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Premier Safety Institute 2017Opioids Opioids are a class of drugs used to reduce pain. Prescription opioids are used to treat moderate to severe pain, and include oxycodone (OxyContin), hydrocodone (Vicodin), morphine, and methadone. Fentanyl is a synthetic opioid pain reliever, more powerful than other opioids used for severe pain, typically in advanced cancer. Heroin is an illegal opioidOpioid dependence/addictionOpioids are a class of drugs that include prescription pain relievers, oxycodone, hydrocodone, codeine, morphine and fentanyl, and as well as illicit drugs like heroin.Taking opioids even for a few days can cause a physical dependence on them that can lead to addiction.Opioids create artificial “endorphins” in the brain and nervous system to produce pleasurable effects and relieve pain. Within the first few days on opioids, the body gradually stops making its own endorphins naturally. When opioids are stopped abruptly without tapering they can suffer withdrawal symptoms, including worsening pain, nausea, anxiety, depression, restlessness, suicidal thoughts and other debilitating effects. Staying on the opioids, even after the pain is gone, is the only way to feel good and avoid these symptoms. The risk of chronic opioid use was found to increase with each additional day of opioid medication use starting with the third day, with sharpest increase in chronic use after the fifth and thirty-first day, a second prescription or refill, and an initial 10 or 30 day supply. CDC 2017National opioid epidemicThe U.S. opioid epidemic is continuing. Drug overdose deaths nearly tripled during 1999–2014. In 2014, among 47,055 drug overdose deaths, 61% involved an opioid. Each day, 46 people die from an overdose of prescription painkillers in the US.Health care providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills.10 of highest prescribing states for painkillers are in the South, especially AL, TN, WVa.Healthcare related- in-patients, outpatients, emergency department (ED)Opioids use in hospitals- Premier research Premier research at nearly 300 U.S. hospitals, found that opioids were being used in more than half of hospital admissions of non-surgical patients. Thirty percent had charges for 2 different opioids.Among pediatric inpatients, two specific opioids (fentanyl and morphine) were found to be among the HYPERLINK "" \o "top 10 medications" \t "_blank" top 10 most administered medications.Adverse event – inpatients. Research also found that in-patients who experienced an opioid-related adverse event had greater costs, long length of stay, and more readmissions. Inpatient stays. Over the last 10 years, opioid-related inpatient stays increased by 64 percent (AHRQ 2017).Emergency departmentPremier research found that approximately one third of patients having potentially suboptimal medication practices (medications known to interfere with opioid metabolism) and short acting opioids (with higher abuse potential) were more likely to be seen in the ED a second time. AHRQ. Opioid-related-related emergency department visits increased 99 percent over the last ten years (AHRQ 2017). Opioids were also responsible for half of the more than 1.2 million emergency department visits in the U.S. involving the nonmedical use of pharmaceuticals, the top two being hydrocodone and oxycodone.Surgical patients. A 2017 study in JAMA-Surgery found that 6 percent of 36,177 patients without opioid use in past year who were prescribed opioids for minor to major surgical procedures were still on opioids 3 months later, long after most should have recovered. There was no difference in long term opioid use between those who had minor vs major surgical procedures. Extrapolated to just the 50 million outpatient procedures each year, this represents up to 3 million that may become newly dependent on opioids.Women- childbearing age. More than one-fourth of privately-insured, and one-third of Medicaid-enrolled women of childbearing age filled prescriptions for opioid-based (narcotic) painkillers between 2008 and 2012. OBGYNs provide a substantial amount of care to women of childbearing age. They contribute to opioid prescribing and are in the position to identify and offer treatment for women suffering from chronic pain or addiction.Multimodal treatment recommended. According to a task force of the American Society of Anesthesiologists, clinicians should be multimodal whenever possible, and consider the use or addition of non-narcotic medications, such?as NSAIDS, Cox-2 inhibitors, acetaminophen, regional infusions of local anesthetics, steroids, ketamine, and gabapentinoids.Patient controlled Analgesia. Opioids are often given IV via Patient controlled analgesia (PCA) pumps to achieve better pain management. Respiratory depression and respiratory arrest is a serious unintended consequence of opioids given via PCA pumps – an estimate of 15% of these patients are not continuously monitored.TJC CMS. The Joint Commission in a sentinel event alert on opioids and CMS in Memo to States and in CMS Conditions for Participation guidance for medication administration call for continuous monitoring for in-patients receiving IV opioids. Continuous monitoring is done via pulse oximetry or capnography.Medicare populationThe Medicare population has among the highest and fastest-growing rates of diagnosed opioid use disorder, currently at more than 6 of every 1,000 beneficiaries. For Medicaid beneficiaries, the prevalence of diagnosed opioid use disorder is even higher, at 8.7 per 1,000, a figure estimated to be over 10 times higher than in populations who receive coverage under private insurance companies.Federal-National Initiatives and GuidelinesWhite House. The Trump administration has established a White House-level commission by executive order on March 29 to examine the opioid epidemic (membership and responsibilities in process) to recommend where the federal government can have the biggest impact. The President's Commission on Combating Drug Addiction and the Opioid Crisis is due to issue a final report to Trump in October.CMS has made addressing opioid misuse a top priority and is providing help and resources to clinicians, beneficiaries and families as part of the HHS Opioid Initiative launched in March 2015 Details in its “Opioid Misuse Strategy, 2017.” CMS. CMS is removing the pain management dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey for purposes of public reporting and the Hospital VBP Program, beginning with the FY 2018 program year.CDC published the CDC Guideline for Prescribing Opioids for Chronic Pain that focus on treating chronic pain outside of active cancer treatment, palliative care, and end-of-life care, and includes drug selection, dosage, duration, follow-up, discontinuation and assessing risks and harm of useAMA. The AMA Opioid Task Force encourages physicians to register for and use their state’s prescription drug monitoring program (PDMP) to help make more informed prescribing decisions.MeasuresPremier (used in Premier QUEST and HIIN collaboratives)Naloxone reversal among acute inpatients with opioids administered during hospital stayORADE- Opioid-related adverse drug event per 10,000 patients (ICD-10 version)PQA- Pharmacy Quality Alliance NQF-endorsed opioid measuresUse of opioids at high dosage in persons without cancerUse of opioids from multiple providers in persons without cancerUse of opioids at high dosage from multiple providers in persons without cancerDrug DiversionThe epidemic of addiction to opioids is the major driver of drug diversion and can occur at any point along the supply chain. Drug diversion in healthcare facilities (employee stealing for their own use) results in care delivered by impaired provider, denial of essential pain therapy, and outbreaks from hepatitis C virus or bacterial pathogens when tampering with injectable opioids involving hundreds of patients, according to the CDC. ................
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