Opioid over prescription: Practice Gap discussion at Update Course 2018

And actually this is our last case. So this is number one on David Letterman's hit parade, if you will. This is a teenager who's being discharged home following inpatient treatment of injuries he has sustained in an automobile crash. The intern is told to prescribe oral pain medicine. Which of the following is most appropriate in order to decrease the patient's chance of opioid abuse? So A would be a prospective referral to a substance abuse program, B would be include a prescription for naloxone, C, limit the quantity of pills prescribed, and D, avoid non-opioid medications. Let's see. So, Craig, the, the one choice I don't see on there is non-opioid medications as a primary pain relief. Because as I'm familiar with the studies, Tylenol plus NSAIDs or like Motrin are equally as effective as narcotics without the side effects of headache and constipation and nausea. So, I, my choice is always, and you can addict it to Tylenol, I guess, but um yeah, so I think it's a much safer alternative than using narcotics. I talk to you. Detroit yeah yeah. Kelly Harbaugh at our institution showed that 5% of kids will become um long-term users, um, if they, uh, if they, uh, are given opioids. And, and not only that, that that problem exists not just with surgeons, it exists with dentists and exists with all kinds of healthcare and in fact, the, the subsequent prescriptions that they get are, are not necessarily from the surgeon. So you may give them the first one and somebody else gives them the second one and so on and so forth. And, but our limit, but the excess, um. Uh, opioids that we give patients are probably are the biggest, uh, entry point for narcotics into our system and subsequent abuse, um, uh, that we have, and so limiting them is, is really required and, and substituting it with non-opioid, um, uh, medications is, is important in order to be able to do that. Um, so, um, I, this, this is a, it's a big deal and a lot of centers are trying to work out. Um, doing, looking at, at how many we really, how many, um, uh, pills are really required, if any, and not only that, the other side of that is disposal because parents keep them and, and then they leak into, into, uh, our society and so urging parents to dispose is also an important aspect. Does my children's hospitals have a narcotic disposal program for the narcotics you prescribe? So actually we, we use these Derab bags and we're running a study where we give parents Derab bags. Um, and Callie is also doing a study where with all different pediatric specialties looking at at how many narcotics patients got, how many they used, what their pain control was, and how they disposed. The problem with disposal is that in general the disposal sites have been our police agencies, and most people are hesitant to go to a police agency to dispose their pain medications. So that's been a problem, but there now are bags and and other. Means other means of disposal that make it much easier. It's a lot of this is education and and teaching parents in our case that you need to dispose of them actually one thing that's really interesting is probably the most, the most uh common reason for house burglaries now is, is those that are seeking drugs that are left over and simply sitting in your drawers or, or medicine cabinets or whatever. So, at one point, I, I may be incorrect, but I thought in the absence of any good disposal system, the recommendation was to flush them down the toilet. Is that a bad recommendation or that's not good? OK. So this is why we've highlighted this as our number one practice gap, because although we might think, as we're all well aware of the opioid epidemic, epidemic, we know that, uh, boy, it was just a decade ago that the IOM was telling us that we weren't adequately maintaining or managing people's pain, and now we've, we've flipped it entirely. The statistics, and they're listed up up on the slide that, uh, the. Consumption of hydrocodone, oxycodone increased 200 and 500% respectively. Opioid deaths have quadrupled. It's in pediatric, pediatric hospitalizations and emergency ward visits have doubled, and again, most of this is a result of prescribed medications. So we are in that. So you've already highlighted many of the, the suggestions we've heard them from the group. Number one, be more. Cautious about prescribing those limiting the amount that you prescribe, substituting non-opioid analgesics, that's, that's huge, Rusty, and, and oftentimes they may not need any, any narcotic, and that's a way of not, not, uh, uh, that entry at all, uh, employ non-pharmaceutical approaches, decrease the quantity of the prescribed drugs, and, uh, encourage appropriate, uh, disposal, so. Um, so, uh, I just want to make a point about, uh, um, something that Dave alluded to earlier. Um, I think Dave, you either presented this or told me about this at ABSA, right? We did this. I, I was a narcotic prescriber. I gave my hernias, I gave everyone my appies. I gave everyone narcotics. It was just routine. And when I saw this talk, I stopped, and I've not had one single call yet. So, the whole point of these is not just to be taught and walk home and go to do, keep doing our thing. Uh, we want to see change. Last year, um, we talked about the GIPS procedure and we pulled everyone and everyone switched very fast. I think this is one of these things that you can start tomorrow. Uh, because I was surprised that because of your presentation, it changed my practice, so. I'm in. So the tweet is, is avoiding narcotics that we really don't need them, uh, like we thought, David. So we have a question from the audience. OK, so, um. my finger, uh. So it's non-opioid. Uh, prescriptions, we have a drop-off box on site. Non-combination opioids limit the amount. If no disposable, um, site, FDA says only for narcotics, flush liquids can mix with coffee grounds and trash. Comment on that. So you can flush narcotics. Yeah, I, I, well, yeah, mixing it with coffee grounds. I know about that's one way to, uh, to, uh, dispose of them. Um, I, I only know that there's been a, um, that, that people have not wanted to have narcotics flushed, um, down the, uh, down the toilet or whatever. And I, I won't, I won't pretend to be an expert as to why. But I think the key message is we can't leave them around. They get into the wrong hands, and, and that's why these children are showing up in the. Most urban areas now have traces of opioids in their water supply, because so many people just flush it down the toilet. And one last thing I guess I would say is that we have to be aware too of patches, because uh I know like fentanyl patches and things like that are used for certain things and, you know, I've certainly seen kids come in who have swallowed patches thinking that it's candy or gum or something like that and I've had bad toxic reactions, so. So, um, interestingly, at, uh, there's at Michigan, there's something called Michigan Open, the, I forget it was something for opiate, opiate, uh, something network, and, and they have gone, they've have had drives where they go to high schools throughout the state and they have parents or, or patients bring their opiates, um, to those drives, and they've collected immense amount of opiates that they've removed, you know, from the system. So that's something that people can easily do that has a big effect. Wow, that's great. I think, uh, by way of, uh, finishing you up for this, uh, second session, David.