The Financial Impact to Employers April 10-12, 2012

Walt Disney World Swan Resort

Accepted Learning Objectives: 1. Identify the primary causes for increased health care costs as it relates to opioid abuse. 2. Outline simple steps that employers can implement within their work place to reduce their risks, lower their costs and improve productivity. 3. Explain why employers should be concerned about prescription drug abuse even if they are not currently dealing with an abuse-related issue in their workplace.

Disclosure Statement

•  All presenters for this session, Michael Gavin and Dennis Jay, have disclosed no relevant, real or apparent personal or professional financial relationships.

The Cost of Pain

A 2011 report from the Institute of Medicine estimated the total cost of dealing with chronic pain is between $560 and $635 billion per year.

That same year, drug manufacturers generated $11 billion in revenue from opioids.

How did we get here? Culture of Treatment

Harder Answers:

•  Lose weight •  Change diet •  Exercise •  Sleep hygiene •  Socioeconomic /

psychosocial factors

Easier Answers:

•  Surgical intervention •  Prescription drug therapy

•  74% of all physician office visits result in a prescription1

•  15-20% of all physician office visits result in a prescription for an opioid2

1 Source: Centers for Disease Control and Prevention 2 Source: IMS Health

How did we get here? Culture of Treatment (cont.)

•  $11 billion in annual sales

•  Case study: Oxycontin

‒  A substantial and sustained marketing effort begun in the late 1990s led to significant growth in the use of the drug

‒  Sales of Oxycontin in 1996: $45 million

‒  Sales of Oxycontin in 2009: $3 billion

‒  Purdue Pharma ad from 1998 titled “I got my life back”

1 Source: Substance Abuse and Mental Health Services Administration (SAMHSA) 2 Source: CDC Vitalsigns publication, November 2011

How did we get here? Culture of Treatment (cont.)

•  More than 50M Americans suffer from chronic pain1

•  Pain reliever abuse more than tripled, from 6.8% in 1998 to 26.5% in 2008 (Treatment Episode Data Set)1

•  15,000+ Americans died in 2008 from prescription drug overdose2

•  12,000,000+ Americans (12 years or older) in 2010 reported non-medical use of prescription drugs within the past year2

•  500,000+ ER visits in 2009 from abuse or misuse of prescription drugs2

•  $72,500,000,000+ in annual costs to health insurers for non-medical use of prescription drugs2

•  Enough prescription drugs were prescribed in 2010 to medicate every American adult around-the-clock for one month2

1 Source: Substance Abuse and Mental Health Services Administration (SAMHSA) 2 Source: CDC Vitalsigns publication, November 2011

How did we get here? Lack of Predictability

•  All 42 year old males •  All office-based knowledge workers

•  Chronic low back pain •  Failed back surgery

•  Failed conservative therapy

•  NSAID trial ineffective

•  Trial of low dose opioid

John, Joe, and Jim

How did we get here? Lack of Predictability (cont.)

•  Pain relief •  High functioning •  No dose escalation •  Eventually moves to “as needed” for the opioid prescription

•  Tolerance •  Dose escalation •  Switch to Oxycontin •  Dependence •  Out of work •  Addiction •  Detox/rehab

•  Unmotivated to return to work

•  Would rather “game the system”

John Jim

At the outset, it’s difficult to distinguish John, Joe, and Jim

•  Tolerance •  Dose escalation •  Switch to Oxycontin •  Dependence •  Out of work •  Addiction •  Detox/rehab

•  Motivated to get healthy and back to work

•  Supportive family •  Engaged in

treatment

Joe

How did we get here? Treatment of Co-morbidities

PAIN PAIN PAIN

Acute (1-3 months)

Sub-Acute/Transitional (3-6 months)

Chronic Pain Syndrome (>6 months)

•  Insomnia •  Atrophy •  Fear of

movement

•  Sexual dysfunction

•  Addiction

Source: Dr. Gary Mills, Pacifica Pain Management Services

•  Insomnia •  Atrophy •  Depression •  Weight gain

How did we get here? Treatment of Co-morbidities (cont.)

PAIN

Chronic Pain Syndrome (>6 months)

•  Insomnia

•  Atrophy

•  Depression

•  Weight gain

•  Sexual dysfunction

•  Constipation

•  Addiction

Source: Dr. Gary Mills, Pacifica Pain Management Services

Ambien

Soma

Cymbalta

Surgery?

Viagra

(… then Fentanyl?)

All of this makes the pain harder to

identify and treat

Doc-Q-Lace

Oxycontin

What to do? Match Case and Context

Biomedical

Medical / Legal

Legal

Bio-psycho-social

Current medical treatment is sub-optimal, what’s needed is better medical treatment

Employee is receiving inappropriate treatment; what can be done (by jurisdictional rule)?

Employee is engaging in fraud/abuse; involve law enforcement for remediation

Identify what’s driving the employee behavior and address root cause

What to do? Have a Plan

Biomedical

Medical / Legal

Bio-psycho-social

These options aren’t mutually exclusive – good utilization management and employee assistance programs can mitigate risk

What to do? Guiding Principles

DISCUSSION

ENFORCEMENT

OVERSIGHT

EDU

CA

TION

STATUTORY ACTION

What to do? Guiding Principles

•  Employee by employee, doctor by doctor, case by case

•  Multiple areas of education:

‒  Clinical (pharmacology, interactions, alternative therapies)

‒  Claims (best practices, centers of excellence, statutory rules)

‒  Issues (welcome to the first annual National Rx Abuse Summit!)

•  Multiple stakeholders:

‒  Doctors, nurses, claims executives, patients, and attorneys

EDUCATION

What to do? Guiding Principles

•  Engage the treating physicians / prescribers

•  Conversation should be:

‒  Peer to peer

‒  Collegial

‒  Evidence-based

•  Not a typical “peer review”… “how can we help?”

•  Incorporate the psycho-social element

DISCUSSION

What to do? Guiding Principles

1.  Has the patient signed an opioid treatment agreement or narcotic contract?

2.  Does the provider have the patient undergo regular urine drug monitoring?

3.  Does the provider have the patient fill out a pain scale questionnaire on every visit?

4.  Did the provider consult a prescription drug monitoring database (PDMP) prior to writing the prescription(s)?

5.  Has an opioid risk assessment been completed on this patient to evaluate the possibility of the patient’s developing medication use/abuse problems?

DISCUSSION (cont.)

What to do? Guiding Principles

5.  Does the provider consult the prescription drug monitoring system database (CURES) prior to prescribing any medications for this patient?

6.  What are the specific treatment goals for this patient given the patient’s current objective findings and level of function?

7.  Are there any generic equivalents or more cost-effective alternative equivalents that can be used for the medications that are recommended for continuation?

8.  For any recommendations to continue a medication, please state a recommended timeframe for re-evaluation of the medical necessity of those medications.

9.  If agreement is reached to continue a medication (generic, name brand, therapeutic equivalent), is a reduction in dosage or the number per month/day possible without reducing efficacy?

DISCUSSION (cont.)

What to do? Guiding Principles

•  Integration with the Pharmacy Benefit Manager is critical

•  Don’t settle for “reporting” alone; demand solutions

•  Recognize the short-term lack of incentive to remove drugs from a patient’s regimen

•  Demand solutions (and outcomes)

ENFORCEMENT

What to do? Guiding Principles

•  Even when DISCUSSION goes well, consistent oversight is needed to ensure implementation of treatment changes

•  Should be nurse-led

•  Focus on reinforcing the evidence-based recommendations and agreements with treating physicians

•  Engage with the claimant to make a psychosocial assessment of the likelihood of success:

‒  Motivation?

‒  History of substance abuse?

‒  Environment?

OVERSIGHT

What to do? Guiding Principles

•  When the “hand shake” doesn’t work, deploy the “hammer”

•  In work comp, the tools vary by jurisdiction:

‒  Utilization review (UR)

‒  Independent Medical Exam (IME)

‒  Directed care

‒  Dispute resolution (work comp boards, ALJ, etc.)

•  In group health, the tools vary by contract

STATUTORY ACTION

What to do? Guiding Principles

DISCUSSION

ENFORCEMENT

OVERSIGHT

EDU

CA

TION

STATUTORY ACTION

Questions? Michael Gavin Chief Marketing Officer, PRIUM Email: mgavin@prium.net Website: www.prium.net Blog: http://prium-evidencebased.blogspot.com/