {YES NO
(HH):104741::"YES"}
{Urine tox screen recommended at the first visit. Document when last dose
of medication was taken. See "clinical pearls" about ordering urine tox
screen}
Return patient chronic pain template
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SUBJECTIVE:
Patient reports taking medications as prescribed {YES NO (HH):104741::"YES"}
The next 3 questions have to do with pain intensity; 1 is no pain and 10 is unbearable pain)
1. Average pain level this week: {NUMBERS 0-10:102198}
2. Worst pain level this week: {NUMBERS 0-10:102198}
3. Today's pain level: {NUMBERS 0-10:102198}
4. On a scale of 0 to 10, which best describes how, DURING THE PAST WEEK, the pain has
INTERFERED with your:
a. General Activity: {PAIN INTERFERENCE SCALE:104453}
b. Mood: {PAIN INTERFERENCE SCALE:104453}
c. Normal Work: {PAIN INTERFERENCE SCALE:104453}
d. Enjoyment of life: {PAIN INTERFERENCE SCALE:104453}
5. Are you experiencing any other symptoms or have you had any illnesses since your last visit? ***
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{Update social history. Type .soch to bring in brief social history}
{type .phq9 to bring in phQ9 depression survey}
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Objective:
Appears well, in no apparent distress. Vital signs: There were no vitals taken for this visit..
{AFFECT:103406}
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ASSESSMENT:
Candidate for ongoing treatment of chronic pain medications: {YES NO (HH):104741::"YES"}
{Consider ordering random urine tox screen}
Pain management agreement
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The purpose of this Agreement is to prevent misunderstandings about certain medicines you will
be taking for pain management. This is to help both you and your doctor comply with the laws
regarding controlled medications.
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I understand that if I break this Agreement, my doctor will stop prescribing these pain-control
medicines.
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I will not share, sell, or trade my medication with anyone. This is against the law.
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I agree that I will submit to random urine drug testing.
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I understand the reason for this random urine drug testing.
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I agree that I will use my medicine only as it is prescribed.
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I understand that I will not receive early refills on my narcotic pain medications
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I will not attempt to obtain any controlled medicines, including but not limited to opioid pain
medicines, controlled stimulants, or antianxiety medications from any other doctor.
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I will not use any illegal substances, including but not limited to marijuana, cocaine, amphetamine,
and heroin.
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I will safeguard my pain medicine from loss or theft.
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I understand lost or stolen medicines will not be replaced.
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I agree that refills of my prescriptions for pain medicine will be made only at the time of an office
visit or during regular office hours.