Although other drug overdose epidemics (e.g., heroin/crack cocaine) have created a great deal of media activity, in reality, prescription drugs taken mostly by mouth have caused a much greater fatal overdose epidemic than illicit drugs of unknown quantity or quality ever have. Mortality “rates are currently 7-8 times higher in Ohio than rates during the ‘black tar’ heroin epidemic in the mid-1970s and 6-7 times what they were during the peak years of crack cocaine in the early 1990s,”
Lessons Learned from Drug Court Cuyahoga County Ohio Court of Common Pleas Judge David T. Matiamarch 2012
JUDGE DAVID T. MATIACUYAHOGA COURT OF COMMON PLEAS
Enough prescription painmedication was prescribed tomedicate every adult Americanaround the clock for 1 month!
Prior to 2011 Boscarino study rates of addicition assiciated with prescription opiod therapy werebelieved to be 2-18%.July 2011 study assessed rates of opioid abuse/dependence using both DSM-IV and proposed DSM-V criteria in CNCP: 35%!!!!! Credits to Dr. Binit Shah at UHHS. Boscarino JA, Rukstalis MR, Hoffman SN. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. Jour of Add Dis 2011;30:185-94.
34% of the patients treating with opioids used illegal drugs inaddition to those prescribed.1Only 15% of the chronic pain patients who were not treated withopioids used illegal drugs. 1. Christo PJ, Manchikanti L, Ruan X, et al. Urine drug testing in chronic pain. Pain Phys 2011;14:123-43 2 Wong WS, Chen PP, Yap J, et al. Chronic pain and psychiatric morbidity: a comparison between patients attending specialist orthopedics clinic and multidisciplinary pain clinic. Pain Med 2011;12:426-59.
In a large epidemiologic study in Denmark, chronic pain patients using opioids had worsepain, higher health care utilization and lower activity levels than matched chronic painpatients not using opioids.1Opioid use may go against important principles of chronic pain management includingincreased self-efficacy, reduced reliance on the health care system, reinforcement of painbehavior, and passivity and loss of autonomy by externalization of the locus of control.2 Credits to Dr. Binit Shah at UHHS. 1. Eriksen J, Sjogren P, Bruera E, et al. Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain 2006;125:172-9. 2. Large RG, Schug Sa. Opioids for chronic pain of non-malignant origin- caring or crippling? Health Care Anal 1995;3:5-11.
A systematic review of randomized trials for multiple opioids utilized formanaging various chronic pain conditions, showed fair evidence fortramadol in managing osteoarthritis. For all other conditions and all otherdrugs excluding tramadol, the evidence was poor based on either weakpositive evidence or indeterminate or negative evidence.Credits to Dr. Binit Shah at UHHS.Manchikanti L, Ailinani H, Koyyalagunta D, et al. A systematic review of randomized trials of long-term opioidmanagement for chronic non-cancer pain. Pain Phys 2011;14:91-121.
Pill Mills are on the decline. 2007 10 pill mills in Scioto County alone 2011 1 pill mill (Thank you House Bill 93).
Chronic Intractable Pain is a challenging problem faced by the practicingphysician. It is a common presenting complaint in the outpatient setting. Thetreatment of this condition is complex and nuanced, but for some patients, after athorough evaluation has been completed and after numerous alternate treatmentshave been considered or attempted, opioid therapy may be a consideration. It is well known that there are substantial risks associated with thetreatment of chronic pain with opioids, including but not limited to, tolerance,physical dependence, psychological dependence, addiction, opioid-inducedhyperalgesia and death. There is also a risk of diversion that may complicate thisform of treatment. University Hospitals (“UH”) wishes to mitigate the treatmentrisks and professional risks of its physicians associated with the prescribing ofopiods for the treatment of chronic non-cancer pain. After extensive review anddiscussion, UH is recommending the following set of guidelines for its physiciansto follow when the treatment of chronic intractable non-cancer pain with opioidsis undertaken. 1. Prior to considering any prescription of opioids for a chronic non-cancerpain condition, such as low back pain, a referral to a pain medicine specialistshould be sought to evaluate for other treatment options besides opioids. Chronicopioid therapy should be considered only after exhausting other non-opioidoptions.
Extra resources to handle a commonreoccurring issue.
•JUDICIAL ATTENTION•SUPERVISION•TREATMENT OF SUFFICIENTDURATION
•1996 Common Pleas Judges reject drug court funds.•Cleveland Municipal Court (Judge Larry Jones) starts county’sfirst drug court.•2008 Judge Jones leaves for Court of Appeals.•2008 Common Pleas Judges vote to take over Drug Court•May 2009 Common Pleas admits first defendant to Drug Court.
1. Dependency is a disease.2. It’s really, really expensive.3. It’s a big believer in diversity.4. Too much spent treating symptoms and too little spent treating the disease.5. Medical profession is an unwitting partner.