Colorado’s Opioid Solution: Clinicians United to Resolve the Epidemic (CO’s CURE) The Colorado Chapter of the American College of Emergency Physicians 2020 Opioid Prescribing and Treatment Guidelines Developed by Colorado ACEP 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 Editor-in-Chief Donald E. Stader III, MD, FACEP Copy Editors Emergency Physician Editors Paula Benson Dylan Luyten, MD, FACEP Julie Denning Ashley Morse, MD Rachel Donihoo Erik Verzmeniks, MD, FACE Steve Young, MD Task Force Chair Erik Verzmeniks, MD, FACEP Associate Editors Elizabeth Esty, MD Task Force Members, Volunteers and Other Contributors John Spartz Travis Barlock, MD Kevin Boehnke, PhD Section Editors Jon Clapp, MD Robert Valuck, PhD, RPh, FNAP Will Dewispelaere Introduction and The Opioid Epidemic in Colorado Kenneth Finn, MD Erik Verzemnieks, MD, FACEP Chris Johnston, MD Limiting Opioid Use in the Emergency Department Kevin Kuachar, PharmD Rachael Duncan, PharmD, BCCCP Emily Lampe, MD Charleen Gnisci Melton, PharmD, BCCCP Judy Lane, MD Donald E. Stader III, MD, FACEP Julia Luyten Alternatives to Opioids for the Treatment of Pain Rachael Rzasa Lynn, MD Martin Krsak, MD Jeffrey Wagner, MD Donald E. Stader III, MD, FACEP Helena Winston, MD Harm Reduction Narin Wongngamnit, MD Elizabeth Esty, MD 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 Opioid Epidemic in Colorado The Origins of the Opioid Epidemic CO’S CURE Limiting Opioid Use in the Emergency Department ....................................................................................................... 9 Practice Recommendations Policy Recommendations Alternatives to Opioids for the Treatment of Pain ....................................................................................................... 19 Practice Recommendations ALTO Medications ALTO Procedures ALTO Treatment Pathways Harm Reduction ......................................................................................................................................................... 44 High Stakes: The Risks of IV Drug Use and Infectious Complications Practice Recommendations Policy Recommendations Treatment of Opioid Use Disorder .............................................................................................................................. 57 Practice Recommendations Policy Recommendations The Future and Ending the Opioid Epidemic in Colorado ............................................................................................. 69 Appendices ................................................................................................................................................................ 70 I. Understanding Pain: A Complex Biopsychosocial Phenomenon II. Materials Used for IV Drug Use III. Steps to Injecting Heroin and Unsafe Practices IV. Map and Listing of Syringe Access Programs in Colorado V. Screening Tools VI. Clinical Opioid Withdrawal Scale VII. Buprenorphine Hospital Quick Start VIII. Adjuvant Treatment of Opioid Withdrawal IX. Discharge Checklist for Patients Initiated on MAT X. Managing Acute Pain in Patients on MAT XI. Cannabinoids and Pain References ................................................................................................................................................................. 90 Page 3 Introduction Medical providers across Colorado and the nation are 2017, and prescription opioids were involved in 218,000 facing one of the most devastating public health crises of a overdose deaths during this same period.5 In 2017, 58 generation. Opioids, both prescription and illicit, have opioid prescriptions (for an average length of 18 days) become the leading cause of accidental death in the United were written for every 100 patients in the United States.6 States for adults aged 50 years or younger.1 Correspondingly, hospital visits for opioid-related adverse drug events The dire consequences of the widespread availability of (including accidental overdose and prolonged opioid use), prescription opioids emerged over time. The “lag period” physical dependence and the development of opioid use between a patient’s first exposure to an opioid (either disorder (OUD) have become an increasingly common part medical or nonmedical) and their first treatment admission of medical practice. The number of lives impacted by the is an average of seven years. For patients who die of an crisis is astonishing. The Centers for Disease Control and overdose, the time between first exposure to an opioid 7,8 Prevention (CDC) reports that opioid overdose killed nearly and death is between nine and 13 years. In 2017, opioids 400,000 Americans between 2000 and 2001,2 and another were responsible for 34% of all substance abuse treatment 9 3 admissions for patients aged 12 years and older. 130 Americans are dying every day (FIGURE 1). More than 10.3 million people over the age of 12 years The financial implications of this epidemic are equally self-reported misusing opioids in 2018 (9.9 million misused staggering. The nonmedical use of opioid pain relievers prescription pain relievers and 808,000 used heroin).4 The cost society approximately $1 trillion between 2001 and pharmaceutical use of opioids skyrocketed between 1990 2016; unless major changes are made, the financial impact and 1996; prescriptions for fentanyl rose 1,000%, followed is projected to grow by another $500 billion by 2020 10 by morphine (49%), oxycodone (15%) and hydromorphone (FIGURE 2). (12%).5 The number of prescription opioids sold in the United States increased five-fold between 1999 and (FIGURE 1) Three Waves of the Rise in Opioid Overdose Deaths, 1999-2017 SOURCE: CDC MMWR2 Page 4 Introduction continued (FIGURE 2) Total and Projected Costs of the Opioid Epidemic, 2001-2016 SOURCE: Altarum10 While a number of external factors have contributed The Opioid Epidemic in Colorado to the liberal use of these potentially lethal drugs, the Coloradans have been significantly affected by this national medical community is compelled to acknowledge its role public health crisis. Since 2000, the state has seen 6,030 in creating this crisis. However, it also has the power to overdose deaths from opioids.11 There were a total of reverse these grim statistics by reforming its practices with 1,635 prescription opioid-related overdose deaths in resolve and innovation. Colorado from 2013 to 2017, which translates to a rate of 5.8 deaths per 100,000 residents.12 Heroin-related opioid These guidelines are meant to inform and augment overdose deaths have increased 76% since 2013.12 clinical judgment, not replace it. Although CO’s CURE acknowledges the value of opioids in certain clinical 2017 Colorado Statistics situations, including the treatment of sickle cell pain, • More than 3.7 million opioid prescriptions were dispensed hospice, severe trauma, burn and cancer pain, it advocates to one million patients (TABLE 1). These numbers fell using extreme caution in all cases. slightly from a high of 4.3 million opioid prescriptions for These guidelines are a compilation of ideas and 1.1 million patients in 2015.12 suggestions that can be implemented by clinicians and • There were 1,012 drug overdose deaths, 57% of which hospitals to improve patient care in the context of the involved an opioid.12 opioid epidemic. Adopting these guidelines in their entirety • 15% of opioid-naive patients were prescribed long-acting is not necessary, or often feasible in many hospitals. opioids.13 Rather, each hospital and clinician should consider which • 10% of patient prescription days overlapped the use of of these suggestions are most appropriate given the opioid and benzodiazepine prescriptions.13 unique processes and resources of the hospital, and should • According to data from the Colorado Prescription Drug have them reviewed by legal counsel and compliance Monitoring Program (PDMP), 671.3 opioid prescriptions leaders. The suggestions in these guidelines should not be were filled per 1,000 residents.13 viewed as a substitute for clinical judgment or obtaining • There were 134.3 treatment admissions for heroin per legal counsel particularized to the hospital’s situation. 100,000 Coloradans and 40.6 treatment admissions for pharmaceutical opioids per 100,000 residents.1 Page 5 Introduction continued (TABLE 1) Characteristics of Opioid Prescriptions Dispensed, Colorado 2014-2017 Characteristics 2014 2015 2016 2017 Number of Prescriptions Dispensed 4,039,048 4,310,254 4,159,575