CO's CURE Initiative

Colorado’s Opioid Solution: Clinicians United to Resolve the Epidemic (CO’s CURE) Colorado Pharmacists Society 2020 Opioid Prescribing and Treatment Guidelines Developed by Colorado Pharmacists Society in partnership with Colorado Hospital Association, Colorado Medical Society and Colorado Consortium for Prescription Drug Abuse Prevention CO’s CURE is a proud collaboration of the following sponsoring and participating societies and organizations. The CO’s CURE initiative’s leadership thanks each for its contributions, expertise and commitment to ending the opioid epidemic together. SPONSORING ORGANIZATIONS COLORADO EST. 1871 MEDICAL SOCIETY PARTICIPATING ORGANIZATIONS FUNDED BY Colorado Department of Human Services, Office of Behavioral Health SPECIAL THANKS TO Support for Hospital Opioid Use Treatment (Project SHOUT) and BridgetoTreatment.org Dedicated to the clinicians across Colorado and the patients for whom they care Page 1 Contributors Editors-in-Chief Contributing Editors Rachael Duncan, PharmD, BCPS, BCCCP Kevin Boehnke, PhD Donald E. Stader III, MD, FACEP Julie Denning Sara Wettergreen, PharmD, BCACP Kenneth Finn, MD Yee Ming Lee, PharmD, BCPS, ABCP Associate Editor Ina Liko, PharmD Elizabeth Esty, MD Nate Novotny Jack Spartz Section Editors Helena Winston, MD Robert Valuck, PhD, RPh, FNAP Narin Wongngamnit, MD Introduction: The Opioid Epidemic Jennifer Biltoft, PharmD, BCPS Jonathan Clapp, MD Neal Hurst, PharmD Ryan Leyland, PharmD Limiting Opioids in Clinical Practice Jody Adams, PharmD, BCPS Jennifer Biltoft, PharmD, BCPS Toral Patel, PharmD, BCPS Rachael Rzasa-Lynn, MD Alternatives to Opioids for the Treatment of Pain Rhianna Fink, PharmD, BCACP Martin Krsak MD Donald E. Stader III, MD, FACEP Chris Stock, PharmD Harm Reduction Will Gersch, PharmD Brandon Utter, PharmD, BCPS, BCPP Steven Young, MD Treatment of Opioid Use Disorder Debra Parsons, MD, FACP Donald E. Stader III, MD, FACEP Darlene Tad-y, MD, SFHM Robert Valuck, PhD, RPh, FNAP The Future and Ending the Opioid Epidemic in Colorado Page 2 Table of Contents Introduction ................................................................................................................................................................. 4 The Origins of the Opioid Epidemic The Opioid Epidemic in Colorado CO’S CURE Limiting Opioids in Clinical Practice............................................................................................................................... 9 Practice Recommendations Policy Recommendations Alternatives to Opioids for the Treatment of Pain ....................................................................................................... 19 Practice Recommendations Policy Recommendations Harm Reduction ......................................................................................................................................................... 28 Practice Recommendations Policy Recommendations Treatment of Opioid Use Disorder .............................................................................................................................. 34 Practice Recommendations Policy Recommendations The Future and Ending the Opioid Epidemic in Colorado ............................................................................................. 41 Appendices ................................................................................................................................................................ 42 I. Additional Resources for Limiting Opioids II. Pharmacogenomic Guidance for Opioid Therapy III. Understanding Pain: A Complex Biopsychosocial Phenomenon IV. Links to National Society Pain Treatment Guidelines V. Pharmacogenomic Guidance for Use of ALTO Agents VI. Cannabinoids and Pain VII. Additional Resources for OUD Assessment and Diagnosis VIII. Additional Resources for OUD Treatment References ................................................................................................................................................................. 60 Page 3 Introduction Clinicians across Colorado and the nation are facing one Prevention (CDC) reports that opioid overdose killed of the most devastating public health crises in decades. nearly 400,000 Americans between 1999 and 2017, and Opioids, both prescription and illicit, have become the currently an average of 130 Americans die every day of leading cause of accidental death in the United States opioid overdose (FIGURE 1).2,3 The economic costs of this for adults 50 years of age or younger.1 Opioid-related epidemic are projected to exceed $1.5 trillion by the end adverse drug events (ORADEs), opioid overdose, physical of 2020 (FIGURE 2); the human costs are incalculable.4 dependence and the development of opioid use disorder What makes this crisis especially tragic is that the medical (OUD) have become an increasingly common part of establishment and the practice patterns of physicians have medical practice. The number of lives impacted by the played a significant role in creating and perpetuating it. crisis is astonishing. The Centers for Disease Control and (FIGURE 1) Three Waves of the Rise in Opioid Overdose Deaths, 1999-2017 SOURCE: CDC MMWR2 More than 10.3 million people over the age of 12 years The dire consequences of the widespread availability of self-reported misusing opioids in 2018, with 9.9 million prescription opioids emerged over time. The “lag period” misusing prescription pain relievers and 808,000 using between a patient’s first exposure to an opioid (either heroin.5 The pharmaceutical use of opioids skyrocketed medical or nonmedical) and his or her first treatment between 1990 and 1996: prescriptions for fentanyl rose admission is an average of seven years. For patients who 1,000%, followed by morphine (49%), oxycodone (15%) die of an overdose, the time between their first exposure and hydromorphone (12%).6 The number of prescription to an opioid and death is between nine and 13 years.8,9 In opioids sold in the United States increased five-fold 2017, opioids were responsible for 34% of all substance between 1999 and 2017, and prescription opioids were use disorder (SUD) treatment admissions for patients involved in 218,000 overdose deaths over this time period. aged 12 years and older.10 The economic implications In 2017, there were 58 opioid prescriptions written for of this epidemic are staggering. The nonmedical use of every 100 patients in the United States, with an average opioid pain relievers cost society approximately $1 trillion prescription length of 18 days.7 between 2001and 2016; unless major changes are made, the economic toll is projected to grow by another $500 billion by the end of 2020 (FIGURE 2).4 Page 4 Introduction continued (FIGURE 2) Total and Projected Costs of the Opioid Epidemic, 2001-2016 SOURCE: Altarum4 While a number of external factors have contributed his assertions about the safety of opioid medications.17 to the liberal use of these potentially lethal drugs, the As a result, many pharmaceutical companies began medical community is compelled to acknowledge its role in to aggressively market their opioids for wider use at creating this crisis. Fortunately, clinicians, pharmacists and increased dosages and in extended-release formulations. health care systems also have the power to reverse these grim statistics by reforming their practices with resolve and This shift in perspective was reinforced by the Veterans innovation. Health Administration, which adopted pain as the “fifth vital sign” in 1999.18 The Joint Commission, a governing The Origins of the Opioid Epidemic body responsible for hospital accreditation, added pain Concerned about potential adverse effects, including management as a requirement for accreditation in 2,11 addiction and overdose, few physicians prescribed 2000. During the same period, a report by the Institute opioids for chronic noncancer pain throughout most of of Medicine, “Relieving Pain in America,” painted pain the 20th century.11 That changed in 1986, however, when management as a “moral imperative, a professional pain expert Russell Portenoy published a limited case responsibility, and the duty of people in the healing 19 series of 38 hospital patients that suggested that chronic professions.” In addition to these mounting institutional noncancer pain could be managed safely with high doses pressures, patient satisfaction surveys increasingly of opioids without posing a risk of addiction.12 Since then, compelled medical clinicians to place a premium on the scientific validity of Portenoy’s original work has pain management. These highly subjective scorecards, been called into question; in recent years, the researcher which were routinely linked to remuneration, used the himself has publicly doubted the relative efficacy and management of pain as a marker for patients’ satisfaction 2,20 safety of long-term opioid use for the treatment of chronic with the care they received. Once reserved for the noncancer pain.13-16 Portenoy’s findings were endorsed treatment of severe pain, opioid analgesics became by both the American Academy of Pain Medicine and routinely prescribed for a wide range of pain complaints. the American Pain Society, which further legitimized Page 5 Introduction continued Further, the quantity and depth of pain and SUD education The Opioid Epidemic in Colorado provided in health care education is concerning. In a Coloradans have been significantly affected by this national survey of medical education, it was found that the mean public health

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