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December 18, 2018

Opioid monthly: How one rural community is addressing the opioid epidemic—by treating it like a natural disaster

Daily Briefing

    Editor's note: The Opioid Monthly is compiled by OptumLabs. The Daily Briefing is published by Advisory Board, a division of Optum, which also owns OptumLabs.

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    From the literature

    Prescribing patterns: After surgery, patients take an average of five more opioid pills for every 10 extra prescribed to them, making the size of an opioid prescription the strongest predictor of prolonged opioid use, according to a study of 33 Michigan health systems published in JAMA Surgery. The good news is many patients are already using far less opioids than they are prescribed: 2,392 adults who had surgery between January and September 2017 reported taking only 27% of their prescription. Patient-reported opioid use data can help inform more appropriate opioid prescription quantities after surgeries that minimize the risk of unsafe use and associated harms.

    Prescribing patterns: Physicians are more likely to avoid unnecessary opioid prescriptions when there are non-opioid pain management alternatives to choose from, as demonstrated in a study in JAMA Otolaryngology-Head & Neck Surgery. For the study, researchers assessed 528 patients who had thyroid or parathyroid surgery after a new institutional multimodal analgesia (MMA) protocol was implemented in 2015. The MMA called for use of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin before surgery, and acetaminophen and ibuprofen for pain after surgery. By 2017, providers adhered to the MMA protocol for nearly 88% of cases, while the frequency of opioid prescriptions decreased from 13% in 2015 to less than 2% in 2017. The non-opioid MMAs were safe for patients and proved a useful prescribing alternative for providers.

    Long-term opioid use: Many (~30%) workers who are injured on the job continue using opioids for more than three months, according to a study of 9,596 Maryland-based workers' compensation claimants from 2006-2018, published in JAMA Network Open. Patient-level risk factors for persistent use included being 60 years or older; sustaining a strain, sprain or crush injury; earning more than $60,000 a year; and having chronic joint pain. These characteristics can help inform targeted interventions to lower long-term use of opioids after work injuries.

    Overdose rates: Drug overdose deaths have gradually fallen over 6 months, and experts are cautiously optimistic. According to preliminary CDC data, deaths from drug overdoses are now down 2.8% from the peak in September 2017. This may be an effect of the many recent policies and initiatives aimed at prevention and expanded addiction treatment, yet it's uncertain if the trend will continue as the epidemic changes shape. You can explore this trend state-by-state and by drug class using the CDC dashboard.

    Massachusetts governor Charlie Baker warns us, for example, that fentanyl (laced in not only heroin but other drugs, such as cocaine) continues to drive up overdose deaths, and Massachusetts (and other states) may not see similar drops in 2018.

    From the media

    New opioid development: FDA last month approved Dsuvia—a powerful new opioid (sufentanil) tablet that melts under the tongue—despite very strong opposition from physician advisors and a critical letter from Public Citizen warning of sufentanil's lethal potency and high risk for diversion. FDA Commissioner Scott Gottlieb defended the new drug's safety, as it will be restricted to in-hospital use with patients who need fast pain relief or have trouble taking a pill or using an IV. The drug development was also funded by the Department of Defense, as it may have potential to replace morphine on the battlefield. Palmer MacKie of Indiana University School of Medicine sums up the broad public concern with NPR: "We may find a niche for [Dsuvia] but it's not like we need it, and for sure, at some level, it's going to be diverted."

    Overdose prevention paradox: Dangerously potent street drugs are getting cheaper while the opioid overdose antidote naloxone becomes more expensive—and these two opposing market forces are driving up opioid-related deaths, as reported in STAT. The cost of a Narcan (naloxone) kit has gone up from $1 a decade ago to about $150 today. And now the list price of a new naloxone auto-injector that requires no assembly or prior training (making it easier for any member of the public to save a life during an emergency) has risen to over $4,000. FDA is holding meetings this month to expand national access to these lifesaving products. In the meantime, pharmacists are educating and training their customers to use Narcan.

    Two segments on 60 Minutes investigated the Naloxone situation on November 18—watch them at the links below:

    From policy

    Telemedicine: Indian Health Service providers can now prescribe medication assisted treatment (MAT) via telemedicine with fewer restrictions, expanding evidence-based opioid use disorder treatment to American Indians and Alaska Natives in rural and isolated areas. The IHS Internet Eligible Controlled Substance Provider Designation relieves providers of the Ryan Haight Online Pharmacy Consumer Protection Act, which requires patients to get an initial in-person evaluation and to be located in a DEA-registered facility to have MAT prescribed to them remotely. Learn more here.

    Community action: Rural Americans rate drug misuse as the most urgent health problem in their communities, followed by cancer and access to care, according to a recent poll from NPR, the Robert Wood Johnson Foundation, and the Harvard T.H. Chan School of Public Health. Of the surveyed residents, 57% say opioid misuse is a serious problem in their community—and they do not perceive the situation is improving. Long-term job growth and better public education are two primary areas that those surveyed believe can help.

    Community action: This rural community in Washington is mobilizing around their local opioid crisis as they would for a natural disaster with a Multi-Agency Coordination (MAC) group that meets every two weeks and includes broad representatives from across town to work through long-term goals with a step-by-step process. One key initiative is providing homeless people who have opioid use disorder with social support to find and get to treatment, rather than arresting them. Listen more on NPR.

    Access our new resources on the opioid epidemic

    The opioid epidemic is a complex, multi-dimensional public health problem. Use this list of helpful resources on how hospitals and health systems can play a role to treat opioid addiction and prevent further increase in opioid abuse.

    Access our Opioid Resources Here

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