conquering the challenges of opiate prescribing for non ... · conquering the challenges of opiate...

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Conquering the Challenges of Opiate Prescribing for Non-Cancer PainApril 4, 2017

© 2017 HealthCare Information Management, Inc. Proprietary and Confidential.2

• Practicing Physician in Family Medicine• Former Primary Care Medical Director• Washington State Medical Quality

Assurance Commissioner• HCIM Senior Strategic Adviser• Member of the HCIM Healthcare

Strategic Advisory Council (HSAC)

Claire E. Trescott, M.D.


The Story • Description of initial work to standardize opiate prescribing at

Group Health• Standardization of processes • Outcomes • What did and didn’t work over the years • Updating the work in 2016, incorporating the new CDC

recommendations


Size of the Problem – Crisis• 100 million with chronic pain• Over 18,000 opioid-related deaths • 78 Americans die every day from opioid overdose• Over half of all deaths involve a prescription opioid• 2 million Americans abuse or are dependent on prescription opioids• As many as 1 in 4 people (25%) who receive prescription opioids long

term for non-cancer pain in primary care settings struggle with addiction• Every day, over 1,000 people are treated in emergency departments for

misusing prescription opioids• The United States has 5% of the world’s population, but consumes 80% of

the world’s opioids and 99% of the world’s hydrocodone• 70% of abusers were given opiates from family or friends, only 30%

were actually prescribed


Group Health/Kaiser PermanenteIntegrated Health Delivery System• Founded in 1946• Consumer governed, non-profit• Membership: 661,500; Staff: 9,365• Revenue: $3 billion

Multispecialty Group Practice• 25 primary care medical centers• 6 specialty units, 1 maternity hospital• 985 salaried medical group members • Contracted network• > 9,000 practitioners, 39 hospitals

Group Health Research Institute• 34 Investigators• 235 active grants, $39 million


New CultureNew Lean Management System Ability to design new processes Ability to put standard work in place in 25 clinics Confidence we can sustain

Medical Home Chassis in Place Care plans Outreach Prepared for visit


Standardized Improvement Methodology Understand Current State Sponsor sets goals and guardrails Allow frontline workers to design the future

Rapid Process Improvement Workshop Design standard processes Define roles and standard work Outline training and measurement

New Approach


Program RequirementsAll patients on Chronic Opioid Therapy will have a collaborative care plan

• Diagnosis• Patient goals (function!)• Risk/benefit discussion• Medication and dose• Treatment plan• Instructions for follow up


Program Requirements• Old Patient Pain Management Contracts were outmoded• New Pain Management “Agreement” for selected patients Published in the EMRs – visible and functional

• Expectations for Patients: Request refills 7 days in advance Participate in urine drug screens Use only one prescriber for narcotics


It is recommended that the clinician have a discussion with the patient before the UDS that includes:

• The purpose for testing• What will be screened • What results the patient expects • Prescriptions or any other drugs the patient has taken• Time of last dose of opioids • Actions that may be taken based on the results of the screen• The patient should be notified that the results will become part of

their permanent electronic medical record

Urine Drug Screening (UDS)


• Integrated into outreach and pre-visit• Pain and function questions in rooming• Pain and function scales built into Wellness tab• Care plans updated and posted in EMR

“Don’t worry, this isn’t all on you, doctor.”- Claire Trescott, MD

Implementation:Standard Work on Medical Home Chassis


Common Physician BarriersOld School:• Physicians reluctant to order UDS• Confusion how to react to abnormal UDS• Some have a very large number of patients• Do not see a problem with their own patient management

New School:• Physicians refusing to prescribe • Over-delegate tough messages• Unable to follow the care plan• Difficulty cross-covering for their colleagues


Implementation Percent of COT Patients with Care Plans

0%

20%

40%

60%

80%

100%

Jun-10

Aug-10Oct-

10

Dec-10

Feb-11

Apr-11

Jun-11

Aug-11Oct-

11

Dec-11

Guideline implementationSeptember 2010


0%

5%

10%

15%

20%

25%

2005 Sept

2006 Mar

2006 Sep

2007 Mar

2007 Sep

2008 Mar

2008 Sep

2009 Mar

2009 Sep

2010 Mar

2010 Sep

2011 Mar

IGP

Network

17.8 % > 120 mg. MED

9.4 % > 120 mg. MED

Reduction in High Dose Opioid Prescribing


Tangible Impacts• Best rollout ever• Decreased patient complaints• Decreased tension in the clinics• Fewer patients on high doses• Much more urine screening• Starting to develop better programs for chronic pain• Factors of success: sponsorship, methods and processes in

place, met real problem, state mandates, financial incentives


CDC and Surgeon General Call to Action in 2016• Reduce exposure to opioids, prevent abuse, and stop

addiction• Expand access to treatment, including medication-assisted

treatment, for people struggling with opioid addiction• Expand access and use of Naloxone• Promote use of state prescription drug monitoring programs• Implement and strengthen state strategies that help prevent

high-risk prescribing and prevent opioid overdose


Expectations for Prescribers• Patients shall be risk-stratified to the highest appropriate

category by the prescribing clinician• Patients shall have regular COT monitoring visits that occur at

a frequency based on the patient's risk stratification, and include standard components

• Patients shall receive all chronic pain management prescriptions from one physician and one pharmacy wherever possible

• Prescribing physicians shall have a one-time completion of at least 4 hours of continuing medical education relating to chronic opioid therapy


• > 90 mg MED is high risk

The definition of high-risk COT dosing has changed from > 120 mg MED to > 90 mg MED, per the 2016 guideline of the Centers for Disease Control and Prevention (Dowell 2016).

Addiction Risk Stratification


• > 90 mg MED is high risk• Opioid Overdose: A person taking ≥ 100 mg MED will be 9x as

likely to overdose as a person taking < 20 mg MED. (Dunn 2010)• Approximately 1 overdose in 7 is fatal

The definition of high-risk COT dosing has changed from > 120 mg MED to > 90 mg MED, per the 2016 guideline of the Centers for Disease Control and Prevention (Dowell 2016).

Overdose Risk Stratification


Important Factors That Increase Risk


Major Changes as of September 2016Monitoring requires that all components (assessment for opioid risk, assessment for pain and function, prescription monitoring, urine drug screening, care plan update, problem list update) be done at a defined frequency, per intensity level:• Low-intensity: once per year• Moderate-intensity: every 6 months• High-intensity: every 3 monthsScreening for

conditions affecting opioid risk

History

Physical exam ◊

Pain & function assessment

UsingPEG Tool

Prescription monitoring

UsingPMP database

Opioid risk assessment ◊

UsingOpioid Risk Tool (ORT)

Psychological comorbidity screening ◊

UsingPHQ-9

AUDIT-C 2-question drug

use screen

Urine drug screening

UsingAppendix C

Care planUsing

.opioidcareplanCare Plan AVS

Documentation & coding

Using.opioidvisit

.opioidproblistGHC.17 ◊ Z79.891

◊ Required at initial COT monitoring visit only


PEG Tool (Pain, Enjoyment, General Function)• How to tell if there is improvement• Monitor and document effect of treatment over time• Similar to other tracking tools (such as PHQ-9 for depression) • Graphed in flowsheets


Clinically Meaningful Improvement in Function• You need a standardized tool to quantify function• Patient’s rating of pain is reliable and real• Use PEG to ask about pain and function to assess and

document treatment effectiveness• Continue COT only if 30% improvement in pain and function

from start of treatment or in response to a dose change• If it’s not working, dose should be reduced or stopped, as risk

outweighs benefit


Naloxone – A Rescue Medication• Recommend and prescribe Naloxone as a preventive rescue

medication for patients (and their family members) in the moderate and high intensity groups – those who are taking opioid therapy ≥ 40 mg MED per day or have other risk factors for opioid overdose

• Our preferred product is Narcan nasal spray; counsel family members or other personal contacts who can assist patients that are at risk of opioid-related overdose


Screen for Opioid Use Disorder• Screen all patients at initial visit (25% chance)• Screen at any misuse or deviation from COT plan• Use DSM 5 Criteria – Substance Use Disorder Checklist in

Flowsheets• Addiction is a known risk/side effect of the prescribed

medication and can occur at any point in treatment• Addiction is a neurobiological problem, not a character flaw

and a medical issue, not a moral failing


Treat Opioid Use Disorder• Withdrawal treatment = preparation for treatment; provide

meds and counseling regarding withdrawal and what to expect, how to manage symptoms

• Provide referral to medication-assisted treatment, mutual help, and addiction treatment (AVOID BENZOS)

• FDA approved medications for opioid use disorder are buprenorphine (Suboxone), methadone, and Naltrexone; first 2 must be provided by a credentialed provider

• It is illegal for providers to treat opioid use disorders or opioid withdrawal with opioid medications except under very specific circumstances


Probability of AddictionThe CDC’s Anuj Shah and his colleagues studied a sample of 1.3 million opioid users from 2006-2015 and found that:• The probability that an opioid-naive patient would become a chronic opioid

user increased sharply after as little as 5 days of use• Certain types of opioids led to increased risks in chronic use among opioid-

naive patients: Long-acting opioid (27.3% probability of continued use at 1 year, 20.5%

of continued use at 3 years) Treatment with tramadol (13.7% at 1 year, 6.8% at 3 years) Schedule II short-acting opioid other than hydrocodone or

oxycodone (8.9% at 1 year, 5.3% at 3 years)


Prevent Conversion from Acute to Chronic Use• The best way to minimize chronic opioid use is to minimize

acute opioid prescribing• Long-term opioid use often begins with treatment of acute pain• For acute pain, use lowest effective dose of immediate-release

opioids and prescribe no greater quantity than that needed for the expected duration of pain severe enough to require opioids; three days or less will often be sufficient; more than seven days will rarely be needed (CDC 2016)


State Prescription Drug Monitoring Laws


#Turn The Tide with Dr. Vivek Murthy,our 19th U.S. Surgeon General As HEALTH CARE PROFESSIONALS, we believe we have the unique power to end the opioid crisis.

We pledge to:• Educate ourselves to treat pain safely and effectively• Screen our patients for opioid use disorder and provide or

connect them with evidence-based treatment• Talk about and treat addiction as a chronic illness, not a moral

failing• www.turnthetiderx.org


The Hidden Impact of Overprescribing• Poison control centers receive 32 calls a day about children

exposed to opioids• From 2000-2015, 60% of the children exposed to opioids were

younger than 5 years old, while teenagers accounted for 30%• Pediatric exposure to opioids increased 86% from 2000-2009

but decreased overall for all ages under 20 from 2009-2015• Increasing awareness among people with prescription drugs,

physicians putting more thought into prescribing opioids, and prescription drug monitoring programs implemented by many states and efforts by different organizations could have contributed to the decrease in exposure


We’re Committed to the Transformation of Health Care


For a copy of this presentation and additional resources, engage with us at:

www.hcim.com/connect


Additional Resources


Acute Phase(0–6 weeks post episode of pain or surgery) • Check your individual state's prescription monitoring program

before prescribing• Don't prescribe opioids for non-specific back pain, headaches,

or fibromyalgia• Prescribe the lowest necessary dose for the shortest duration;

Opioid use beyond the acute phase is rarely indicated• Three days or less will often be sufficient; more than seven

days will rarely be needed


Subacute Phase(6–12 weeks post episode of pain or surgery)• Don't continue opioids without clinically meaningful

improvement in function and pain (CMIF)• Screen for comorbid mental health conditions and risk for

opioid misuse using validated tools• Recheck the PMP and administer a baseline urine drug screen

(UDS) if you plan to prescribe opioids beyond 6 weeks

http://www.wapmp.org/


Perioperative(through time of hospital discharge)• Tapering opioids is not required before surgery, but avoid

escalating the dose before surgery; set appropriate expectations with patients that their pain management needs will be met following surgery, with the understanding that they will return to their preoperative dose (or less) following surgery

• Discharge with acetaminophen, NSAIDs, or very limited supply (2-3 days) of short-acting opioids for some minor surgeries

• For patients on chronic opioids, taper to preoperative doses or lower within 6 weeks following major surgery


Special Populations• Pregnant women: Counsel women before and during

pregnancy about maternal, fetal, and neonatal risks• Elderly patients: For older adults, initiate opioids at a 25–50%

lower dose than for younger adults• Adolescents and children: Avoid prescribing opioids for most

chronic pain problems• Cancer survivors: Rule out recurrence or secondary

malignancy for any new or worsening pain


Consider Taper – Including but not limited to…These conditions increase the risk of adverse outcomes with opioid use. Strongly consider tapering opioids if any of these conditions are present:• Opioid use disorder is a contraindication to chronic opioid therapy by law• Previous opioid overdose is a contraindication to chronic opioid therapy• Concurrent use of benzodiazepines: see the FDA Safety Warning• Concurrent use of sleeping pills, alcohol, muscle relaxants, THC, illicit

drugs, sedating antihistamines • Uncontrolled psychological issues, including depression, anxiety, or PTSD • Age 65 years and over, COPD, CHF, cognitive concerns, osteoporosis (due

to meds themselves and fall risk), renal or hepatic insufficiency, severe obesity (obesity-related hypoventiliation), obstructive sleep apnea

• Pregnancy: because of possible risks to the fetus posed by opioid withdrawal, consult with an obstetric provider or other appropriate specialist

http://www.fda.gov/Drugs/DrugSafety/ucm518473.htm

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