Posts Tagged opioid

Opioid Use Decreased in Medicare Part D While MAT Increased

Opioid Use Decreased in Medicare Part D While MAT Increased

The nation has been grappling with an opioid crisis for years. In 2017 alone, there were 47,600 opioid-related overdose deaths in the United States. It continues to be a public health emergency. U.S. Department of Health & Human Services Office of the Inspector General has been tracking opioid use in Medicare during this crisis, particularly since 2016.

In a statement, the Centers for Medicare & Medicaid Services said: “Fighting the opioid epidemic has been a top priority for the Trump administration. We are encouraged by the OIG’s conclusion which finds significant progress has been made in our efforts to decrease opioid misuse while simultaneously increasing medication-assisted treatment in the Medicare Part D program.”

OIG has identified beneficiaries at serious risk of misuse or overdose and has identified prescribers with questionable prescribing for these beneficiaries. These types of analyses are crucial to understanding and addressing the national opioid crisis. Building on past OIG work, this data brief details opioid use in Medicare Part D in 2018 and trends in drugs used to treat opioid use disorder.

We based this data brief on an analysis of Part D prescription drug event records for opioids received in 2018. We determined the beneficiaries’ morphine equivalent dose, which is a measure that converts all of the various opioids and strengths into one standard value.

WHAT WE FOUND

Alabama had the highest proportion of beneficiaries receiving opioids through Medicare Part D, while Hawaii had the lowest proportion.

  • Nearly 3 in 10 Medicare Part D beneficiaries received opioids in 2018, a significant decrease from the previous 2 years.
  • At the same time, the number of beneficiaries receiving drugs for medication-assisted treatment for opioid use disorder has steadily increased and reached 174,000 in 2018.
  • In addition, the number of beneficiaries receiving prescriptions through Part D for naloxone-a drug that can reverse the effects of an opioid overdose-more than doubled from 2017 to 2018.
  • About 354,000 beneficiaries received high amounts of opioids in 2018, with about 49,000 of them at serious risk of opioid misuse or overdose; this was fewer than in the previous 2 years.
  • About 200 prescribers had questionable opioid prescribing for beneficiaries at serious risk.

WHAT WE CONCLUDE

Progress has been made in decreasing opioid use in Part D, increasing the use of drugs for medication-assisted treatment, and increasing the availability of naloxone. It is imperative for the Department of Health and Human Services-including CMS and OIG-to continue to implement effective strategies and develop new ones to address this epidemic.

Read the complete Data Brief

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STUDY: Risk of Suicide Attempt by Children Doubles if Parent Uses Opioids

STUDY: Risk of Suicide Attempt by Children Doubles if Parent Uses Opioids

The suicide rate among young people in the U.S. has risen dramatically in the past 15 years. Over the same time period, opioid use and abuse in adults also has increased considerably. Researchers from the University of Chicago and the University of Pittsburgh reported on a connection between these two epidemics in a study published this week in JAMA Psychiatry.

“Until now, there has been little focus on the association between the increase in opioid use among adults and the risk of suicidal behavior by their children,” said Robert D. Gibbons, PhD, the Blum-Riese Professor of Biostatistics and director of the Center for Health Statistics at UChicago and senior author of the paper. “We theorized such a link was plausible because parental substance abuse is a known risk factor for suicide attempts by their children. In addition, depression and suicide attempts by parents — which are known to be related to suicidal behavior in their offspring — are more common among adults who abuse opioids.”

The researchers analyzed data from more than 240,000 parents, ages 30 to 50, between 2010 and 2016. Half of the group had filled opioid prescriptions for at least 365 days. The other half had no history of using the drug during that time. The two groups were matched on a number of factors related to suicide attempts and opioid use. Rates of suicide attempts were studied in over 330,000 children, ages 10 to 19, from these two groups of parents over the same six-year period.

Of the children whose parents used opioids, 678 (0.37%) attempted suicide. Of the sons and daughters of parents who did not use opioids, 212 (0.14%) made a suicide attempt. The researchers found that opioid use by a parent is associated with a doubling of the risk of suicide attempts by their children. The results were statistically significant even when adjusted for child age and sex, depression or substance use disorder in child or parent, and history of a suicide attempt in a parent.

“These findings demonstrate that opioid use by a parent or parents doubles the risk for suicidal behavior by their children,” said David A. Brent, MD, psychiatrist and chair of suicide studies at the University of Pittsburgh, also an author on the paper. “The epidemics of adult opiate abuse and child suicidal behavior appear to be linked, and the disturbing upward trends in mortality due to opiates and due to child suicide may have common roots.”

Gibbons and Brent call for improved diagnosis and treatment of parents who use opioids as well as mental health screening and referral to care for their children. “These actions could help reverse the upward trend in deaths due to the twin epidemics of suicide and opioid overdose,” Gibbons said.

The study, “Association Between Parental Medical Claims for Opioid Prescriptions and Risk of Suicide Attempt by Their Children,” was supported by a grant from the National Institutes of Health. Kwan Hur, PhD, in the Center for Health Statistics at the University of Chicago, was also an author of the study.

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CDC Clarifies Opioid Prescribing Guidelines

CDC Clarifies Opioid Prescribing Guidelines

Since the Centers for Disease Control and Prevention released its Guidelines for Prescribing Opioids for Chronic Pain in 2016, physicians have relied on the document for recommendations when prescribing pain medication to their patients. However, because the CDC did not specifically clarify the guidelines in the original release, many physicians’ groups have been concerned the guidelines were misapplied to the detriment of pain patients.

The CDC issued the guideline in March 2016 in an attempt to curb widespread opioid abuse, which claimed more than 20,000 U.S. lives in the previous year along. The guideline was intended for primary care clinicians and advised them to prescribe treatments other than opioids for chronic pain outside of active cancer treatment, palliative care and end-of-life care.

Three years later, more than 300 health care professionals wrote to the CDC urging clarification of the guideline and suggesting the possibility it is being misapplied by physicians and insurers, and even harming patients. The letter was signed by prominent medical experts, including three former White House “drug czars” who served in the Obama, Clinton and Nixon administrations. The University of Alabama at Birmingham School of Medicine’s Professor Stefan G. Kertesz, M.D., is also one of the signees of the letter.

“We urge the CDC to issue a bold clarification about the 2016 guideline — what it says and what it does not say, particularly on the matters of opioid taper and discontinuation,” the group wrote in the letter, which was also sent to leaders of the House Committee on Energy and Commerce and the Senate Committee on Health Education Labor and Pensions.

In a letter released publicly in April, the CDC said the guidelines were not intended to deny chronic pain patients relief from opioids and encouraged physicians to use their “clinical judgment” in prescribing the medications, which can be addictive. The letter also spoke specifically to the use of opioids in the treatment of cancer and sickle cell patients, making it clear the guideline was not meant to limit access to pain management for patients with these conditions.

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Drug Overdoses in Young People on the Rise

Drug Overdoses in Young People on the Rise

PISCATAWAY, NJ – In American adolescents and young adults, death rates from drug poisoning, particularly from opioids, have sharply increased over the last 10 years, according to new research in the Journal of Studies on Alcohol and Drugs.

In 2006, the death rate from drug poisoning from any type of legal or illicit drug was 8.1 deaths for every 100,000 people in the population ages 15 to 24. This rose to 9.7 per 100,000 by 2015, mainly fueled by deaths from opioid use. In this age group, death rates from opioids — both prescription opioids and illicit opioids such as heroin — rose 4.8 percent on average annually from 2006 to 2015, with an even steeper incline of 15.4 percent a year between 2013 and 2015.

“The surge in drug poisoning deaths . . . among adolescents and young adults reflects the ease of access to pharmaceutical drugs, especially prescription opioids . . . and later transition to more potent opioids,” the authors write. Many young people are introduced to opioids through prescription drugs, such as Vicodin or OxyContin. They often misuse these drugs with motivations to relieve pain, relax, feel good, or get high.

“[W]hen people addicted to prescription opioids face difficulty accessing these drugs because of tighter controls, they often turn to increasingly available and cheaper heroin,” the authors continue. Those who switch from prescription drugs to heroin are at high risk for drug overdose because these individuals are “accustomed to titrated prescription drugs and do not realize that heroin varies in potency and can be cut or mixed with dangerous and potentially deadly substances,” such as fentanyl.

To conduct their study, researchers led by Bina Ali, Ph.D., of the Pacific Institute for Research and Evaluation in Maryland, analyzed mortality data from the National Center for Health Statistics from 2006 through 2015. In addition to examining average annual rate changes in drug poisoning death rates for adolescents (ages 15-19) and young adults (ages 20-24), Ali and her colleagues estimated the costs to society associated with these deaths. This included the costs of medical interventions (emergency transport; treatment in hospitals, nursing homes, and hospices; and autopsies), work loss (loss of earnings and household work that young people would have made over the remainder of an average life), and quality-of-life loss (the monetary value of intangible losses such as pain and suffering).

The investigators found that drug poisoning death rates in adolescents and young adults were higher for Whites (11.9 for every 100,000 people) and American Indian/Alaskan Natives (10.0) compared with Blacks (2.6), Asian/Pacific Islanders (2.3), and Hispanics (4.0). Over time, the rates significantly increased for Whites (1.7 percent per year from 2006 to 2015), Asian/Pacific Islanders (4.3 percent per year from 2006 to 2015), and Blacks (11.8 percent per year from 2009 to 2015).

Drug poisoning death rates in adolescents and young adults vary by state. For example, the rate in West Virginia was approximately 5 times higher than the rate in Nebraska (15.1 vs. 3.1 per 100,000). When looking at changes between 2006 and 2015, New York had the highest increase in drug poisoning death rate, with a 9.4 percent increase each year. This was followed by Ohio, Massachusetts and New Jersey (with 9.1 percent, 9.0 percent and 8.7 percent increases annually, respectively).

The estimated costs of drug poisoning deaths among young people in the United States were $27.1 million in medical costs, $8.5 billion in work loss costs, and $26.5 billion for quality-of-life loss in 2015.

“The burden of drug poisoning deaths among adolescents and young adults is substantial,” Ali and her colleagues conclude. “With the burden of drug poisoning deaths among adolescents and young adults estimated at $35.1 billion nationally, targeted state-specific efforts are warranted.”

Evidence-based and promising strategies exist, such as knowledge and skills development for physicians, young people, and their parents; expansion of prescription drug monitoring programs, prescription drug disposal methods, and naloxone distribution programs; and medication-assisted treatment that combines medications with counseling and behavioral therapies. Interventions that are tailored for high-risk populations and directed at multiple levels (individuals, communities, and public health systems) are needed to reduce premature deaths from drug overdoses, according to Ali.

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Ali, B., Fisher, D. A., Miller, T. R., Lawrence, B. A., Spicer, R. S., Swedler, D. I., & Allison, J. (2019). Trends in drug poisoning deaths among adolescents and young adults in the United States, 2006-2015. Journal of Studies on Alcohol and Drugs, 80, 201-210. doi:10.15288/jsad.2019.80.201

The Journal of Studies on Alcohol and Drugs is published by the Center of Alcohol Studies at Rutgers, The State University of New Jersey. It is the oldest substance-related journal published in the United States.

To learn about education and training opportunities for addiction counselors and others at the Rutgers Center of Alcohol Studies, please visit https://education.alcoholstudies.rutgers.edu.

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STUDY: Opioid Epidemic May Have Cost U.S. Governments $37.8 Billion in Tax Revenue

STUDY: Opioid Epidemic May Have Cost U.S. Governments $37.8 Billion in Tax Revenue

UNIVERSITY PARK, Pa. — The opioid epidemic may have cost U.S. state and federal governments up to $37.8 billion in lost tax revenue due to opioid-related employment loss, according to Penn State researchers. Additionally, the researchers found that Pennsylvania was one of the states with the most lost revenue, with approximately $638.2 million lost to income and sales tax. The study looked at data between 2000 and 2016.

Joel Segel, assistant professor of Health Policy and Administration, said that the results — recently published in the journal Medical Care — could help governments that are hoping to make up for lost revenue.

“This is a cost that was maybe not thought about as explicitly before, and a cost that governments could potentially try to recoup,” Segel said. “Instead of focusing on the cost of treating people with opioid use disorder, you could think about it in terms of a potential benefit to getting people healthy, back on their feet, and back in the workforce.”

Previous research estimated that in 2016 there were nearly 2.1 million Americans with an opioid use disorder, and approximately 64,000 deaths were the result of an opioid overdose. According to the National Institute on Drug Abuse, there were 2,235 opioid-related overdose deaths­­­ in Pennsylvania alone.

Segel said that while previous studies have looked at the cost of the opioid epidemic in terms of substance abuse treatment and other medical costs, he and the other researchers were interested in exploring other costs that may not have been captured before.

“We wanted to take a systematic approach to how we could think about some of the tax revenue that is lost if someone is unable to work due to opioid use,” Segel said. “This could be an important consideration for either state or federal budgets.”

The researchers used data from the National Survey on Drug Use and Health, as well as information from a previous study that estimated declines in the labor force due to the opioid epidemic. They used the TAXSIM calculator from the National Bureau of Economic Research to estimate losses in tax revenue.

After analyzing the data, the researchers found that from 2000 to 2016, there was an estimated decline of 1.6 million participants in the labor force, with about 68,000 of those in Pennsylvania. There were about 180,000 overdose deaths, with approximately 6,100 occurring in Pennsylvania.

Additionally, the researchers estimated losses of $11.8 billion to state governments and $26 billion to the federal government in tax revenue due to reductions in the labor force. For state governments, this included lost sales tax and income tax revenue. Losses to the federal government were entirely due to lost income tax revenue.

Segel said the results help show the value of treating people with opioid use disorder and should be considered when treatment programs are being considered and evaluated.

“The state of Pennsylvania has been developing some innovative programs, and our results are something to consider as these programs are being considered for implementation,” Segel said. “Not only are treatment programs beneficial to the individual and to society, but if you’re thinking about the total cost of these treatment programs, future earnings from tax revenue could help offset a piece of that.”

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Penn State has made a multi-year investment in bringing together researchers from many fields to address the challenges of substance abuse in Pennsylvania and beyond.

Dennis P. Scanlon, distinguished professor of health policy and administration and director of the Center for Health Care Policy Research; Yunfeng Shi, assistant professor of health policy and administration; and John R. Moran, associate professor of health policy and administration, all with Penn State, also participated in this work.

This work was supported by the Commonwealth of Pennsylvania under the project “Estimation of Societal Costs to States Due to the Opioid Epidemic,” and part of larger work supported under a Strategic Planning Implementation award from the Penn State Office of the Provost, “Integrated Data Systems Solutions for Health Equity.”

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Alabama Medicaid Cumulative MME Edit Coming Early 2019

Alabama Medicaid Cumulative MME Edit Coming Early 2019

UPDATE April 26, 2019: Effective May 1, 2019 the Alabama Medicaid Agency will begin implementing cumulative daily MME edits for opioid experienced recipients.

Higher doses of opioids are associated with higher risk of overdose and death – even relatively low dosages (20-50 MME per day) may increase risk.1 Therefore, Alabama Medicaid will limit the amount of cumulative MME allowed per day on opioid claims. The edit will begin at 250 cumulative MME per day and will gradually decrease over time. The final cumulative MME target is scheduled to be 90 MME per day.  This edit is different, and in addition to, the short-acting opioid naïve edit implemented on November 1, 2018.

Phase-In Period:
Beginning May 1, 2019, Alabama Medicaid will begin with a “phase-in” period for 3 months. Claims that exceed the cumulative daily MME limit of 250 MME will be denied at the pharmacy Point of Sale (POS).  The dispensing pharmacist will be provided a universal prior authorization (PA) number on the rejection screen and may enter this universal PA number on the claim to allow it to be paid. Pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient’s total daily MME.

Hard Edit Implementation:
Beginning August 1, 2019, opioid claims that exceed the cumulative MME edit of 250 MME/day will be denied.  The universal PA will no longer be valid to bypass the 250 MME edit.  Pharmacy override requests for quantities exceeding the MME limit may be submitted to Health Information Designs (HID) and will be reviewed for medical necessity. See link below for override form.

Edit Details:

  • The universal PA number to override the 250 MME edit will be 0009996321
  • The universal PA number will be provided on each cumulative MME rejection screen for the pharmacist   convenience
  • Additional edits such as therapeutic duplication, maximum quantity limitations, early refill, non-preferred edits will still apply
  • Claims prescribed by oncologists will bypass the edit
  • Long term care and hospice recipients are excluded
  • Children are included in the edit
  • A Recipient Information Sheet for prescribers and pharmacists to provide to recipients can be found at http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx.

Anticipated Phase Down:
The Agency anticipates gradually decreasing the daily cumulative MME limit every 4 months. The first decrease to 200 MME/day will be implemented on December 1, 2019.  Prior to each decrease, a new universal PA number will be assigned to override claims that exceed the new threshold.  Providers will be notified via an ALERT prior to each decrease.  Again, pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient’s total daily MME.

Examples of MME calculations/day include:

  • 10 tablets per day of hydrocodone/acetaminophen 5/325 = 50 MME/day
  • 6 tablets per day of hydrocodone/acetaminophen 7.5/325 = 45 MME/day
  • 5 tablets per day of hydrocodone/acetaminophen 10/325 = 50 MME/day
  • 2 tablets per day of oxycodone 15 mg = 45 MME/day
  • 3 tablets per day of oxycodone 10 mg = 45 MME/day
  • 10 tablets per day of tramadol 50 mg = 50 MME/day
  • 1 patch per 3 days of fentanyl 25mcg/hr = 60 MME/day

A link with more information regarding MME calculations is https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf.

IMPORTANT: Only if the override is denied, then the excess quantity above the maximum unit limit is deemed a non-covered service, and the recipient can be charged as a cash recipient for that amount in excess of the limit.  A prescriber must not write separate prescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override process.  FAILURE TO ABIDE BY MEDICAID POLICY MAY RESULT IN RECOUPMENTS AND/OR ADMINISTRATIVE SANCTIONS.  Source: Provider Billing Manual 27.2.3

1 https://www.cdc.gov/drugoverdose/prescribing/guideline.html

Override Requests:
Once the hard edit is implemented, the MME Override Request Form will be used by the prescriber when requesting an override. The form will be found at: http://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.

Any policy questions concerning this provider ALERT should be directed to the Pharmacy Program at (334) 242-5050.

The Agency has developed a consumer-friendly handout to explain the new edit to recipients. A copy is attached to this email and may also be found at http://www.medicaid.alabama.gov/documents/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Services/9.4.13_Opioid_Edit_Recipient_Handout.pdf


ORIGINAL ARTICLE April 2019: In addition to the opioid naïve 5 and 7-day limits, the Alabama Medicaid Agency is working toward implementing cumulative Morphine Milligram Equivalent (MME) edits in early 2019.

Higher doses of opioids are associated with a higher risk of overdose and death; even relatively low dosages (20-50 MME per day) may increase risk.1 Alabama has led the nation for the past six years in the opioid prescribing rate per 100 population (121 in 2016; 107.2 in 2017) and had nearly three times more opioid prescriptions per 100 population than New York.2

The Alabama Medicaid Agency previously executed many programs to address opioid use such as monthly maximum unit limits, therapeutic duplication edits, Drug Utilization Review (DUR) letters, academic detailing report cards and face to face visits, prior authorization, and other educational efforts. Most recently, Medicaid implemented limits for opioid naïve patients to limit first-time use to five days for children and seven days for adults, limiting daily use to 50 MME. Overrides are available for medical necessity.

In an effort to continue combating the opioid crisis, beginning May 1, 2019*, Alabama Medicaid will limit the amount of cumulative MMEs allowed per day on claims for opioid experienced recipients. The edit will begin at 250 cumulative MME per day and will gradually decrease over time. The final MME target is 90 MME per day.

Claims for opioids that exceed the maximum daily cumulative MME limit will be denied. Claims prescribed by oncologists will be excluded from the edit. Long term care and hospice patients will also be excluded; however, children will be included. Overrides for quantities exceeding the MME limit for medical necessity may be submitted to Health Information Designs (HID). Information regarding override requirements and MME examples will be made available on the Alabama Medicaid Agency website closer to the implementation of the new limitations.

The Agency will implement a robust educational program to include academic detailing visits to the prescribers and pharmacies of the first round of affected patients, extensive training, and notifications to the impacted providers through a provider ALERT closer to implementation. Please check the Alabama Medicaid Pharmacy webpage for additional information: http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx

*At the time of article submission, the implementation date is May 1, 2019, for a ‘phase in’ for 250MME/day. During the phase-in period, a universal prior authorization number will be provided on the pharmacy claim rejection, with an explanation to notify the affected patient/prescriber. Hard stops/edits will begin after the phase-in period.

  1. “Calculating Total Daily Dose of Opioids for Safer Dosage”. CDC. https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf. Accessed 2/1/2019.
  2. “Understanding the Epidemic”. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed 2/1/2019.

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Attention Primary Care Providers: Alcohol and Drug Conference is March 19-21

Attention Primary Care Providers: Alcohol and Drug Conference is March 19-21

 

See also: Are You Interested in Becoming a DATA-Waived Physician?

Alabama Department of Mental Health has partnered with the Alabama Department of Public Health on a grant to increase awareness of substance use disorders among primary care professionals. This grant will allow ADMH to pay the registration fee only for any of the following to attend the Alabama School of Alcohol and Other Drug Studies (ASADS):

  • MD
  • DO
  • PA
  • CRNP
  • CNM
  • RN

The Medical Foundation of Alabama designates this live activity for a maximum of 27 AMA PRA Category 1 Credit(s)™.

ASADS has been conducting conferences for over 43 years. Over the past couple of years, there has been a heavy emphasis in the community and at the state level to begin to develop a system of care that integrates primary care and substance abuse treatment. There are many great speakers at this year’s conference.

Dr. Alta DeRoo, M.D., FACOG, will present Medication Assisted Treatment (MAT) Waiver Training. This is required 8-hour training.

T4: Medication Assisted Treatment (MAT) Waiver Training

This course is designed for MDs, DOs, PAs and CRNPs who are interested in becoming a 2000 Data Waived physician. This class will be held from 8 a.m. – 5 p.m. to meet the 8-hour requirement.

Course Description:

This presentation is designed to train qualified physicians in dispensing or prescribing specifically approved Schedule III, IV and V narcotic medications for the treatment of opioid addiction in an office-based setting. The goal of this training is to acquire the knowledge and skills needed to provide optimal care to opioid use disorder patients by providing:

1) an overview of opioid use disorder,

2) the efficacy and safety of buprenorphine,

3) process of patient selection,

4) clinical use of buprenorphine,

5) nonpharmacological interventions,

6) medical psychiatric conditions in opioid use disorder patients, office procedures, and

7) special treatment population.

This eight-hour training, which will include eight separate modules and four case studies. Each of the speakers will be presenting for two hours. The remaining two hours are broken up over the four case studies. Designated by the DHHS, this training meets the eight-hour requirement and is designed for physicians to dispense buprenorphine in office practice for treatment of opioid use disorder. Participation in this training will provide physicians with a comprehensive overview of buprenorphine prescribing and its safe and effective use in an office-based setting. This training is designed for physicians and other primary care providers who are likely to treat opioid-dependent persons in their practice, such as those in family practice, general internal medicine, psychiatry, pediatrics, adolescent medicine specialists, and Opioid Treatment Programs.

Course Objectives:

After attending the course, a participant will be able to:

• review addiction treatment in office-based practices;

• discuss the pharmacological treatments of opioid use disorder;

• determine what medical record documentation must be followed;

• discuss the process of buprenorphine induction as well as stabilization and maintenance techniques;

• describe how to take a patient history and evaluation; and

• review safety concerns and drug interactions.

Dr. Merrill Norton, Ph.D., will be conducting a three-part series on The Pain of Pleasure: A Pharmacist’s Guide to Opioid Use Disorders for Prescribers and Other Healthcare Professionals.

Dr. Cardwell Nuckols, Ph.D.The Neurobiology of Addiction: The Addiction Process in Three Stages

Dr. Boyett, D.M.D., D.O., DFASAM, and Dr. Taylor, M.D., M.P.H., F.A.S.A.MThe Delivery of Office-Based Addiction Treatment (OBOT) in the 21st Century

ADMH can pay the registration fee only. To have your registration fee paid, complete the registration form and return it to Kathy House at kathy.house@mh.alabama.gov no later than Feb. 24.

REGISTRATION FORM           BROCHURE

See also: Are You Interested in Becoming a DATA-Waived Physician?

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New Statistics Show Doctors Positively Impacting Opioid Epidemic

New Statistics Show Doctors Positively Impacting Opioid Epidemic

MONTGOMERY — Alabama’s physicians are having a positive impact on the opioid epidemic here at home while national statistics are showing for the first time, Americans’ odds of dying from an accidental opioid overdose are higher – 1 in 96 – than from a motor vehicle crash – 1 in 103.

Using data from the Center for Disease Control and Prevention comparing overdose deaths from 2017 to 2018, states and the District of Columbia are ranked by the largest positive change between the two years. The area with the largest decrease in opioid deaths ranked No. 1, while the state with the highest increase in opioid deaths ranked No. 50.

Alabama ranked 14 in the new CDC study with a decrease of 5.3 percent.

  • Predicted 12-month count, June 2017: 836
  • Predicted 12-month count, June 2018: 792

Because fatal drug overdoses are often underestimated, the CDC also factored for predicted cases. Metrics include percent completeness in overall death reporting, the percentage of deaths with the cause of death pending further investigation and the percentage of drug overdose deaths with specific or drug classes reported, according to the CDC.

National rankings of fatal opioid overdose rates in each state and the District of Columbia for 2017 are also based on data from the CDC’s National Center for Health Statistics. The data include deaths from both legally prescribed and illegally produced fentanyl.

The age-adjusted opioid overdose death rate for the U.S. was 14.9 per 100,000 individuals. In Alabama, the age-adjusted opioid overdose death rate was 9 per 100,000 individuals. Alabama ranked 36 out of 51 states, including the District of Columbia for 2017, the third lowest in the Southeast and far below the national average.

“This is extremely good news for Alabama and shows that the hard work of our physicians and the programs that the Medical Association and our leadership have instituted are truly making a difference in our state by saving lives,” said Association Executive Director Mark Jackson. “Until 2013 Alabama was one of the only states offering an opioid prescribing education course when the FDA developed the blueprint for Risk Evaluation and Mitigation Strategies for producers of controlled substances. As the need for that prescribing track has grown, we’ve made adjustments to ensure the prescribers attending it will receive the latest information available. Now, we’ve added an online, OnDemand track that makes it even easier for prescribers to get the latest education available. With any luck, Alabama’s death numbers due to prescription drugs will continue to drop. Our efforts are definitely paying off in a big, big way.”

Visit the OnDemand Education Center at www.alamedical.org/onlinecme.

Posted in: Opioid

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It’s Not Just About Opioids…

It’s Not Just About Opioids…

According to the National Institute on Drug Abuse, more than 30 percent of overdoses in the United States involving opioids also involve benzodiazepines, or “benzos.” Statistics from the Centers for Disease Control and Prevention show more than 115 Americans die each day from an opioid-related overdose.

However, between 1996 and 2013 the number of adults who filled a benzodiazepine prescription increased by 67 percent from 8.1 million to 13.5 million. In 2015, 23 percent of people who died of an opioid-related overdose also tested positive for benzodiazepines.

In a study published in the British Medical Journal in March 2017 of more than 300,000 continuously insured patients receiving opioid prescriptions between 2001 and 2013, the percentage of persons also prescribed benzodiazepines rose to 17 percent in 2013 from nine percent in 2001. The study showed those concurrently using both drugs are at higher risk of visiting the emergency department or being admitted to a hospital for a drug-related emergency.

In March 2016, the CDC issued new guidelines for the prescribing of opioids, which included a recommendation to avoid prescribing benzodiazepines concurrently with opioids when possible. In October 2016, the Food and Drug Administration issued a “black box” warning for prescription opioids and benzodiazepines highlighting the dangers of administering these medications together. (See https://www.advisory.com/daily-briefing/2016/09/01/black-box-opioid-benzodiazepines)

Let’s talk about benzos.

As with all medications, benzodiazepines have their usefulness. If prescribed and taken correctly, this class of medications can be extraordinarily helpful to patients. Benzodiazepines calm or sedate a person by raising the level of the inhibitory neurotransmitter GABA in the brain. Common benzodiazepines include alprazolam (Xanax), diazepam (Valium) and clonazepam (Klonopin).

Alprazolam is the most prescribed benzodiazepine in Alabama, according to the Alabama Board of Medical Examiners.

“Benzodiazepines are very effective medications for the treatment of acute anxiety just as opioids are very useful for the treatment of acute pain. But also like opioids, benzodiazepines will cause the development of physiologic tolerance if used regularly, and this often causes a loss of therapeutic effect if the dose is not continuously escalated. For this reason, they are not ideal medications as the primary treatment of chronic anxiety,” said Luke Engeriser, M.D., Assistant Professor of Psychiatry at USA Health College of Medicine and Deputy Chief Medical Officer, AltaPointe Health Systems in Mobile. “Benzodiazepines are most useful when prescribed for brief periods when someone is going through a major crisis or exacerbation of symptoms, for example after the loss of a loved one. Ideally, regular use of the medication would only be for one or two weeks. We
also sometimes will use a benzodiazepine for a time-limited period when we are initiating an antidepressant medication like an SSRI or SNRI for treatment of chronic anxiety. Although these antidepressant medications are very effective for anxiety, it sometimes takes a few weeks before the medication has a sufficient therapeutic effect.”

Other physicians, like David Herrick, M.D., of Montgomery, agree with Dr. Engeriser that as physicians prescribe benzodiazepines, extra care should be taken in monitoring the patient.

“All medications have their place, but it’s the way they are used or misused that’s creating a deadly problem. While using opioids and benzos together is not completely forbidden, it is something that has to be done very, very carefully. Most people don’t have to be on benzodiazepines all the time. If the patient has a real anxiety disorder, then that patient should be under the care of a psychiatrist,” Dr. Herrick said. “Benzos are intended to be used for the short term. I think the medical community should consider benzodiazepines just as risky as opioids and monitor and treat their patients who are using them just as carefully as their patients who are taking opioids…with the same amount of care and concern.”

Going back to school.

According to Dr. Merrill Norton, PharmD., ICCDP-D, Clinical Associate Professor at the University of Georgia College of Pharmacy, although benzodiazepines have been in use since the 1950s, education about their proper use and potential harm has not kept up with the times.

“The problem with opioids and benzodiazepines, even at prescribed levels, is understanding which opioid interacts with which benzo?” Dr. Norton explained. “This is where the physician has to be very astute. What needs to happen now is a consistent training mechanism for physicians who prescribe buprenorphine, methadone, or have patients on these medications. What the benzo is doing is helping modify the anxiety that is being triggered by the opioid withdrawal. That’s why they use it. And this is why the physician needs to be better trained not only in the prescribing of the opioid but also with benzos and how they react to one another.”

Dr. Norton suggested before prescribing a benzodiazepine, physicians should evaluate the patient for tendencies to misuse drugs and/or alcohol or if the patient has a history of misuse. Depending on the complexity of the patient’s care needs, consultation or referral to an addiction medicine physician may be necessary. Certain aberrant behaviors also may be a feature in some patients who are prescribed benzodiazepines and may include diversion of valid prescriptions, illicit sale or use in manners alternate to the prescribed dosage, route and frequency.

“Physicians need to know that benzodiazepines are useful short term but have extreme dangers to medication safety to patients who are placed on long-term regimes. Physicians also need to be aware of each benzodiazepine medication’s half-life, tolerance curves, basic pharmacodynamics and pharmacokinetic properties of each, and how to identify and manage benzodiazepine withdrawal when it occurs. Basically, physicians need to re-educate themselves on these medications. I’m finding that most physicians are already very cautious when it comes to prescribing benzodiazepines, but I don’t know how aware they are of the many types of drug interactions that can happen,” Dr. Norton said.

The Medical Association will again offer three live Prescribing and Pharmacology of Controlled Drugs courses in 2019. Drs. Engeriser, Herrick and Norton have all participated in these lectures in the past as guest faculty members and stress the importance of presenting evidence-based information and case studies to the attendees. The courses in 2019 will be March 2-3 in Auburn, Aug. 2-4 in Destin, and Nov. 23-24 in Birmingham. More information about specific topics and faculty will be available from the Association’s Education Department at a later date.

The Medical Association recently unveiled its new online OnDemand Education Center, which includes seven Alabama Opioid Prescribing courses that meet the Alabama Board of Medical Examiners’ requirements for holders of an ASCS and are free to members. One course specifically deals with benzodiazepines: Use and Misuse of Benzodiazepines.

What tools can physicians use to avoid potentially deadly medication interactions?

There are many tools physicians can use to help screen their patients for a history of alcohol and/or drug addiction before prescribing benzodiazepines. Physicians agree that adding a benzodiazepine into the mix of medications for a patient who has a history of addiction may only be adding fuel to the fire.

“Prescribing a benzodiazepine to a patient with a history of addiction to other substances increases the risk that a patient could develop an addiction to benzodiazepines or that the benzodiazepine could trigger a relapse on the drug of choice. When prescribing any controlled substance, we should also regularly check the PDMP,” explained Dr. Engeriser.

The Prescription Drug Monitoring Program was developed to promote the public health and welfare by detecting diversion, abuse and misuse of prescription medications classified as controlled substances under the Alabama Uniform Controlled Substances Act. Under the Code of Alabama, 1975, § 20-2-210, et seq., the Alabama Department of Public Health was authorized to establish, create and maintain a controlled substances prescription database program. This law requires anyone who dispenses Class II, III, IV, V controlled substances to report daily the dispensing of these drugs to the database. For more information about the Alabama PDMP, or to set up an account, log on here: http://alabamapublichealth.gov/pdmp/

Another helpful tool Dr. Norton suggested physicians can have at their fingertips to help spot bad drug interactions is the app, UpToDate. This app is one of the fastest apps physicians can use to double-check for drug interactions as they are writing prescriptions. It is, however, a subscription service, but the app comes with clinical decision support with evidence-based clinical information, including drug topics and recommendations. To learn more about UpToDate, services, subscription options, and how to download the app for your mobile device or EHR, log on here: https://www.uptodate.com/home/why-uptodate

Medical Association members can also subscribe to The Medical Letter on Drugs and Therapeutics at a reduced rate. The Medical Letter is a biweekly publication that provides evidence-based, peer-reviewed evaluations of new FDA-approved drugs with conclusions reached by a consensus of experts; new information on previously approved drugs including pivotal clinical trials, new indications, and safety warnings; consensus recommendations for
the preferred and alternative treatments for common disorders; and comparative reviews of drugs for a given indication with particular attention to clinical efficacy, adverse effects, drug interactions, and cost. A subscription includes online and print access, a mobile app, and CME opportunities. To learn more about The Medical Letter, log on here: https://bit.ly/2Jj2EwW

What’s next?

A new study by the University of Michigan and published in the Journal of General Internal Medicine maps out county-by-county the prescribing habits of benzodiazepines. The South ranks at the top of the spectrum.

The study is based on data about all prescriptions written in 2015 by primary care providers for patients in the Medicare Part D prescription drug program. The researchers combined that information with county-level health and socioeconomic data from the County Health Rankings project, a project of the Robert Wood Johnson Foundation and the University of Wisconsin.

In the single year studied, the 122,054 primary care providers included in the study prescribed 728 million days’ worth of benzodiazepines to their patients, at a cost of $200 million.

The states with the highest intensity of prescribing — which the researchers defined as prescription days of benzodiazepines relative to all prescribed medication days — were Alabama, Tennessee, West Virginia, Florida and Louisiana. States with the lowest intensity were Minnesota, Alaska, New
York, Hawaii and South Dakota. Across all types of providers, primary care and otherwise, benzodiazepines accounted for 2.3 percent of all medication days prescribed to Part D participants by those providers that year.

Physicians agree it’s time to take another look at these medications.

“Benzos have as many problems as opioids do — they are addictive, sedating and deadly if they are not prescribed and used properly.” Dr. Herrick said. “We as physicians need to be more aware of these dangers and treat benzos the way we treat opioids with a lot more respect than we are right now. If you write the prescription and sign your name to it, you had better understand what you’re writing before you hand it off to your patient because it could cost that patient his life. We have gotten a bit cavalier about how we prescribe benzos, and we need to take a look at how and why we prescribe them. This is a real issue, and we need to take it more seriously. It’s time we take a hard look at how these are prescribed and why.”

Dr. Engeriser, however, offered a word of caution. Where physicians who prescribe opioids may have instinctively wanted to stop prescribing them altogether as the national epidemic was on the rise that cannot be the case with benzodiazepines.

“As providers become more careful about prescribing practices, there will likely be an increase in the desire to stop using benzodiazepines for certain patients. Benzodiazepine withdrawal is similar to alcohol withdrawal and can lead to seizures, delirium tremens, and death. For that reason, it is critical that patients not have their benzodiazepines abruptly stopped. There are different strategies for the tapering of benzodiazepines. The important thing in the outpatient setting is to taper the benzodiazepine slowly enough that severe withdrawal symptoms do not emerge. This is often done more easily with a benzodiazepine with a longer half-life such as clonazepam than a shorter half-life like alprazolam. On an inpatient unit, benzodiazepine taper can be more rapid, using as needed benzodiazepines to treat emergent withdrawal, with dosing guided by a scale, such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar).” Dr. Engeriser said.

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Study: Is the Opioid Crisis Response Overlooking Women?

Study: Is the Opioid Crisis Response Overlooking Women?

CONNECTICUT Women’s Health Research at Yale is calling on a government committee to revise its report on a coordinated response to the opioid epidemic so that it reflects the unique needs of women.

In a commentary published in the peer-reviewed journal Biology of Sex Differences, WHRY Director Carolyn M. Mazure, Ph.D., and Jill Becker, Ph.D., chair of the Biopsychology Area of the University of Michigan Psychology Department, detailed the laboratory, clinical and epidemiological evidence showing the need for the report to endorse and encourage the research of sex and gender differences. They argued such data is necessary to generate gender-based interventions that more fully address the opioid epidemic.

“All data must be reported by sex and gender so that gender-specific treatment and prevention strategies derived from this research are provided to practitioners and the public,” the authors said. “We encourage biomedical researchers and clinical care providers, as well as the public, to insist that a successful response to the opioid crisis should highlight the importance of understanding sex and gender differences in the current opioid epidemic.”

Mazure and Becker noted that the draft report of the White House National Science and Technology Council’s Fast-Track Action Committee (FTAC) created to respond to the opioid crisis does include important concerns about maternal and neonatal exposure to opioids. But they said the draft, released in October, overlooks significant and growing data on sex and gender differences in opioid use disorder (OUD). For example, they wrote that women are more likely than men to be prescribed and use opioid analgesics, and females and males experience pain and the effects of opioids differently.

In addition, women more quickly develop addictions after first using addictive substances, and women are more likely than men to relapse after a quit attempt.

The authors also described how women with opioid addiction are more likely than men to have experienced early trauma and have been diagnosed with depression. And women with opioid addiction suffer greater functional impairment in their lives, impacting their ability to work, secure steady housing, and — because women are more often family caretakers — avoid negative effects on children.

“Our experimental models will not begin to yield the desired information until they employ appropriate models that include both females and males, and our clinical and epidemiological investigations will not uncover needed data until both women and men are studied,” the authors said. “A successful response to the opioid crisis will only be found when scientists, practitioners and the public incorporate the essential importance of understanding sex and gender differences into the solution for OUD.”

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