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Opiates-Overview , Reflections, and Next Steps. Southern Oregon Pain Conference 5/9/14 Amit Shah, MD Jackson Care Connect. Overview-Epidemiology. Most, if not all, aware of opiate inappropriate use, misuse and related high rates of morbidity and mortality with chronic and/or high dose usage

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opiates overview reflections and next steps

Opiates-Overview , Reflections, and Next Steps

Southern Oregon Pain Conference 5/9/14

Amit Shah, MD

Jackson Care Connect

overview epidemiology
  • Most, if not all, aware of opiate inappropriate use, misuse and related high rates of morbidity and mortality with chronic and/or high dose usage
  • It is clear (national, state, and local) that inappropriate prescribing of opiates is not acceptable
    • -JAMA-”Providers inappropriately prescribing are the most significant reason for current epidemic”
    • 2012 Federal study that Oregon physicians only second to “*” in willingness to prescribe opiates
  • Prescribing patterns have changed but not to expected population-public health levels needed
    • 2012 JCC 7 out of top 10 prescriptions were opiates, pain related
    • 2013 JCC 2 out of 10 prescriptions were opiates and unlike 2012 3 out of 10 were antidepressants but 15-17 yo trend continues to rise
    • 2014 JCC 4 out of 10 were opiates and 7 out of 10 were pain related…what happened?
prevalence shocking view
Prevalence-Shocking view

What do these represent?

  • 25,932
  • 2,149,668
  • 474,420
dark history
Dark history…
  • Cephalon-Actiq-New Yorker
  • Purdue Pharma, Execs to Pay $634.5 Million Fine in OxyContin Case
    • President, top lawyer and former chief medical officer will pay $634.5 million in fines for claiming the drug was less addictive and less subject to abuse than other pain medications
    • Purdue learned from focus groups with physicians in 1995 that doctors were worried about the abuse potential of OxyContin. The company then gave false information to its sales representatives that the drug had less potential for addiction and abuse than other painkillers
dark history1
Dark History…
  • U.S. Senate panel launches investigation of painkillers, drug companies
    • seeking financial and marketing records from three companies that make opioid drugs, including OxyContin and Vicodin, and seven national organizations
dark history2
Dark History…
  • Pain is the 5th vital sign
  • Limited to no standards on managing chronic pain
  • Limited to no BH/CD support structures in place
  • Limited to no understanding of the neuro-biology and underlying BH issues
  • If you prescribe controlled substances your license will be reviewed vs. to not prescribe your license will be reviewed
  • Truth?
    • 11 year OMB case review re: opiate prescribing
1 9 35 161 461
  • “1:9:35:161:461” should be known to all
  • http://jama.ama-assn.org/content/307/8/774.full
  • http://jama.ama-assn.org/content/307/8/774.full
    • Morbidity and Mortality Weekly Report
    • JAMA. 2012;307(8):774-776.
overview prescription vs chronic pain
Overview-Prescription vs. Chronic Pain
  • Important to think of these as separated but related issues (confusing 2 together has unintended consequences)
  • Must work on provider, patient, community change regarding this
  • “Easy” to address prescription, but find that until this done other critical interventions cannot occur
  • Chronic Pain=Chronic Disease and so must be managed accordingly:
    • “Hey, this is no different than kidney disease or cancer or any other disease” Vermont Governor State of Union Address
how to move the needle
How to “move the needle”
  • National, state, and local efforts identified the following key strategies:
    • “absolute” adherence to prescribing guidelines-must be policy-not just PCPs but starts here
    • Starts with ceiling dose
    • Build behavioral health and chemical dependence treatment
    • “Upskilling” providers (especially PCPs)
    • Education for provider/staff/ patients/communities
    • IT support
data driving change
Data driving change
  • Hard conversations…
  • Statistics not lie…but often only tell part of the story
  • “What happens in exam room stays in exam room” -pressures to meet visit expectations more and more difficult and often deemed “futile” when opiates in equation

Opiate Use-Prescribing

members using opiates may belong to one or more risk groups
Members using opiates may belong to one or more risk groups
  • Chronic use risk: > 60 total days supply in 90 days
  • Adverse effect risk (cocktail effect): combination with benzodiazepines, phenothiazines, or muscle relaxants
  • Dental utilization risk: potentially inappropriate dental opiate prescriptions
  • Pain syndrome risk: high morphine equivalent per day > 120mg
  • High risk opioids: methadone or fentanyl
  • Chemical dependency risk: concurrent buprenorphine or chemical dependency visit claim in past year
  • High diversion risk: high pill count of > 10 per day
  • High FWA risk: utilizer of >= 5 pharmacies or >= 5 prescribers in 90 days
jcc members using opiates are categorized in these groups
JCC members using opiates are categorized in these groups

JCC members by number of members in risk group

* Benzodiazepine claims for clonazepam only, the majority of benzodiazepine claims are paid under DMAP.

r egulatory support
Regulatory support
  • 42 CFR 431.54(e), 456.3 and 455.1-16: Federal requirement of all Medicaid agencies to have programs to evaluate FWA and over-utilization and allows for lock-in programs.
  • OAR 410-121-0135 and ORS 414.350 , 414.360 (c) (a-h): State provision pursuant to above federal requirement for a Pharmacy Management Program limiting clients to a specific pharmacy.
  • DMAP selects clients for the Pharmacy Management Program who
    • used 3 or more pharmacies during the prior 6 months
    • use multiple prescribers to obtain prescriptions of the same or comparable medications
    • have altered a prescription
    • exhibit patterns of prescription drug use 1

1. Oregon Health Authority Pharmaceutical Services Administrative Rulebook Chapter 410, Division 121, effective February 21, 2013

specific interventions
Specific interventions
  • Ceiling dose
    • Current Oregon “standard” is 120 MED
      • Study re: 50-200 MED mortality-WA set 120 MED
      • Current trend is 60 MED
      • Portland 120 but moving to 60
      • CPCCO 120 but considering 60
      • YCCO 120
      • Medford-AllCare 120, OPG recommend 120, JCC will adopt community standard
      • 3 groups of high dose patients-Diverter, High Risk, all others
        • Trend is can work on “all others” over time
specific interventions map
Specific Interventions-Map
  • 3 Core focus areas:
    • What is need in clinic and with providers
      • Guidelines, education, “up skilling”
    • Behavioral Health
    • Chemical Dependency/Addiction Management/Treatment
specific interventions1
Specific Interventions
  • National (Neighbors)
    • WA furthest along: ECHO, 60 MED, provider education, policy regulatory requirements (licensure, state law refer to specialist, strong evaluation)
  • State
    • EDIE, SBIRT, Screening for Depression, PDMP, less State, “centralized” approach than WA
  • Portland
    • Community adherence to guidelines (forced interventions), ED dental diversion, OCEP adherence, centralized MAT/referral, BH foundation in PCP clinics, ECHO, provider up skilling (EMR protocols, pharmacy protocols), non-medication interventions-OT, PT, CD integration-care coordination, SBIRT, Screening for Depression, just starting jail to community interventions
    • Required PIP, Guideline adherence, CCO ongoing opiate oversight-subgroup (as delegated by CAP), CCO red flag patient identification and interventions (lock down, etc.), specific clinical guidelines for high occurring dx (HA, LBP),population analytics, SBIRT, ECHO, Pain Clinic formation in partnership with BH/CD, Mid Valley BH,PCP, Hospital, Dental piloted in coast-”Buy it and Build it”
  • YCCO
    • Moving in CPCCO space but more “build it” model, SBIRT, community adherence to guidelines, moving toward 60
what should we do
What should we do?
  • Pilot and spread
    • Clear outcomes wanting from pilot and “move fast”
    • Once have momentum hard to stop
  • Build BH/CD (in PCP, in ED [e.g. ED navigator ?screens CD], centralized vs. PCP office vs. both)
  • PCP upskilling –IT, ECHO, opiate oversight-some kind of case consultation, support, etc. “real time”
  • Build community resources for non-medication treatments
  • Organization priority-”buy in” support
  • Public Health communications-messaging
  • Regulatory
    • Credentialing
  • Ceiling dose management
    • Build PCP tools to do this (EMR, tapering protocols, etc.)
  • Guideline adherence
    • Ceiling dose-community, multi-payor standard (120?)
    • Clarity on contraindications
    • Clarity on determining appropriate vs. inappropriate for opiates
    • Develop key, highly penetrated diagnosis/ clinical guidelines (HA, dental pain, LBP)
how to do
How to do?
  • OPG-community clarity on specific concrete outcomes wanting in 90 days, 6 months, 1 year (“bite size”)
  • Pilot to accomplish above
  • Integration with High Utilizer strategy
  • Plan for BH/CD build
  • High penetration diagnosis guidelines
  • Plan for non-medication management strategies
  • Pain clinic services-”build it or buy it,” PCP office focus or centralized like CPCCO?
  • PCP up skilling with concrete tools
    • Education on the neurophysiology of persistent pain
  • IT support
    • EMR optimization
    • ECHO, EDIE, JHIE, Vista Logic
    • CCO analytics (red flag list, lock down, patient lists, utilization analysis, risk)
  • Policy
    • Multipayor ceiling
    • Credentialing
    • Aligning hospitals (e.g. ER guidelines)

“One’s philosophy is not best expressed in words; it is expressed in the choices one makes…and the choices we make are ultimately our responsibility.”