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Lynam presentation

  1. 1. Edward Lynam, MD Medical DirectorQuest Counseling, Reno, NV
  2. 2. Remembering History “Those who cannot remember the past are doomed to repeat it.” George Santayana
  3. 3. Commercialization of Opiates 1 British East India Company Tea from China Boston Tea Party! Silver to China Silver shortages Opium from Bengal/India to China Qing Dynasty Opium War(s) Silver and Tea from China, Opium to China
  4. 4. China By 1940: 40 million opium addicts, 10% of population A century of corruption, decline, and defeat Mao and Communists: solved addiction problem
  5. 5. Commercialization of Opiates 2 Purdue Pharma, 1990’s Oxycontin: sustained release oxycodone Marketing drove it from $48 million in 1996 to $1 billion in 2001 $200 million in marketing in 2001 alone Free 7 to 30 day supplies Bonuses to sales staff more than base salary 5000 health professionals given all expense paid stays at fancy resorts to become speakers
  6. 6. Medical Use of Oral Opiates Dysentery and Diarrhea (historical) Cough Suppression (rare) Pain Management  Acute  Pre-op  Op  Post-op  Chronic  Cancer, end of life: palliative  Non-cancer
  7. 7. Effects of Opiates CNS and PNS opiate receptors (therapeutic):  Decreased pain perception: analgesia  Decreased reaction to pain: psychological  Increased tolerance to pain: more functional activity  Mild to severe neurocognitive impairment  Nausea and/or Constipation  Itching and miosis  Immune/Reproductive hormone changes  Accidents and delayed return to employment
  8. 8. Effects of Opiates in Addiction Above therapeutic dosage  Euphoria: false sense of exaggerated well being  Accelerated development of tolerance  Respiratory depression leading to hypoxic death  Cuts the normal response to carbon dioxide  Lungs can fill with fluid  Tolerance to this effect not predictable at high doses  Half of deaths had used another respiratory depressant
  9. 9. Misuse of Prescription Opiates30 to 40% of prescribed doses are not used properly
  10. 10. Engaging Prescribers  Federal Efforts: starting 2011  Office of National Drug Control Policy (ONDCP)  Food and Drug Administration (FDA)  Drug Enforcement Administration (DEA)
  11. 11. Strategy Expand awareness and education to physicians, researchers, and the public Expand efforts to monitor the prescribing of these drugs, including calling upon every state to set up a program (43 so far) Make it easier for consumers to dispose of drugs Shut down “pill mills” and reduce doctor shopping
  12. 12. Educating Prescribers Training: substance abuse in general curriculum DEA licensure: requiring specific educational content Manufacturers: requiring “re”-educational fundingOpioid Risk Evaluation and Mitigation Strategy (REMS) Physicians for Responsible Opioid Prescribing (PROP) Best Practices for Emergency Medicine
  13. 13. Washington State Agency Medical Directors Group  Published guidelines  Opiate dosing calculator (web and app)  Free patient assessment tools  Free 4 hour CME activity  Searchable Directory of Pain Management Specialists  Other resources
  14. 14. What do prescribers need to do? Establish a clear upper limit on dosing Written care agreements  No early refills or replacement of lost or stolen  Refills only on clinic visits  Random urine screening Red flags: end access State monitoring system Engage family in safety education
  15. 15. Conclusion Historically Opiate Addiction is linked to commercialization Prescription Opiates have legitimate medical role A large percentage end up being misused or abused Unintentional deaths have skyrocketed Public education is important Prescribers need greater education States can help with monitoring, disposal programs, shutting down pill mills, and doctor shopping