SAFE Solutions - User contributions [en]

Build Education and Raise Awareness

2022-07-22T03:04:07Z

Katherine: /* Impactful Federal, State, and Local Policies */

= Introductory Paragraph =

Many public establishments -like schools and places of work-maintain a zero tolerance for substance use. While this high standard ensures safety, it can sometimes leave individuals with nowhere to turn if they find themselves with a substance use problem. Places of employment and schools can further assist their stakeholders by not only having high standards but also by motivating them to maintain a drug-free lifestyle through education and connection to resources. This process can begin by raising awareness of the importance of substance use in society and carefully selecting the right tools to inform and assist individuals to maintain a drug-free lifestyle in and outside of work or school<ref>https://www.samhsa.gov/workplace/employer-resources/prepare-workplace</ref>.

= Key Information =

Drug education programs have changed over the years from prioritizing abstinence only in public schools, to incorporating mental health, social skills, family bonding, and behavior management in school and corporate settings.

Education for Children and Adolescents

The National Institute on Drug Abuse website has a comprehensive list of drug education programs that have evolved to target risk factors and behavioral issues that lead to first-time use. Some of those programs are more selective than others, focusing on already at-risk children and families with students who may have experimented with drugs or alcohol. Great progress has been made in education and prevention. Science has come a long way in identifying multiple solutions for preventing the onset of drug use and providing resources to those already using substances. Raising awareness of the seriousness of the issue is a top priority for organizations like the NIDA <ref>https://nida.nih.gov/publications/preventing-drug-use-among-children-adolescents/preface</ref>.

Education in the Workplace
Many businesses have realized the importance of drug education and prevention in the workplace. More businesses, especially smaller businesses, could benefit from implementing drug education. This type of education can be costly and many times businesses feel they can not afford to add it to the budget. However, research shows that by implementing a drug education and drug testing program, employers and employees both experience positive outcomes. The proven benefits of drug education programs in the workplace are listed below <ref>https://drugabuse.com/addiction/workplace-drug-abuse/</ref>.

*Increased morale
*Decreased workplace accidents
*Reduced employee theft
*Increased productivity
*Reduced employee turnover
*Decreased cost of insurance, such as workers’ compensation

The American Addiction Center provides guidance on what quality drug education programs should include the following:

*Rules and expectations with terms clearly defined
*Prevention methods and education
*Testing
*Quality employee assistance programs

One possible way to raise awareness in the workplace is to distribute materials, in writing and through visual presentations, that pertain to drug use and its impacts on the work environment and employees. Adding in a Drug Awareness day and presenting information and resources that are available to employees can increase understanding of what to do and who to turn to when an individual is struggling with substance use.

By providing education to employees about common signs that indicate someone is struggling with addiction, a workplace may be able to intervene and provide assistance before the problem escalates. Some signs of substance use may be overlooked as common ailments and other signs are more noticeable. Below are some examples <ref>https://drugabuse.com/addiction/workplace-drug-abuse/</ref>.

Common Signs of Substance Use
*Frequent Accidents
*Erratic Behavior
*Dilated Pupils
*Slurred Speech
*Extreme Mood Swings
*Paranoia
*Glassy Eyes
*Noticeable Exhaustion
*Frequent Absenteeism

= Relevant Research =

'''Adults Survey on Drug Education'''

A study conducted by the American Addiction Centers surveyed 500 men and women. Thirty-seven participants reported that the most effective way they learned about drug education was by learning about the possible dangers of substance use. In the next highest category, at 20%, participants reported that the most effective drug prevention education approach was listening to the powerful testimonials of recovered adults. This information could be helpful in building an effective drug education program. Surprisingly, 41.2% of respondents reported that they did not receive any education about the science of addiction. Many of the respondents reported that they were not educated on some of the most commonly abused drugs. About half of the 500 adults surveyed endorsed no formal education about meth, ecstasy, heroin, or other opioids. These statistics support the need for building more educational resources and programs that address the gaps in the above-mentioned statistics <ref>https://americanaddictioncenters.org/learn/drug-education-survey/</ref>.

'''Rates of Drug Use in the Workforce'''

Almost 70% of drug users are actively employed in the workplace according to the Substance Abuse and Mental Health Administration (SAMHSA) <ref>https://www.nsc.org/forms/substance-use-employer-calculator</ref>. The Tennessee Department of Labor and Workforce Development reported that ⅓ of employees are aware of the presence and illegal sales of drugs at their place of employment <ref>https://www.nsc.org/forms/substance-use-employer-calculator</ref>. Drugs in the workplace have detrimental effects on all individuals due to impaired decision making and increased risk of damage to property and increased changes of physical harm due to accidents. Drug use also costs employers money because of increased turnover and increased time off. By implementing support for individuals with SUDS and integrating effective education, employers may save thousands of dollars.

= Impactful Federal, State, and Local Policies =

SAMHSA’s Division of Workplace Programs (DWP) performs regulatory, knowledge development, and technical assistance for federally regulated workplace programs in efforts to eliminate illicit drug use in the workplace. The DWP is also responsible for evaluating evidenced-based drug-free programs in non-federal workplaces <ref>https://www.samhsa.gov/workplace/about</ref>.

= Available Tools and Resources =
'''Opioid Response Network''' (ORN)<ref>https://opioidresponsenetwork.org/documents/ORN_Brochure%20-%20FINAL%2007.07.21%20digital.pdf</ref> provides training and education that is evidence-based and designed to meet the needs of a community or organization, all at no cost.

'''Substance Use Employer Cost Calculator'''
This resource provides information about the real costs of substance use on employers and businesses. By answering questions, employers can determine how substance use in their workplace can negatively impact their budget.

https://www.nsc.org/forms/substance-use-employer-calculator

= Promising Practices =

‘’’Project ALERT’’’ is a two year program for middle school students that aids in reducing the onset of drug use among youth. Project Alert Plus is a similar program that is geared towards highschool students <ref>https://nida.nih.gov/publications/preventing-drug-use-among-children-adolescents/chapter-4-examples-research-based-drug-abuse-prevention-programs/universal-programs</ref>.

‘’’Promoting Alternative Thinking Strategies (PATHS)’’’ This program focuses on reducing behavioral problems in elementary school students while enhancing their education within the classroom. Both of these approaches help to prevent future substance use <ref>https://nida.nih.gov/publications/preventing-drug-use-among-children-adolescents/chapter-4-examples-research-based-drug-abuse-prevention-programs/universal-programs</ref>.

= Sources =

Build Education and Raise Awareness

2022-07-22T03:03:44Z

Katherine: /* Promising Practices */

= Introductory Paragraph =

Many public establishments -like schools and places of work-maintain a zero tolerance for substance use. While this high standard ensures safety, it can sometimes leave individuals with nowhere to turn if they find themselves with a substance use problem. Places of employment and schools can further assist their stakeholders by not only having high standards but also by motivating them to maintain a drug-free lifestyle through education and connection to resources. This process can begin by raising awareness of the importance of substance use in society and carefully selecting the right tools to inform and assist individuals to maintain a drug-free lifestyle in and outside of work or school<ref>https://www.samhsa.gov/workplace/employer-resources/prepare-workplace</ref>.

= Key Information =

Drug education programs have changed over the years from prioritizing abstinence only in public schools, to incorporating mental health, social skills, family bonding, and behavior management in school and corporate settings.

Education for Children and Adolescents

The National Institute on Drug Abuse website has a comprehensive list of drug education programs that have evolved to target risk factors and behavioral issues that lead to first-time use. Some of those programs are more selective than others, focusing on already at-risk children and families with students who may have experimented with drugs or alcohol. Great progress has been made in education and prevention. Science has come a long way in identifying multiple solutions for preventing the onset of drug use and providing resources to those already using substances. Raising awareness of the seriousness of the issue is a top priority for organizations like the NIDA <ref>https://nida.nih.gov/publications/preventing-drug-use-among-children-adolescents/preface</ref>.

Education in the Workplace
Many businesses have realized the importance of drug education and prevention in the workplace. More businesses, especially smaller businesses, could benefit from implementing drug education. This type of education can be costly and many times businesses feel they can not afford to add it to the budget. However, research shows that by implementing a drug education and drug testing program, employers and employees both experience positive outcomes. The proven benefits of drug education programs in the workplace are listed below <ref>https://drugabuse.com/addiction/workplace-drug-abuse/</ref>.

*Increased morale
*Decreased workplace accidents
*Reduced employee theft
*Increased productivity
*Reduced employee turnover
*Decreased cost of insurance, such as workers’ compensation

The American Addiction Center provides guidance on what quality drug education programs should include the following:

*Rules and expectations with terms clearly defined
*Prevention methods and education
*Testing
*Quality employee assistance programs

One possible way to raise awareness in the workplace is to distribute materials, in writing and through visual presentations, that pertain to drug use and its impacts on the work environment and employees. Adding in a Drug Awareness day and presenting information and resources that are available to employees can increase understanding of what to do and who to turn to when an individual is struggling with substance use.

By providing education to employees about common signs that indicate someone is struggling with addiction, a workplace may be able to intervene and provide assistance before the problem escalates. Some signs of substance use may be overlooked as common ailments and other signs are more noticeable. Below are some examples <ref>https://drugabuse.com/addiction/workplace-drug-abuse/</ref>.

Common Signs of Substance Use
*Frequent Accidents
*Erratic Behavior
*Dilated Pupils
*Slurred Speech
*Extreme Mood Swings
*Paranoia
*Glassy Eyes
*Noticeable Exhaustion
*Frequent Absenteeism

= Relevant Research =

'''Adults Survey on Drug Education'''

A study conducted by the American Addiction Centers surveyed 500 men and women. Thirty-seven participants reported that the most effective way they learned about drug education was by learning about the possible dangers of substance use. In the next highest category, at 20%, participants reported that the most effective drug prevention education approach was listening to the powerful testimonials of recovered adults. This information could be helpful in building an effective drug education program. Surprisingly, 41.2% of respondents reported that they did not receive any education about the science of addiction. Many of the respondents reported that they were not educated on some of the most commonly abused drugs. About half of the 500 adults surveyed endorsed no formal education about meth, ecstasy, heroin, or other opioids. These statistics support the need for building more educational resources and programs that address the gaps in the above-mentioned statistics <ref>https://americanaddictioncenters.org/learn/drug-education-survey/</ref>.

'''Rates of Drug Use in the Workforce'''

Almost 70% of drug users are actively employed in the workplace according to the Substance Abuse and Mental Health Administration (SAMHSA) <ref>https://www.nsc.org/forms/substance-use-employer-calculator</ref>. The Tennessee Department of Labor and Workforce Development reported that ⅓ of employees are aware of the presence and illegal sales of drugs at their place of employment <ref>https://www.nsc.org/forms/substance-use-employer-calculator</ref>. Drugs in the workplace have detrimental effects on all individuals due to impaired decision making and increased risk of damage to property and increased changes of physical harm due to accidents. Drug use also costs employers money because of increased turnover and increased time off. By implementing support for individuals with SUDS and integrating effective education, employers may save thousands of dollars.

= Impactful Federal, State, and Local Policies =

Please list any federal, state, or local laws, policies, or regulations that support this topic or ones that could be a possible barrier. Are there laws or policies other states should know about and replicate for success?

= Available Tools and Resources =
'''Opioid Response Network''' (ORN)<ref>https://opioidresponsenetwork.org/documents/ORN_Brochure%20-%20FINAL%2007.07.21%20digital.pdf</ref> provides training and education that is evidence-based and designed to meet the needs of a community or organization, all at no cost.

'''Substance Use Employer Cost Calculator'''
This resource provides information about the real costs of substance use on employers and businesses. By answering questions, employers can determine how substance use in their workplace can negatively impact their budget.

https://www.nsc.org/forms/substance-use-employer-calculator

= Promising Practices =

‘’’Project ALERT’’’ is a two year program for middle school students that aids in reducing the onset of drug use among youth. Project Alert Plus is a similar program that is geared towards highschool students <ref>https://nida.nih.gov/publications/preventing-drug-use-among-children-adolescents/chapter-4-examples-research-based-drug-abuse-prevention-programs/universal-programs</ref>.

‘’’Promoting Alternative Thinking Strategies (PATHS)’’’ This program focuses on reducing behavioral problems in elementary school students while enhancing their education within the classroom. Both of these approaches help to prevent future substance use <ref>https://nida.nih.gov/publications/preventing-drug-use-among-children-adolescents/chapter-4-examples-research-based-drug-abuse-prevention-programs/universal-programs</ref>.

= Sources =

Build Education and Raise Awareness

2022-07-22T02:46:50Z

Katherine: /* Available Tools and Resources */

= Introductory Paragraph =

Many public establishments -like schools and places of work-maintain a zero tolerance for substance use. While this high standard ensures safety, it can sometimes leave individuals with nowhere to turn if they find themselves with a substance use problem. Places of employment and schools can further assist their stakeholders by not only having high standards but also by motivating them to maintain a drug-free lifestyle through education and connection to resources. This process can begin by raising awareness of the importance of substance use in society and carefully selecting the right tools to inform and assist individuals to maintain a drug-free lifestyle in and outside of work or school<ref>https://www.samhsa.gov/workplace/employer-resources/prepare-workplace</ref>.

= Key Information =

Drug education programs have changed over the years from prioritizing abstinence only in public schools, to incorporating mental health, social skills, family bonding, and behavior management in school and corporate settings.

Education for Children and Adolescents

The National Institute on Drug Abuse website has a comprehensive list of drug education programs that have evolved to target risk factors and behavioral issues that lead to first-time use. Some of those programs are more selective than others, focusing on already at-risk children and families with students who may have experimented with drugs or alcohol. Great progress has been made in education and prevention. Science has come a long way in identifying multiple solutions for preventing the onset of drug use and providing resources to those already using substances. Raising awareness of the seriousness of the issue is a top priority for organizations like the NIDA <ref>https://nida.nih.gov/publications/preventing-drug-use-among-children-adolescents/preface</ref>.

Education in the Workplace
Many businesses have realized the importance of drug education and prevention in the workplace. More businesses, especially smaller businesses, could benefit from implementing drug education. This type of education can be costly and many times businesses feel they can not afford to add it to the budget. However, research shows that by implementing a drug education and drug testing program, employers and employees both experience positive outcomes. The proven benefits of drug education programs in the workplace are listed below <ref>https://drugabuse.com/addiction/workplace-drug-abuse/</ref>.

*Increased morale
*Decreased workplace accidents
*Reduced employee theft
*Increased productivity
*Reduced employee turnover
*Decreased cost of insurance, such as workers’ compensation

The American Addiction Center provides guidance on what quality drug education programs should include the following:

*Rules and expectations with terms clearly defined
*Prevention methods and education
*Testing
*Quality employee assistance programs

One possible way to raise awareness in the workplace is to distribute materials, in writing and through visual presentations, that pertain to drug use and its impacts on the work environment and employees. Adding in a Drug Awareness day and presenting information and resources that are available to employees can increase understanding of what to do and who to turn to when an individual is struggling with substance use.

By providing education to employees about common signs that indicate someone is struggling with addiction, a workplace may be able to intervene and provide assistance before the problem escalates. Some signs of substance use may be overlooked as common ailments and other signs are more noticeable. Below are some examples <ref>https://drugabuse.com/addiction/workplace-drug-abuse/</ref>.

Common Signs of Substance Use
*Frequent Accidents
*Erratic Behavior
*Dilated Pupils
*Slurred Speech
*Extreme Mood Swings
*Paranoia
*Glassy Eyes
*Noticeable Exhaustion
*Frequent Absenteeism

= Relevant Research =

'''Adults Survey on Drug Education'''

A study conducted by the American Addiction Centers surveyed 500 men and women. Thirty-seven participants reported that the most effective way they learned about drug education was by learning about the possible dangers of substance use. In the next highest category, at 20%, participants reported that the most effective drug prevention education approach was listening to the powerful testimonials of recovered adults. This information could be helpful in building an effective drug education program. Surprisingly, 41.2% of respondents reported that they did not receive any education about the science of addiction. Many of the respondents reported that they were not educated on some of the most commonly abused drugs. About half of the 500 adults surveyed endorsed no formal education about meth, ecstasy, heroin, or other opioids. These statistics support the need for building more educational resources and programs that address the gaps in the above-mentioned statistics <ref>https://americanaddictioncenters.org/learn/drug-education-survey/</ref>.

'''Rates of Drug Use in the Workforce'''

Almost 70% of drug users are actively employed in the workplace according to the Substance Abuse and Mental Health Administration (SAMHSA) <ref>https://www.nsc.org/forms/substance-use-employer-calculator</ref>. The Tennessee Department of Labor and Workforce Development reported that ⅓ of employees are aware of the presence and illegal sales of drugs at their place of employment <ref>https://www.nsc.org/forms/substance-use-employer-calculator</ref>. Drugs in the workplace have detrimental effects on all individuals due to impaired decision making and increased risk of damage to property and increased changes of physical harm due to accidents. Drug use also costs employers money because of increased turnover and increased time off. By implementing support for individuals with SUDS and integrating effective education, employers may save thousands of dollars.

= Impactful Federal, State, and Local Policies =

Please list any federal, state, or local laws, policies, or regulations that support this topic or ones that could be a possible barrier. Are there laws or policies other states should know about and replicate for success?

= Available Tools and Resources =
'''Opioid Response Network''' (ORN)<ref>https://opioidresponsenetwork.org/documents/ORN_Brochure%20-%20FINAL%2007.07.21%20digital.pdf</ref> provides training and education that is evidence-based and designed to meet the needs of a community or organization, all at no cost.

'''Substance Use Employer Cost Calculator'''
This resource provides information about the real costs of substance use on employers and businesses. By answering questions, employers can determine how substance use in their workplace can negatively impact their budget.

https://www.nsc.org/forms/substance-use-employer-calculator

= Promising Practices =

Please link to any best practice models or case studies that highlight creative/innovative or successful efforts in support of this strategy. Is there a community that does a really good job in this area that other communities should replicate? Please write a brief description and provide a link.

= Sources =

Build Education and Raise Awareness

2022-07-22T02:45:38Z

Katherine: /* Relevant Research */

= Introductory Paragraph =

Many public establishments -like schools and places of work-maintain a zero tolerance for substance use. While this high standard ensures safety, it can sometimes leave individuals with nowhere to turn if they find themselves with a substance use problem. Places of employment and schools can further assist their stakeholders by not only having high standards but also by motivating them to maintain a drug-free lifestyle through education and connection to resources. This process can begin by raising awareness of the importance of substance use in society and carefully selecting the right tools to inform and assist individuals to maintain a drug-free lifestyle in and outside of work or school<ref>https://www.samhsa.gov/workplace/employer-resources/prepare-workplace</ref>.

= Key Information =

Drug education programs have changed over the years from prioritizing abstinence only in public schools, to incorporating mental health, social skills, family bonding, and behavior management in school and corporate settings.

Education for Children and Adolescents

The National Institute on Drug Abuse website has a comprehensive list of drug education programs that have evolved to target risk factors and behavioral issues that lead to first-time use. Some of those programs are more selective than others, focusing on already at-risk children and families with students who may have experimented with drugs or alcohol. Great progress has been made in education and prevention. Science has come a long way in identifying multiple solutions for preventing the onset of drug use and providing resources to those already using substances. Raising awareness of the seriousness of the issue is a top priority for organizations like the NIDA <ref>https://nida.nih.gov/publications/preventing-drug-use-among-children-adolescents/preface</ref>.

Education in the Workplace
Many businesses have realized the importance of drug education and prevention in the workplace. More businesses, especially smaller businesses, could benefit from implementing drug education. This type of education can be costly and many times businesses feel they can not afford to add it to the budget. However, research shows that by implementing a drug education and drug testing program, employers and employees both experience positive outcomes. The proven benefits of drug education programs in the workplace are listed below <ref>https://drugabuse.com/addiction/workplace-drug-abuse/</ref>.

*Increased morale
*Decreased workplace accidents
*Reduced employee theft
*Increased productivity
*Reduced employee turnover
*Decreased cost of insurance, such as workers’ compensation

The American Addiction Center provides guidance on what quality drug education programs should include the following:

*Rules and expectations with terms clearly defined
*Prevention methods and education
*Testing
*Quality employee assistance programs

One possible way to raise awareness in the workplace is to distribute materials, in writing and through visual presentations, that pertain to drug use and its impacts on the work environment and employees. Adding in a Drug Awareness day and presenting information and resources that are available to employees can increase understanding of what to do and who to turn to when an individual is struggling with substance use.

By providing education to employees about common signs that indicate someone is struggling with addiction, a workplace may be able to intervene and provide assistance before the problem escalates. Some signs of substance use may be overlooked as common ailments and other signs are more noticeable. Below are some examples <ref>https://drugabuse.com/addiction/workplace-drug-abuse/</ref>.

Common Signs of Substance Use
*Frequent Accidents
*Erratic Behavior
*Dilated Pupils
*Slurred Speech
*Extreme Mood Swings
*Paranoia
*Glassy Eyes
*Noticeable Exhaustion
*Frequent Absenteeism

= Relevant Research =

'''Adults Survey on Drug Education'''

A study conducted by the American Addiction Centers surveyed 500 men and women. Thirty-seven participants reported that the most effective way they learned about drug education was by learning about the possible dangers of substance use. In the next highest category, at 20%, participants reported that the most effective drug prevention education approach was listening to the powerful testimonials of recovered adults. This information could be helpful in building an effective drug education program. Surprisingly, 41.2% of respondents reported that they did not receive any education about the science of addiction. Many of the respondents reported that they were not educated on some of the most commonly abused drugs. About half of the 500 adults surveyed endorsed no formal education about meth, ecstasy, heroin, or other opioids. These statistics support the need for building more educational resources and programs that address the gaps in the above-mentioned statistics <ref>https://americanaddictioncenters.org/learn/drug-education-survey/</ref>.

'''Rates of Drug Use in the Workforce'''

Almost 70% of drug users are actively employed in the workplace according to the Substance Abuse and Mental Health Administration (SAMHSA) <ref>https://www.nsc.org/forms/substance-use-employer-calculator</ref>. The Tennessee Department of Labor and Workforce Development reported that ⅓ of employees are aware of the presence and illegal sales of drugs at their place of employment <ref>https://www.nsc.org/forms/substance-use-employer-calculator</ref>. Drugs in the workplace have detrimental effects on all individuals due to impaired decision making and increased risk of damage to property and increased changes of physical harm due to accidents. Drug use also costs employers money because of increased turnover and increased time off. By implementing support for individuals with SUDS and integrating effective education, employers may save thousands of dollars.

= Impactful Federal, State, and Local Policies =

Please list any federal, state, or local laws, policies, or regulations that support this topic or ones that could be a possible barrier. Are there laws or policies other states should know about and replicate for success?

= Available Tools and Resources =
'''Opioid Response Network''' (ORN)<ref>https://opioidresponsenetwork.org/documents/ORN_Brochure%20-%20FINAL%2007.07.21%20digital.pdf</ref> provides training and education that is evidence-based and designed to meet the needs of a community or organization, all at no cost.

= Promising Practices =

Please link to any best practice models or case studies that highlight creative/innovative or successful efforts in support of this strategy. Is there a community that does a really good job in this area that other communities should replicate? Please write a brief description and provide a link.

= Sources =

Build Education and Raise Awareness

2022-07-22T02:43:48Z

Katherine: /* Key Information */

Build Education and Raise Awareness

2022-07-22T02:40:14Z

Katherine: /* Introductory Paragraph */

Increase Access to Non-Pharma Therapies

2022-07-18T18:29:29Z

Katherine: /* Available Tools and Resources */

= Introductory Paragraph =

This objective focuses on Non-Pharmacologic Pain Care (NPPC).

= Key Information =

Currently, most insurance plans do not cover most non-medication therapies. Working with insurance companies to put more alternative and complementary pain therapies in their formularies and services covered can decrease the prescribing of opioids for pain. Using such therapies that are alternatives to opiates can prevent patients from having opiates introduced into their bodies, which is one of the best ways to reduce the number of people who try an opiate. Using alternate therapies can also prevent unpleasant adverse effects of opiates, such as nausea and vomiting. Often times, people using opiates use other illicit and addicting substances to treat their nausea such as marijuana, producing a cycle of dependency on those two drugs that is difficult to break. Also, patients with Substance Use Disorder are more likely to try other addicting drugs, making treatment and quitting harder. There are many benefits of using alternative therapies, and as many fields are being studied, they appear to be a promising way to help deal with the Opioid Crisis. Considering alternative and complementary therapies in today’s society where patients often have complicated medical histories and polymedication can also help them avoid adverse drug reactions and help preserve the health of various organs by putting less stress on liver (which metabolizes the drug and detoxifies the body) and kidney (which excretes the drug). Using therapies that have less toll on the body can help our patients stay healthier and overall improve their quality of life.

'''Current Status''' Attorneys general (AGs) from 37 states have let the insurance industry know that the fight against the nation's opioid crisis won't be won unless health care providers are encouraged to prioritize nonopioid pain management options, including physical therapy, over opioid prescriptions for the treatment of chronic, noncancer pain.<ref>http://www.apta.org/PTinMotion/News/2017/9/27/AGsToAHIP/</ref> Brandeis University Professor Dr. Andrew Kolodny said efforts to limit opioid prescribing in recent years have been positive steps but warns that there are about 10 million to 12 million patients in the U.S. who have been on painkillers for years and need alternative therapies to offset the potential damage that could be caused by being cut off cold turkey.<ref>https://www.modernhealthcare.com/article/20180505/BLOG/180509948/searching-for-solutions-to-the-opioid-crisis</ref>

'''Complementary Health Approaches'''

*Acupuncture
*Chiropractic Care and Spinal Manipulation
*Massage Therapy
*Stretching and Fitness Techniques to Minimize Pain
*Mindfulness and meditation-based therapies
*Tai Chi and Qi Gong
*Yoga
*Biofeedback
*Transcutaneous electrical nerve stimulation, or TENS.  

'''Benefits of Active Self-Care Therapies''' In contrast to medication-based therapies, many Non-Pharmaceutical Pain Care (NPPC) strategies involve significant patient participation and a commitment to self-care. NPCC strategies tend to increase self-efficacy in managing pain and correlate with improved mood and outcomes in many chronic conditions, including pain. <ref>https://doi.org/10.1177/1524839904266792</ref>For example, the military has studied “active self-care therapies” as a category of pain management that may be of value in an integrated, multi-modal approach.

= Relevant Research =

'''Barriers and facilitators to use of non-pharmacological treatments in chronic pain'''<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359906/</ref>

'''Evidence-based Non-Pharmacological strategies for Comprehensive Pain Care'''<ref>https://reader.elsevier.com/reader/sd/pii/S1550830718300223?token=B15C1CF40F445A8637B78A0A83A56604EFE11137BFC75449D9A0D2FF668E226947DCE98C1147CE913ACAAA607D021178&originRegion=us-east-1&originCreation=20220718180015</ref>

SAFE Solutions is an ever-growing platform.  Currently no information is readily available for this section.  SAFE Project is dedicated to providing communities with the most relevant and innovative materials.  We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration.  Please check back soon.

= Impactful Federal, State, and Local Policies =

On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs. The bill is modeled after Morrison County’s program. “We’ve heard a lot of discussion about the opioid problem, and this bill offers a viable solution,” says Kresha. “There’s no sense reinventing the wheel when we know we have something that works.”

H.F. No. 2140 would require the Commissioner of Health to establish opioid abuse prevention pilot projects throughout the state and appropriate funding for these projects. Current language in the bill states each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts.

 

= Available Tools and Resources =

'''CDC Non-pharmaceutical Interventions'''<ref>https://www.cdc.gov/nonpharmaceutical-interventions/index.html</ref>

'''The Joint Commission''' ''Non-pharmacologic and non-opioid solutions for pain management''<ref>
https://www.jointcommission.org/-/media/tjc/documents/resources/pain-management/qs_nonopioid_pain_mgmt_8_15_18_final1.pdf</ref>

'''Pain Assessment and management Standards for Hospitals'''<ref>https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/r3_report_issue_11_pain_assessment_8_25_17_final.pdf?db=web&hash=938C24A464A5B8B5646C8E297C8936C1&hash=938C24A464A5B8B5646C8E297C8936C1</ref>

= Promising Practices =

These programs have shown promising results with varying degrees of research.

 

'''MyStrength''' myStrength helps fill the gap between generalized pain management and prescription opioid use through education, encouragement and evidence-based pain management tools. myStrength, Inc. is a recognized leader and one of the fastest-growing digital behavioral health companies in the US. myStrength enhances traditional care models while addressing issues of cost, lack of access and stigma in order to deliver mental health and well-being resources at scale. The platform targets the most prevalent and costly behavioral health conditions, empowering consumers with innovative self-care resources to manage and overcome challenges with depression, anxiety, substance use disorders and chronic pain. myStrength collaborates with over 100 health plans, community behavioral health centers, integrated health systems and ACOs. More information on myStrength  

'''Little Falls, Minnesota's Program to Reduce Opioid Prescriptions for Pain''' In 2014, doctors in Little Falls, Minnesota noticed that there were a large number of opioid prescriptions and drug-related arrests. Through heightened addiction treatment and monitoring of prescriptions - as well as working with community partners like schools, local health departments, law enforcement, and health alliances - they were able to wean 324 patients off opioids entirely and lower prescriptions of opioids from 48,000 a month to 37,000. Patients must sign a contract when they are prescribed opioids that allows for electronic monitoring of their medical records to look for patterns of abuse, and law enforcement will alter doctors if opioids the doctors prescribed are found in possession of someone other than the patient to whom they were prescribed. Patients caught selling and abusing opioids are not punished; rather, they are given access to Suboxone and to a support team - including a nurse and mental health specialist. Although the program started off as an abstinence-based program, doctors changed to a medically-assisted program when patients started to die.<ref>https://www.aha.org/news/insights-and-analysis/2018-03-28-minnesota-critical-access-hospital-uses-medication-assisted</ref>

This program has gained national attention and is currently being looked at by national policymakers.<ref>http://www.startribune.com/little-falls-effort-to-curb-opioids-gets-big-notice/448037143/</ref> For example, On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs based on the program in Little Falls, MN. H.F. No. 2140 would establish opioid abuse prevention pilot projects throughout the state with appropriate funding. Each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts. The bill is currently going through revisions in Minnesota's house and senate. <ref> https://www.chistgabriels.com/mn-house-bill-on-opioid-abuse-prevention-seeks-to-replicate-chi-st-gabriels-health-and-community-partners-model-program/</ref>Minnesota is all currently taking applications for places interested in starting pilot programs based on Little Falls' model Opioid Abuse Prevention Pilot Projects  

'''Areas of Intervention/Training''' Education for Future Doctors When future doctors go through school, there seems to be very limited education detailing pain and pain management. Pain curricula in medical school education for both MDs and DOs in the U.S. ranges from 1-31 hours during the 3-4 year curriculum, with a mean of 11.13 hours. Thus, the current training system has left primary care practitioners with inadequate tools to deal with some of the most common problems doctors will come across during their years of practice. Any meaningful effort to improve pain management will require a basic culture shift in the nation’s approach to mandating pain-related education for all health professionals who provide care to people with pain.

One possible solution is cross-training between fields. Many, if not most, pain clinics are still housed in anesthesiology clinics, but fellowship pain training can now be pursued not only by anesthesiologists but other specialists in neurology/psychiatry, PM&R, and internal and family medicine. Physicians who receive fellowship training in pain care learn interventional pain strategies that originated in regional anesthesia and acute pain care, including non-pharmacological options. The expansion of these strategies, which are the mainstay of anesthesiology and acute pain practices, to chronic pain care have had more modest success and only in carefully selected patient.<ref>http://www.asacu.org/wp-content/uploads/2017/11/JIM-Acupunctures-Role-in-Solving-the-Opioid-Epidemic.pdf</ref>  

'''Insurance and Coordinated Care''' Coordination of care across disciplines and access to nonpharmacologic care have not been optimized in the current system in most states and territories, and improvement to these systems could help reduce opioid use. There are a few state Medicaid policy initiatives aimed at increasing access to effective nonpharmacologic therapies as a first line treatment for pain conditions. For example, the Oregon Health Plan (OHP – Oregon’s Medicaid program) covers acupuncture therapy, chiropractic and osteopathic manipulation, physical therapy and cognitive behavioral therapy for all back conditions. Vermont’s legislature is piloting a program where they will cover acupuncture therapy for back pain in a Medicaid population and monitor health outcomes and cost-effectiveness. Such programs are promising and there is hope that with more interventions like this, the number of opioids being prescribed will decrease.<ref>https://www.finance.senate.gov/imo/media/doc/Coalition%20of%20Accupuncture%20Associations.pdf</ref>

= Sources =

Increase Access to Non-Pharma Therapies

2022-07-18T18:28:55Z

Katherine: /* Available Tools and Resources */

= Introductory Paragraph =

This objective focuses on Non-Pharmacologic Pain Care (NPPC).

= Key Information =

Currently, most insurance plans do not cover most non-medication therapies. Working with insurance companies to put more alternative and complementary pain therapies in their formularies and services covered can decrease the prescribing of opioids for pain. Using such therapies that are alternatives to opiates can prevent patients from having opiates introduced into their bodies, which is one of the best ways to reduce the number of people who try an opiate. Using alternate therapies can also prevent unpleasant adverse effects of opiates, such as nausea and vomiting. Often times, people using opiates use other illicit and addicting substances to treat their nausea such as marijuana, producing a cycle of dependency on those two drugs that is difficult to break. Also, patients with Substance Use Disorder are more likely to try other addicting drugs, making treatment and quitting harder. There are many benefits of using alternative therapies, and as many fields are being studied, they appear to be a promising way to help deal with the Opioid Crisis. Considering alternative and complementary therapies in today’s society where patients often have complicated medical histories and polymedication can also help them avoid adverse drug reactions and help preserve the health of various organs by putting less stress on liver (which metabolizes the drug and detoxifies the body) and kidney (which excretes the drug). Using therapies that have less toll on the body can help our patients stay healthier and overall improve their quality of life.

'''Current Status''' Attorneys general (AGs) from 37 states have let the insurance industry know that the fight against the nation's opioid crisis won't be won unless health care providers are encouraged to prioritize nonopioid pain management options, including physical therapy, over opioid prescriptions for the treatment of chronic, noncancer pain.<ref>http://www.apta.org/PTinMotion/News/2017/9/27/AGsToAHIP/</ref> Brandeis University Professor Dr. Andrew Kolodny said efforts to limit opioid prescribing in recent years have been positive steps but warns that there are about 10 million to 12 million patients in the U.S. who have been on painkillers for years and need alternative therapies to offset the potential damage that could be caused by being cut off cold turkey.<ref>https://www.modernhealthcare.com/article/20180505/BLOG/180509948/searching-for-solutions-to-the-opioid-crisis</ref>

'''Complementary Health Approaches'''

*Acupuncture
*Chiropractic Care and Spinal Manipulation
*Massage Therapy
*Stretching and Fitness Techniques to Minimize Pain
*Mindfulness and meditation-based therapies
*Tai Chi and Qi Gong
*Yoga
*Biofeedback
*Transcutaneous electrical nerve stimulation, or TENS.  

'''Benefits of Active Self-Care Therapies''' In contrast to medication-based therapies, many Non-Pharmaceutical Pain Care (NPPC) strategies involve significant patient participation and a commitment to self-care. NPCC strategies tend to increase self-efficacy in managing pain and correlate with improved mood and outcomes in many chronic conditions, including pain. <ref>https://doi.org/10.1177/1524839904266792</ref>For example, the military has studied “active self-care therapies” as a category of pain management that may be of value in an integrated, multi-modal approach.

= Relevant Research =

'''Barriers and facilitators to use of non-pharmacological treatments in chronic pain'''<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359906/</ref>

'''Evidence-based Non-Pharmacological strategies for Comprehensive Pain Care'''<ref>https://reader.elsevier.com/reader/sd/pii/S1550830718300223?token=B15C1CF40F445A8637B78A0A83A56604EFE11137BFC75449D9A0D2FF668E226947DCE98C1147CE913ACAAA607D021178&originRegion=us-east-1&originCreation=20220718180015</ref>

SAFE Solutions is an ever-growing platform.  Currently no information is readily available for this section.  SAFE Project is dedicated to providing communities with the most relevant and innovative materials.  We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration.  Please check back soon.

= Impactful Federal, State, and Local Policies =

On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs. The bill is modeled after Morrison County’s program. “We’ve heard a lot of discussion about the opioid problem, and this bill offers a viable solution,” says Kresha. “There’s no sense reinventing the wheel when we know we have something that works.”

H.F. No. 2140 would require the Commissioner of Health to establish opioid abuse prevention pilot projects throughout the state and appropriate funding for these projects. Current language in the bill states each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts.

 

= Available Tools and Resources =

'''CDC Non-pharmaceutical Interventions'''<ref>https://www.cdc.gov/nonpharmaceutical-interventions/index.html</ref>

'''The Joint Commission''' ''Non-pharmacologic and non-opioid solutions for pain management''<ref>
https://www.jointcommission.org/-/media/tjc/documents/resources/pain-management/qs_nonopioid_pain_mgmt_8_15_18_final1.pdf</ref>

'''Pain assessment and management standards for hospitals'''<ref>https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/r3_report_issue_11_pain_assessment_8_25_17_final.pdf?db=web&hash=938C24A464A5B8B5646C8E297C8936C1&hash=938C24A464A5B8B5646C8E297C8936C1</ref>

= Promising Practices =

These programs have shown promising results with varying degrees of research.

 

'''MyStrength''' myStrength helps fill the gap between generalized pain management and prescription opioid use through education, encouragement and evidence-based pain management tools. myStrength, Inc. is a recognized leader and one of the fastest-growing digital behavioral health companies in the US. myStrength enhances traditional care models while addressing issues of cost, lack of access and stigma in order to deliver mental health and well-being resources at scale. The platform targets the most prevalent and costly behavioral health conditions, empowering consumers with innovative self-care resources to manage and overcome challenges with depression, anxiety, substance use disorders and chronic pain. myStrength collaborates with over 100 health plans, community behavioral health centers, integrated health systems and ACOs. More information on myStrength  

'''Little Falls, Minnesota's Program to Reduce Opioid Prescriptions for Pain''' In 2014, doctors in Little Falls, Minnesota noticed that there were a large number of opioid prescriptions and drug-related arrests. Through heightened addiction treatment and monitoring of prescriptions - as well as working with community partners like schools, local health departments, law enforcement, and health alliances - they were able to wean 324 patients off opioids entirely and lower prescriptions of opioids from 48,000 a month to 37,000. Patients must sign a contract when they are prescribed opioids that allows for electronic monitoring of their medical records to look for patterns of abuse, and law enforcement will alter doctors if opioids the doctors prescribed are found in possession of someone other than the patient to whom they were prescribed. Patients caught selling and abusing opioids are not punished; rather, they are given access to Suboxone and to a support team - including a nurse and mental health specialist. Although the program started off as an abstinence-based program, doctors changed to a medically-assisted program when patients started to die.<ref>https://www.aha.org/news/insights-and-analysis/2018-03-28-minnesota-critical-access-hospital-uses-medication-assisted</ref>

This program has gained national attention and is currently being looked at by national policymakers.<ref>http://www.startribune.com/little-falls-effort-to-curb-opioids-gets-big-notice/448037143/</ref> For example, On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs based on the program in Little Falls, MN. H.F. No. 2140 would establish opioid abuse prevention pilot projects throughout the state with appropriate funding. Each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts. The bill is currently going through revisions in Minnesota's house and senate. <ref> https://www.chistgabriels.com/mn-house-bill-on-opioid-abuse-prevention-seeks-to-replicate-chi-st-gabriels-health-and-community-partners-model-program/</ref>Minnesota is all currently taking applications for places interested in starting pilot programs based on Little Falls' model Opioid Abuse Prevention Pilot Projects  

'''Areas of Intervention/Training''' Education for Future Doctors When future doctors go through school, there seems to be very limited education detailing pain and pain management. Pain curricula in medical school education for both MDs and DOs in the U.S. ranges from 1-31 hours during the 3-4 year curriculum, with a mean of 11.13 hours. Thus, the current training system has left primary care practitioners with inadequate tools to deal with some of the most common problems doctors will come across during their years of practice. Any meaningful effort to improve pain management will require a basic culture shift in the nation’s approach to mandating pain-related education for all health professionals who provide care to people with pain.

One possible solution is cross-training between fields. Many, if not most, pain clinics are still housed in anesthesiology clinics, but fellowship pain training can now be pursued not only by anesthesiologists but other specialists in neurology/psychiatry, PM&R, and internal and family medicine. Physicians who receive fellowship training in pain care learn interventional pain strategies that originated in regional anesthesia and acute pain care, including non-pharmacological options. The expansion of these strategies, which are the mainstay of anesthesiology and acute pain practices, to chronic pain care have had more modest success and only in carefully selected patient.<ref>http://www.asacu.org/wp-content/uploads/2017/11/JIM-Acupunctures-Role-in-Solving-the-Opioid-Epidemic.pdf</ref>  

'''Insurance and Coordinated Care''' Coordination of care across disciplines and access to nonpharmacologic care have not been optimized in the current system in most states and territories, and improvement to these systems could help reduce opioid use. There are a few state Medicaid policy initiatives aimed at increasing access to effective nonpharmacologic therapies as a first line treatment for pain conditions. For example, the Oregon Health Plan (OHP – Oregon’s Medicaid program) covers acupuncture therapy, chiropractic and osteopathic manipulation, physical therapy and cognitive behavioral therapy for all back conditions. Vermont’s legislature is piloting a program where they will cover acupuncture therapy for back pain in a Medicaid population and monitor health outcomes and cost-effectiveness. Such programs are promising and there is hope that with more interventions like this, the number of opioids being prescribed will decrease.<ref>https://www.finance.senate.gov/imo/media/doc/Coalition%20of%20Accupuncture%20Associations.pdf</ref>

= Sources =

Increase Access to Non-Pharma Therapies

2022-07-18T18:27:27Z

Katherine: /* Available Tools and Resources */

= Introductory Paragraph =

This objective focuses on Non-Pharmacologic Pain Care (NPPC).

= Key Information =

Currently, most insurance plans do not cover most non-medication therapies. Working with insurance companies to put more alternative and complementary pain therapies in their formularies and services covered can decrease the prescribing of opioids for pain. Using such therapies that are alternatives to opiates can prevent patients from having opiates introduced into their bodies, which is one of the best ways to reduce the number of people who try an opiate. Using alternate therapies can also prevent unpleasant adverse effects of opiates, such as nausea and vomiting. Often times, people using opiates use other illicit and addicting substances to treat their nausea such as marijuana, producing a cycle of dependency on those two drugs that is difficult to break. Also, patients with Substance Use Disorder are more likely to try other addicting drugs, making treatment and quitting harder. There are many benefits of using alternative therapies, and as many fields are being studied, they appear to be a promising way to help deal with the Opioid Crisis. Considering alternative and complementary therapies in today’s society where patients often have complicated medical histories and polymedication can also help them avoid adverse drug reactions and help preserve the health of various organs by putting less stress on liver (which metabolizes the drug and detoxifies the body) and kidney (which excretes the drug). Using therapies that have less toll on the body can help our patients stay healthier and overall improve their quality of life.

'''Current Status''' Attorneys general (AGs) from 37 states have let the insurance industry know that the fight against the nation's opioid crisis won't be won unless health care providers are encouraged to prioritize nonopioid pain management options, including physical therapy, over opioid prescriptions for the treatment of chronic, noncancer pain.<ref>http://www.apta.org/PTinMotion/News/2017/9/27/AGsToAHIP/</ref> Brandeis University Professor Dr. Andrew Kolodny said efforts to limit opioid prescribing in recent years have been positive steps but warns that there are about 10 million to 12 million patients in the U.S. who have been on painkillers for years and need alternative therapies to offset the potential damage that could be caused by being cut off cold turkey.<ref>https://www.modernhealthcare.com/article/20180505/BLOG/180509948/searching-for-solutions-to-the-opioid-crisis</ref>

'''Complementary Health Approaches'''

*Acupuncture
*Chiropractic Care and Spinal Manipulation
*Massage Therapy
*Stretching and Fitness Techniques to Minimize Pain
*Mindfulness and meditation-based therapies
*Tai Chi and Qi Gong
*Yoga
*Biofeedback
*Transcutaneous electrical nerve stimulation, or TENS.  

'''Benefits of Active Self-Care Therapies''' In contrast to medication-based therapies, many Non-Pharmaceutical Pain Care (NPPC) strategies involve significant patient participation and a commitment to self-care. NPCC strategies tend to increase self-efficacy in managing pain and correlate with improved mood and outcomes in many chronic conditions, including pain. <ref>https://doi.org/10.1177/1524839904266792</ref>For example, the military has studied “active self-care therapies” as a category of pain management that may be of value in an integrated, multi-modal approach.

= Relevant Research =

'''Barriers and facilitators to use of non-pharmacological treatments in chronic pain'''<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359906/</ref>

'''Evidence-based Non-Pharmacological strategies for Comprehensive Pain Care'''<ref>https://reader.elsevier.com/reader/sd/pii/S1550830718300223?token=B15C1CF40F445A8637B78A0A83A56604EFE11137BFC75449D9A0D2FF668E226947DCE98C1147CE913ACAAA607D021178&originRegion=us-east-1&originCreation=20220718180015</ref>

SAFE Solutions is an ever-growing platform.  Currently no information is readily available for this section.  SAFE Project is dedicated to providing communities with the most relevant and innovative materials.  We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration.  Please check back soon.

= Impactful Federal, State, and Local Policies =

On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs. The bill is modeled after Morrison County’s program. “We’ve heard a lot of discussion about the opioid problem, and this bill offers a viable solution,” says Kresha. “There’s no sense reinventing the wheel when we know we have something that works.”

H.F. No. 2140 would require the Commissioner of Health to establish opioid abuse prevention pilot projects throughout the state and appropriate funding for these projects. Current language in the bill states each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts.

 

= Available Tools and Resources =

'''CDC Non-pharmaceutical Interventions'''<ref>https://www.cdc.gov/nonpharmaceutical-interventions/index.html</ref>

'''The Joint Commission''' ''Non-pharmacologic and non-opioid solutions for pain management''<ref>
https://www.jointcommission.org/-/media/tjc/documents/resources/pain-management/qs_nonopioid_pain_mgmt_8_15_18_final1.pdf</ref>

= Promising Practices =

These programs have shown promising results with varying degrees of research.

 

'''MyStrength''' myStrength helps fill the gap between generalized pain management and prescription opioid use through education, encouragement and evidence-based pain management tools. myStrength, Inc. is a recognized leader and one of the fastest-growing digital behavioral health companies in the US. myStrength enhances traditional care models while addressing issues of cost, lack of access and stigma in order to deliver mental health and well-being resources at scale. The platform targets the most prevalent and costly behavioral health conditions, empowering consumers with innovative self-care resources to manage and overcome challenges with depression, anxiety, substance use disorders and chronic pain. myStrength collaborates with over 100 health plans, community behavioral health centers, integrated health systems and ACOs. More information on myStrength  

'''Little Falls, Minnesota's Program to Reduce Opioid Prescriptions for Pain''' In 2014, doctors in Little Falls, Minnesota noticed that there were a large number of opioid prescriptions and drug-related arrests. Through heightened addiction treatment and monitoring of prescriptions - as well as working with community partners like schools, local health departments, law enforcement, and health alliances - they were able to wean 324 patients off opioids entirely and lower prescriptions of opioids from 48,000 a month to 37,000. Patients must sign a contract when they are prescribed opioids that allows for electronic monitoring of their medical records to look for patterns of abuse, and law enforcement will alter doctors if opioids the doctors prescribed are found in possession of someone other than the patient to whom they were prescribed. Patients caught selling and abusing opioids are not punished; rather, they are given access to Suboxone and to a support team - including a nurse and mental health specialist. Although the program started off as an abstinence-based program, doctors changed to a medically-assisted program when patients started to die.<ref>https://www.aha.org/news/insights-and-analysis/2018-03-28-minnesota-critical-access-hospital-uses-medication-assisted</ref>

This program has gained national attention and is currently being looked at by national policymakers.<ref>http://www.startribune.com/little-falls-effort-to-curb-opioids-gets-big-notice/448037143/</ref> For example, On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs based on the program in Little Falls, MN. H.F. No. 2140 would establish opioid abuse prevention pilot projects throughout the state with appropriate funding. Each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts. The bill is currently going through revisions in Minnesota's house and senate. <ref> https://www.chistgabriels.com/mn-house-bill-on-opioid-abuse-prevention-seeks-to-replicate-chi-st-gabriels-health-and-community-partners-model-program/</ref>Minnesota is all currently taking applications for places interested in starting pilot programs based on Little Falls' model Opioid Abuse Prevention Pilot Projects  

'''Areas of Intervention/Training''' Education for Future Doctors When future doctors go through school, there seems to be very limited education detailing pain and pain management. Pain curricula in medical school education for both MDs and DOs in the U.S. ranges from 1-31 hours during the 3-4 year curriculum, with a mean of 11.13 hours. Thus, the current training system has left primary care practitioners with inadequate tools to deal with some of the most common problems doctors will come across during their years of practice. Any meaningful effort to improve pain management will require a basic culture shift in the nation’s approach to mandating pain-related education for all health professionals who provide care to people with pain.

One possible solution is cross-training between fields. Many, if not most, pain clinics are still housed in anesthesiology clinics, but fellowship pain training can now be pursued not only by anesthesiologists but other specialists in neurology/psychiatry, PM&R, and internal and family medicine. Physicians who receive fellowship training in pain care learn interventional pain strategies that originated in regional anesthesia and acute pain care, including non-pharmacological options. The expansion of these strategies, which are the mainstay of anesthesiology and acute pain practices, to chronic pain care have had more modest success and only in carefully selected patient.<ref>http://www.asacu.org/wp-content/uploads/2017/11/JIM-Acupunctures-Role-in-Solving-the-Opioid-Epidemic.pdf</ref>  

'''Insurance and Coordinated Care''' Coordination of care across disciplines and access to nonpharmacologic care have not been optimized in the current system in most states and territories, and improvement to these systems could help reduce opioid use. There are a few state Medicaid policy initiatives aimed at increasing access to effective nonpharmacologic therapies as a first line treatment for pain conditions. For example, the Oregon Health Plan (OHP – Oregon’s Medicaid program) covers acupuncture therapy, chiropractic and osteopathic manipulation, physical therapy and cognitive behavioral therapy for all back conditions. Vermont’s legislature is piloting a program where they will cover acupuncture therapy for back pain in a Medicaid population and monitor health outcomes and cost-effectiveness. Such programs are promising and there is hope that with more interventions like this, the number of opioids being prescribed will decrease.<ref>https://www.finance.senate.gov/imo/media/doc/Coalition%20of%20Accupuncture%20Associations.pdf</ref>

= Sources =

Increase Access to Non-Pharma Therapies

2022-07-18T18:09:01Z

Katherine: /* Available Tools and Resources */

= Introductory Paragraph =

This objective focuses on Non-Pharmacologic Pain Care (NPPC).

= Key Information =

Currently, most insurance plans do not cover most non-medication therapies. Working with insurance companies to put more alternative and complementary pain therapies in their formularies and services covered can decrease the prescribing of opioids for pain. Using such therapies that are alternatives to opiates can prevent patients from having opiates introduced into their bodies, which is one of the best ways to reduce the number of people who try an opiate. Using alternate therapies can also prevent unpleasant adverse effects of opiates, such as nausea and vomiting. Often times, people using opiates use other illicit and addicting substances to treat their nausea such as marijuana, producing a cycle of dependency on those two drugs that is difficult to break. Also, patients with Substance Use Disorder are more likely to try other addicting drugs, making treatment and quitting harder. There are many benefits of using alternative therapies, and as many fields are being studied, they appear to be a promising way to help deal with the Opioid Crisis. Considering alternative and complementary therapies in today’s society where patients often have complicated medical histories and polymedication can also help them avoid adverse drug reactions and help preserve the health of various organs by putting less stress on liver (which metabolizes the drug and detoxifies the body) and kidney (which excretes the drug). Using therapies that have less toll on the body can help our patients stay healthier and overall improve their quality of life.

'''Current Status''' Attorneys general (AGs) from 37 states have let the insurance industry know that the fight against the nation's opioid crisis won't be won unless health care providers are encouraged to prioritize nonopioid pain management options, including physical therapy, over opioid prescriptions for the treatment of chronic, noncancer pain.<ref>http://www.apta.org/PTinMotion/News/2017/9/27/AGsToAHIP/</ref> Brandeis University Professor Dr. Andrew Kolodny said efforts to limit opioid prescribing in recent years have been positive steps but warns that there are about 10 million to 12 million patients in the U.S. who have been on painkillers for years and need alternative therapies to offset the potential damage that could be caused by being cut off cold turkey.<ref>https://www.modernhealthcare.com/article/20180505/BLOG/180509948/searching-for-solutions-to-the-opioid-crisis</ref>

'''Complementary Health Approaches'''

*Acupuncture
*Chiropractic Care and Spinal Manipulation
*Massage Therapy
*Stretching and Fitness Techniques to Minimize Pain
*Mindfulness and meditation-based therapies
*Tai Chi and Qi Gong
*Yoga
*Biofeedback
*Transcutaneous electrical nerve stimulation, or TENS.  

'''Benefits of Active Self-Care Therapies''' In contrast to medication-based therapies, many Non-Pharmaceutical Pain Care (NPPC) strategies involve significant patient participation and a commitment to self-care. NPCC strategies tend to increase self-efficacy in managing pain and correlate with improved mood and outcomes in many chronic conditions, including pain. <ref>https://doi.org/10.1177/1524839904266792</ref>For example, the military has studied “active self-care therapies” as a category of pain management that may be of value in an integrated, multi-modal approach.

= Relevant Research =

'''Barriers and facilitators to use of non-pharmacological treatments in chronic pain'''<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359906/</ref>

'''Evidence-based Non-Pharmacological strategies for Comprehensive Pain Care'''<ref>https://reader.elsevier.com/reader/sd/pii/S1550830718300223?token=B15C1CF40F445A8637B78A0A83A56604EFE11137BFC75449D9A0D2FF668E226947DCE98C1147CE913ACAAA607D021178&originRegion=us-east-1&originCreation=20220718180015</ref>

SAFE Solutions is an ever-growing platform.  Currently no information is readily available for this section.  SAFE Project is dedicated to providing communities with the most relevant and innovative materials.  We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration.  Please check back soon.

= Impactful Federal, State, and Local Policies =

On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs. The bill is modeled after Morrison County’s program. “We’ve heard a lot of discussion about the opioid problem, and this bill offers a viable solution,” says Kresha. “There’s no sense reinventing the wheel when we know we have something that works.”

H.F. No. 2140 would require the Commissioner of Health to establish opioid abuse prevention pilot projects throughout the state and appropriate funding for these projects. Current language in the bill states each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts.

 

= Available Tools and Resources =

'''CDC Non-pharmaceutical Interventions'''<ref>https://www.cdc.gov/nonpharmaceutical-interventions/index.html</ref>

= Promising Practices =

These programs have shown promising results with varying degrees of research.

 

'''MyStrength''' myStrength helps fill the gap between generalized pain management and prescription opioid use through education, encouragement and evidence-based pain management tools. myStrength, Inc. is a recognized leader and one of the fastest-growing digital behavioral health companies in the US. myStrength enhances traditional care models while addressing issues of cost, lack of access and stigma in order to deliver mental health and well-being resources at scale. The platform targets the most prevalent and costly behavioral health conditions, empowering consumers with innovative self-care resources to manage and overcome challenges with depression, anxiety, substance use disorders and chronic pain. myStrength collaborates with over 100 health plans, community behavioral health centers, integrated health systems and ACOs. More information on myStrength  

'''Little Falls, Minnesota's Program to Reduce Opioid Prescriptions for Pain''' In 2014, doctors in Little Falls, Minnesota noticed that there were a large number of opioid prescriptions and drug-related arrests. Through heightened addiction treatment and monitoring of prescriptions - as well as working with community partners like schools, local health departments, law enforcement, and health alliances - they were able to wean 324 patients off opioids entirely and lower prescriptions of opioids from 48,000 a month to 37,000. Patients must sign a contract when they are prescribed opioids that allows for electronic monitoring of their medical records to look for patterns of abuse, and law enforcement will alter doctors if opioids the doctors prescribed are found in possession of someone other than the patient to whom they were prescribed. Patients caught selling and abusing opioids are not punished; rather, they are given access to Suboxone and to a support team - including a nurse and mental health specialist. Although the program started off as an abstinence-based program, doctors changed to a medically-assisted program when patients started to die.<ref>https://www.aha.org/news/insights-and-analysis/2018-03-28-minnesota-critical-access-hospital-uses-medication-assisted</ref>

This program has gained national attention and is currently being looked at by national policymakers.<ref>http://www.startribune.com/little-falls-effort-to-curb-opioids-gets-big-notice/448037143/</ref> For example, On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs based on the program in Little Falls, MN. H.F. No. 2140 would establish opioid abuse prevention pilot projects throughout the state with appropriate funding. Each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts. The bill is currently going through revisions in Minnesota's house and senate. <ref> https://www.chistgabriels.com/mn-house-bill-on-opioid-abuse-prevention-seeks-to-replicate-chi-st-gabriels-health-and-community-partners-model-program/</ref>Minnesota is all currently taking applications for places interested in starting pilot programs based on Little Falls' model Opioid Abuse Prevention Pilot Projects  

'''Areas of Intervention/Training''' Education for Future Doctors When future doctors go through school, there seems to be very limited education detailing pain and pain management. Pain curricula in medical school education for both MDs and DOs in the U.S. ranges from 1-31 hours during the 3-4 year curriculum, with a mean of 11.13 hours. Thus, the current training system has left primary care practitioners with inadequate tools to deal with some of the most common problems doctors will come across during their years of practice. Any meaningful effort to improve pain management will require a basic culture shift in the nation’s approach to mandating pain-related education for all health professionals who provide care to people with pain.

One possible solution is cross-training between fields. Many, if not most, pain clinics are still housed in anesthesiology clinics, but fellowship pain training can now be pursued not only by anesthesiologists but other specialists in neurology/psychiatry, PM&R, and internal and family medicine. Physicians who receive fellowship training in pain care learn interventional pain strategies that originated in regional anesthesia and acute pain care, including non-pharmacological options. The expansion of these strategies, which are the mainstay of anesthesiology and acute pain practices, to chronic pain care have had more modest success and only in carefully selected patient.<ref>http://www.asacu.org/wp-content/uploads/2017/11/JIM-Acupunctures-Role-in-Solving-the-Opioid-Epidemic.pdf</ref>  

'''Insurance and Coordinated Care''' Coordination of care across disciplines and access to nonpharmacologic care have not been optimized in the current system in most states and territories, and improvement to these systems could help reduce opioid use. There are a few state Medicaid policy initiatives aimed at increasing access to effective nonpharmacologic therapies as a first line treatment for pain conditions. For example, the Oregon Health Plan (OHP – Oregon’s Medicaid program) covers acupuncture therapy, chiropractic and osteopathic manipulation, physical therapy and cognitive behavioral therapy for all back conditions. Vermont’s legislature is piloting a program where they will cover acupuncture therapy for back pain in a Medicaid population and monitor health outcomes and cost-effectiveness. Such programs are promising and there is hope that with more interventions like this, the number of opioids being prescribed will decrease.<ref>https://www.finance.senate.gov/imo/media/doc/Coalition%20of%20Accupuncture%20Associations.pdf</ref>

= Sources =

Increase Access to Non-Pharma Therapies

2022-07-18T18:06:48Z

Katherine: /* Relevant Research */

= Introductory Paragraph =

This objective focuses on Non-Pharmacologic Pain Care (NPPC).

= Key Information =

Currently, most insurance plans do not cover most non-medication therapies. Working with insurance companies to put more alternative and complementary pain therapies in their formularies and services covered can decrease the prescribing of opioids for pain. Using such therapies that are alternatives to opiates can prevent patients from having opiates introduced into their bodies, which is one of the best ways to reduce the number of people who try an opiate. Using alternate therapies can also prevent unpleasant adverse effects of opiates, such as nausea and vomiting. Often times, people using opiates use other illicit and addicting substances to treat their nausea such as marijuana, producing a cycle of dependency on those two drugs that is difficult to break. Also, patients with Substance Use Disorder are more likely to try other addicting drugs, making treatment and quitting harder. There are many benefits of using alternative therapies, and as many fields are being studied, they appear to be a promising way to help deal with the Opioid Crisis. Considering alternative and complementary therapies in today’s society where patients often have complicated medical histories and polymedication can also help them avoid adverse drug reactions and help preserve the health of various organs by putting less stress on liver (which metabolizes the drug and detoxifies the body) and kidney (which excretes the drug). Using therapies that have less toll on the body can help our patients stay healthier and overall improve their quality of life.

'''Current Status''' Attorneys general (AGs) from 37 states have let the insurance industry know that the fight against the nation's opioid crisis won't be won unless health care providers are encouraged to prioritize nonopioid pain management options, including physical therapy, over opioid prescriptions for the treatment of chronic, noncancer pain.<ref>http://www.apta.org/PTinMotion/News/2017/9/27/AGsToAHIP/</ref> Brandeis University Professor Dr. Andrew Kolodny said efforts to limit opioid prescribing in recent years have been positive steps but warns that there are about 10 million to 12 million patients in the U.S. who have been on painkillers for years and need alternative therapies to offset the potential damage that could be caused by being cut off cold turkey.<ref>https://www.modernhealthcare.com/article/20180505/BLOG/180509948/searching-for-solutions-to-the-opioid-crisis</ref>

'''Complementary Health Approaches'''

*Acupuncture
*Chiropractic Care and Spinal Manipulation
*Massage Therapy
*Stretching and Fitness Techniques to Minimize Pain
*Mindfulness and meditation-based therapies
*Tai Chi and Qi Gong
*Yoga
*Biofeedback
*Transcutaneous electrical nerve stimulation, or TENS.  

'''Benefits of Active Self-Care Therapies''' In contrast to medication-based therapies, many Non-Pharmaceutical Pain Care (NPPC) strategies involve significant patient participation and a commitment to self-care. NPCC strategies tend to increase self-efficacy in managing pain and correlate with improved mood and outcomes in many chronic conditions, including pain. <ref>https://doi.org/10.1177/1524839904266792</ref>For example, the military has studied “active self-care therapies” as a category of pain management that may be of value in an integrated, multi-modal approach.

= Relevant Research =

'''Barriers and facilitators to use of non-pharmacological treatments in chronic pain'''<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359906/</ref>

'''Evidence-based Non-Pharmacological strategies for Comprehensive Pain Care'''<ref>https://reader.elsevier.com/reader/sd/pii/S1550830718300223?token=B15C1CF40F445A8637B78A0A83A56604EFE11137BFC75449D9A0D2FF668E226947DCE98C1147CE913ACAAA607D021178&originRegion=us-east-1&originCreation=20220718180015</ref>

SAFE Solutions is an ever-growing platform.  Currently no information is readily available for this section.  SAFE Project is dedicated to providing communities with the most relevant and innovative materials.  We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration.  Please check back soon.

= Impactful Federal, State, and Local Policies =

On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs. The bill is modeled after Morrison County’s program. “We’ve heard a lot of discussion about the opioid problem, and this bill offers a viable solution,” says Kresha. “There’s no sense reinventing the wheel when we know we have something that works.”

H.F. No. 2140 would require the Commissioner of Health to establish opioid abuse prevention pilot projects throughout the state and appropriate funding for these projects. Current language in the bill states each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts.

 

= Available Tools and Resources =

TR - Increase Access to Alternative Therapies to Treat Pain

 

= Promising Practices =

These programs have shown promising results with varying degrees of research.

 

'''MyStrength''' myStrength helps fill the gap between generalized pain management and prescription opioid use through education, encouragement and evidence-based pain management tools. myStrength, Inc. is a recognized leader and one of the fastest-growing digital behavioral health companies in the US. myStrength enhances traditional care models while addressing issues of cost, lack of access and stigma in order to deliver mental health and well-being resources at scale. The platform targets the most prevalent and costly behavioral health conditions, empowering consumers with innovative self-care resources to manage and overcome challenges with depression, anxiety, substance use disorders and chronic pain. myStrength collaborates with over 100 health plans, community behavioral health centers, integrated health systems and ACOs. More information on myStrength  

'''Little Falls, Minnesota's Program to Reduce Opioid Prescriptions for Pain''' In 2014, doctors in Little Falls, Minnesota noticed that there were a large number of opioid prescriptions and drug-related arrests. Through heightened addiction treatment and monitoring of prescriptions - as well as working with community partners like schools, local health departments, law enforcement, and health alliances - they were able to wean 324 patients off opioids entirely and lower prescriptions of opioids from 48,000 a month to 37,000. Patients must sign a contract when they are prescribed opioids that allows for electronic monitoring of their medical records to look for patterns of abuse, and law enforcement will alter doctors if opioids the doctors prescribed are found in possession of someone other than the patient to whom they were prescribed. Patients caught selling and abusing opioids are not punished; rather, they are given access to Suboxone and to a support team - including a nurse and mental health specialist. Although the program started off as an abstinence-based program, doctors changed to a medically-assisted program when patients started to die.<ref>https://www.aha.org/news/insights-and-analysis/2018-03-28-minnesota-critical-access-hospital-uses-medication-assisted</ref>

This program has gained national attention and is currently being looked at by national policymakers.<ref>http://www.startribune.com/little-falls-effort-to-curb-opioids-gets-big-notice/448037143/</ref> For example, On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs based on the program in Little Falls, MN. H.F. No. 2140 would establish opioid abuse prevention pilot projects throughout the state with appropriate funding. Each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts. The bill is currently going through revisions in Minnesota's house and senate. <ref> https://www.chistgabriels.com/mn-house-bill-on-opioid-abuse-prevention-seeks-to-replicate-chi-st-gabriels-health-and-community-partners-model-program/</ref>Minnesota is all currently taking applications for places interested in starting pilot programs based on Little Falls' model Opioid Abuse Prevention Pilot Projects  

'''Areas of Intervention/Training''' Education for Future Doctors When future doctors go through school, there seems to be very limited education detailing pain and pain management. Pain curricula in medical school education for both MDs and DOs in the U.S. ranges from 1-31 hours during the 3-4 year curriculum, with a mean of 11.13 hours. Thus, the current training system has left primary care practitioners with inadequate tools to deal with some of the most common problems doctors will come across during their years of practice. Any meaningful effort to improve pain management will require a basic culture shift in the nation’s approach to mandating pain-related education for all health professionals who provide care to people with pain.

One possible solution is cross-training between fields. Many, if not most, pain clinics are still housed in anesthesiology clinics, but fellowship pain training can now be pursued not only by anesthesiologists but other specialists in neurology/psychiatry, PM&R, and internal and family medicine. Physicians who receive fellowship training in pain care learn interventional pain strategies that originated in regional anesthesia and acute pain care, including non-pharmacological options. The expansion of these strategies, which are the mainstay of anesthesiology and acute pain practices, to chronic pain care have had more modest success and only in carefully selected patient.<ref>http://www.asacu.org/wp-content/uploads/2017/11/JIM-Acupunctures-Role-in-Solving-the-Opioid-Epidemic.pdf</ref>  

'''Insurance and Coordinated Care''' Coordination of care across disciplines and access to nonpharmacologic care have not been optimized in the current system in most states and territories, and improvement to these systems could help reduce opioid use. There are a few state Medicaid policy initiatives aimed at increasing access to effective nonpharmacologic therapies as a first line treatment for pain conditions. For example, the Oregon Health Plan (OHP – Oregon’s Medicaid program) covers acupuncture therapy, chiropractic and osteopathic manipulation, physical therapy and cognitive behavioral therapy for all back conditions. Vermont’s legislature is piloting a program where they will cover acupuncture therapy for back pain in a Medicaid population and monitor health outcomes and cost-effectiveness. Such programs are promising and there is hope that with more interventions like this, the number of opioids being prescribed will decrease.<ref>https://www.finance.senate.gov/imo/media/doc/Coalition%20of%20Accupuncture%20Associations.pdf</ref>

= Sources =

Increase Access to Non-Pharma Therapies

2022-07-18T17:52:30Z

Katherine: /* Relevant Research */

= Introductory Paragraph =

This objective focuses on Non-Pharmacologic Pain Care (NPPC).

= Key Information =

Currently, most insurance plans do not cover most non-medication therapies. Working with insurance companies to put more alternative and complementary pain therapies in their formularies and services covered can decrease the prescribing of opioids for pain. Using such therapies that are alternatives to opiates can prevent patients from having opiates introduced into their bodies, which is one of the best ways to reduce the number of people who try an opiate. Using alternate therapies can also prevent unpleasant adverse effects of opiates, such as nausea and vomiting. Often times, people using opiates use other illicit and addicting substances to treat their nausea such as marijuana, producing a cycle of dependency on those two drugs that is difficult to break. Also, patients with Substance Use Disorder are more likely to try other addicting drugs, making treatment and quitting harder. There are many benefits of using alternative therapies, and as many fields are being studied, they appear to be a promising way to help deal with the Opioid Crisis. Considering alternative and complementary therapies in today’s society where patients often have complicated medical histories and polymedication can also help them avoid adverse drug reactions and help preserve the health of various organs by putting less stress on liver (which metabolizes the drug and detoxifies the body) and kidney (which excretes the drug). Using therapies that have less toll on the body can help our patients stay healthier and overall improve their quality of life.

'''Current Status''' Attorneys general (AGs) from 37 states have let the insurance industry know that the fight against the nation's opioid crisis won't be won unless health care providers are encouraged to prioritize nonopioid pain management options, including physical therapy, over opioid prescriptions for the treatment of chronic, noncancer pain.<ref>http://www.apta.org/PTinMotion/News/2017/9/27/AGsToAHIP/</ref> Brandeis University Professor Dr. Andrew Kolodny said efforts to limit opioid prescribing in recent years have been positive steps but warns that there are about 10 million to 12 million patients in the U.S. who have been on painkillers for years and need alternative therapies to offset the potential damage that could be caused by being cut off cold turkey.<ref>https://www.modernhealthcare.com/article/20180505/BLOG/180509948/searching-for-solutions-to-the-opioid-crisis</ref>

'''Complementary Health Approaches'''

*Acupuncture
*Chiropractic Care and Spinal Manipulation
*Massage Therapy
*Stretching and Fitness Techniques to Minimize Pain
*Mindfulness and meditation-based therapies
*Tai Chi and Qi Gong
*Yoga
*Biofeedback
*Transcutaneous electrical nerve stimulation, or TENS.  

'''Benefits of Active Self-Care Therapies''' In contrast to medication-based therapies, many Non-Pharmaceutical Pain Care (NPPC) strategies involve significant patient participation and a commitment to self-care. NPCC strategies tend to increase self-efficacy in managing pain and correlate with improved mood and outcomes in many chronic conditions, including pain. <ref>https://doi.org/10.1177/1524839904266792</ref>For example, the military has studied “active self-care therapies” as a category of pain management that may be of value in an integrated, multi-modal approach.

= Relevant Research =

'''Barriers and facilitators to use of non-pharmacological treatments in chronic pain'''<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359906/</ref>

SAFE Solutions is an ever-growing platform.  Currently no information is readily available for this section.  SAFE Project is dedicated to providing communities with the most relevant and innovative materials.  We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration.  Please check back soon.

= Impactful Federal, State, and Local Policies =

On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs. The bill is modeled after Morrison County’s program. “We’ve heard a lot of discussion about the opioid problem, and this bill offers a viable solution,” says Kresha. “There’s no sense reinventing the wheel when we know we have something that works.”

H.F. No. 2140 would require the Commissioner of Health to establish opioid abuse prevention pilot projects throughout the state and appropriate funding for these projects. Current language in the bill states each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts.

 

= Available Tools and Resources =

TR - Increase Access to Alternative Therapies to Treat Pain

 

= Promising Practices =

These programs have shown promising results with varying degrees of research.

 

'''MyStrength''' myStrength helps fill the gap between generalized pain management and prescription opioid use through education, encouragement and evidence-based pain management tools. myStrength, Inc. is a recognized leader and one of the fastest-growing digital behavioral health companies in the US. myStrength enhances traditional care models while addressing issues of cost, lack of access and stigma in order to deliver mental health and well-being resources at scale. The platform targets the most prevalent and costly behavioral health conditions, empowering consumers with innovative self-care resources to manage and overcome challenges with depression, anxiety, substance use disorders and chronic pain. myStrength collaborates with over 100 health plans, community behavioral health centers, integrated health systems and ACOs. More information on myStrength  

'''Little Falls, Minnesota's Program to Reduce Opioid Prescriptions for Pain''' In 2014, doctors in Little Falls, Minnesota noticed that there were a large number of opioid prescriptions and drug-related arrests. Through heightened addiction treatment and monitoring of prescriptions - as well as working with community partners like schools, local health departments, law enforcement, and health alliances - they were able to wean 324 patients off opioids entirely and lower prescriptions of opioids from 48,000 a month to 37,000. Patients must sign a contract when they are prescribed opioids that allows for electronic monitoring of their medical records to look for patterns of abuse, and law enforcement will alter doctors if opioids the doctors prescribed are found in possession of someone other than the patient to whom they were prescribed. Patients caught selling and abusing opioids are not punished; rather, they are given access to Suboxone and to a support team - including a nurse and mental health specialist. Although the program started off as an abstinence-based program, doctors changed to a medically-assisted program when patients started to die.<ref>https://www.aha.org/news/insights-and-analysis/2018-03-28-minnesota-critical-access-hospital-uses-medication-assisted</ref>

This program has gained national attention and is currently being looked at by national policymakers.<ref>http://www.startribune.com/little-falls-effort-to-curb-opioids-gets-big-notice/448037143/</ref> For example, On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs based on the program in Little Falls, MN. H.F. No. 2140 would establish opioid abuse prevention pilot projects throughout the state with appropriate funding. Each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts. The bill is currently going through revisions in Minnesota's house and senate. <ref> https://www.chistgabriels.com/mn-house-bill-on-opioid-abuse-prevention-seeks-to-replicate-chi-st-gabriels-health-and-community-partners-model-program/</ref>Minnesota is all currently taking applications for places interested in starting pilot programs based on Little Falls' model Opioid Abuse Prevention Pilot Projects  

'''Areas of Intervention/Training''' Education for Future Doctors When future doctors go through school, there seems to be very limited education detailing pain and pain management. Pain curricula in medical school education for both MDs and DOs in the U.S. ranges from 1-31 hours during the 3-4 year curriculum, with a mean of 11.13 hours. Thus, the current training system has left primary care practitioners with inadequate tools to deal with some of the most common problems doctors will come across during their years of practice. Any meaningful effort to improve pain management will require a basic culture shift in the nation’s approach to mandating pain-related education for all health professionals who provide care to people with pain.

One possible solution is cross-training between fields. Many, if not most, pain clinics are still housed in anesthesiology clinics, but fellowship pain training can now be pursued not only by anesthesiologists but other specialists in neurology/psychiatry, PM&R, and internal and family medicine. Physicians who receive fellowship training in pain care learn interventional pain strategies that originated in regional anesthesia and acute pain care, including non-pharmacological options. The expansion of these strategies, which are the mainstay of anesthesiology and acute pain practices, to chronic pain care have had more modest success and only in carefully selected patient.<ref>http://www.asacu.org/wp-content/uploads/2017/11/JIM-Acupunctures-Role-in-Solving-the-Opioid-Epidemic.pdf</ref>  

'''Insurance and Coordinated Care''' Coordination of care across disciplines and access to nonpharmacologic care have not been optimized in the current system in most states and territories, and improvement to these systems could help reduce opioid use. There are a few state Medicaid policy initiatives aimed at increasing access to effective nonpharmacologic therapies as a first line treatment for pain conditions. For example, the Oregon Health Plan (OHP – Oregon’s Medicaid program) covers acupuncture therapy, chiropractic and osteopathic manipulation, physical therapy and cognitive behavioral therapy for all back conditions. Vermont’s legislature is piloting a program where they will cover acupuncture therapy for back pain in a Medicaid population and monitor health outcomes and cost-effectiveness. Such programs are promising and there is hope that with more interventions like this, the number of opioids being prescribed will decrease.<ref>https://www.finance.senate.gov/imo/media/doc/Coalition%20of%20Accupuncture%20Associations.pdf</ref>

= Sources =

Increase Access to Non-Pharma Therapies

2022-07-18T17:52:07Z

Katherine: /* Relevant Research */

= Introductory Paragraph =

This objective focuses on Non-Pharmacologic Pain Care (NPPC).

= Key Information =

Currently, most insurance plans do not cover most non-medication therapies. Working with insurance companies to put more alternative and complementary pain therapies in their formularies and services covered can decrease the prescribing of opioids for pain. Using such therapies that are alternatives to opiates can prevent patients from having opiates introduced into their bodies, which is one of the best ways to reduce the number of people who try an opiate. Using alternate therapies can also prevent unpleasant adverse effects of opiates, such as nausea and vomiting. Often times, people using opiates use other illicit and addicting substances to treat their nausea such as marijuana, producing a cycle of dependency on those two drugs that is difficult to break. Also, patients with Substance Use Disorder are more likely to try other addicting drugs, making treatment and quitting harder. There are many benefits of using alternative therapies, and as many fields are being studied, they appear to be a promising way to help deal with the Opioid Crisis. Considering alternative and complementary therapies in today’s society where patients often have complicated medical histories and polymedication can also help them avoid adverse drug reactions and help preserve the health of various organs by putting less stress on liver (which metabolizes the drug and detoxifies the body) and kidney (which excretes the drug). Using therapies that have less toll on the body can help our patients stay healthier and overall improve their quality of life.

'''Current Status''' Attorneys general (AGs) from 37 states have let the insurance industry know that the fight against the nation's opioid crisis won't be won unless health care providers are encouraged to prioritize nonopioid pain management options, including physical therapy, over opioid prescriptions for the treatment of chronic, noncancer pain.<ref>http://www.apta.org/PTinMotion/News/2017/9/27/AGsToAHIP/</ref> Brandeis University Professor Dr. Andrew Kolodny said efforts to limit opioid prescribing in recent years have been positive steps but warns that there are about 10 million to 12 million patients in the U.S. who have been on painkillers for years and need alternative therapies to offset the potential damage that could be caused by being cut off cold turkey.<ref>https://www.modernhealthcare.com/article/20180505/BLOG/180509948/searching-for-solutions-to-the-opioid-crisis</ref>

'''Complementary Health Approaches'''

*Acupuncture
*Chiropractic Care and Spinal Manipulation
*Massage Therapy
*Stretching and Fitness Techniques to Minimize Pain
*Mindfulness and meditation-based therapies
*Tai Chi and Qi Gong
*Yoga
*Biofeedback
*Transcutaneous electrical nerve stimulation, or TENS.  

'''Benefits of Active Self-Care Therapies''' In contrast to medication-based therapies, many Non-Pharmaceutical Pain Care (NPPC) strategies involve significant patient participation and a commitment to self-care. NPCC strategies tend to increase self-efficacy in managing pain and correlate with improved mood and outcomes in many chronic conditions, including pain. <ref>https://doi.org/10.1177/1524839904266792</ref>For example, the military has studied “active self-care therapies” as a category of pain management that may be of value in an integrated, multi-modal approach.

= Relevant Research =

'''Barriers and facilitators to use of non-pharmacological treatments in chronic pain'''

SAFE Solutions is an ever-growing platform.  Currently no information is readily available for this section.  SAFE Project is dedicated to providing communities with the most relevant and innovative materials.  We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration.  Please check back soon.<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359906/</ref>

= Impactful Federal, State, and Local Policies =

On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs. The bill is modeled after Morrison County’s program. “We’ve heard a lot of discussion about the opioid problem, and this bill offers a viable solution,” says Kresha. “There’s no sense reinventing the wheel when we know we have something that works.”

H.F. No. 2140 would require the Commissioner of Health to establish opioid abuse prevention pilot projects throughout the state and appropriate funding for these projects. Current language in the bill states each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts.

 

= Available Tools and Resources =

TR - Increase Access to Alternative Therapies to Treat Pain

 

= Promising Practices =

These programs have shown promising results with varying degrees of research.

 

'''MyStrength''' myStrength helps fill the gap between generalized pain management and prescription opioid use through education, encouragement and evidence-based pain management tools. myStrength, Inc. is a recognized leader and one of the fastest-growing digital behavioral health companies in the US. myStrength enhances traditional care models while addressing issues of cost, lack of access and stigma in order to deliver mental health and well-being resources at scale. The platform targets the most prevalent and costly behavioral health conditions, empowering consumers with innovative self-care resources to manage and overcome challenges with depression, anxiety, substance use disorders and chronic pain. myStrength collaborates with over 100 health plans, community behavioral health centers, integrated health systems and ACOs. More information on myStrength  

'''Little Falls, Minnesota's Program to Reduce Opioid Prescriptions for Pain''' In 2014, doctors in Little Falls, Minnesota noticed that there were a large number of opioid prescriptions and drug-related arrests. Through heightened addiction treatment and monitoring of prescriptions - as well as working with community partners like schools, local health departments, law enforcement, and health alliances - they were able to wean 324 patients off opioids entirely and lower prescriptions of opioids from 48,000 a month to 37,000. Patients must sign a contract when they are prescribed opioids that allows for electronic monitoring of their medical records to look for patterns of abuse, and law enforcement will alter doctors if opioids the doctors prescribed are found in possession of someone other than the patient to whom they were prescribed. Patients caught selling and abusing opioids are not punished; rather, they are given access to Suboxone and to a support team - including a nurse and mental health specialist. Although the program started off as an abstinence-based program, doctors changed to a medically-assisted program when patients started to die.<ref>https://www.aha.org/news/insights-and-analysis/2018-03-28-minnesota-critical-access-hospital-uses-medication-assisted</ref>

This program has gained national attention and is currently being looked at by national policymakers.<ref>http://www.startribune.com/little-falls-effort-to-curb-opioids-gets-big-notice/448037143/</ref> For example, On March 6, 2017, Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs based on the program in Little Falls, MN. H.F. No. 2140 would establish opioid abuse prevention pilot projects throughout the state with appropriate funding. Each pilot project would establish a multidisciplinary controlled substance care team, deliver health care services and care coordination to reduce inappropriate use of opioids, address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes, provide prescriber and dispenser education, promote best practices related to opioid disposal, and engage community partners outside the health care system in such efforts. The bill is currently going through revisions in Minnesota's house and senate. <ref> https://www.chistgabriels.com/mn-house-bill-on-opioid-abuse-prevention-seeks-to-replicate-chi-st-gabriels-health-and-community-partners-model-program/</ref>Minnesota is all currently taking applications for places interested in starting pilot programs based on Little Falls' model Opioid Abuse Prevention Pilot Projects  

'''Areas of Intervention/Training''' Education for Future Doctors When future doctors go through school, there seems to be very limited education detailing pain and pain management. Pain curricula in medical school education for both MDs and DOs in the U.S. ranges from 1-31 hours during the 3-4 year curriculum, with a mean of 11.13 hours. Thus, the current training system has left primary care practitioners with inadequate tools to deal with some of the most common problems doctors will come across during their years of practice. Any meaningful effort to improve pain management will require a basic culture shift in the nation’s approach to mandating pain-related education for all health professionals who provide care to people with pain.

One possible solution is cross-training between fields. Many, if not most, pain clinics are still housed in anesthesiology clinics, but fellowship pain training can now be pursued not only by anesthesiologists but other specialists in neurology/psychiatry, PM&R, and internal and family medicine. Physicians who receive fellowship training in pain care learn interventional pain strategies that originated in regional anesthesia and acute pain care, including non-pharmacological options. The expansion of these strategies, which are the mainstay of anesthesiology and acute pain practices, to chronic pain care have had more modest success and only in carefully selected patient.<ref>http://www.asacu.org/wp-content/uploads/2017/11/JIM-Acupunctures-Role-in-Solving-the-Opioid-Epidemic.pdf</ref>  

'''Insurance and Coordinated Care''' Coordination of care across disciplines and access to nonpharmacologic care have not been optimized in the current system in most states and territories, and improvement to these systems could help reduce opioid use. There are a few state Medicaid policy initiatives aimed at increasing access to effective nonpharmacologic therapies as a first line treatment for pain conditions. For example, the Oregon Health Plan (OHP – Oregon’s Medicaid program) covers acupuncture therapy, chiropractic and osteopathic manipulation, physical therapy and cognitive behavioral therapy for all back conditions. Vermont’s legislature is piloting a program where they will cover acupuncture therapy for back pain in a Medicaid population and monitor health outcomes and cost-effectiveness. Such programs are promising and there is hope that with more interventions like this, the number of opioids being prescribed will decrease.<ref>https://www.finance.senate.gov/imo/media/doc/Coalition%20of%20Accupuncture%20Associations.pdf</ref>

= Sources =

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:47:52Z

Katherine: /* Impactful Federal, State, and Local Policies */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

'''How can prescription drug misuse be prevented?'''<ref>https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/how-can-prescription-drug-misuse-be-prevented</ref>''Misuse of Prescription Drugs Research Report''

=Impactful Federal, State, and Local Policies=

'''Help & Resources for the National Opioid Crisis''' Grant and Funding opportunities.<ref>https://www.grants.gov/search-grants.html?cfda=93.430%2093.664%2093.378%2093.687%2093.732%2093.191%2093.732%2093.732%2093.162%2093.928%2093.527%2093.193%2093.933%2093.243%2093.276%2093.788%2093.959%2093.279%2093.273%2093.912%2093.136%2093.421%2093.772%2093.087</ref>

'''Prescribing Policies: States Confront Opioid Overdose Epidemic'''<ref>https://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx</ref>

'''2016 State Legislation Limiting Opioid Prescriptions'''<ref>https://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx</ref>

=Tools & Resources=
'''The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain''' The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.<ref>https://www.cdc.gov/opioids/providers/prescribing/guideline.html</ref>

'''Health & Human Services Help & Resources for National Opioid Crisis'''<ref>https://www.hhs.gov/opioids/</ref> Safe and Proper Use of Opioids and prescribing.<ref>https://www.hhs.gov/opioids/prevention/safe-opioid-prescribing/index.html</ref>

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

*Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
*Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
*Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.<ref>https://aishealth.mmitnetwork.com/</ref>
*Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
*Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.<ref>https://aishealth.mmitnetwork.com/</ref>
*Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
*Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
*Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
*Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.<ref>https://aishealth.mmitnetwork.com/</ref>

A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations<ref>https://www.justice.gov/usao/file/895091/download</ref>
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up<ref>https://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html</ref>

<ref>https://www.cdc.gov/drugoverdose/pdmp/</ref>- State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.<ref>https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain</ref>

*Arizona - quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.<ref>https://forensicfluids.com/</ref>
*Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.<ref>https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use</ref>
*Ohio In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*West Virginia doctors are going to to be ranked based on how much they prescribe opioids<ref>https://www.medscape.com/viewarticle/842715_2</ref>

'''Saliva Drug Screening''' For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.<ref>https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063</ref>

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run. Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. ''Contact'': John Cribbs at john@nodrugsneeded.com

'''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. <ref>https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test</ref> -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication. ''Contact'': John Cribbs at john@nodrugsneeded.com. <ref>https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education</ref>-''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

==Sources==

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:44:58Z

Katherine: /* Impactful Federal, State, and Local Policies */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

'''How can prescription drug misuse be prevented?'''<ref>https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/how-can-prescription-drug-misuse-be-prevented</ref>''Misuse of Prescription Drugs Research Report''

=Impactful Federal, State, and Local Policies=

'''Help & Resources for the National Opioid Crisis''' Grant and Funding opportunities.<ref>https://www.grants.gov/search-grants.html?cfda=93.430%2093.664%2093.378%2093.687%2093.732%2093.191%2093.732%2093.732%2093.162%2093.928%2093.527%2093.193%2093.933%2093.243%2093.276%2093.788%2093.959%2093.279%2093.273%2093.912%2093.136%2093.421%2093.772%2093.087</ref>

'''Prescribing Policies: States Confront Opioid Overdose Epidemic'''<ref>https://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx</ref>

=Tools & Resources=
'''The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain''' The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.<ref>https://www.cdc.gov/opioids/providers/prescribing/guideline.html</ref>

'''Health & Human Services Help & Resources for National Opioid Crisis'''<ref>https://www.hhs.gov/opioids/</ref> Safe and Proper Use of Opioids and prescribing.<ref>https://www.hhs.gov/opioids/prevention/safe-opioid-prescribing/index.html</ref>

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

*Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
*Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
*Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.<ref>https://aishealth.mmitnetwork.com/</ref>
*Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
*Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.<ref>https://aishealth.mmitnetwork.com/</ref>
*Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
*Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
*Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
*Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.<ref>https://aishealth.mmitnetwork.com/</ref>

A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations<ref>https://www.justice.gov/usao/file/895091/download</ref>
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up<ref>https://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html</ref>

<ref>https://www.cdc.gov/drugoverdose/pdmp/</ref>- State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.<ref>https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain</ref>

*Arizona - quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.<ref>https://forensicfluids.com/</ref>
*Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.<ref>https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use</ref>
*Ohio In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*West Virginia doctors are going to to be ranked based on how much they prescribe opioids<ref>https://www.medscape.com/viewarticle/842715_2</ref>

'''Saliva Drug Screening''' For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.<ref>https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063</ref>

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run. Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. ''Contact'': John Cribbs at john@nodrugsneeded.com

'''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. <ref>https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test</ref> -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication. ''Contact'': John Cribbs at john@nodrugsneeded.com. <ref>https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education</ref>-''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

==Sources==

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:42:59Z

Katherine: /* Tools & Resources */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

'''How can prescription drug misuse be prevented?'''<ref>https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/how-can-prescription-drug-misuse-be-prevented</ref>''Misuse of Prescription Drugs Research Report''

=Impactful Federal, State, and Local Policies=

'''Help & Resources for the National Opioid Crisis''' Grant and Funding opportunities.<ref>https://www.grants.gov/search-grants.html?cfda=93.430%2093.664%2093.378%2093.687%2093.732%2093.191%2093.732%2093.732%2093.162%2093.928%2093.527%2093.193%2093.933%2093.243%2093.276%2093.788%2093.959%2093.279%2093.273%2093.912%2093.136%2093.421%2093.772%2093.087</ref>

=Tools & Resources=
'''The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain''' The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.<ref>https://www.cdc.gov/opioids/providers/prescribing/guideline.html</ref>

'''Health & Human Services Help & Resources for National Opioid Crisis'''<ref>https://www.hhs.gov/opioids/</ref> Safe and Proper Use of Opioids and prescribing.<ref>https://www.hhs.gov/opioids/prevention/safe-opioid-prescribing/index.html</ref>

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

*Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
*Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
*Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.<ref>https://aishealth.mmitnetwork.com/</ref>
*Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
*Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.<ref>https://aishealth.mmitnetwork.com/</ref>
*Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
*Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
*Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
*Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.<ref>https://aishealth.mmitnetwork.com/</ref>

A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations<ref>https://www.justice.gov/usao/file/895091/download</ref>
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up<ref>https://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html</ref>

<ref>https://www.cdc.gov/drugoverdose/pdmp/</ref>- State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.<ref>https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain</ref>

*Arizona - quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.<ref>https://forensicfluids.com/</ref>
*Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.<ref>https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use</ref>
*Ohio In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*West Virginia doctors are going to to be ranked based on how much they prescribe opioids<ref>https://www.medscape.com/viewarticle/842715_2</ref>

'''Saliva Drug Screening''' For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.<ref>https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063</ref>

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run. Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. ''Contact'': John Cribbs at john@nodrugsneeded.com

'''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. <ref>https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test</ref> -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication. ''Contact'': John Cribbs at john@nodrugsneeded.com. <ref>https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education</ref>-''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

==Sources==

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:39:30Z

Katherine: /* Tools & Resources */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

'''How can prescription drug misuse be prevented?'''<ref>https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/how-can-prescription-drug-misuse-be-prevented</ref>''Misuse of Prescription Drugs Research Report''

=Impactful Federal, State, and Local Policies=

'''Help & Resources for the National Opioid Crisis''' Grant and Funding opportunities.<ref>https://www.grants.gov/search-grants.html?cfda=93.430%2093.664%2093.378%2093.687%2093.732%2093.191%2093.732%2093.732%2093.162%2093.928%2093.527%2093.193%2093.933%2093.243%2093.276%2093.788%2093.959%2093.279%2093.273%2093.912%2093.136%2093.421%2093.772%2093.087</ref>

=Tools & Resources=
'''The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain''' The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.<ref>https://www.cdc.gov/opioids/providers/prescribing/guideline.html</ref>

'''Health & Human Services Help & Resources for National Opioid Crisis'''<ref>https://www.hhs.gov/opioids/</ref>

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

*Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
*Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
*Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.<ref>https://aishealth.mmitnetwork.com/</ref>
*Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
*Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.<ref>https://aishealth.mmitnetwork.com/</ref>
*Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
*Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
*Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
*Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.<ref>https://aishealth.mmitnetwork.com/</ref>

A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations<ref>https://www.justice.gov/usao/file/895091/download</ref>
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up<ref>https://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html</ref>

<ref>https://www.cdc.gov/drugoverdose/pdmp/</ref>- State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.<ref>https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain</ref>

*Arizona - quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.<ref>https://forensicfluids.com/</ref>
*Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.<ref>https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use</ref>
*Ohio In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*West Virginia doctors are going to to be ranked based on how much they prescribe opioids<ref>https://www.medscape.com/viewarticle/842715_2</ref>

'''Saliva Drug Screening''' For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.<ref>https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063</ref>

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run. Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. ''Contact'': John Cribbs at john@nodrugsneeded.com

'''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. <ref>https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test</ref> -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication. ''Contact'': John Cribbs at john@nodrugsneeded.com. <ref>https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education</ref>-''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

==Sources==

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:37:33Z

Katherine: /* Impactful Federal, State, and Local Policies */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

'''How can prescription drug misuse be prevented?'''<ref>https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/how-can-prescription-drug-misuse-be-prevented</ref>''Misuse of Prescription Drugs Research Report''

=Impactful Federal, State, and Local Policies=

'''Help & Resources for the National Opioid Crisis''' Grant and Funding opportunities.<ref>https://www.grants.gov/search-grants.html?cfda=93.430%2093.664%2093.378%2093.687%2093.732%2093.191%2093.732%2093.732%2093.162%2093.928%2093.527%2093.193%2093.933%2093.243%2093.276%2093.788%2093.959%2093.279%2093.273%2093.912%2093.136%2093.421%2093.772%2093.087</ref>

=Tools & Resources=
'''The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain''' The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.<ref>https://www.cdc.gov/opioids/providers/prescribing/guideline.html</ref>

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

*Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
*Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
*Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.<ref>https://aishealth.mmitnetwork.com/</ref>
*Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
*Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.<ref>https://aishealth.mmitnetwork.com/</ref>
*Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
*Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
*Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
*Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.<ref>https://aishealth.mmitnetwork.com/</ref>

A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations<ref>https://www.justice.gov/usao/file/895091/download</ref>
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up<ref>https://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html</ref>

<ref>https://www.cdc.gov/drugoverdose/pdmp/</ref>- State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.<ref>https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain</ref>

*Arizona - quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.<ref>https://forensicfluids.com/</ref>
*Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.<ref>https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use</ref>
*Ohio In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*West Virginia doctors are going to to be ranked based on how much they prescribe opioids<ref>https://www.medscape.com/viewarticle/842715_2</ref>

'''Saliva Drug Screening''' For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.<ref>https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063</ref>

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run. Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. ''Contact'': John Cribbs at john@nodrugsneeded.com

'''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. <ref>https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test</ref> -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication. ''Contact'': John Cribbs at john@nodrugsneeded.com. <ref>https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education</ref>-''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

==Sources==

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:37:12Z

Katherine: /* Tools & Resources */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

'''How can prescription drug misuse be prevented?'''<ref>https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/how-can-prescription-drug-misuse-be-prevented</ref>''Misuse of Prescription Drugs Research Report''

=Impactful Federal, State, and Local Policies=

=Tools & Resources=
'''The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain''' The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.<ref>https://www.cdc.gov/opioids/providers/prescribing/guideline.html</ref>

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

*Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
*Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
*Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.<ref>https://aishealth.mmitnetwork.com/</ref>
*Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
*Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.<ref>https://aishealth.mmitnetwork.com/</ref>
*Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
*Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
*Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
*Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.<ref>https://aishealth.mmitnetwork.com/</ref>

A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations<ref>https://www.justice.gov/usao/file/895091/download</ref>
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up<ref>https://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html</ref>

<ref>https://www.cdc.gov/drugoverdose/pdmp/</ref>- State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.<ref>https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain</ref>

*Arizona - quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.<ref>https://forensicfluids.com/</ref>
*Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.<ref>https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use</ref>
*Ohio In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*West Virginia doctors are going to to be ranked based on how much they prescribe opioids<ref>https://www.medscape.com/viewarticle/842715_2</ref>

'''Saliva Drug Screening''' For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.<ref>https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063</ref>

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run. Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. ''Contact'': John Cribbs at john@nodrugsneeded.com

'''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. <ref>https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test</ref> -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication. ''Contact'': John Cribbs at john@nodrugsneeded.com. <ref>https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education</ref>-''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

==Sources==

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:34:09Z

Katherine: /* Relevant Research */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

'''How can prescription drug misuse be prevented?'''<ref>https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/how-can-prescription-drug-misuse-be-prevented</ref>''Misuse of Prescription Drugs Research Report''

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

*Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
*Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
*Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.<ref>https://aishealth.mmitnetwork.com/</ref>
*Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
*Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.<ref>https://aishealth.mmitnetwork.com/</ref>
*Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
*Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
*Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
*Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.<ref>https://aishealth.mmitnetwork.com/</ref>

A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations<ref>https://www.justice.gov/usao/file/895091/download</ref>
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up<ref>https://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html</ref>

<ref>https://www.cdc.gov/drugoverdose/pdmp/</ref>- State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.<ref>https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain</ref>

*Arizona - quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.<ref>https://forensicfluids.com/</ref>
*Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.<ref>https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use</ref>
*Ohio In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*West Virginia doctors are going to to be ranked based on how much they prescribe opioids<ref>https://www.medscape.com/viewarticle/842715_2</ref>

'''Saliva Drug Screening''' For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.<ref>https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063</ref>

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run. Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. ''Contact'': John Cribbs at john@nodrugsneeded.com

'''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. <ref>https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test</ref> -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication. ''Contact'': John Cribbs at john@nodrugsneeded.com. <ref>https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education</ref>-''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

==Sources==

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:23:51Z

Katherine: /* Promising Practices */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

*Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
*Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
*Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.<ref>https://aishealth.mmitnetwork.com/</ref>
*Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
*Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.<ref>https://aishealth.mmitnetwork.com/</ref>
*Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
*Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
*Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
*Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.<ref>https://aishealth.mmitnetwork.com/</ref>

A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations<ref>https://www.justice.gov/usao/file/895091/download</ref>
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up<ref>https://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html</ref>

<ref>https://www.cdc.gov/drugoverdose/pdmp/</ref>- State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.<ref>https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain</ref>

*Arizona - quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.<ref>https://forensicfluids.com/</ref>
*Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.<ref>https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use</ref>
*Ohio In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*West Virginia doctors are going to to be ranked based on how much they prescribe opioids<ref>https://www.medscape.com/viewarticle/842715_2</ref>

'''Saliva Drug Screening''' For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.<ref>https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063</ref>

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run. Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. ''Contact'': John Cribbs at john@nodrugsneeded.com

'''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. <ref>https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test</ref> -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication. ''Contact'': John Cribbs at john@nodrugsneeded.com. <ref>https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education</ref>-''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

==Sources==

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:21:29Z

Katherine: /* Promising Practices */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

*Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
*Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
*Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.<ref>https://aishealth.mmitnetwork.com/</ref>
*Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
*Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.<ref>https://aishealth.mmitnetwork.com/</ref>
*Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
*Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
*Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
*Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.<ref>https://aishealth.mmitnetwork.com/</ref>

A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations<ref>https://www.justice.gov/usao/file/895091/download</ref>
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up<ref>https://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html</ref>

<ref>https://www.cdc.gov/drugoverdose/pdmp/</ref>- State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.<ref>https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain</ref>

*Arizona - quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.<ref>https://forensicfluids.com/</ref>
*Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.<ref>https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use</ref>
*Ohio In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*West Virginia doctors are going to to be ranked based on how much they prescribe opioids<ref>https://www.medscape.com/viewarticle/842715_2</ref>

'''Saliva Drug Screening''' For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.<ref>https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063</ref>

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run. Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. ''Contact'': John Cribbs (john@nodrugsneeded.com) ''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. <ref>https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test</ref> -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com <ref>https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education</ref>-''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

==Sources==

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:20:04Z

Katherine: /* Promising Practices */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

*Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
*Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
*Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.<ref>https://aishealth.mmitnetwork.com/</ref>
*Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
*Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.<ref>https://aishealth.mmitnetwork.com/</ref>
*Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
*Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
*Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
*Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.<ref>https://aishealth.mmitnetwork.com/</ref>

A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations<ref>https://www.justice.gov/usao/file/895091/download</ref>
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up<ref>https://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html</ref>

<ref>https://www.cdc.gov/drugoverdose/pdmp/</ref>- State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.<ref>https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain</ref>

*Arizona - quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.<ref>https://forensicfluids.com/</ref>
*Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.<ref>https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use</ref>
*Ohio In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*West Virginia doctors are going to to be ranked based on how much they prescribe opioids<ref>https://www.medscape.com/viewarticle/842715_2</ref>

'''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.<ref>https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063</ref>

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. <ref>https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test</ref> -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com <ref>https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education</ref>-''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

==Sources==

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:18:13Z

Katherine: /* Promising Practices */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

*Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
*Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
*Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.<ref>https://aishealth.mmitnetwork.com/</ref>
*Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
*Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.<ref>https://aishealth.mmitnetwork.com/</ref>
*Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
*Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
*Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
*Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.<ref>https://aishealth.mmitnetwork.com/</ref>

'''Results''' A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations<ref>https://www.justice.gov/usao/file/895091/download</ref>
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up<ref>https://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html</ref>

<ref>https://www.cdc.gov/drugoverdose/pdmp/</ref>- State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.<ref>https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain</ref>

*Arizona - quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.<ref>https://forensicfluids.com/</ref>
*Kentucky prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.<ref>https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use</ref>
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*West Virginia doctors are going to to be ranked based on how much they prescribe opioids<ref>https://www.medscape.com/viewarticle/842715_2</ref>

'''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.<ref>https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063</ref>

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. <ref>https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test</ref> -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com <ref>https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education</ref>-''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

==Sources==

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:14:29Z

Katherine: /* Promising Practices */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.<ref>https://aishealth.mmitnetwork.com/</ref>
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.<ref>https://aishealth.mmitnetwork.com/</ref>
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.<ref>https://aishealth.mmitnetwork.com/</ref>

'''Results''' A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations<ref>https://www.justice.gov/usao/file/895091/download</ref>
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up<ref>https://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html</ref>

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.<ref>https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965/as-views-change-on-opioids-patients-and-providers-find-few-other-options-for-managing-pain</ref>

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.<ref>https://forensicfluids.com/</ref>
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.<ref>https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/prescription-opioid-use-risk-factor-heroin-use</ref>
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids<ref>https://www.medscape.com/viewarticle/842715_2</ref>

'''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.<ref>https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0496?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063</ref>

Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. <ref>https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test</ref> -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) <ref>https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education</ref>-''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T17:00:49Z

Katherine: /* Promising Practices */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

'''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.<ref>https://aishealth.mmitnetwork.com/</ref>
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.<ref>https://aishealth.mmitnetwork.com/</ref>
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:59:10Z

Katherine: /* Promising Practices */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.<ref>https://aishealth.mmitnetwork.com/</ref>

This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:56:26Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)<ref>http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign=</ref>
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:55:41Z

Katherine: /* Promising Practices */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:54:34Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse.<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>

*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

http://pediatrics.aappublications.org/content/136/5/e1169
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:52:56Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

http://pediatrics.aappublications.org/content/136/5/e1169
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:51:46Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids<ref>https://www.planagainstpain.com/explore-our-toolkit/2017-national-report/</ref>
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

http://pediatrics.aappublications.org/content/136/5/e1169
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:50:03Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse<ref>http://pediatrics.aappublications.org/content/136/5/e1169</ref>
*Middle age women consume the most opioids[9]
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

http://pediatrics.aappublications.org/content/136/5/e1169
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:49:18Z

Katherine: /* Promising Practices */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse[8]
*Middle age women consume the most opioids[9]
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

http://pediatrics.aappublications.org/content/136/5/e1169
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:48:20Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug." <ref>http://www.planagainstpain.com/resources/usnd/</ref> Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines. "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.<ref>http://www.planagainstpain.com/resources/usnd/</ref>

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse[8]
*Middle age women consume the most opioids[9]
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

#[https://www.drugrehab.com/opioid-epidemic/ [4]]
#http://www.planagainstpain.com/resources/usnd/ [5]
#http://www.planagainstpain.com/resources/usnd/ [6]
#http://www.planagainstpain.com/resources/usnd/ [7]
##
##*
##**
##***
##****[http://pediatrics.aappublications.org/content/136/5/e1169 [8]]
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:45:42Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics. <ref>https://www.drugrehab.com/featured/opioid-epidemic-causes/</ref> This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug."[5] Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines.[6] "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.[7]

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse[8]
*Middle age women consume the most opioids[9]
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

#[https://www.drugrehab.com/opioid-epidemic/ [4]]
#http://www.planagainstpain.com/resources/usnd/ [5]
#http://www.planagainstpain.com/resources/usnd/ [6]
#http://www.planagainstpain.com/resources/usnd/ [7]
##
##*
##**
##***
##****[http://pediatrics.aappublications.org/content/136/5/e1169 [8]]
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:44:16Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.<ref>http://www.nytimes.com/2007/05/10/business/11drug-web.html</ref>The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics.[4] This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug."[5] Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines.[6] "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.[7]

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse[8]
*Middle age women consume the most opioids[9]
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

#[https://www.drugrehab.com/opioid-epidemic/ [4]]
#http://www.planagainstpain.com/resources/usnd/ [5]
#http://www.planagainstpain.com/resources/usnd/ [6]
#http://www.planagainstpain.com/resources/usnd/ [7]
##
##*
##**
##***
##****[http://pediatrics.aappublications.org/content/136/5/e1169 [8]]
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:43:28Z

Katherine: /* Sources */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.3] The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics.[4] This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug."[5] Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines.[6] "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.[7]

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse[8]
*Middle age women consume the most opioids[9]
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

#[https://www.drugrehab.com/opioid-epidemic/ [4]]
#http://www.planagainstpain.com/resources/usnd/ [5]
#http://www.planagainstpain.com/resources/usnd/ [6]
#http://www.planagainstpain.com/resources/usnd/ [7]
##
##*
##**
##***
##****[http://pediatrics.aappublications.org/content/136/5/e1169 [8]]
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:42:16Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.<ref>www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse</ref> At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.3] The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics.[4] This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug."[5] Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines.[6] "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.[7]

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse[8]
*Middle age women consume the most opioids[9]
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

= Sources =

----

<ref>[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-prescriptions-20170706-story.html [1]],</ref>
#U.S. Department of Health and Human Services, “Press Release: Prescription painkiller overdoses at epidemic levels,” November 1, 2011, www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html.
#Nora D. Volkow, “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse,” National Institute on Drug Abuse, May 14, 2014, www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse.
#Pokrovnichka, Anjelina. "History of Oxycontin: Labeling and Risk Management Program."
#Meier, Barry. "In Guilty Plea, OxyContin Maker to Pay $600 Million." ''The New York Times''. The New York Times, 09 May 2007. Web. 01 Feb. 2017. <[http://www.nytimes.com/2007/05/10/business/11drug-web.html [2]]>.
#Meier, Barry. "In Guilty Plea, OxyContin Maker to Pay $600 Million." ''The New York Times''. The New York Times, 09 May 2007. Web. 01 Feb. 2017. <[http://www.nytimes.com/2007/05/10/business/11drug-web.html [3]]>.
#[https://www.drugrehab.com/opioid-epidemic/ [4]]
#http://www.planagainstpain.com/resources/usnd/ [5]
#http://www.planagainstpain.com/resources/usnd/ [6]
#http://www.planagainstpain.com/resources/usnd/ [7]
##
##*
##**
##***
##****[http://pediatrics.aappublications.org/content/136/5/e1169 [8]]
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:40:16Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.<ref>www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html</ref> In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.[2] At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.[3] The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics.[4] This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug."[5] Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines.[6] "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.[7]

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse[8]
*Middle age women consume the most opioids[9]
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

= Sources =

----

<ref>[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-prescriptions-20170706-story.html [1]],</ref>
#U.S. Department of Health and Human Services, “Press Release: Prescription painkiller overdoses at epidemic levels,” November 1, 2011, www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html.
#Nora D. Volkow, “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse,” National Institute on Drug Abuse, May 14, 2014, www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse.
#Pokrovnichka, Anjelina. "History of Oxycontin: Labeling and Risk Management Program."
#Meier, Barry. "In Guilty Plea, OxyContin Maker to Pay $600 Million." ''The New York Times''. The New York Times, 09 May 2007. Web. 01 Feb. 2017. <[http://www.nytimes.com/2007/05/10/business/11drug-web.html [2]]>.
#Meier, Barry. "In Guilty Plea, OxyContin Maker to Pay $600 Million." ''The New York Times''. The New York Times, 09 May 2007. Web. 01 Feb. 2017. <[http://www.nytimes.com/2007/05/10/business/11drug-web.html [3]]>.
#[https://www.drugrehab.com/opioid-epidemic/ [4]]
#http://www.planagainstpain.com/resources/usnd/ [5]
#http://www.planagainstpain.com/resources/usnd/ [6]
#http://www.planagainstpain.com/resources/usnd/ [7]
##
##*
##**
##***
##****[http://pediatrics.aappublications.org/content/136/5/e1169 [8]]
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:39:14Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.[1] In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin'' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.[2] At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.[3] The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics.[4] This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug."[5] Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines.[6] "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.[7]

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse[8]
*Middle age women consume the most opioids[9]
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

= Sources =

----

<ref>[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-prescriptions-20170706-story.html [1]],</ref>
#U.S. Department of Health and Human Services, “Press Release: Prescription painkiller overdoses at epidemic levels,” November 1, 2011, www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html.
#Nora D. Volkow, “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse,” National Institute on Drug Abuse, May 14, 2014, www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse.
#Pokrovnichka, Anjelina. "History of Oxycontin: Labeling and Risk Management Program."
#Meier, Barry. "In Guilty Plea, OxyContin Maker to Pay $600 Million." ''The New York Times''. The New York Times, 09 May 2007. Web. 01 Feb. 2017. <[http://www.nytimes.com/2007/05/10/business/11drug-web.html [2]]>.
#Meier, Barry. "In Guilty Plea, OxyContin Maker to Pay $600 Million." ''The New York Times''. The New York Times, 09 May 2007. Web. 01 Feb. 2017. <[http://www.nytimes.com/2007/05/10/business/11drug-web.html [3]]>.
#[https://www.drugrehab.com/opioid-epidemic/ [4]]
#http://www.planagainstpain.com/resources/usnd/ [5]
#http://www.planagainstpain.com/resources/usnd/ [6]
#http://www.planagainstpain.com/resources/usnd/ [7]
##
##*
##**
##***
##****[http://pediatrics.aappublications.org/content/136/5/e1169 [8]]
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Reduce Over-Prescription of Prescription Drugs

2022-07-18T16:37:47Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.[1] In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin''' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.[2] At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.[3] The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics.[4] This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug."[5] Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines.[6] "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.[7]  

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse[8]
*Middle age women consume the most opioids[9]
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council <ref>http://www.nsc.org/pages/home.aspx nsc.org</ref> is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)? ; A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

= Sources =

----

<ref>[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-prescriptions-20170706-story.html [1]],</ref>
#U.S. Department of Health and Human Services, “Press Release: Prescription painkiller overdoses at epidemic levels,” November 1, 2011, www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html.
#Nora D. Volkow, “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse,” National Institute on Drug Abuse, May 14, 2014, www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse.
#Pokrovnichka, Anjelina. "History of Oxycontin: Labeling and Risk Management Program."
#Meier, Barry. "In Guilty Plea, OxyContin Maker to Pay $600 Million." ''The New York Times''. The New York Times, 09 May 2007. Web. 01 Feb. 2017. <[http://www.nytimes.com/2007/05/10/business/11drug-web.html [2]]>.
#Meier, Barry. "In Guilty Plea, OxyContin Maker to Pay $600 Million." ''The New York Times''. The New York Times, 09 May 2007. Web. 01 Feb. 2017. <[http://www.nytimes.com/2007/05/10/business/11drug-web.html [3]]>.
#[https://www.drugrehab.com/opioid-epidemic/ [4]]
#http://www.planagainstpain.com/resources/usnd/ [5]
#http://www.planagainstpain.com/resources/usnd/ [6]
#http://www.planagainstpain.com/resources/usnd/ [7]
##
##*
##**
##***
##****[http://pediatrics.aappublications.org/content/136/5/e1169 [8]]
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Expand DNA Testing to Improve Precision MAT/MAR Therapies

2022-07-14T22:14:55Z

Katherine: /* The Opportunity with Precision MAT */

=Introductory Paragraph =
Genetics and genetic makeup impact how individuals respond to medications. Genetic and DNA testing can enhance personalized medicine to improve Medication-assisted therapies.<ref>https://healthitanalytics.com/news/why-genetic-testing-is-key-to-advancing-precision-medicine</ref>

*Individuals all process and metabolize drugs in differing ways.<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5447546/</ref>
*Someone's genetic makeup, the amount of enzymes, and specific receptors they have contribute to how a person can metabolize medicine
*A person's genetic makeup also impacts how certain foods will affect how drugs are metabolized.
*Genetic testing reveals information that can help us accurately tailor medications on a patient-to-patient basis. This is called Precision or Personalized Medicine
*In the past, physicians have had limited tools when it comes to evaluating options or dosages for Medication Assisted Treatment Plans
*The result is that Medication Assisted Treatment plans usually rely on a series of "trial and error" doses that are adjusted based on response of the patient to the doses being tried without using insights from genetic tests to optimize the plan for each patient.
*When the does of medication is not ideal, the patient either receives insufficient benefit from the medication or has side effects or adverse drug reactions.<ref>https://www.journals.elsevier.com/addictive-behaviors-reports</ref>
*The inconsistent impact of medication used in MAT is a contributing factor to the high relapse rates in opioid addicted patients. Even for those receiving MAT, the relapse rate tends to be about 50%
*Patients who abstain from opioids in the first two weeks have a good chance of good 12-week outcome. However, those who use opioids in each of the first 2 weeks (even in week 1 alone) have very little chance of abstaining by week 12

=Key Information=

"Precision medicine focuses on providing health care with increased resolution, accounting for aspects that are unique to the individual and their disease. By definition, precision medicine involves all phases of care: prevention, diagnosis, and treatment."<ref>https://ascpt.onlinelibrary.wiley.com/doi/full/10.1002/cpt.1622</ref>

==The Opportunity with Precision MAT ==

With today's more refined analysis of the human genome map, their is a growing database of variability of gene alleles and how they account for changes in drug metabolism.
A clinical genomic test can be performed and a report can be created that displays the expected benefits and risks the patient has if they receive any one of over 200 medications (in this case with a focus on the drugs being used to treat opioid addiction), and how the patient's dietary regimen can affect medications they may be taking or will take in the future to treat their addiction and potential related diseases.

*This Webinar provides a good overview on Pharmacogenetics and MAT: <ref>https://www.creighton.edu/events/PIPAN2022</ref>
*Such dynamic, interactive reports can then be used by physicians and other medical providers such as nurse practitioners, pharmacists, therapists, dietitians and other social service professionals to develop more precise treatment plans of care for the individual patient.
*An on-going research study is showing that more precise dosing in Medication Assisted Treatment, based on more accurate analysis of Gene allele variability| has decreased relapse rates in opioid addicted patients down to 25% over an 18 month tracking period.<ref>https://dnacenter.com/blog/swabs-vs-blood-samples-dna-testing/</ref>

== Genetic Tests ==

*A genetic test is performed by obtaining a simple cheek swab that collects DNA from the cells on the inside of a person’s mouth. The specimen collection can be performed by an appropriately trained individual and the report results available in 1-2 weeks.
*Using a cheek swab is one of the two most popular ways to do DNA tests[13] .
*Insurance coverage varies for this test which costs approximates between $500 and $1,200 based on whether annual pharmacy consultative services are included.
*Medicare is the most reliable payer and the commercial carriers range in reliability of payment. Few Medicaid carriers are currently paying for these tests today but with the significant funding being made available to individual states to address the opioid addiction crisis, the anticipation is that the state based Medicaid plans will begin to address this coverage gap.
*Premier DNA is a genetics testing company that has created a integrated care model combining genetic testing, interactive genetic reporting, and pharmacy consultation. They offer this program under the registered trade name Med Op Rx. This service becomes a useful tool to guide the physician in terms of implementing the most precise MAT program given the individual patient's genetic makeup.

=Relevant Research=
There is ongoing research and funding around precision medicine across both mental and physical health including substance use and medication assisted therapy.

'''Genetic testing: Opportunities to unlock value in precision medicine'''<ref>https://www.mckinsey.com/industries/life-sciences/our-insights/genetic-testing-opportunities-to-unlock-value-in-precision-medicine</ref>

'''Pharmacogenetic Testing: A Tool for Personalized Drug Therapy Optimization'''<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7765968/</ref>

'''U.S. Department of Veteran Affairs Office of Research & Development''' ''Genomics & Mental Health''<ref>https://www.research.va.gov/topics/genomics.cfm#research3</ref>

'''Biomarkers in precision medicine for mental illnesses'''<ref>https://acamh.onlinelibrary.wiley.com/doi/full/10.1111/jcpp.13357</ref>

'''Precision Medicine & Global Mental Health'''<ref>https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30406-6/fulltext</ref>

'''Study design and implementation of the Precision Medicine In Mental health Care (PRIME Care) Trial'''<ref>https://www.sciencedirect.com/science/article/pii/S1551714420303256</ref>

=Impactful Federal, State, and Local Policies=
'''Precision Medicine Initiative''' 2015/2016 White House initiative to improve precision medicine. The mission is to enable a new era of medicine through research, technology, and policies that empower patients, researchers, and providers to work together toward development of individualized care.<ref>https://obamawhitehouse.archives.gov/precision-medicine</ref>

'''Personalized Medicine Coalition''' PMC engages on a number of key priorities in public and science policy to advance its mission. This site includes information on funding and appropriations for precision medicine.<ref>https://www.personalizedmedicinecoalition.org/Policy/Research_Funding</ref>

'''Department of Health and Human Services Grants''' ''Development of Psychosocial Therapeutic and Preventive Interventions for Mental Disorders (R61/R33)''<ref>https://grants.nih.gov/grants/guide/rfa-files/RFA-MH-17-604.html</ref>

=Available Tools and Resources=

Genetic Testing and Precision Medicine- ''A personalized medical approach to improve outcomes.<ref>https://healthitanalytics.com/news/why-genetic-testing-is-key-to-advancing-precision-medicine</ref>

Personalized Medicine Coalition- ''Personalized Medicine Report'' <ref>https://www.personalizedmedicinecoalition.org/Userfiles/PMC-Corporate/file/The_PM_Report.pdf</ref>

Therapeutic drug monitoring: A patient management tool for precision medicine<ref>https://ascpt.onlinelibrary.wiley.com/doi/full/10.1002/cpt.298</ref>

Therapeutic drug monitoring in the era of precision medicine<ref>https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.13047</ref>

=Promising Practices=

'''Precision Medicine's value''' - Includes promising practices and developments in the field of precision medicine and therapies.<ref>https://www.managedhealthcareexecutive.com/view/exploring-precision-medicines-value</ref>

'''Personalized Medicine Coalition''' Promoting Innovation and Delivery of Cell and Gene Therapies<ref>https://www.personalizedmedicinecoalition.org/index.cfm</ref>

= Sources =

----

Expand DNA Testing to Improve Precision MAT/MAR Therapies

2022-07-14T22:10:23Z

Katherine: /* Introductory Paragraph */

=Introductory Paragraph =
Genetics and genetic makeup impact how individuals respond to medications. Genetic and DNA testing can enhance personalized medicine to improve Medication-assisted therapies.<ref>https://healthitanalytics.com/news/why-genetic-testing-is-key-to-advancing-precision-medicine</ref>

*Individuals all process and metabolize drugs in differing ways.<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5447546/</ref>
*Someone's genetic makeup, the amount of enzymes, and specific receptors they have contribute to how a person can metabolize medicine
*A person's genetic makeup also impacts how certain foods will affect how drugs are metabolized.
*Genetic testing reveals information that can help us accurately tailor medications on a patient-to-patient basis. This is called Precision or Personalized Medicine
*In the past, physicians have had limited tools when it comes to evaluating options or dosages for Medication Assisted Treatment Plans
*The result is that Medication Assisted Treatment plans usually rely on a series of "trial and error" doses that are adjusted based on response of the patient to the doses being tried without using insights from genetic tests to optimize the plan for each patient.
*When the does of medication is not ideal, the patient either receives insufficient benefit from the medication or has side effects or adverse drug reactions.<ref>https://www.journals.elsevier.com/addictive-behaviors-reports</ref>
*The inconsistent impact of medication used in MAT is a contributing factor to the high relapse rates in opioid addicted patients. Even for those receiving MAT, the relapse rate tends to be about 50%
*Patients who abstain from opioids in the first two weeks have a good chance of good 12-week outcome. However, those who use opioids in each of the first 2 weeks (even in week 1 alone) have very little chance of abstaining by week 12

=Key Information=

"Precision medicine focuses on providing health care with increased resolution, accounting for aspects that are unique to the individual and their disease. By definition, precision medicine involves all phases of care: prevention, diagnosis, and treatment."<ref>https://ascpt.onlinelibrary.wiley.com/doi/full/10.1002/cpt.1622</ref>

==The Opportunity with Precision MAT ==

With today's more refined analysis of the human genome map, their is a growing database of variability of gene alleles and how they account for changes in drug metabolism.
A clinical genomic test can be performed and a report can be created that displays the expected benefits and risks the patient has if they receive any one of over 200 medications (in this case with a focus on the drugs being used to treat opioid addiction), and how the patient's dietary regimen can affect medications they may be taking or will take in the future to treat their addiction and potential related diseases.

*This Webinar provides a good overview on Pharmacogenetics and MAT: <ref>https://pcssnow.org/event/clinical-applications-pharmacogenomic-testing-opioid-use-disorder-management/</ref>
*Such dynamic, interactive reports can then be used by physicians and other medical providers such as nurse practitioners, pharmacists, therapists, dietitians and other social service professionals to develop more precise treatment plans of care for the individual patient.
*An on-going research study is showing that more precise dosing in Medication Assisted Treatment, based on more accurate analysis of Gene allele variability| has decreased relapse rates in opioid addicted patients down to 25% over an 18 month tracking period.<ref>https://dnacenter.com/blog/swabs-vs-blood-samples-dna-testing/</ref>

== Genetic Tests ==

*A genetic test is performed by obtaining a simple cheek swab that collects DNA from the cells on the inside of a person’s mouth. The specimen collection can be performed by an appropriately trained individual and the report results available in 1-2 weeks.
*Using a cheek swab is one of the two most popular ways to do DNA tests[13] .
*Insurance coverage varies for this test which costs approximates between $500 and $1,200 based on whether annual pharmacy consultative services are included.
*Medicare is the most reliable payer and the commercial carriers range in reliability of payment. Few Medicaid carriers are currently paying for these tests today but with the significant funding being made available to individual states to address the opioid addiction crisis, the anticipation is that the state based Medicaid plans will begin to address this coverage gap.
*Premier DNA is a genetics testing company that has created a integrated care model combining genetic testing, interactive genetic reporting, and pharmacy consultation. They offer this program under the registered trade name Med Op Rx. This service becomes a useful tool to guide the physician in terms of implementing the most precise MAT program given the individual patient's genetic makeup.

=Relevant Research=
There is ongoing research and funding around precision medicine across both mental and physical health including substance use and medication assisted therapy.

'''Genetic testing: Opportunities to unlock value in precision medicine'''<ref>https://www.mckinsey.com/industries/life-sciences/our-insights/genetic-testing-opportunities-to-unlock-value-in-precision-medicine</ref>

'''Pharmacogenetic Testing: A Tool for Personalized Drug Therapy Optimization'''<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7765968/</ref>

'''U.S. Department of Veteran Affairs Office of Research & Development''' ''Genomics & Mental Health''<ref>https://www.research.va.gov/topics/genomics.cfm#research3</ref>

'''Biomarkers in precision medicine for mental illnesses'''<ref>https://acamh.onlinelibrary.wiley.com/doi/full/10.1111/jcpp.13357</ref>

'''Precision Medicine & Global Mental Health'''<ref>https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30406-6/fulltext</ref>

'''Study design and implementation of the Precision Medicine In Mental health Care (PRIME Care) Trial'''<ref>https://www.sciencedirect.com/science/article/pii/S1551714420303256</ref>

=Impactful Federal, State, and Local Policies=
'''Precision Medicine Initiative''' 2015/2016 White House initiative to improve precision medicine. The mission is to enable a new era of medicine through research, technology, and policies that empower patients, researchers, and providers to work together toward development of individualized care.<ref>https://obamawhitehouse.archives.gov/precision-medicine</ref>

'''Personalized Medicine Coalition''' PMC engages on a number of key priorities in public and science policy to advance its mission. This site includes information on funding and appropriations for precision medicine.<ref>https://www.personalizedmedicinecoalition.org/Policy/Research_Funding</ref>

'''Department of Health and Human Services Grants''' ''Development of Psychosocial Therapeutic and Preventive Interventions for Mental Disorders (R61/R33)''<ref>https://grants.nih.gov/grants/guide/rfa-files/RFA-MH-17-604.html</ref>

=Available Tools and Resources=

Genetic Testing and Precision Medicine- ''A personalized medical approach to improve outcomes.<ref>https://healthitanalytics.com/news/why-genetic-testing-is-key-to-advancing-precision-medicine</ref>

Personalized Medicine Coalition- ''Personalized Medicine Report'' <ref>https://www.personalizedmedicinecoalition.org/Userfiles/PMC-Corporate/file/The_PM_Report.pdf</ref>

Therapeutic drug monitoring: A patient management tool for precision medicine<ref>https://ascpt.onlinelibrary.wiley.com/doi/full/10.1002/cpt.298</ref>

Therapeutic drug monitoring in the era of precision medicine<ref>https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.13047</ref>

=Promising Practices=

'''Precision Medicine's value''' - Includes promising practices and developments in the field of precision medicine and therapies.<ref>https://www.managedhealthcareexecutive.com/view/exploring-precision-medicines-value</ref>

'''Personalized Medicine Coalition''' Promoting Innovation and Delivery of Cell and Gene Therapies<ref>https://www.personalizedmedicinecoalition.org/index.cfm</ref>

= Sources =

----

Expand DNA Testing to Improve Precision MAT/MAR Therapies

2022-07-14T22:09:06Z

Katherine: /* Sources */

=Introductory Paragraph =
Genetics and genetic makeup impact how individuals respond to medications. Genetic and DNA testing can enhance personalized medicine to improve Medication-assisted therapies.<ref>https://healthitanalytics.com/news/why-genetic-testing-is-key-to-advancing-precision-medicine</ref>

*Individuals all process and metabolize drugs in differing ways.<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5447546/</ref>
*Someone's genetic makeup, the amount of enzymes, and specific receptors they have contribute to how a person can metabolize medicine[2]
*A person's genetic makeup also impacts how certain foods will affect how drugs are metabolized. [3]
*Genetic testing reveals information that can help us accurately tailor medications on a patient-to-patient basis.[4][5] This is called Precision or Personalized Medicine[6][7]
*In the past, physicians have had limited tools when it comes to evaluating options or dosages for Medication Assisted Treatment Plans [8]
*The result is that Medication Assisted Treatment plans usually rely on a series of "trial and error" doses that are adjusted based on response of the patient to the doses being tried without using insights from genetic tests to optimize the plan for each patient.[9]
*When the does of medication is not ideal, the patient either receives insufficient benefit from the medication or has side effects or adverse drug reactions.<ref>https://www.journals.elsevier.com/addictive-behaviors-reports</ref>
*The inconsistent impact of medication used in MAT is a contributing factor to the high relapse rates in opioid addicted patients. Even for those receiving MAT, the relapse rate tends to be about 50% [10]
*Patients who abstain from opioids in the first two weeks have a good chance of good 12-week outcome. However, those who use opioids in each of the first 2 weeks (even in week 1 alone) have very little chance of abstaining by week 12[11]

=Key Information=

"Precision medicine focuses on providing health care with increased resolution, accounting for aspects that are unique to the individual and their disease. By definition, precision medicine involves all phases of care: prevention, diagnosis, and treatment."<ref>https://ascpt.onlinelibrary.wiley.com/doi/full/10.1002/cpt.1622</ref>

==The Opportunity with Precision MAT ==

With today's more refined analysis of the human genome map, their is a growing database of variability of gene alleles and how they account for changes in drug metabolism.
A clinical genomic test can be performed and a report can be created that displays the expected benefits and risks the patient has if they receive any one of over 200 medications (in this case with a focus on the drugs being used to treat opioid addiction), and how the patient's dietary regimen can affect medications they may be taking or will take in the future to treat their addiction and potential related diseases.

*This Webinar provides a good overview on Pharmacogenetics and MAT: <ref>https://pcssnow.org/event/clinical-applications-pharmacogenomic-testing-opioid-use-disorder-management/</ref>
*Such dynamic, interactive reports can then be used by physicians and other medical providers such as nurse practitioners, pharmacists, therapists, dietitians and other social service professionals to develop more precise treatment plans of care for the individual patient.
*An on-going research study is showing that more precise dosing in Medication Assisted Treatment, based on more accurate analysis of Gene allele variability| has decreased relapse rates in opioid addicted patients down to 25% over an 18 month tracking period.<ref>https://dnacenter.com/blog/swabs-vs-blood-samples-dna-testing/</ref>

== Genetic Tests ==

*A genetic test is performed by obtaining a simple cheek swab that collects DNA from the cells on the inside of a person’s mouth. The specimen collection can be performed by an appropriately trained individual and the report results available in 1-2 weeks.
*Using a cheek swab is one of the two most popular ways to do DNA tests[13] .
*Insurance coverage varies for this test which costs approximates between $500 and $1,200 based on whether annual pharmacy consultative services are included.
*Medicare is the most reliable payer and the commercial carriers range in reliability of payment. Few Medicaid carriers are currently paying for these tests today but with the significant funding being made available to individual states to address the opioid addiction crisis, the anticipation is that the state based Medicaid plans will begin to address this coverage gap.
*Premier DNA is a genetics testing company that has created a integrated care model combining genetic testing, interactive genetic reporting, and pharmacy consultation. They offer this program under the registered trade name Med Op Rx. This service becomes a useful tool to guide the physician in terms of implementing the most precise MAT program given the individual patient's genetic makeup.

=Relevant Research=
There is ongoing research and funding around precision medicine across both mental and physical health including substance use and medication assisted therapy.

'''Genetic testing: Opportunities to unlock value in precision medicine'''<ref>https://www.mckinsey.com/industries/life-sciences/our-insights/genetic-testing-opportunities-to-unlock-value-in-precision-medicine</ref>

'''Pharmacogenetic Testing: A Tool for Personalized Drug Therapy Optimization'''<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7765968/</ref>

'''U.S. Department of Veteran Affairs Office of Research & Development''' ''Genomics & Mental Health''<ref>https://www.research.va.gov/topics/genomics.cfm#research3</ref>

'''Biomarkers in precision medicine for mental illnesses'''<ref>https://acamh.onlinelibrary.wiley.com/doi/full/10.1111/jcpp.13357</ref>

'''Precision Medicine & Global Mental Health'''<ref>https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30406-6/fulltext</ref>

'''Study design and implementation of the Precision Medicine In Mental health Care (PRIME Care) Trial'''<ref>https://www.sciencedirect.com/science/article/pii/S1551714420303256</ref>

=Impactful Federal, State, and Local Policies=
'''Precision Medicine Initiative''' 2015/2016 White House initiative to improve precision medicine. The mission is to enable a new era of medicine through research, technology, and policies that empower patients, researchers, and providers to work together toward development of individualized care.<ref>https://obamawhitehouse.archives.gov/precision-medicine</ref>

'''Personalized Medicine Coalition''' PMC engages on a number of key priorities in public and science policy to advance its mission. This site includes information on funding and appropriations for precision medicine.<ref>https://www.personalizedmedicinecoalition.org/Policy/Research_Funding</ref>

'''Department of Health and Human Services Grants''' ''Development of Psychosocial Therapeutic and Preventive Interventions for Mental Disorders (R61/R33)''<ref>https://grants.nih.gov/grants/guide/rfa-files/RFA-MH-17-604.html</ref>

=Available Tools and Resources=

Genetic Testing and Precision Medicine- ''A personalized medical approach to improve outcomes.<ref>https://healthitanalytics.com/news/why-genetic-testing-is-key-to-advancing-precision-medicine</ref>

Personalized Medicine Coalition- ''Personalized Medicine Report'' <ref>https://www.personalizedmedicinecoalition.org/Userfiles/PMC-Corporate/file/The_PM_Report.pdf</ref>

Therapeutic drug monitoring: A patient management tool for precision medicine<ref>https://ascpt.onlinelibrary.wiley.com/doi/full/10.1002/cpt.298</ref>

Therapeutic drug monitoring in the era of precision medicine<ref>https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.13047</ref>

=Promising Practices=

'''Precision Medicine's value''' - Includes promising practices and developments in the field of precision medicine and therapies.<ref>https://www.managedhealthcareexecutive.com/view/exploring-precision-medicines-value</ref>

'''Personalized Medicine Coalition''' Promoting Innovation and Delivery of Cell and Gene Therapies<ref>https://www.personalizedmedicinecoalition.org/index.cfm</ref>

= Sources =

----

Reduce Over-Prescription of Prescription Drugs

2022-07-14T22:07:00Z

Katherine: /* Sources */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.[1] In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin''' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.[2] At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.[3] The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics.[4] This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug."[5] Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines.[6] "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.[7]  

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse[8]
*Middle age women consume the most opioids[9]
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
<div class="_">In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council ([http://www.nsc.org/pages/home.aspx nsc.org]) is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy.   When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)?   A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief.   When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

= Sources =

----

<ref>[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-prescriptions-20170706-story.html [1]],</ref>
#U.S. Department of Health and Human Services, “Press Release: Prescription painkiller overdoses at epidemic levels,” November 1, 2011, www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html.
#Nora D. Volkow, “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse,” National Institute on Drug Abuse, May 14, 2014, www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse.
#Pokrovnichka, Anjelina. "History of Oxycontin: Labeling and Risk Management Program."
#Meier, Barry. "In Guilty Plea, OxyContin Maker to Pay $600 Million." ''The New York Times''. The New York Times, 09 May 2007. Web. 01 Feb. 2017. <[http://www.nytimes.com/2007/05/10/business/11drug-web.html [2]]>.
#Meier, Barry. "In Guilty Plea, OxyContin Maker to Pay $600 Million." ''The New York Times''. The New York Times, 09 May 2007. Web. 01 Feb. 2017. <[http://www.nytimes.com/2007/05/10/business/11drug-web.html [3]]>.
#[https://www.drugrehab.com/opioid-epidemic/ [4]]
#http://www.planagainstpain.com/resources/usnd/ [5]
#http://www.planagainstpain.com/resources/usnd/ [6]
#http://www.planagainstpain.com/resources/usnd/ [7]
##
##*
##**
##***
##****[http://pediatrics.aappublications.org/content/136/5/e1169 [8]]
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]

Expand the Use of MAT/MAR in Correctional Facilities

2022-07-14T21:40:54Z

Katherine: /* Key Information */

=Introductory Paragraph=

Several prisons are working towards implementing Mediation-assisted Treatment (MAT) to individuals struggling with mental health and substance use disorders. Individuals with mental health and substance use disorders may revolve in and out of prison and correctional facilities with a release back into the community where their substance use cycle continues if they have not received treatment. Medication-assisted treatment is utilized as an intervention in a controlled, safe environment and provides an opportunity to help individuals with substance use disorder.

Treatment for SUD including MAT, has been shown to reduce drug use, overdose, and reduce mortality rates and reduce recidivism rates. <ref>https://www.sheriffs.org/publications/Jail-Based-MAT-PPG.pdf</ref>

=Key Information=

The Opioid epidemic has become a national public health crisis with an increase in overdose and overdose deaths. Those in the criminal justice systems are also impacted by this epidemic. A National Survey on Drug Use and Health indicated the odds of being involved in the criminal justice system increase for those using opioids and other drugs such as heroin.<ref>https://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf</ref>

Those in the criminal justice system transitioning back into the community after incarceration have greater rates of returning to the criminal justice system or of relapsing when returning into their community. Medication-assisted treatment (MAT) could assist those with substance use disorder and reduce the rate of relapse. The FDA and SAMSHA identify MAT medications as methadone, buprenorphine, or naltrexone for use for treatment of individuals with opioid use disorders (OUDs). MAT may also be used in conjunction with behavioral health therapy.<ref> https://www.drugabuse.gov/publications/effective-treatments-opioid-addiction/effective-treatments-opioid-addiction</ref> Your Safe Solutions also includes additional information on Medication-assisted Treatments (MAT). <ref>https://www.yoursafesolutions.us/wiki/Expand_Access_to_Medication-Assisted_Treatment_(MAT)</ref>

Medication and counseling in jails and prisons can lower overdose deaths after release. Studies have shown the importance of treatment while incarcerated and have shown that people who are incarcerated are at higher risk of overdose death post-release.<ref>https://pubmed.ncbi.nlm.nih.gov/17215533/</ref>

Many of the resource guides for implementation and best practices surrounding Medication-assisted Treatment (MAT) in correctional facilities recognize the importance of support and buy in from correctional facilities leadership, support staff and community to be a success.<ref>https://www.sheriffs.org/publications/Jail-Based-MAT-PPG.pdf</ref>

'''Who should receive MAT in correctional facilities?'''

Suggested guidelines from the National Council of Behavioral Health provide the following guidelines <ref>https://store.samhsa.gov/sites/default/files/d7/priv/pep19-matbriefcjs_0.pdf</ref>

'''Criteria that some jails have applied include'''
*Consider the capacity of the correctional facility as a factor in the resources needed
*Individuals previously on MAT in the community prior to arrest
*Individuals diagnosed with a moderate or severe OUD
*Individuals at the highest risk of return to use or overdose, according to a validated risk assessment
*Individuals who are within a few weeks of release to the community

'''Why Implement MAT in Prisons?'''

*Individuals who are incarcerated have very high risks of opioid overdose upon release<ref> https://pubmed.ncbi.nlm.nih.gov/30024795/</ref>
*Individuals with opioid use disorder (OUD) have higher risk of being involved in the criminal legal system<ref>https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-opioid-use-disorder-treated-in-criminal-justice-system</ref>

'''Benefits'''
*Reduces return to use of illicit opioids <ref>https://pubmed.ncbi.nlm.nih.gov/29913516/</ref>
*Reduces risk of opioid overdose death
*Increases retention in treatment
*Reduces recidivism<ref>https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2671411</ref>
*Reduces risk of suicide during incarceration
*Legal imperative -Increasing judicial recognition that MOUD should be standard care in jails and failing to provide MOUD violates individuals’ rights <ref>https://www.aclu.org/press-releases/federal-judge-rules-jail-must-allow-access-medication-assisted-treatment</ref>

=Relevant Research=

'''Addiction Treatment Within U.S. Correctional Facilities: Bridging the Gap Between Current Practice and Evidence-Based Care'''<ref>https://pubmed.ncbi.nlm.nih.gov/26076211/</ref>

'''Release from prison- A high risk of death for former inmates'''<ref>https://pubmed.ncbi.nlm.nih.gov/17215533/</ref>

'''Pew Study Opioid Use Disorder Treatment in Jails and Prisons'''<ref>https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2020/04/opioid-use-disorder-treatment-in-jails-and-prisons</ref>

=Impactful Federal, State, and Local Policies=

'''Massachusetts passed Chapter 208, An Act for Prevention and Access to Appropriate Care and Treatment of Addiction, authorizing a four-year pilot administering all three FDA-approved medications to treat OUD'''<ref> https://malegislature.gov/Laws/SessionLaws/Acts/2018/Chapter208</ref>

'''Support Act for Patients and Community Act'''<ref> https://www.congress.gov/bill/115th-congress/house-bill/6</ref>

'''State Based Medicaid may provide funding for MAT''' ''Medicaid Coverage of Medication Assisted Treatment (MAT): A 50-state overview''<ref>https://www.ncsl.org/research/health/mat-opiate-50-state-table-medicaid.aspx</ref>

'''Joint Public Correctional Policy on the Treatment of Opioid Use Disorders for Justice Involved Individuals''' <ref>https://www.asam.org/docs/default-source/public-policy-statements/2018-joint-public-correctional-policy-on-the-treatment-of-opioid-use-disorders-for-justice-involved-individuals.pdf?sfvrsn=26de41c2_2</ref>

=Available Tools and Resources=

'''Use of Medication-Assisted Treatment for Opioid Use Disorder in Criminal Justice Settings''' <ref>https://store.samhsa.gov/sites/default/files/d7/priv/pep19-matusecjs.pdf</ref>

'''Jail-based Medication-Assisted Treatment Promising Practices, Guidelines, and Resources for the Field''' <ref>https://www.sheriffs.org/publications/Jail-Based-MAT-PPG.pdf</ref>

'''Prison/Jail Medication-Assisted Treatment Manual''' <ref>https://www.rsat-tta.com/Files/RSAT_Prison_Med_Treat_FINAL.pdf</ref>

'''The Bureau of Justice Assistance RSAT TTA program''' offers training and technical assistance to county and states<ref>https://www.rsat-tta.com/</ref>

'''Medication-Assisted Treatment (MAT) for Opioid Use Disorder in Jails and Prisons- A Planning and Implementation Toolkit'''<ref>https://www.thenationalcouncil.org/medication-assisted-treatment-for-opioid-use-disorder-in-jails-and-prisons/</ref>

'''Opioid Response Network- Medications for Opioid Use Disorder (MOUD) in Corrections'''<ref>https://opioidresponsenetwork.org/MOUDCorrections.aspx</ref>

=Promising Practices=

'''Jail-based Medication-Assisted Treatment Promising Practices, Guidelines, and Resources for the Field'''-Includes promising practices and specific states with case studies including KY, RI, MA, WA.<ref>https://www.sheriffs.org/publications/Jail-Based-MAT-PPG.pdf</ref>

'''Prison/Jail Medication-Assisted Treatment Manual'''<ref>https://www.rsat-tta.com/Files/RSAT_Prison_Med_Treat_FINAL.pdf</ref> Includes Training and Technical Assistance

'''Pennsylvania Department of Corrections MAT'''<ref>https://www.cor.pa.gov/About%20Us/Initiatives/Pages/Medication-Assisted-Treatment.aspx</ref>

'''SAMSHA Medication Assisted Treatment for OUD in Criminal Justice Settings''' <ref>https://store.samhsa.gov/product/Use-of-Medication-Assisted-Treatment-for-Opioid-Use-Disorder-in-Criminal-Justice-Settings/PEP19-MATUSECJS</ref>

=Sources=

Expand the Use of MAT/MAR in Correctional Facilities

2022-07-14T21:39:45Z

Katherine: /* Key Information */

=Introductory Paragraph=

Several prisons are working towards implementing Mediation-assisted Treatment (MAT) to individuals struggling with mental health and substance use disorders. Individuals with mental health and substance use disorders may revolve in and out of prison and correctional facilities with a release back into the community where their substance use cycle continues if they have not received treatment. Medication-assisted treatment is utilized as an intervention in a controlled, safe environment and provides an opportunity to help individuals with substance use disorder.

Treatment for SUD including MAT, has been shown to reduce drug use, overdose, and reduce mortality rates and reduce recidivism rates. <ref>https://www.sheriffs.org/publications/Jail-Based-MAT-PPG.pdf</ref>

=Key Information=

The Opioid epidemic has become a national public health crisis with an increase in overdose and overdose deaths. Those in the criminal justice systems are also impacted by this epidemic. A National Survey on Drug Use and Health indicated the odds of being involved in the criminal justice system increase for those using opioids and other drugs such as heroin.<ref>https://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf</ref>

Those in the criminal justice system transitioning back into the community after incarceration have greater rates of returning to the criminal justice system or of relapsing when returning into their community. Medication-assisted treatment (MAT) could assist those with substance use disorder and reduce the rate of relapse. The FDA and SAMSHA identify MAT medications as methadone, buprenorphine, or naltrexone for use for treatment of individuals with opioid use disorders (OUDs). MAT may also be used in conjunction with behavioral health therapy.<ref> https://www.drugabuse.gov/publications/effective-treatments-opioid-addiction/effective-treatments-opioid-addiction</ref> Your Safe Solutions also includes additional information on Medication-assisted Treatments (MAT). <ref>https://www.yoursafesolutions.us/wiki/Expand_Access_to_Medication-Assisted_Treatment_(MAT)</ref>

Medication and counseling in jails and prisons can lower overdose deaths after release. Studies have shown the importance of treatment while incarcerated and have shown that people who are incarcerated are at higher risk of overdose death post-release.<ref>https://pubmed.ncbi.nlm.nih.gov/17215533/</ref>

Many of the resource guides for implementation and best practices surrounding Medication-assisted Treatment (MAT) in correctional facilities recognize the importance of support and buy in from correctional facilities leadership, support staff and community to be a success.<ref>https://www.sheriffs.org/publications/Jail-Based-MAT-PPG.pdf</ref>

'''Who should receive MAT in correctional facilities?'''

Suggested guidelines from the National Council of Behavioral Health provide the following guidelines <ref>https://store.samhsa.gov/sites/default/files/d7/priv/pep19-matbriefcjs_0.pdf</ref>

'''Criteria that some jails have applied include'''
*Consider the capacity of the correctional facility as a factor in the resources needed
*Individuals previously on MAT in the community prior to arrest
*Individuals diagnosed with a moderate or severe OUD
*Individuals at the highest risk of return to use or overdose, according to a validated risk assessment
*Individuals who are within a few weeks of release to the community

'''Why Implement MAT in Prisons?'''

*Individuals who are incarcerated have very high risks of opioid overdose upon release<ref> https://pubmed.ncbi.nlm.nih.gov/30024795/</ref>
*Individuals with opioid use disorder (OUD) have higher risk of being involved in the criminal legal system<ref>https://www.ncchc.org/filebin/Resources/Jail-Based-MAT-PPG-web.pdf</ref>

'''Benefits'''
*Reduces return to use of illicit opioids <ref>https://pubmed.ncbi.nlm.nih.gov/29913516/</ref>
*Reduces risk of opioid overdose death
*Increases retention in treatment
*Reduces recidivism<ref>https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2671411</ref>
*Reduces risk of suicide during incarceration
*Legal imperative -Increasing judicial recognition that MOUD should be standard care in jails and failing to provide MOUD violates individuals’ rights <ref>https://www.aclu.org/press-releases/federal-judge-rules-jail-must-allow-access-medication-assisted-treatment</ref>

=Relevant Research=

'''Addiction Treatment Within U.S. Correctional Facilities: Bridging the Gap Between Current Practice and Evidence-Based Care'''<ref>https://pubmed.ncbi.nlm.nih.gov/26076211/</ref>

'''Release from prison- A high risk of death for former inmates'''<ref>https://pubmed.ncbi.nlm.nih.gov/17215533/</ref>

'''Pew Study Opioid Use Disorder Treatment in Jails and Prisons'''<ref>https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2020/04/opioid-use-disorder-treatment-in-jails-and-prisons</ref>

=Impactful Federal, State, and Local Policies=

'''Massachusetts passed Chapter 208, An Act for Prevention and Access to Appropriate Care and Treatment of Addiction, authorizing a four-year pilot administering all three FDA-approved medications to treat OUD'''<ref> https://malegislature.gov/Laws/SessionLaws/Acts/2018/Chapter208</ref>

'''Support Act for Patients and Community Act'''<ref> https://www.congress.gov/bill/115th-congress/house-bill/6</ref>

'''State Based Medicaid may provide funding for MAT''' ''Medicaid Coverage of Medication Assisted Treatment (MAT): A 50-state overview''<ref>https://www.ncsl.org/research/health/mat-opiate-50-state-table-medicaid.aspx</ref>

'''Joint Public Correctional Policy on the Treatment of Opioid Use Disorders for Justice Involved Individuals''' <ref>https://www.asam.org/docs/default-source/public-policy-statements/2018-joint-public-correctional-policy-on-the-treatment-of-opioid-use-disorders-for-justice-involved-individuals.pdf?sfvrsn=26de41c2_2</ref>

=Available Tools and Resources=

'''Use of Medication-Assisted Treatment for Opioid Use Disorder in Criminal Justice Settings''' <ref>https://store.samhsa.gov/sites/default/files/d7/priv/pep19-matusecjs.pdf</ref>

'''Jail-based Medication-Assisted Treatment Promising Practices, Guidelines, and Resources for the Field''' <ref>https://www.sheriffs.org/publications/Jail-Based-MAT-PPG.pdf</ref>

'''Prison/Jail Medication-Assisted Treatment Manual''' <ref>https://www.rsat-tta.com/Files/RSAT_Prison_Med_Treat_FINAL.pdf</ref>

'''The Bureau of Justice Assistance RSAT TTA program''' offers training and technical assistance to county and states<ref>https://www.rsat-tta.com/</ref>

'''Medication-Assisted Treatment (MAT) for Opioid Use Disorder in Jails and Prisons- A Planning and Implementation Toolkit'''<ref>https://www.thenationalcouncil.org/medication-assisted-treatment-for-opioid-use-disorder-in-jails-and-prisons/</ref>

'''Opioid Response Network- Medications for Opioid Use Disorder (MOUD) in Corrections'''<ref>https://opioidresponsenetwork.org/MOUDCorrections.aspx</ref>

=Promising Practices=

'''Jail-based Medication-Assisted Treatment Promising Practices, Guidelines, and Resources for the Field'''-Includes promising practices and specific states with case studies including KY, RI, MA, WA.<ref>https://www.sheriffs.org/publications/Jail-Based-MAT-PPG.pdf</ref>

'''Prison/Jail Medication-Assisted Treatment Manual'''<ref>https://www.rsat-tta.com/Files/RSAT_Prison_Med_Treat_FINAL.pdf</ref> Includes Training and Technical Assistance

'''Pennsylvania Department of Corrections MAT'''<ref>https://www.cor.pa.gov/About%20Us/Initiatives/Pages/Medication-Assisted-Treatment.aspx</ref>

'''SAMSHA Medication Assisted Treatment for OUD in Criminal Justice Settings''' <ref>https://store.samhsa.gov/product/Use-of-Medication-Assisted-Treatment-for-Opioid-Use-Disorder-in-Criminal-Justice-Settings/PEP19-MATUSECJS</ref>

=Sources=

Enhance Treatment and Recovery Support During Incarceration

2022-07-14T21:32:24Z

Katherine: /* Benefits of Successful Prison Treatment Programs */

= Introductory Paragraph =

Research has shown that a vast amount of the inmate population, on both the state and federal level, suffer from substance use disorder, a psychological disorder, or a combination of the two. Studies have shown that proper treatment during incarceration that is followed through to post release, significantly lowers their risk for relapse, criminality, inmate misconduct, and recidivism.

= Key Information =

The Criminal Justice System has supported treatment during incarceration by offering psychotherapy sessions, religious ministry meetings and 12-step programs such as Alcoholics Anonymous to inmates with substance use problems. <ref>https://www.alec.org/article/drug-treatment-programs-of-the-federal-bureau-of-prisons-exist-but-need-more-availability/</ref>

While there is significant need for more availability, federal prisons offer a number of programs designed to assist inmates in overcoming a substance use disorder such as:

*'''Drug Abuse Education'''
**Entails a series of classes that educate inmates on substance use disorder and the effects it has on your body and mind <ref>https://www.alec.org/article/drug-treatment-programs-of-the-federal-bureau-of-prisons-exist-but-need-more-availability/</ref>
*'''Nonresidential Drug Abuse Treatment'''
**A12 week CBT (cognitive-behavioral therapy) program that is organized in group sessions
**This program addresses criminal lifestyles while also giving inmates the opportunity to increase skills in the areas of rational thinking, communication, and institution to community adjustment
**Inmates that are enrolled in this program normally have short sentences, do not meet the Residential Drug Abuse Program, are waiting to be enrolled in RDAP, are in transition back into the community or have a positive urinalysis test <ref>https://www.alec.org/article/drug-treatment-programs-of-the-federal-bureau-of-prisons-exist-but-need-more-availability/</ref>
*'''Residential Drug Abuse Program (RDAP)'''
**The most intensive program that the Bureau provides
**Inmates in this program live in their own separate community from the rest of the population. Inmates take part in daily half-day programming and half-day of work, school, or vocational activities; this program is normally nine months in length
**Research shows inmates that take part in RDAP are less likely to recidivate and relapse to drug use by significant amounts compared to those inmates who do not take part in RDAP <ref>https://www.alec.org/article/drug-treatment-programs-of-the-federal-bureau-of-prisons-exist-but-need-more-availability/</ref>
*'''Community Treatment Services (CTS)'''
**Provides continued care to inmates who have been released and put into Residential Reentry Centers or on Home Confinement
**Evidence shows that the period after being released is the most vulnerable time for inmates to relapse back to drug use or criminal activity; continued treatment after release is vital to the success of the offender completing their treatment <ref>https://www.alec.org/article/drug-treatment-programs-of-the-federal-bureau-of-prisons-exist-but-need-more-availability/</ref>

=== Benefits of Successful Prison Treatment Programs ===
<div>Well-designed prison treatment programs reduce relapse, criminality, inmate misconduct and recidivism — the likelihood that a convicted criminal will reoffend. They also increase levels of education, mend relationships, boost employment opportunities upon release and improve overall health. <ref>https://doi.org/10.1007/s11920-013-0414-z</ref></div> <div> </div> <div>Research shows that residential prison treatment is cost-effective if prisoners continue treatment after their release. The cost of treatment pales in comparison to the cost of incarceration. Rehab helps prisoners overcome drug use and reduces the economic burden of recidivism. <ref>https://doi.org/10.1007/s11920-013-0414-z</ref></div>

'''Issues Affecting the Availability of Effective Treatment'''

'''Overcrowding of Jails and Prisons'''

Overcrowding of jails and prisons is a leading factor as to why inmates with drug dependency problems are not enrolled in these programs. The overcrowding of jails leads to an increase in the length of the waiting lists to enter drug treatment programs. In addition to overcrowding, staff shortages and limited resources are part of the issue of low enrollment in drug treatment programs.<ref>https://www.alec.org/article/drug-treatment-programs-of-the-federal-bureau-of-prisons-exist-but-need-more-availability/</ref>

'''Need for Trauma-Informed Care'''

Incarcerated prisoners are marked by considerable diversity, yet they share a common experience of incarceration. Prisons can be violent, harsh, psychologically damaging environments; incarcerated people live in an environment that is both depersonalizing and dehumanizing. Moreover, the social stigma associated with incarceration, combined with the depersonalizing effects of imprisonment, may result in a sense of hopelessness and powerlessness, as well as deeply internalized shame and guilt. Thus, in addition to treating substance abuse and other mental disorders, the consensus panel recommends that in-prison treatment also address the trauma of the incarceration itself as well as a prison culture that conflicts with treatment goals.<ref>https://www.ncbi.nlm.nih.gov/books/NBK572935/</ref>

'''Training'''

Residential Substance Abuse Training RSAT training and technical assistance tool

= Relevant Research =

Research has shown that treatment of substance abuse for those incarcerated provides the opportunity for recovery and decreased recidivism. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2681083/</ref>

=Impactful Federal, State, and Local Policies=

Several states are working to address the Opioid epidemic and embracing new strategies such as utilizing Medicaid 1115 Demonstration Waivers which increases provision of Medication Assisted Therapy (MAT) to individuals in the criminal justice system. <ref> https://store.samhsa.gov/sites/default/files/d7/priv/medicaidfinancingmatreport_0.pdf</ref>

New York State passed legislation in 2015 to allow individuals Medication Assisted Therapy <ref>https://www.nysenate.gov/legislation/bills/2019/S2161</ref> in diversion programs The legislation ensures those participating would not face charges due to MAT medications/drug screens. <ref>https://www.lac.org/assets/files/Medication-Assisted-Treatment-in-Drug-Courts-Recommended-Strategies.pdf </ref>

=Tools & Resources=

Residential Substance Abuse Training RSAT training and technical assistance tool. This provides training for correctional professionals.<ref> https://nicic.gov/training</ref>

Reentry resources for individuals, providers, communities and States <ref>https://www.samhsa.gov/sites/default/files/topics/criminal_juvenile_justice/reentry-resources-for-consumers-providers-communities-states.pdf</ref>

Building an Offender Reentry Program: Guide for Law Enforcement <ref>https://bja.ojp.gov/sites/g/files/xyckuh186/files/Publications/Reentry_LE.pdf</ref>

Medication Assisted Treatment in Criminal Justice Systems: Guidance to the States <ref>https://store.samhsa.gov/sites/default/files/d7/priv/pep19-matbriefcjs_0.pdf</ref>

Criminal Conduct & Substance Abuse Treatment: Strategies for Self-Improvement and Change Pathways to Responsible Living- Workbook for participants <ref>https://www.ojp.gov/ncjrs/virtual-library/abstracts/criminal-conduct-substance-abuse-treatment-strategies-self</ref>

Principles of Drug Abuse Treatment for criminal justice populations <ref>https://www.txwp.uscourts.gov/wp-content/uploads/2017/05/Recommended-Reading-Drug-Abuse-Treatment-for-Criminal-Justice-Populations.pdf</ref>

=Promising Practices=

Pennsylvania Department of Corrections Medication Assisted Treatment – includes a 2019 Pilot Program
<ref>https://www.cor.pa.gov/Initiatives/Documents/Medication%20Assisted%20Treatment/Handout%20for%20MAT_For%20Offenders_2.0.png</ref>

= Sources =
</div> </div> </div> </div> </div> </div> </div> </div> </div>
[[Category:SAFE-Law Enforcement and Criminal Justice]]

Reduce Over-Prescription of Prescription Drugs

2022-07-13T15:22:18Z

Katherine: /* Key Information */

=Introductory Paragraph=

Reducing prescription of opioids contributes to reducing risk in multiple ways. First, it reduces the number of people who are beginning to use prescription opioids for legitimate prescribed reasons but who may begin to develop a dependence on opioids or a strong desire to keep using them when the specific medical need ends. Second, reducing the prescription of opioids will reduce the number of excess pills that are often diverted for inappropriate use.

=Key Information=

'''Evidence that Reducing Prescriptions Leads to Fewer Opioid Related Deaths'''

States that have cracked down on doctors and pain clinics have seen in a decline in prescriptions and opioid-related deaths.[1] In other cases, it seems that reducing access to prescription opioids can lead people to steal pills, purchase pills on the black market (which may be fake pills containing fentanyl) or switch to heroin (which is cheaper, but now often is laced with deadly fentanyl.

'''History'''

'''OxyContin''' The rate of pain reported by Americans has not changed much over time, and yet the number of painkiller prescriptions has increased 300 percent since 1999.[2] At the same time, the number of deaths due to prescription opioid overdoses has quadrupled.[3] The rise in availability of prescription opioids began with the prescription of OxyContin. OxyContin (oxycodone) was released by Purdue Pharmaceuticals in 1996 and marketed as having a lower abuse potential then other narcotics.[4] This enticed physicians to prescribe the oxycodone-based narcotic for common conditions, such as back aches and knee pain, in addition to the original intended recipients, cancer patients and the terminally ill. By 2010, 1 in every 5 pain related doctor's visits in the United States resulted in a narcotic prescription. Individuals discovered snorting or injecting the powder from crushed OxyContin tablets produces a high similar to heroin and "by 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug."[5] Purdue Pharmaceuticals knew the drug had a high potential for abuse, but continued to market it as a time-released drug with low risk of abuse. In 2007, Purdue Pharma plead guilty in federal court to criminal charges for misleading doctors and patients and paid out over $600 million in fines.[6] "For years the sole focus was on reducing non-medical use, reducing abuse," Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing. "They were trying to stop kids from getting into grandma's medicine cabinet. Nobody was asking why does every grandma now have opioids in her medicine cabinet." - Searching for Relief: the Opioid Epidemic in the United States.[7]  

'''Useful Statistics'''

*Surgery-related overprescribing results in 3.3 billion unused pills available for misuse[8]
*Middle age women consume the most opioids[9]
*Surgery is a gateway to persistent opioid use and potential misuse[10]
*An analysis of Monitoring the Future data found that legitimate use of prescribed opioids before high school graduation was associated with a 33 percent increased risk of future opioid misuse. One reason these results are concerning is that they were concentrated among youth with no previous substance use and with prior disapproval of opioid misuse[11]
*Gen X women and knee replacement had the highest rate of persistent opioid use following their operation (22.8%)[12]
*Enough opioids were prescribed in 2016 to provide every American with 36 pills[13]
*Immediate-release opioids are easiest to misuse[14]
*38 percent of U.S. adults were prescribed an opioid in 2015[15]
*An estimated 5 to 8 million Americans use opioids for ongoing management of chronic pain, yet long-term opioid use has become increasingly controversial in light of the current opioid epidemic, the accompanying rise in overdose deaths and addiction rates, as well as little evidence that opioids improve function or speed resolution of the pain.[16]
*Previously the majority of heroin users entering treatment began their misuse with heroin.[17] National-level general population heroin data shows now 80% of new heroin users start off using pain pills. [18]
*One shocking study found that 90% of people who had overdosed on opioids were still able to get a prescription filled.[19]
*The CDC has urged states to make prescription-monitoring programs easier for doctors and pharmacists to use.[20]
*

'''Prescription Rates'''
<div class="_">A detailed analysis of opioid prescribing rates show various trends across the country.[22]</div> <div class="_"> </div>
*Providers in the highest prescribing counties prescribed 6 times more opioids per person than the lowest prescribing counties in 2015.
*Half of US counties had a decrease in the amount of opioids (MME*) prescribed per person from 2010 to 2015.
*The MME prescribed per person in 2015 was about 3 times as high as in 1999.

 ''Characteristics of counties with higher opioid prescribing:''

*Small cities or large towns
*Higher percent of white residents
*More dentists and primary care physicians
*More people who are uninsured or unemployed
*More people who have diabetes, arthritis, or disability

 

'''Effectiveness'''
<div class="_">In a paper published by the National Safety Council, with a focus in looking at prescription opioids, doctors are beginning to prove that prescription opioids are not as strong as the public may seem. The National Safety Council ([http://www.nsc.org/pages/home.aspx nsc.org]) is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities, and on the road through leadership, research, education and advocacy.   When digging into whether or not a pain killer is effective or not, doctors look at the ''Number Needed to Treat.'' NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication and the effect is usually 50 percent pain relief. Fifty percent relief of pain is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50 percent pain relief (effective relief)?   A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100 percent effective at reducing pain by 50 percent - everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means one out of two, or 50 percent, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief.   When comparing opioids versus over the counter pain medicines, we see a steep decline in the NNT. Most would assume that opioids would beat out over the counter pain relievers-- this happens to not be the case. In the paper, doctors state that over the counter pain relievers have a lower NNT than that of opioid pain medication. <ref>http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?</ref>

=Relevant Research=

=Impactful Federal, State, and Local Policies=

=Tools & Resources=

=Promising Practices=

'''Express Scripts'''

<ref>https://www.express-scripts.com/index.html Express Scripts</ref> is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for it's members. The company now seeks to help curb the prescription of opioids and thus subsequent additions by: engaging prescribers, mobilizing payers, and protecting patients. '''Tool''': Express Scripts developed the Advanced Opioid Management Solution, launched in early June 2017, which is a comprehensive program that works across the care continuum to prevent opioid use and misuse before it happens.[24] This program is uniquely positioned to reach across three critical touchpoints:

*the pharmacy
*physicians
*patients

 '''Methods''':

#Limit first-time users of short-acting opioids to an initial fill of seven days.[25]
#Enhanced prior authorization also is required for all long-acting opioids to block fills for new users.[26]
#Morphine Equivalent Dose (MED) edit program gives visibility to, and requires prior authorization for, members accumulating quantities of opioid medication exceeding 200Mg morphine equivalent dose per day.[27]
#Concurrent drug utilization review (CDUR) ensures opioid prescriptions are appropriate, medically necessary and unlikely to result in adverse medical consequences.[28]
#Sends automated messages directly to all opioid-writing physicians at the point of care via their electronic medical record portal to inform them of potential duplicate therapy, misuse and abuse, drug-drug interactions, use of multiple prescribers or pharmacies — or when a patient is approaching MED thresholds.[29]
#Sends out an educational letter after their first fill to educate them of the serious potential risks of opioid use, safe handling instructions, important restrictions and proper disposal of unused medication.[30]
#Opioid neuroscience specialist pharmacists conduct proactive outreach to patients triggered by one of several scenarios where the PBM’s data signals concerning patterns of use, such as filling two or more different short-acting opioids within the last 30 days.[31]
#Provides disposal bags to first-time opioid users that the system indicates are likely to have leftover medications. The bags include clear instructions for handling and disposal in a member’s home, with no driving or special disposal day required.[32]
#Limits patients to obtaining an opioid prescription from only one doctor and to filling that prescription at only one pharmacy when the fraud, waste and abuse program detects drug-seeking behavior.[33]

 '''Results''': A recent pilot program in the Express Scripts Lab with more than 100,000 members new to opioids showed:

*38% reduction in hospitalizations[34]
*40% drop in emergency room visits in the intervention group versus the control group during six months of follow-up[35]
*A subset receive the educational letter who had high-risk patterns of opioid us also received a counseling call showed a 19% decrease in the day’s supply of opioid dispensing during six months of follow up[36]

 '''[https://www.cdc.gov/drugoverdose/pdmp/ Prescription Drug Monitoring Programs (PDMPs)]''' - State-run electronic databases should be used to track the prescribing and dispensing of controlled prescription drugs to patients. PDMPs are now available in 49 states. This program can give a physician or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help physicians, pharmacists or someone prescribing opioids, identify patients at high-risk who would benefit from early interventions.[37] '''Prescriber Report Card Programs'''

*''Arizona -'' quarterly report cards are prepared and distributed by the state's Prescription Drug Monitoring Program. Each card details a provider’s prescribing history, including their ranking compared to the “average” prescriber of the same specialty and a summary or graphical representation of their prescribing history. The Arizona PDMP saw evidence that more prescribers were querying the PDMP and adjusted their prescribing habits after Arizona PDMP began issuing prescriber report cards. In Pinal County, for example, the percentage of prescribers meeting the “outlier” criteria for total dosage units fell 26 percent, and prescriber PDMP usage increased 14 percent in just one year.[38]
*''Kentucky -'' prescription data is configured to count the number of prescriptions and dosage units dispensed for the previous 90 days. Data categories on the report card include (a) the average for all Kentucky prescribers, (b) the average for prescribers within the selected specialty, and (c) the number for the requesting prescriber. Under consideration for enhancements to the report are the inclusion of the number of dosage units per prescription, morphine milligram equivalent (MME) calculations for a patient, and comparisons by a specific medication.[39]
*''Ohio -'' In 2015 Ohio PDMP created a 'Practice Insight Report' providing a brief summary to each provider of their prescribing patterns. This report card included 4 different sections: 1) top 25 patients by number of other prescribers visited in past 12 months, 2) Top 25 patients by active cumulative morphine equivalent (ACME) (Ohio’s acronym for MME), 3) Top 10 medications prescribed in the previous 12 months for the prescriber’s entire practice, 4) A listing of the prescriber’s patients issued a controlled substances prescription in the previous 12 months.
*''West Virginia -'' doctors are going to to be ranked based on how much they prescribe opioids[40]

 '''Saliva Drug Screening''' – For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system.[42][43] Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run.[44] Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. [citation needed] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''DEA Diversion Control Program (DCP)''' - This program is responsible for regulating and controlling more than 1.6 million DEA registrants involved in manufacturing, distributing, prescribing, and dispensing controlled prescription drugs (CPDs). DEA’s Diversion Control efforts are geared toward preventing the non-medical use of CPDs by providing education and training within the pharmaceutical and medical communities and pursuing those practitioners who are operating outside of reasonable medical standards. [45] '''[https://labtestsonline.org/understanding/analytes/pharmacogenetic-tests/ Pharmacogenetics Test]''' -At $350 per test and only needed once in your life, this is a cost effective approach to ensure that patients receive an appropriate dose of pain medication.[46] ''Contact'': John Cribbs (john@nodrugsneeded.com) '''[https://www.shatterproof.org/advocacy/state-by-state-information/prescriber-education Prescriber Education] -''' Physicians who prescribe opioid painkillers should receive training on the risks of overusing immediate release, extended-release, and long-acting formulations of pain medications. This training should be tied to the recently released ''CDC Guideline for Prescribing Opioids for Chronic Pain''>

'''Possible interventions by Healthcare Providers include:'''

'''Limiting the Supply of Prescription Opioids in Circulation'''

*Decrease supply by changing prescribing practices, reducing both dose and quantity.
*Provide non-opioid alternatives for effective chronic pain management, and work with payers to adequately reimburse for effective pain management modalities.
*Be diligent in follow-up on diversion/prevention opportunities.
*Partner with pharmacists and check their state's Prescription Drug Monitoring Program before prescribing opioids.

= Sources =

----

#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-prescriptions-20170706-story.html [1]]
#U.S. Department of Health and Human Services, “Press Release: Prescription painkiller overdoses at epidemic levels,” November 1, 2011, www.cdc.gov/media/releases/2011/ p1101_flu_pain_killer_overdose.html.
#Nora D. Volkow, “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse,” National Institute on Drug Abuse, May 14, 2014, www.drugabuse.gov/about-nida/ legislative-activities/testimony-to-congress/2015/americas- addiction-to-opioids-heroin-prescription-drug-abuse.
#Pokrovnichka, Anjelina. "History of Oxycontin: Labeling and Risk Management Program."
#Meier, Barry. "In Guilty Plea, OxyContin Maker to Pay $600 Million." ''The New York Times''. The New York Times, 09 May 2007. Web. 01 Feb. 2017. <[http://www.nytimes.com/2007/05/10/business/11drug-web.html [2]]>.
#Meier, Barry. "In Guilty Plea, OxyContin Maker to Pay $600 Million." ''The New York Times''. The New York Times, 09 May 2007. Web. 01 Feb. 2017. <[http://www.nytimes.com/2007/05/10/business/11drug-web.html [3]]>.
#[https://www.drugrehab.com/opioid-epidemic/ [4]]
#[http://www.planagainstpain.com/resources/usnd/ [5]]
#[http://www.planagainstpain.com/resources/usnd/ [6]]
#[http://www.planagainstpain.com/resources/usnd/ [7]]
##
##*
##**
##***
##****[http://pediatrics.aappublications.org/content/136/5/e1169 [8]]
#[http://www.planagainstpain.com/resources/usnd/ [9]]
#[http://www.planagainstpain.com/resources/usnd/ [10]]
#[http://www.planagainstpain.com/resources/usnd/ [11]]
#[http://www.huffingtonpost.com/entry/2015-opioids-survey_us_597fbf42e4b08e1430051bd1?utm_medium=email&utm_campaign= [12]]TheMorningEmail080117&utm_content=TheMorningEmail080117+CID_aab2173fd55d83c6c55bbc305653daee&utm_source=Email+marketing+software&utm_term=Reuters&ncid=newsltushpmgnewsTheMorningEmail080117
#National Institutes of Health, “Pathways to Prevention Workshop: the Role of Opioids in the Treatment of Chronic Pain,” September 29–30, 2014, prevention. nih.gov/docs/programs/p2p/ODPPainPanelStatement Final_10-02-14.pdf.
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [13]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [14]]
#[http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-new-prescriptions-20121228-story.html [15]]
#[http://www.cbsnews.com/news/heroin-use-rising-among-women-and-wealthy/ [16]]
#[http://www.npr.org/sections/health-shots/2016/01/20/462922517/opioid-abuse-takes-a-toll-on-workers-and-their-employers [17]]
#[https://www.cdc.gov/vitalsigns/opioids/index.html [18]]
#[http://safety.nsc.org/e1t/c/*W6CHc0S1bs90mW5pT6S629r1ky0/*W5Wm51M29Q9W7W3c2kqN3Dpbm_0/5/f18dQhb0S82-9dsQYMW8gpJQQ4mQf6dW4WJlYv5v_Sk4W3hHhdL5zh-NRVp3s9r7s5LskW8TyWk78TzqkrW4PQc0q2LFGHLW30TPxY54WFDnW5nDKL98W1PGmW3r3nBD31H9sVW4hz-Fq1SPxGDW1BMbsb1WwbdJW32q5tY5mG4wFW3CRqwb1YycPYW83_Pyq834DLzW8XWrn35rp7Y0W30sdJJ36tN1gMX-DyYVw63gN60kSQkZTmcZW4DqHqz6dgmw3W4yqK9Q4C-8H8W6gGQPz7F0yWMW81MffF7sLfzkN4W9-mlHMtq4VvBBZq1tBsMLW1s-GnB6HBHnDW6qG7343c41hBW7c9Y-_7lbxYdW76642w718dPTW1kk6RR7dgC7QW7n16Xd22R_v1W7l-z6Z7FTLlDW7n-lrS7sbXk9W7MHjJF7brZwzW1CtFTd7s945bW1vfNMV7vcKw0W6yvxtq2kV0jMW7CKBGl7wWTJRVFk2JC63VwclW34Zlnj3kYc04W4p7yDT2zz89mN5wL512Vy7F8W24DKvM3J3WSWVSd58l5q55vCW7mtWSc6kk_8HW8Jc99_3k-J7dW2Q8FtZ87ShD1W27h-j23_1-KkN8Mbtl5cYJKQW7dJ18n3PQ5gzf5n2LtT04 Evidence for the Efficacy of Pain Medications] [http://www.nsc.org/RxDrugOverdoseDocuments/Evidence-Efficacy-Pain-Medications.pdf?utm_campaign=Advocacy%20:%20Rx%20Drug%20Overdose&utm_source=hs_automation&utm_medium=email&utm_content=14359125&_hsenc=p2ANqtz--rGDOmg26G3XFqlpBlzTdhUD6HeBCp9sVYabAUNAOTCZ5fNJ3Oi5AeQtO8TjiF0JIE0rVvK6GByIraVOjKP12epF3vxA&_hsmi=14359125 [19]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [20]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [21]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [22]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [23]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [24]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [25]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [26]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [27]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [28]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [29]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [30]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [31]]
#[https://aishealth.com/archive/ndbn081117-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=115985453 [32]]
#[https://www.cdc.gov/drugoverdose/pdmp/ [33]]
#[https://www.justice.gov/usao/file/895091/download [34]]
#[http://www.pdmpassist.org/pdf/Report_Card_TAG_20160315_final.pdf [35]]
#[http://www.beckershospitalreview.com/hospital-physician-relationships/w-va-to-measure-rank-physicians-on-opioid-prescribing.html [36]]
#[http://www.modernhealthcare.com/article/20160611/MAGAZINE/306119965?utm_source=modernhealthcare&utm_medium=email&utm_content=20160611-MAGAZINE-306119965&utm_campaign=am [37]]
#Kintz P, Samyn N. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. ''Ther Drug Monit.'' 2002;24(2):239-246.
#Choo RE, Huestis MA. Oral fluid as a diagnostic tool. ''Clin Chem Lab Med.'' 2004;42(11):1273-1287.
#[http://forensicfluids.com/oral-v-urine/#turnaround [38]]
#[https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use [39]]
#[http://www.medscape.com/viewarticle/842715_2 [40]]
#[https://www.shatterproof.org/advocacy/federal-initiatives/prescription-drug-monitoring-programs [41]]
#[http://catalyst.nejm.org/act-now-prescription-opioid-crisis/?utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=51100063&_hsenc=p2ANqtz-_oQWJ7-DxzFgvqArz6FRbZcZ6IGV9pybacNCcFzbO79WW05_bglhgesjejwFT992hRSFxknyMnqcTkzXYbtEhFGfokyDf4jl773soGbB7y_VGsB1k&_hsmi=51100063 [42]]
</div> </div> </div> </div> </div> </div> </div> </div> </div> </div>
</div> </div> </div> </div>  
</div>
 

[[Category:Pages with broken file links]][[Category:SAFE-Prescriptions and Medical Response]]