Tackling the Opioid Epidemic: Safe Opioid Use In Pain Management Ryan, Chaput, Pharm.D. Patricia Gray, Pharm.D., FCSHP Joel Hyatt, M.D. Kaiser Permanente (KP) Southern California Region (SCAL)

DISCLOSURE STATEMENT: I nor my family have any significant financial relationships with any commercial interests that might bias the information given today during my presentation This educational activity has not received commercial support

The speakers have no conflicts of interest to disclose. Ryan Chaput, Pharm.D. Patricia Gray, Pharm.D., FCSHP Joel Hyatt, M.D.

Learning Objectives After attending this 2.5 hour session, “Tackling the Opioid Epidemic: Safe Use of Opioids in Pain Management”, the attendee will be able to:

1.

Discuss the core recommendations of the new CDC Opioid Guidelines

2.

Explain the basic principles of opioid management

3.

Choose alternatives to opioid therapy

4.

Identify at least three core interventions to reduce overuse, abuse, and overdose of opioids in your patients and community practice Apply at least two data measurement strategies to identify the at risk opioid patients and track progress in your practice Recognize the prescription opioid epidemic is a community health issue and we each have opportunities to take action in many settings

5. 6.

Outline for Today’s Session: “Tackling the Opioid Epidemic” 1 – CDC Opioid Guidelines, Opioid Management and Opioid Alternatives - Ryan Chaput, Pharm.D. 2 minute Easing the Pain- Bio Stretch Break 2 – An Integrated, Population Care Management Approach Patricia Gray, Pharm.D., FCSHP 3 minute Easing the Pain - Bio Stretch Break 3 – Community Health Improvement Strategies: It Takes a Village – Joel Hyatt, M.D.

4 – Panel Discussion with Q&A

5

October 14, 2016

Time for Q&A 5 min. at end of each talk & Panel Q&A Session

serving 10.6 million members across 8 Regions nationwide 38 hospitals

630 medical offices 18,652 physicians 189,302 Employees • • • • •

4.2 million members 13 service areas Over 7,000 physicians 135 medical office buildings 14 Kaiser Foundation Hospitals • Over 130 licensed pharmacies

CDC Opioid Guideline Update, Opioid Management, and Opioid Alternatives Ryan Chaput, Pharm.D. Kaiser Permanente Riverside, CA

Test Questions Question 1: What is the approximate MME of fentanyl patch 25mcg/hr? a) b) c) d)

50 MME 100 MME 60 MME 37.5 MME

Test Questions

Question 2:Which of the following would generally NOT be considered a red flag for opioid abuse/misuse? a) b) c) d)

Losing medication Doctor shopping Urine drug screen negative for prescribed opioid Calling in for a refill 2 days before the prescription is due

2016 CDC Opioid Guideline Highlights (excludes cancer, palliative, end-of-life care)

• Nonpharmacologic and nonopioid therapy first • Establish treatment goals • Discuss risks/benefits of opioids • If starting opioids, use immediate-release opioids instead of extended-release opioids/long-acting opioids

2016 CDC Opioid Guideline Highlights (excludes cancer, palliative, end-of-life care)

• Review patient’s controlled substance prescription history • Urine Drug Screen (UDS) • Avoid concurrent use of opioids and benzodiazepines • Evidence-based treatment for patients with opioid use disorder

2016 CDC Opioid Guideline Highlights (excludes cancer, palliative, end-of-life care)

• Reassess risk/benefits before increasing dose >50 MME/day

• Avoid increasing dose >90 MME/day • For acute pain, prescribe the lowest effective dose and do not prescribe greater quantity than needed • Re-evaluate risks/benefits within 1 to 4 weeks of initiation/escalation and then at least every 3 months thereafter • Consider naloxone for patients at higher risk for overdose

For more information and tools visit http://www.cdc.gov/drugoverdose • • • • •

Guidelines for Prescribing Opioids for Chronic Pain Prescribing Checklist Tapering Guide Non-opioid alternatives Additional tools/resources

Who wants to learn about opioid management…….?

Goals of Chronic Pain Management • Decrease pain level • Functional improvement • Minimize potential medication side effects • Emphasize non-pharmacologic tools • Individualize management to each patient and patient’s response

Chronic Pain Management Clinical Pearls • Medication is only ¼ of the treatment “pie” • Meds: maximize analgesia/function and minimize side effects • Activity modification • Body mechanics • Managing mental health and general wellness

• You should NOT be working harder than the patient • Emphasize self-care

• Set realistic goals with patient • Cure? Pain-free?

• Multi-modal approach • Emphasize non-pharmacologic treatments • Adjuvant medications are key

Interdisciplinary Committees And Pain Pharmacist

Interdisciplinary Committees • • • • •

Triage high risk patients Assess/Track progress Physician education Assist physicians with complicated patient cases Development of policies, protocols, practice recommendations

Pain Pharmacist • • • • •

Manage opioid tapers Track progress Physician education Patient education – CBTR Treatment coordination

Non-Pharmacologic Management of Chronic Pain

Pacing • Heat/Ice • Deep breathing • Guided imagery • Distraction •

• Cognitive Behavioral Therapy & Rehabilitation (CBTR) • Physical Therapy • Acupuncture • TENS unit • Exercise/movement

Initial Medication Considerations

• Etiology of pain • Age • Renal and Hepatic function • Substance abuse history • Co-morbidities • Allergies or Intolerances • Drug interactions • Formulary • Co-morbidities

Acetaminophen (APAP)

Non-Steroidal AntiInflammatory Drugs (NSAIDs)

• Analgesic and antipyretic properties • No appreciable antiinflammatory effects • Avoid or use with caution in hepatic impairment and/or alcohol use

• Analgesic, antipyretic, and anti-

inflammatory properties • Black Box Warnings

• Cardiovascular events • Treatment of peri-op pain in setting of CABG • GI events

• Warnings/Precautions • • • • • •

Cardiovascular events GI events CABG surgery Hypertension Hepatic impairment Renal impairment

Topicals • Capsaicin

• Salicylates • Menthol • Topical anesthetics • NSAIDs • Compounded creams/gels

Antidepressants: TCAs

• Secondary Amines: Nortriptyline, Desipramine • Tertiary Amines: Amitriptyline, Doxepin • May be considered for neuropathic pain • Dosing – generally requires titration • Side effects • • • • •

Anticholinergic effects Orthostatic hypotension Sedation Weight gain QT prolongation

• Cautions • • • • •

Use of MAOI within 14 days Acute recovery phase of MI Elderly Drug interactions Suicidal thinking/behavior

Antidepressants: SNRIs • Venlafaxine (Effexor ®), Duloxetine (Cymbalta ®) • May be considered for neuropathic pain • Dosing – generally requires titration • Side effects • • • • •

HA Somnolence/dizziness Insomnia Hypertension Tachycardia

• Cautions (Venlafaxine) • • • • •

Use of MAOI within 14 days Renal or hepatic impairment Suicidal thinking/behavior Cardiovascular disease: hypertension/tachycardia Drug interactions

Anticonvulsants • Gabapentin (Neurontin ®), Topiramate (Topamax ®), Pregabalin (Lyrica ®) • Used for neuropathic pain Gabapentin • Dosing: consider starting at 100-300mg at bedtime and slow titration at weekly intervals to max of 3600mg/day

• Side effects • • • •

Fatigue Somnolence Dizziness Peripheral edema

• Cautions

• Renal impairment • Titrate slowly in elderly

Skeletal Muscle Relaxants (SMRs) • Tizanidine (Zanaflex ®), Baclofen (Lioresal ®), Methocarbamol (Robaxin ®), Cyclobenzaprine (Flexeril ®), Metaxalone (Skelaxin ®) • May be useful for muscle spasm/spasticity and myofascial pain

• Side effects: In general, all may cause sedation and muscle weakness • Avoid in the elderly

Opioids • Alkaloids derived from opium • Natural and synthetic agents • Mimicks naturally occurring substances

• 3 major chemical classes • Phenanthrenes: morphine, codeine, hydrocodone, hydromorphone, oxycodone, oxymorphone • Phenylpiperidines: meperidine, fentanyl • Diphenylheptanes: methadone, propoxyphene

Opioid recommendations have swung back and forth over the years…. No Opioids

Lots of Opioids

Responsible Use of Opioids

American Pain Society – American Academy of Pain Medicine Opioid Guidelines 2009 “By panel consensus, a reasonable definition for high dose opioid therapy is >200mg daily of oral morphine (or equivalent), based on maximum opioid doses studied in randomized trials and average opioid doses observed in observational studies”

Centers for Medicare and Medicaid Services (CMS) 2012 CMS released memo addressing the public health concern surrounding potential opioid overutilization • Effort to improve the safe and effective use of opioids in Medicare Part D • Daily morphine equivalent dose (MED) above 120mg for at least 90 consecutive days w/ >3 prescribers and >3 pharmacies

CDC’s Guideline for Prescribing Opioids for Chronic Pain 2016 Earlier this year the CDC released new opioid guidelines that further reduced the recommended dose of opioids to 50 mg MEDs/day and run a CURES report for each patient to determine if they are receiving medications from multiple providers

B. Run list of the patients receiving 1 or more opioids in combinations with a benzodiazepine in the hospital or community pharmacy practice C. Recommend ED policy change for patients presenting with exacerbation of chronic pain to give SQ hydromorphone q 4-6 hrs instead via a slow IV drip of hydromorphone D. Run prescription list of patients on opioids at > 50 mg MEDs/day with no history of naloxone use

National CDC DATA. CDC.gov

Notable Celebrity Deaths Due to Unintentional Overdose, Combination Prescription Drugs and Addiction

2007

2008

2009

National CDC DATA. CDC.gov

How are we or I going to tackle this overwhelming challenge, manage chronic pain in our patients and make a difference?

We have to do something!

SCAL Results- Improvements in Opioid Utilization: Since January, 2010 to YE 2015       

89% reduction in OxyContin (oxycodone LA) prescribing 66% reduction in Opana ER (hydromorphone) prescribing 98% reduction in opioid/acetaminophen combination prescriptions with > 200 tabs- (no Rxs filled in 2016 > 200) 95% reduction in brand opioid prescribing when a generic is available to almost zero Rxs (Brand had greater street value for diversion) 84% reduction in "Trinity" prescribing (opioid + benzodiazepine + carisoprodol- “Soma”) 31% reduction - patients on > 120 MED/day of opioids (2010-2014) 21% reduction - patients on > 100 MEDs/day of opioids (4th Q 2015-3rd Q 2016)

Data Source: Kaiser Permanente SCAL Drug Use Management

An Integrated, Population Care Management Approach: 9 Core Strategies of Success Early 2010 1. Conducted initial data and analysis “The U.S. and we have a problem” …SCAL Physician and Pharmacy Leadership

First clue: We had an opioid problem- SCAL Rx Utilization DATA We discovered that OxyContin LA (oxycodone) was our most prescribed, non-formulary medication by cost!!

*Source: Kaiser Permanente SCAL Utilization Data- Jan 2010, Drug Utilization Management

Hydrocodone/APAP Volume PMPMk – Jan 2010

*Source: Kaiser Permanente SCAL Utilization Data- Jan 2010, Drug Utilization Management

KP SCAL Utilization Data: 1. Prescribers (2007)

25% of patients in the sample received > 4 gms/day from combination APAP opioids prescriptions from 4 or more different prescribers in a 12 month period!

2. Early Refills/Overlapping Scripts (2007)

and

*Based on a SCAL study of 1,276 MRNs in 12 months ending 3/07DSB Reports Kaiser Permanente Drug Utilization Management

In a sample of 1,276 patients, 50% of patients had more than 20 refills in a 12-month period!

2. Supported by Bold Leadership – Acknowledge, Call to Action & Priority Commitment: • CDC 2010 Goal: • Reduce overuse, abuse, and overdose of opioids (and other controlled prescription drugs) while ensuring patients with pain are safely and effectively treated. • In 2010-11, High Risk for Overdose/Death: > 120 mg/day MED (Morphine Equiv. Dose)

“This is about saving lives, improving quality of care, and protecting our clinicians and the organization”… SCPMG Quality Leadership 2010

Solution

3. Combined Leadership and Accountability: Change Management

4. Built Collaborative, Multi-Team Infrastructure with Passionate Leadership:

DUAT

Local Medical Center Review Teams

Info Systems Workgroup

MultiDisciplinary Task Force Pharmacy Subcommittee

SCAL SCPMG/Pharmacy Executive Team Task Force

Project management Data and analytic support

InterDepartmental Specialty Support Group

 Clinical Ops Manager  Drug Utilization Manager  Drug Education Coordinator  Pharmacy Ops Managers  Chronic Pain Management Pharmacists  Drug Information and Formulary  Pharmacy Benefits  Quality Management  Compliance

5. Provided Prescriber and Pharmacist Education: Evidence Based Medicine The World Has Changed: Chronic Pain Treatment Reconsidered Opioids have proven efficacy and relative safety for treating acute pain and pain during terminal illness Opioids do NOT have proven efficacy or safety for treating chronic pain long-term

High dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia (OIH), decreasing patient pain threshold, and potentially masking resolution of a pre-existing pain condition

5. Provided Prescriber and Pharmacist Education: Evidence Based Medicine (Con’t)

Opioids are powerful drugs and should be reserved for severe, acute non-cancer pain

Avoid the 90 Day Cliff- Studies more likely to become lifelong! - If on >90 days tend to be at a higher-risk for overdose and death!

5. Provided Prescriber and Pharmacist Education: Evidence Based Medicine (Con’t)

Doses > 100mg MED/day = RED FLAG!

6. Implemented Evidence-Based Best Practices

“Patients receiving high doses of opioids show no worsening of pain scores or aberrant drug behaviors after significant dose reductions compared with patients who do not have dose reductions, a new study suggests.” Mayo Clinic Experience in the Pain Rehabilitation Center Patients on daily opioid prescription pain medications at discharge: 7% Decrease in pain severity, despite discontinuing pain meds: 70% Reduction in pain severity at dismissal: 73% Greater control over pain: 84%

7. Developed Professional & Formulary Guidelines, Policies and Agreements The Medical Board of California • Guidelines for Prescribing Controlled Substances for Pain http://www.mbc.ca.gov/Licensees/Prescribing/Pain_Guidelines.aspx • Guidelines on history/physical, treatment plan, informed consent, office visits, consultation, records, etc.

CA Health and Safety Code 11153 • Pharmacists’ Corresponding Responsibility – “The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription….[who must verify that prescriptions are issued for a legitimate medical purpose].” • Supported by the CA State Board of Pharmacy

Formulary Guidelines, Policies & Procedures, Inter-department Agreements

8. Deployed Decision Support EMR Tools • • • • • • •

Best Practice Alerts Protocols Smart Sets Smart Dot Phrases On-Line DR.ADVISE Standardized Order Sets and Coding Treatment Agreement Letters & Patient Education

9. Provided Timely Data & Tracking : Quarterly Rx and Patient Data & Analysis To Prescribers and Pharmacists Early 2010-2012

2013+

• High dose patient lists • Quarterly prescriber utilization #Rxs & Unique Patients Dashboards & Scorecards • High patient & prescriber utilizer reports > 15 units/day Opioids • Facility & individual action plans

• High risk of diversion lists- Top 10 by Area in SCAL by 9 categories • ED and UC Parenteral prescribing reports • Reports on Patients with lack of prescriber follow-up reports > 6 months • Quarterly Tracking of Utilization- DUAT • 2013: Changed metrics to track >120 mg MED/day (CMS) • 2015: : Changed metrics to track >100 mg MED/day (CMS)

9. Provided Timely Data & Tracking Results : Quarterly Rx and Patient Data & Analysis, By SCAL Medical Center Area To Prescribers and Pharmacists- example: 4th Q 2011- 1st Q 2012

Data Source: Kaiser Permanente Drug Use Management

9. Timely Data and Tracking Results: Crucial Component of Success! Data by Drug Use Management, Pharmacy Analytics & Compliance  Drug Utilization Action Team (DUAT): Scorecards and Quarterly Data Tracking of Initiatives: By Area, Prescriber, Prescription and Patient drilldowns  Center for Medicaid and Medicare (CMS)- Claims Data  Monitors opioid utilization for Medicare members and requiring that the prescriber documents follow-up actions for all high risk patients  Pharmacy Adverse Drug Event Reports  KP Compliance: Fraud, Waste and Abuse Report- Top 10 by 9 Categories by each Medical Center Area  Ad-hoc Reports

10. Implemented Various Target Initiatives: (Con’t) 2013-2015

2013 +

• KP Outpatient Pharmacist Escalation Policy: Phone calls to prescribers- concerns, excessive dosing and RED FLAGS: • Flag high pill count (>200 pills/Rx short-acting > 400 pills long-acting ) and high dose (>120 mg MED/day. Changed to > 100 mg MED/day) • Identify & avoid “Trinity” combinations = opioid analgesic + benzodiazepine + Soma • Benefit change- Refill Policy for all Schedule II Opioid Medications – No refills under 30 days, Quantity = 30 day supply • All Pharmacists Enrollment and Access to CURES • Decision Support in EMR- Alternative Alerts, Guidelines, order entry questionnaires with hard stops

10. Implemented Various Target Initiatives: (Con’t) • First implemented in all EDs in San Diego County, then at KP San Diego • Spread to LA County EDs & KP SCAL EDs • Handed to all patients at ED Discharge • Follows American Academy of Emergency Medicine (AAEM) recommendations • Avoid SQ/IM injectable opioids for chronic pain patients for exacerbations (non-cancer, nonhospice/palliative pain): Use slow IV Drip hydromorphone • Limit ED/UC discharge prescription quantity, no refills, no lost/stolen replacements

10. Various Targeted Initiatives (Con’t)

KP Fontana Area 2014 and Spread over SCAL 2015

Pharmacist Education: KP Common Drug Seeking Red-Flag Behaviors: 2013 1. Feigns Illness - complains of back/neck pain, headaches, cough without other symptoms 2. Repeated requests for replacement of "lost“, “dog ate it” drugs or prescriptions 3. Insists on specific medication and/or brand-name & early refills  Oxycontin, Opana have very high street value—tablets sell for $100 each  I have to have it now, going on a trip again

5. Abusive or threatening behavior when denied drugs. 6. Does not get appropriate treatment for legitimate medical issues 7. Wants prescriptions to be filled at non-Kaiser Permanente pharmacy 8. Cancels follow-up appointments 9. Won’t fill prescriptions for noncontrolled substances such as antibiotics 10. Frequent Emergency Room / Urgent Care Visits

Pharmacist Education: KP Common Drug Seeking Red-Flag Behaviors: Ca Board of Pharmacy (2015)

www.pharmacy.ca.gov

National DEA Take Back Drug Day- Drop off Sites, Worked with Local Area Law Enforcement biannually

http://www.deadiversion.usdoj.gov/drug_disposal/takeback/

April 29,2016

Implemented Enhanced Tapering Plan: Tools- May 2016

Working on Safety Initiative: Prescriber Naloxone Prescribing for High Risk Patients and Pharmacist Furnishing Pilot Sites

http://www.cdc.gov/drugoverdose/prescribing/resources.html

http://www.pharmacy.ca.gov/publications/naloxone_fact_sheet.pdf

Working on Safety Initiative: Combination Opioid and Benzodiazepines Strategy: In collaboration with PCP, Psych, & Pain Medicine Specialists: 1. Identification of patients and 2. Recommend a slow taper off one or both medications 3. With frequent patient followup 4. With Cognitive Behavior Therapy (CBT Classes) and other safer drug and nondrug therapies http://www.cdc.gov/drugoverdose/prescribing/resources.html

“Tackling the Opioid Epidemic: An Integrated, Population Care Management Approach ”

9 Core Strategies of Success 1. Initial Data and Analysis 2. Bold Leadership & Call to Action 3. Leadership + Accountability = Change Management 4. Collaborative, Multi-team Infrastructure with Passionate Leadership 5. Prescriber & Pharmacist Education

6. Evidence- Based Best Practices 7. Professional Guidelines, Policies, Agreements 8. EMR Decision Support Tools, protocols, etc. 9. Timely Data & Tracking Results 10. Various Targeted Initiatives

Game Over?

Tacking the Opioid Epidemic

Test Questions Question 3: Which of the following is NOT an example of a core interventions Pharmacists can apply in their practice to reduce overuse, abuse, and overdose of opioids: A. Use “Red Flags” to determine if a patient’s opioid prescription should be refilled in your pharmacy. B. Establish a multidisciplinary Controlled Substance Committee in your hospital practice to develop initiatives to improve acute and chronic pain management in hospitalized patients C. Develop opioid dispensing policies to support the pharmacists in using “Corresponding Responsibility” D. Volunteer at your local law enforcement “ National Take Back Drug Day” to collect unwanted medications and donate drugs to a local charity

Test Questions Question 3: Which of the following is NOT an example of a core interventions Pharmacists can apply in their practice to reduce overuse, abuse, and overdose of opioids? A. Use “Red Flags” to determine if a patient’s opioid prescription should be refilled in your pharmacy B. Establish a multidisciplinary Controlled Substance Committee in your hospital practice to develop initiatives to improve acute and chronic pain management in hospitalized patients C. Develop opioid dispensing policies to support the pharmacists in using “Corresponding Responsibility”

D. Volunteer at your local law enforcement “ National Take Back Drug Day” to collect unwanted medications and donate drugs to a local charity

Test Questions Question 4: Which of the following is NOT an example of a data measurement strategies pharmacist can use to identify the at risk opioid patients, use to make a safety intervention and track results in your practice? A. Create list of patients in the hospital that are receiving > 50 mg MEDs/day and run a CURES report for each patient to determine if they are receiving medications from multiple providers B. Run list of the patients receiving 1 or more opioids in combinations with a benzodiazepine in the hospital or community pharmacy practice C. Recommend ED policy change for patients presenting with exacerbation of chronic pain to give SQ hydromorphone q 4-6 hrs instead via a slow IV drip of hydromorphone D. Run prescription list of patients on opioids at > 50 mg MEDs/day with no history of naloxone use

Test Questions Question 4: Which of the following is NOT an example of a data measurement strategies pharmacist can use to identify the at risk opioid patients, use to make a safety intervention and track results in your practice? A. Create list of patients in the hospital that are receiving > 50 mg MEDs/day and run a CURES report for each patient to determine if they are receiving medications from multiple providers B. Run list of the patients receiving 1 or more opioids in combinations with a benzodiazepine in the hospital or community pharmacy practice C. Recommend ED policy change for patients presenting with exacerbation of chronic pain to give SQ hydromorphone q 4-6 hrs instead via a slow IV drip of hydromorphone D. Run prescription list of patients on opioids at > 50 mg MEDs/day with no history of naloxone use

Community Health Improvement Strategies for Tackling the Opioid Epidemic: It Takes a Village Joel D. Hyatt, MD Emeritus Assistant Regional Medical Director Community Health Initiatives Southern California Permanente Medical Group Kaiser Permanente Southern California

Prescription Opioid Epidemic: Community & Public Health Issue

Building the LA County Prescription Drug Abuse Medical Task Force (PDAMTF)

All 76 ED’s in LA County adopted AAEM Guidelines (2013) and patient handouts March, 2015

Safer Prescribing Practices Medication-assisted Treatment ◦ Buprenorphine and other meds

Preventing Overdoses ◦ Naloxone access

Goal to Expand from EDs to Urgent Care Clinics

All 76 ED’s in LA County  to all Major Urgent Care Clinics

Medical (Dental) Practice Initiative Provider Groups/Delivery Systems

Health Plans

Cigna

+ LA-AFP, LA-ACP,

Increased Awareness & Activation White House

Law Enforcement

HHS, CDC

Professional Organizations (AAFP, ACP, ADA, AMA, Pharmacy Boards…

Congress FDA CMS (Medicare, Medicaid, ie, MediCal)

DEA Public Health

States (DPH, Legislatures, Ags)

Health Plans (KP, Cigna, Blue Shield, LA Care, Anthem…)

CHCF

Surgeon General

IHI

CA SWGRO (Cov. CA, CalPERS, DHCS)

PDMP (CURES)

NCQA, PQA, HEDIS

Retail Pharmacy and PBMs

And more……..

It Takes a Village Working Together Need for coordination, collaboration, communication Pharmacists have a critical role to play in many community settings

Question 5: Which of the following groups are taking action to stem the opioid epidemic? A. California Department of Justice B. White House C. California Health Care Foundation D. Coroner’s Office E. CSHP F. American Dental Association

G. CA State Legislature H. You I.

All of the above

Question 5: Which of the following groups are taking action to stem the opioid epidemic? A. California Department of Justice B. White House C. California Health Care Foundation D. Coroner’s Office E. CSHP F. American Dental Association

G. CA State Legislature H. You I.

All of the above

References 1.

Dowell D, Haegerich TM, Chou R, et al. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep 2016; 65

2.

www.cdc.gov/drugoverdose/. Web. 21 Aug 2016

3.

Tudor CG (2012, Sept 6). Memo: Supplemental Guidance Related to Improving Drug Utilization Review Controls in Part D. Centers for Medicare and Medicaid Services, 1-45

4.

www.healthy.ohio.gov/vipp/data/rxdata.aspx. 2015 Ohio Drug Overdose Data: General Findings. Web. 14 Aug 2016

5.

McPherson M. “Demystifying Opioid Conversion Calculations – A Guide for Effective Dosing.” Bethesda: ASHP, 2010. Print

6.

Tudor CG. “Supplemental Guidance Related to Improving Drug Utilization Review Controls in Part D.” Centers for Medicare & Medicaid Services. 6 Sep 2012

7.

www.globalrph.com. Web. 13 Feb 2012

8.

Fisch MJ, Cleeland CS: Managing cancer pain. In: Skeel RT, ed.: Handbook of Cancer Chemotherapy. 6th ed. Phil Lippincott Williams & Wilkins, 2003, pp 663

9.

Dolophine (Methadone) package insert. bidocs.boehringer-ingelheim.com. N.p. n.d. Web. 21 Sep 2011

References (con’t) 10. Toombs J. “Oral Methadone Dosing for Chronic Pain.” Pain-Topics.org. N.p. 12 Mar 2008. Web. 14 Sep 2011 11. Walker PW, et al. J Palliat Med 2008; 11: 1103-1108 12. Vallejo R, et al. “Pharmacology of Opioids in the Treatment of Chronic Pain Syndromes.” Pain Physician: July/August 2011; 14:E343-E360 13. Johnson S. “Opioid Safety in Patients with Renal or Hepatic Dysfunction.” Pain-Topics.org. N.p. 30 Nov 2007. Web. 2 May 2012 14. www.lexicomp.com. Web. 5 May 2012 15. Trescot A, et al. “Opioid Pharmacology.” Pain Physician 2008; Opioid Special Issue: 11:S133-S153 16. Krantz M, et al. Ann Intern Med 2009; 150: 387-95, 417-18 17. Ramasubbu C, Gupta A. “Pharmacological Treatment of Opioid-Induced Hyperalgesia: A Review of the Evidence.” J of Pain & Pall Care Pharmacotherapy. 2011; 25: 219-230 18. Chou R, et al. “Clinical Guidelines for the use of Chronic Opioid Therapy in Chronic Noncancer Pain.” J of Pain, Vol 10, No 2 (February), 2009: pp 113-130 19. http://cl.kp.org/pkc/national/topics/adult/chronicpain/index.html. KP intranet. 5 May 2012

References (con’t) 20. Ca Medical Board: 2014 Guidelines for Prescribing Controlled Substances for Pain http://www.mbc.ca.gov/Licensees/Prescribing/Pain_Guidelines.asp

21. 90 Day Cliff references: 1. Turk DC, Okifuji A. Pain terms and taximonies. In: Fisman SM, Ballantyne JC, Rathmell, JP eds Bonica’s Management of Pain (4th ed) Lippincott Williams and Wilkins pp 14-43. 2010. 2. Braden JB, Fan MY, Edlund MJ, Martin BC, Deviries A, Sullivan MD. Trends in use of opioids by noncancer pain type 20002005 among Arkansas Medicaid and HealthCore enrollees: results from the TROUP study. J Pain. Nov 2008;9 (11):10261035. 3. Korff MV, Saunders K, Thomas Ray G, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain. Jul-Aug 2008;23(6):521-527. 4. Martin BC. Fan MY, Edlund MJ, Devries A, Branden JB, Sullivan MD. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med. Dec 2011;26(12):1420-1427. 5. Volinn E, Fargo JD, Fine PG. Opioid therapy for nonspecific low back pain and the outcome of chronic work loss. Pain. Apr 2009;142(3):194-201.

22. Ca Board of Pharmacy: http://www.pharmacy.ca.gov/  Naloxone Pharmacist Finishing Protocol, patient fact sheet, press releases, etc.  DEA National Take Back Drug Day  Information for CURES  Corresponding Responsibility brochure  http://www.cdc.gov/drugoverdose/prescribing/resources.html

References (con’t) 23. Surgeon General: http://www.surgeongeneral.gov/priorities/opioids/index.html and 24. http://turnthetiderx.org/ 25. DEA National Take Back Drug: http://www.deadiversion.usdoj.gov/drug_disposal/takeback 26. Marc R. Larochelle, Jane M. Liebschutz, et al. Opioid Prescribing After Nonfatal Overdose and Association With Repeated Overdose: A Cohort Study Opioid Prescribing After Nonfatal Overdose. Ann Intern Med. 2016;164(1):1-9. 27. Phillip O. Coffin, Emily Behar, et al. Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain. Ann Intern Med. 2016;165(4):292-293. 28. Physicians For Responsible Opioid Prescribing, May 26, 2011- YouTube Video: Chapter I: Risk of Addiction, Opioid Therapy for Chronic Non-Cancer Pain Myths and Facts: https://www.youtube.com/watch?v=QYWykvy3xDI 28. John Hopkins Bloomberg School of Public Health: The Prescription Opioid Epidemic: An Evidenced Based Approach, Nov. 2015. http://www.jhsph.edu/research/centers-and-institutes/center-for-drug-safety-andeffectiveness/opioid-epidemic-town-hall-2015/2015-prescription-opioid-epidemicreport.pdf

References (con’t) 29.

Case Studies: Three California Health Plans Take Action Against Opioid Overuse (June, 2016) http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20CaseStudiesHealthPla nsOpioid.pdf

30.

Changing Course: The Role of Health Plans in Curbing the Opioid Epidemic http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20ChangingHealthPlansO pioid.pdf

31.

Kate M Dunn, Kathleen W Saunders, JD, et al. Overdose and prescribed opioids: Associations among chronic non-cancer pain patients. Ann Intern Med. 2010 January 19; 152(2): 85–92.

32.

Robert M. Califf, Janet Woodcock, Stephen Ostroff. A Proactive Response to Prescription Opioid Abuse, NEJM.org, 2016 Feb 4 ; 1-6.

33.

Yuanyuan Liang and Barbara J. Turner. Assessing Risk for Drug Overdose in a National Cohort: Role for Both Daily and Total Opioid Dose? J Pain. 2015 April ; 16(4): 318–325.

34.

California SB 482: Controlled substances: CURES database.(2015-2016) https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB482

35.

H Ryan, L Girion, and S Glover. A Times Investigation Part 1. “You want a description of Hell?”, Oxycontin’s 12-hour problem? LA Times 2016 May 5. http://www.latimes.com/projects/oxycontin-part1,

36.

H Ryan, L Girion, and S Glover. A Times Investigation Part 2. More than 1 million OxyContin pills ended up in the hands of criminals and addicts. What the drugmaker knew. LA Times 2016 July 10. http://www.latimes.com/projects/la-me-oxycontin-part2/

“Tackling the Opioid Epidemic: Safe Opioid Use In Pain Management”

Question & Answers Interactive Panel Discussion

Session Code: 1. Write down the course code. Space has been provided in the daily program-at-aglance sections of your program book. 2. To claim credit: Go to www.cshp.org/cpe before December 1, 2016.