Harm Reduction for the Lost Generation

Paul C. Coelho, MD Board Certified PM&R

Subspecialty Certified Pain Medicine

Table Of Contents

1. The Opioid Epidemic

2. The Lost Generation

3. Harm Reduction Strategies

Prescription For Disaster

http://www.newyorker.com/magazine/2014/05/05/prescription-for-disaster

Variation in Opioid Prescribing 1999-2008

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm

Opioid Prescribing Variation 2008

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509148/

Opioid Prescribing Variation 2008

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509148/

Benton County

Opioid Overdose Deaths 2006-2010

https://www.whitehouse.gov/blog/2014/02/11/5-things-know-about-opioid-overdoses

Opioid Overdose Deaths 2006-2010

https://www.whitehouse.gov/blog/2014/02/11/5-things-know-about-opioid-overdoses

Lincoln County

Prescription Opioid Epidemic

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm

14% Increase in ODD 2013 - 2014

policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000-2014.pdf

OR 13.3% Increase

Prescription Opioid Epidemic

http://www.pnas.org/content/early/2015/10/29/1518393112.full.pdf

Guns, MVA’s & ODD’s 2000-2015

http://www.realclearpolicy.com/blog/2015/12/21/guns_vs_cars_and_drugs_1500.html

Oregon Ranks #1 in the Nation in Prescription

Opioid Abuse

www.orpdmp.com/orpdmpfiles/PDF_Files/Reports/Statewide_10.01.11_to_03.31.12.pdf

Prescription Opioid Deaths In Oregon 2000-2011

http://www.orpdmp.com/orpdmpfiles/PDF_Files/Reports/NGA-overdose-presentation_Millet_12-05-2012.pdf

Top Oregon Counties for Opioid Prescriptions

160.0000

172.5000

185.0000

197.5000

210.0000

Josep

hine

Dougla

s

Sher

man

Linco

ln

Clatso

pLin

n

Crook

Curry

Jacks

on

Jeffer

son

County

http://www.orpdmp.com/orpdmpfiles/PDF_Files/Reports/Statewide_10.01.11_to_03.31.12.pdf

Prescribed Opioid Addiction Tx By Age

http://wwwdasis.samhsa.gov/teds09/TEDS2k9NChp2.htm

Age of Opioid ODD

www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf

Risk Factors for an ODD

http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf

Dose as a Risk Factor For ODD

https://www.aan.com/uploadedFiles/Website_Library_Assets/Documents/3.Practice_Management/2.Quality_Improvement/2.Patient_Safety/2.Patient_Safety_Education/C171%20-%20Franklin.pdf

Methadone as a Risk Factor for ODD

https://public.health.oregon.gov/DiseasesConditions/InjuryFatalityData/Documents/oregon-drug-overdose-report.pdf

Methadone as a Risk Factor for ODD

https://public.health.oregon.gov/DiseasesConditions/InjuryFatalityData/Documents/oregon-drug-overdose-report.pdf

Benzodiazepines & Opioids as a Risk Factor for ODD

https://public.health.oregon.gov/DiseasesConditions/InjuryFatalityData/Documents/oregon-drug-overdose-report.pdf

The Lost Generation

http://www.nytimes.com/2012/04/09/health/opioid-painkiller-prescriptions-pose-danger-without-oversight.html?_r=0ext

Dependence Vs Addiction?

http://www.ncbi.nlm.nih.gov/pubmed/22892799

Pain Vs Fear of Withdrawal?

http://www.ncbi.nlm.nih.gov/pubmed/24814051

Buprenorphine for the Lost Generation

http://www.ncbi.nlm.nih.gov/pubmed/25220043

Buprenorphine for the Lost Generation

http://www.ncbi.nlm.nih.gov/pubmed/23584313

Buprenorphine Is A Powerful Analgesic

http://www.compoundchem.com/2014/09/25/painkillers/

Harm Reduction for the Lost Generation

Identify the population at risk: a. Methadone b. Dose > 120MED c. Coprescribed benzo’s &/or sedatives

Prescribe Nasal Naloxone

1. SB 384 legalized for lay administration in 2013.

2. Stock in your pharmacies. 3. Some patients must pay out of

pocket ($35.00.) 4. http://www.prescribetoprevent.org/

wp-content/uploads/2012/11/naloxone-one-pager-in-nov-2012.pdf

Dose MTD < 30 or MED < 240

1. Offer an alternative analgesic to MTD: MS04, etc.

2. Offer an opioid taper with an end point below 120MED.

3. Offer a benzodiazepine taper.

http://agencymeddirectors.wa.gov/mobile.html

Dose MTD > 30 or MED > 240

Hi Dose Patient

Taper BuprenorphineVS

Buprenorphine

1. Schedule III drug, partial mu agonist 2. FDA approved for both pain - Butrans/Belbuca - and addiction - Suboxone/Subutex. 3. Ceiling effect for respiratory suppression (RS).

Buprenorphine’s Ceiling Effect for R.S.

Buprenorphine & ODD

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm

Legacy Opioid Patients

Lost Generation

Dream Land

http://www.amazon.com/Dreamland-True-Americas-Opiate-Epidemic-ebook/dp/B00U19DTS0/ref=sr_1_1?s=books&ie=UTF8&qid=1448131519&sr=1-1&keywords=dreamland

Thank You

www.supportprop.org