cl 3 saenger martin

Clinical Track: Improved Outcomes with

Improved Prescribing Prac<ces

Presenters: Michael Saenger, MD, FACP Robert E Mar<n, J.D.,CEAP

Moderator: Dr. David Sugerman, MD, MPH, FACEP, CDR

Disclosures

•  Michael Saenger has disclosed no relevant, real or apparent personal or professional financial rela<onships.

•  Robert E Mar<n has disclosed no relevant, real or apparent personal or professional financial rela<onships.

Learning Objec<ves

1.  Outline strategies for incorpora<ng improved prescribing methods into a physician’s prac<ce.

2.  Assess chronic pain pa<ents for their probability to abuse opiates.

3.  Iden<fy alterna<ve methods of trea<ng chronic pain pa<ents who abuse opiates.

Improved Outcomes with Improved Prescribing Prac<ces

Michael Saenger, MD, FACP Pain Management Lead Physician, VISN 7

Director, Empower Veterans; Atlanta VA Medical Center April 22, 2014

Na<onal Rx Drug Abuse Summit

Overview

•  Background of – Chronic Pain – VA Models – Evidence for Opioids in Chronic Pain

•  Examples of Improvement – Grady Health System’s Primary Care – Atlanta VA Medical Center Community Clinic – Minneapolis VA – VHA Opioid Safety Ini<a<ve

Complex Chronic Pain: Dis<nct from Acute Nocicep<ve Pain

Mariano et al; VISN 20 and 7 Bio-‐Psycho-‐Social Training; 2014

Recent Veterans and Chronic Pain: 50% OEF Men; 75% OEF Women

Lew,… Kerns, Clark and Cifu; JRRD; 2009

PTSD

Chronic Pain

mTBI

VHA Stepped Care Model for Chronic Pain Management

Step 3 MulB-‐

Disciplinary

Step 2 Subspecialty Consults

Step 1 PACT –Veteran (Self Care desired)

PACT = Pa<ent Aligned Care Team, Aka Pa<ent Centered Medical Home

From VHA The Office of

Pa<ent Centered Care and Cultural

Transforma<on

Personalized Health Plan

No Change in Chronic Low Back Pain 73mg Morphine versus Placebo

Martell … Kerns…; Ann Int Med; 2007

Cyber Seminar, 2012

Risk VA Overdose Death by Dose

Improvements – Primary Care Grady Health System

•  Con<nuity clinic – 2 coun<es – Safety-‐net facility – Resident clinics – Pa<ents from served AND distant coun<es

•  Task Force –  Inter-‐professional, mul<-‐disciplinary – New Policy; Medica<on Agreement and Log Book

Improvements – Primary Care Grady Health System

•  Nurse sustained – Medica<on Agreement

– Urine Drug Screening

•  30% reduc<on in monthly opioid prescrip<ons

Improvements – Community Based Outpa<ent Clinic

Atlanta VA Medical Center

•  Inter-‐professional Re-‐educa<on

•  System and Quality Improvement approach – How to accomplish efficiently?

•  eConsulta<on

Re-‐Learning, Inter-‐Professionally

Really ALL PCMH: Clerk, LPN, Social Worker, Clinical Pharmacist, Dietician, Psychologist…

AND in ALL Sub-‐Specialty Clinics…

•  Emergency Department •  Dental •  Orthopedics, General and Neuro Surgery … •  Gynecology •  Neurology, Hematology & Inpa<ent Medicine

•  Pain Clinic and/or PM&R

•  Mental Health

“Universal Precau<ons”

•  Counseling and Expecta<on Agreement •  One prescriber •  Regular appointments

•  Func<onal re-‐assessment

•  Par<cipate in mul<-‐modal plan

•  Frequent Urine Drug Screening (UDS) •  Prescrip<on Drug Monitoring Program (PDMP)

Improvements – Community Based Outpa<ent Clinic

Atlanta VA Medical Center

Opioid Safety Ini<a<ve (OSI)

•  VHA Central Office – Co-‐Led by Dr. Kerns, recent Director Pain for VA

•  Goal: safety by reducing high dose opioids

•  ID: top prescribers for every facility

•  Re-‐emphasizing: “3 Step Model” of pain care

OSI Goals < 6 Months, updated: April 2, 2014 Dr. Petzel, Under-‐Secretary for Health for VA

1.  Educate for safe and effec<ve use of UDS: All prescribers of opioids

2.  Increase use of UDS

3.  Educate prescribers to use state’s PDMP

4.  Establish safe and effec<ve tapering program: Star<ng with Benzodiazepine + Opioid group


5. Field Risk Stra<fica<on Toolkit, for those who: Should not be on LTOT; or Should be on less LTOT

6.  Establish systems of care for tapering: Methadone Oxycodone Hydromorphone


7.  Review all pa<ents on > 200 mg MEDD

8.  Provide at least two approved Complementary and Alterna<ve therapies (CAM) at each Facility

9.  Explore use of Behavioral Health Interdisciplinary Program Model in Conjunc<on with Pa<ent Aligned Care Team

Improvements -‐ Minneapolis VA

•  Leter from Chief of Staff to Providers

•  2 hour Opioid Safety Ini<a<ve Educa<on

•  Q2Month Audit and Feedback on % on either – Oxycon<n –  > 200 mg MED

•  Chronic Pain eConsult Service

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Fentanyl Patch

Methadone

Morphine

Oxycodone IR

Oxycodone/APAP

OxyConBn

Minneapolis VA Opioid PrescripBon Trends December 2010 – September 2013

Anders Westanmo, PharmD and Peter Marshall, MD

Improvements -‐ VHA with OSI

•  Key indicators progress July 2012 -‐ Dec 2013: – 27,783 more Veterans on long-‐term opioids had an urine drug screen

– 13,859 fewer Veterans on long-‐term opioids

– 10,664 fewer Veterans on opioids and benzodiazepines at the same <me

– Average dose per day of select opioids has begun to decline slightly

VISN 7 “Supplemental Guidelines” to 2010 VA-‐DoD Clinical Prac<ce Guidelines

•  Right Pa<ent [Contra-‐Indica<ons]

•  “Universal Precau<ons” Bundle [Safety]

•  Ceiling Dosages [for Opioid Trial]

VISN 7 [Contra-‐indica<ons]: Phased-‐In

VISN 7 Ceiling Dosages: Phased-‐In

•  < 100 mg MED (Morphine Equivalents Daily) – No Contra-‐indica<ons

•  <45mg MED – Rela<ve Contra-‐indica<ons

•  0 mg – Absolute Contra-‐indica<ons

VISN 20… Web-‐Based Training Modeling Bio-‐Psycho-‐Social Approach

Collabora<ve Self-‐Care

•  Bio-‐Psycho-‐Social-‐Spiritual Approach

–  Involving all of Pa<ent Centered Medical Home

– Caring for whole person

Kerns, Mariano, Hunt, Burgo and many others

Focusing on Func<on

•  Not on “5th Vital Sign”

•  Applying Mo<va<onal Interviewing

•  Coaching all Veterans to prac<ce: – Stress Management – Gradual, progressive exercise

Kerns, Mariano, Hunt, Burgo and many others

Addressing pain aggravators

•  Undertreated Mental Health concerns (PTSD/Anxiety…)

•  Moral Injury

•  Central Sensi<za<on Syndromes

•  Substance Abuse

Proven Help = CBT Cogni<ve Behavioral Therapy

•  Training for ALL with Chronic Pain:

– Relaxa<on and Mindful Acceptance

– Overcoming Catastrophizing and Fear of Pain •  “Mo<on is Lo<on”

– Goals and Pacing •  Progressive small improvements

Adjunc<ve Therapies •  Complementary / Integra<ve Medicine (CAM)

–  Alexander technique or Yoga or Mindfulness; and –  Massage or Spinal Manipula<on or Acupuncture

•  Non-‐opioid Analgesics

•  ? S<mulators

•  Most do not need –  Opioids round the clock –  Injec<ons nor Surgeries –  Step 3, Mul<disciplinary Pain Clinic

Saenger, APA PCSS-‐O Webinars, Evidence for CAM for Chronic LBP, parts 1&2, 2013

Summary: Need System of Changes •  BETTER Pain Management Strategies for our Pa<ents

–  Integrated self-‐management training (behavioral & movement therapies)

•  Supplemental Guidance – supported by –  Leadership –  Stakeholders

•  Educa<on – Inter-‐professional

•  Audit and Feedback

•  Support for Primary Care –  Efficiencies –  Sub-‐Specialty eConsulta<on ….

Ques<ons?

Improved Outcomes With Improved Prescribing Prac<ces

Robert E Mar<n, J.D.,CEAP Director of Substance Abuse Services

Carolinas Healthcare System

Objec<ves

1.  Discuss strategies for incorpora<ng improved prescribing methods into a physician’s prac<ce.

2. Assess chronic pain pa<ents for their probability to abuse opiates.

3. Iden<fy alterna<ve methods of trea<ng chronic pain pa<ents who abuse opiates.

Collateral Damage

•  Drug overdose was the leading cause of injury death in 2010. Among people 25 to 64 years old, drug overdose caused more deaths than motor vehicle traffic crashes.

•  Drug overdose death rates have been rising steadily since 1992 with a 102% increase from 1999 to 2010 alone.

www.cdc.gov

Where Do All The Opiates Come From?

Where Do The Opiates Go?

•  In 2010, of the 38,329 drug overdose deaths in the United States, 22,134 (60%) were related to pharmaceu<cals.

•  Of the 22,134 deaths rela<ng to prescrip<on drug overdose in 2010, 16,651 (75%) involved opioid analgesics (also called opioid pain relievers or prescrip<on painkillers)

•  In 2011, about 1.4 million ED visits involved the nonmedical use of pharmaceu<cals. Among those ED visits, 501,207 visits were related to an<-‐anxiety and insomnia medica<ons, and 420,040 visits were related to opioid analgesics.

www.cdc.gov

Risk Factors •  Family history of addicBon. Drug addic<on is more common in some families and likely involves the effects of many genes.

•  Being male. Men are twice as likely to have problems with drugs. New flash! This is changing.

•  Having another psychological problem. •  Peer pressure. Par<cularly for young people, peer pressure is a strong factor in star<ng to use and abuse drugs.

•  Lack of family involvement. •  Anxiety, depression and loneliness. Using drugs can become a way of coping with these painful psychological feelings.

•  Taking a highly addicBve drug.

What is it?

•  Addic<on

•  Pseudo-‐addic<on (inadequate analgesic)

•  Other psychiatric diagnoses: encephalopathy, borderline personality disorder, depression, and anxiety

•  Criminal intent

Managing the Risk •  Treatment agreements

•  One physician •  One pharmacy

•  Appointments

•  Prescrip<on frequency •  Include family or important persons

•  Non-‐adherence •  Urine drug screens

•  Specific substance iden<fica<on •  So the failed now what?

Partnering

•  Refer for assessment •  Selec<ng a program

•  Con<nuing case management

•  Are you undertrea<ng the pain? •  Has tolerance increased/ineffec<ve medica<on/dosing

•  Refer for assessment

Which Pa<ent Do You See? •  Not out of control •  Quality of life •  Would decrease

medica<ons if side effects are present

•  Treatment plan to address physical problem and ac<ve in using other forms of treatment

•  Follows the agreement for the use of opioids

•  May have medica<on le{ over or request for refills are consistent with schedule.

•  Wants more and more o{en

•  Pain medica<on has decreased quality of life

•  Opiates despite side effects

•  Unaware or in denial about problems and singularly focused on drug therapy

•  Violates medica<on contract

•  “The dog ate my homework”

What Do They Do With The Prescrip<ons?

•  Sell

•  Trade

• Horde

• Use

Why do paBents turn to heroin?

•  Cheaper •  Works •  PaBent in control of medicaBon •  Physician did not assess

addicBon potenBal

White powder heroin “China White”

Heroin

•  Black Tar Heroin

Black Tar Heroin

•  Rela<vely crude and unrefined opiate product, does not require the complex lab equipment, high-‐purity acetyla<ng chemicals or lengthy steps necessary to produce pure heroin.

•  Atrac<ve to clandes<ne drug producers. •  Black tar heroin is produced in La<n America. •  Most commonly found in the western and southern parts of the United States.

•  Best zip codes of Charlote. •  Younger people and professionals.

Non-‐opiate Treatments

•  Massage •  Hydro •  Acupuncture •  Guided imagery •  Non-‐opiate medica<ons •  Electro s<mula<on •  Physical therapy •  Not every injury is reversible

What Now?

Thank You. Now Some Ques<ons For More Informa<on…….

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