DUR Board Meeting May 14, 2008

1. DUR Board Meeting May 14, 2008 West Virginia Department of Health and Human Resources Bureau for Medical Services Drug Utilization Review Board

2. DUR Board Meeting May 14, 2008 DUR Interventions • Monthly DUR cycles, profile review by DUR Review Committee, includes review of Lock-In cases • Methadone – general warning intervention letter • Pain Management – long term use of short acting narcotics • Duplicate atypical antipsychotic therapy • Polypharmacy – 20 or more different drugs • Use of muscle relaxants • Atypical antipsychotic agents and diabetes

3. DUR Board Meeting May 14, 2008 • Monthly DUR Review Committee • Committee meets the last Monday of the month • 200 DUR cases – high risk score patients, includes those with multiple providers and criteria exceptions • 50 Lock-In cases • Lock-In re-review and annual review cases

4. DUR Board Meeting May 14, 2008 • All patients taking Methadone during October 2007 • 297 patients and letters mailed 11/29/07 • Letter had general warning about Methadone toxicities • 12 letters could not be mailed or returned due to bad address • 114 responses – 39% response rate • During March 2008 there were 332 patients with a claim for methadone

5. DUR Board Meeting May 14, 2008 Pain Management – long term use of short acting narcotics • Patients taking 4 or more doses per day of short acting agent for 90 days and no long acting agent • 389 prescriber letters generated • 54 deleted, hospital DEA or bad address • 335 letters mailed 12/26/07 • Represents 332 patients • 86 responses (26% response rate)

6. DUR Board Meeting May 14, 2008 Pain Management – long term use of short acting narcotics • 38 patient continuing without a problem • 14 has appointment to discuss therapy • 11 no longer my patient • 6 will reassess and modify therapy • 5 tried to modify patient non-cooperative • 4 tried to modify therapy, symptoms returned • 3 ER or on call prescriber • 1 not seen patient recently • 1 response did not discuss therapy • 2 unaware what others ere prescribing • 1 patient deceased

7. DUR Board Meeting May 14, 2008 Pain Management – long term use of short acting narcotics Prescriber hand written comments • will try long acting agent • has pain contract and is compliant with med • cannot afford cost of long acting agent • has chronic pain • referred to pain management specialist • insurance will not cover long acting agent • scheduled for specialty consult • I am very aware of the long acting pain meds • did not prescribe opioids • patient has not received any meds here

8. DUR Board Meeting May 14, 2008 Pain Management – long term use of short acting narcotics • Looked for current claim for long acting narcotic in the 332 patients not taking a long acting agent as of December 2007 • Time period searched 2/1/08 to 4/12/08 • Long acting agents include long acting fentanyl patch, long acting morphine, long acting oxycodone, methadone and Ultram ER. • 27 patients of the 332 found to be now taking a long acting agent – 6 of the 27 had prescriber responses to DUR letter • Did not verify current eligibility for the 332 patients

9. DUR Board Meeting May 14, 2008 Duplicate atypical antipsychotic agents • 675 patients identified – two atypical agents with 30 days supply each within 25 days • 635 identified for intervention • 811 prescriber letters generated • 90 letters could not be sent – due to prescriber number • Limited responses as of first week in May • During March 2008, there were 7,706 patients with a claim for an atypical agent • Approximately 8% on duplicate therapy

10. DUR Board Meeting May 14, 2008 • Polypharmacy • Patients with more than 20 different drugs during each month of a three month period • Different drug label name, could be same drug different dose • 4th quarter 2007, 584 recipients, 1,598 prescribers • Date being re-run on 1st quarter 2008 and letters will be sent next week • Prescribers will receive a letter with a list of patients names and ID numbers and an abbreviated 3 month drug history profile for each patient on the list • Otherwise many prescribers would have received many letters • General response form will not be patient specific

11. DUR Board Meeting May 14, 2008 Utilization of Muscle Relaxants • During first quarter 2008 • 11,169 patients received at least one claim for a muscle relaxant • Without looking at diagnosis • 4 patients had 10 or more claims • 170 patients had between 5 and 9 claims • 2,846 patients had 3 or 4 claims • 1,212 had a diagnosis of chronic pain or chronic pain syndrome (ICD-9 code 338.2 and 338.4) • 425 patients with 3 or more claims • 91 with 4 or more prescriptions

12. DUR Board Meeting May 14, 2008 Utilization of Muscle Relaxants For the time frame of 01/01/07-03/31/08 • There were 66 recipients who received 11 or more prescriptions for a skeletal muscle relaxant that had a diagnosis of chronic pain or chronic pain syndrome • Other diagnosis for long term therapy included spondylosis, cervicalgia, lumbago, other unspecified back disorders

13. DUR Board Meeting May 14, 2008 Criteria for atypical antipsychotic agents • Atypical agents and diabetes • Any patient with a claim for an atypical antipsychotic agent and a drug for the treatment of diabetes or diabetes diagnosis will trigger alert • 1,287 criteria exceptions for April 2008

14. DUR Board Meeting May 14, 2008 • Criteria for atypical antipsychotic agents • Low dose quetiapine (<200mg) for sedative use • Multiple atypical agents, 3 or more atypical agents within 30 days • Multiple antipsychotic agents - 3 or more of any antipsychotic agent within 30 days

15. DUR Board Meeting May 14, 2008 • Atypical Antipsychotic Agents • Maximum Quantity Limits • Abilify® 5 mg; 15 mg - 1 tablet per day • Geodon® 20 mg; 40 mg - 2 capsules per day • Invega® 3 mg, 6 mg; 9 mg - 1 tablet per day • Risperdal 0.25 mg; 0.5 mg; 1 mg; 2 mg - 2 tablets per day • Seroquel® 25 mg - 4 tablets per day • Zyprexa® 2.5 mg; 5 mg; 7.5 mg - 1 tablet per day • Zyprexa® Zydis® 5 mg - 1 tablet per day