Jim Shames MDMedical Director Jackson County

Health and Human Services

Jackson County OregonPopulation 206,412

(Jackson County averages over 250,000 opioid prescriptions per year)

Opioid Overdose Risk (fatal & non-f:atal) by AverageDaily Dose of Medically Prescribed Opioids

As the dose increases, so does mortalityMortality risk compared to Morphine Equivalent Dose (MED)

9-fold increase

in risk relative

to low-dosepatients

Dunn et al., Annals Int Med, 2010

**

**

** Significant increment in risk p<0.05

Overdose deaths in US compared to motor vehicle accidents

The 3 legged stool for community engagement: The 3 Ps

• Prescribers (Health Professionals): Need to learn about current best practices concerning the treatment of Chronic Complex Non-Cancer Pain (CCNP)

• Patients: Need behavioral and other supports to learn to manage their chronic pain without reliance on opioids

• Public: Need to understand the changes in scientific understanding of pain management so they can support their loved ones. Need to learn about naloxone.

The abundance of prescription opioids is the result of prescriptions!

Prescribers

If we don’t solve this problem as a community, we are only passing it on to the next provider.

Oregon Pain Guidance(formerly Opioid Prescribers Group)

Attendees: Physicians, Mid-level providers, Nurses, Substance Abuse Counselors, CCOs, Therapists, Pharmacists, Medical specialty (Pain Medicine, ED), Dental, Community Justice Partners

Oregon Pain Guidance (OPG)• Public Health initiative to reduce opioid overdoses by addressing the problem

at its core: medical providers• CME and dinner provided• OPG evolution:

Brainstormed >Created guidelines > guideline acceptance

• Topics for discussion:– Trauma Informed Care– Benzodiazepines– Challenging conversations– Oregon Medical Board– 120 MED policy– Best practices

• OPG Steering Committee: – Meet every 2 weeks– Handle the work of the OPG

Summary of guidelines:

• Assess prior to prescribing!• Encourage non opioid treatments (They really work).• Measure functional improvement.• Compassionately say “No.”• Keep MED below 120 and methadone below 40 mg.• Assess for aberrant behaviors (UDS, PDMP, pill counts, call backs)• Don’t combine benzodiazepines and opioids• Collaborate with community partners

Completely Agree 58%Agree 24%

Neutral 12%

Disagree6%

(analysis of 112 JaCo and JoCo prescribers: OPG survey)

We do need to provide compassionate care to those with certain painful conditions

We don’t want to throw the baby out with the bathwater

Opioids have a role to play

• In the treatment of acute and post surgical pain

• In cancer and other deteriorating painful conditions

• In some chronic conditions, when utilized at safe doses

• Provider resources• Patient resources• Public resources• Supported by

Medicaid insurance plans and Public Health

• Please link us to your websites.

www.oregonpainguidance.org

The Dissemination concept

• Critical mass: If enough providers understand the guidelines, word of mouth and peer pressure will lead to adoption.

• Information is transmitted via the pilot’s providers, OPG, KOBI messaging, website, consults, conferences,

Educating the Public through TV spots

Patients

Help from the CCOs

• They help support the OPG• Pay for behavioral health consultants to assist

primary care providers• Support the Website, the Pain Conference, the

Guidelines• They both have a 120 MED policy for their

members• Are thought leaders at the Steering Committee

meetings

Providing local alternatives to opioids

• Pain Resiliency Program• By referral from Primary

Care• Support by CCOs• Curriculum:

– Evaluation, orientation– “Pain School”– Peer to Peer support– Movement therapy– Behavioral support– Feedback to Medical Home

Help from others

• Jefferson Regional Health Alliance• Federal Harold Rogers Grant (see next slide)• Jackson County Health and Human Services• In kind contributions from many local non

profits

Interdisciplinary Action Committee: IDAC

• Problem focused monthly meetings• Participants: – District Attorney– Sheriff, Police– Drug Court– Public Health– Substance Abuse treatment – Southern Oregon University – Parole and probation

Naloxone

• Oregon allows bystander use

• Medford Police were one of the first in the State to initiate naloxone use by their officers.

• Plans for broader community use

All Rx opioids methadone alone Heroin0

5

10

15

20

25

201120122013

Jackson County accidental overdose data for the past 3 years:

Thank You

shamesjg@jacksoncounty.org