ENVISION
ENGAGE
INNOVATE
Arizona Opioid Prescribing Practices for Chronic Non-Terminal Pain
Jill Weinstein, FNP-BC, DNP Candidate; Cathy Michaels, PhD, RN, FAAN; Heather Carlisle, PhD, DNP, RN-BC, FNP-BC, AGACNP-BC; Christy Pacheco, DNP, FNP-BC
Chronic Non Terminal Pain (CNTP)
Arizona Rx Drug Initiative (5 Major Goals)
Problem
According to the CDC1: CNTP is pain lasting longer than 3 months, not
resolved by appropriate treatment, resulting in altered pain perception and
decline in social function.
• In 2011, 100 million Americans reported suffering from CNTP
• 22% of primary care consultations are for patients with CNTP
1. Reduce Illicit Acquisition and Diversion of Rx Drugs
2. Promote Responsible Prescribing and Dispensing Policies and Practices
Lack of information regarding the current statewide practice patterns for
CNTP in terms of:
• Prescribers’ knowledge of evidence based recommendations
• Current practice and management of CNTP among primary care
providers in Arizona
• Barriers and facilitators to safe opioid prescribing
Economic burden due to CNTP is estimated between $560-$635 billion
annually.
National Impact of Deregulation, Overprescribing
and Increased Opioid Sales
• Between 1999 and 2010, opioid sales increased from 96mg/person to 7.1
kilograms/person2
• Average morphine equivalent dose increased from 40mg/day MED/day
to between 80 and 140mg/day MED/day2
• Opioid related deaths rose over 300% between 1999 and 20113
• Opioid analgesics were involved in more than 40% of all drug poisoning
deaths4
Arizona Opioid Epidemic
• 6th highest drug overdose mortality rate in the U.S. – 41% attributed to
opioids 5,6
• 5th in the nation for opioid prescribing rates in 20115
• 1/3 of all emergency department visits due to opioid abuse or
dependency involve persons under 24 7
• 5:1,000 babies born in Pima County suffer from neonatal abstinence
syndrome primarily caused by maternal opiate use7
• In Mohave County, 11% of youth report prescription drug misuse; they
report getting the drugs from friends or at home7
2014 AZ Opioid Prescribing Guidelines
Key Recommendations
Comprehensive evaluation
Opioid therapy initiated at
lowest effective dose
Routinely monitor pain and
treatment progress
Using safe and effective
methods for prescribing
Examples
Medical, social, pain-related history and
assessment, substance abuse, psych. disorders,
co-morbidities, urine screen, AZ CSPMP
Opioid trial, document informed consent –
risks/benefits, treatment goals, conditions for
discontinuation and tapering
Document “6 A’s” – analgesia, activity, aberrant
behaviors, adverse effects, affect & adjuncts
Monitor high doses with vigilance, avoid use of
benzodiazepines and opioids, consult/referral
when appropriate
AZ Controlled Substance Prescription Monitoring Program8
On-line database for practitioners to view substance dispensing information
3. Increase Public Awareness and Patient Education about Rx Drug Misuse
4. Enhance Rx Drug Practice and Policies in Law Enforcement
5. Enhance Assessment and Referral to Treatment
Impact of Rx Initiative9 Pilot Study
• Between 2008-2013, non-pilot counties had a
4.09% increase in opioid related deaths vs. a
28.29% decrease in opioid related deaths in
pilot counties
• Decrease in number of controlled substance
prescriptions and pills in pilot counties
• 116.7% increase in CSPMP queries between
2012-Q2 2014
• 131.96% increase in prescribers signed up for
CSPMP in pilot counties after Rx Initiative
began
Project Proposal
Develop a survey to:
1. Investigate the awareness of evidence-based recommendations in
regard to opioid prescribing
2. Describe current clinical practice patterns of primary care providers in
Arizona who treat patients with CNTP
3. Identify implementation barriers to evidence based recommendations
in regard to prescribing opioids for CNTP in Arizona
The survey will be the first phase of a three phase project
Phase I: Pilot survey content will be guided by barriers identified by the
CDC8
• Providers’ awareness and/or familiarity with state recommendations –
access to guidelines, providers’ practice patterns in opioid prescribing
• Workflow limitations – access to state prescription monitoring program,
time and staff limitations, frequency of adherence to and use of pain
contracts and urine toxicity screening
• Resource obstacles – reimbursement limitations, availability of pain
specialists or pharmacists
Phase II: The survey will be conducted by an interprofessional student
group to be administered to PCPs working with CNTP patients in practices
across the state. Descriptive and correlational analyses will be performed.
Participating Pilot Counties
Phase III: Dissemination of results to stakeholders, participating clinic sites,
and at conferences, seminars, meetings
References available upon request