Turning Off the Faucet from Above: Health Plan Involvement in Safe Prescribing

1. Turning Off the Faucet from Above:
Health Plan Involvement
in Safe Prescribing
Presenters:
• Roneet Lev, MD, Director of Operations, Scripps Mercy Hospital Emergency
Department, and Chair, San Diego County (CA) Rx Drug Abuse Medical Task
Force
• Daniel Calac, MD, FAAP, Chief Medical Officer, Indian Health Council, Inc.
• Margaret Mendes, PharmD, Program Director, Academic Detailing Service, VA
Desert Pacific Healthcare Network
• George Scolari, Behavioral Health Program Manager, Community Health Group
Third-Party Payer Track
Moderator: Mark D. Birdwhistell, MPA, Vice President for
Administration and External Affairs, University of Kentucky HealthCare

2. Disclosures
Daniel Calac, MD, FAAP; Roneet Lev, MD;
Margaret Mendes, PharmD; George Scolari; and
Mark D. Birdwhistell, MPA, have disclosed no
relevant, real, or apparent personal or
professional financial relationships with
proprietary entities that produce healthcare
goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
1. Describe strategies to engage health plans in
safe prescribing efforts.
2. Identify some red flag medications and
combinations that are key to safe prescribing.
3. Outline some health plan policies that can be
used for safe prescribing.
4. Provide accurate and appropriate counsel as
part of the treatment team.

5. Roneet Lev, MD, Director of Operations, Scripps Mercy Hospital San Diego
Chair, San Diego Prescription Drug Abuse MedicalTask Force
DanielCalac, MD, Chief Medical Officer, Indian Health Council, Inc
Margaret Mendes Pharm D, Program Director,VA San Diego Healthcare System
George Scolari, Behavioral Health Program Manager,Community Health Group

6. VA Health Care
The San Diego Medical Task Force and Death Diaries
Community Health Group
1
3
4
2 Indian Health Council
5 Health Plan Recommendations

7. San Diego Death Diaries
Medical Examiner and PDMP
Data Results

8.  Facilitator
 DEA
 Emergency Physicians
 Primary Care
 Pain Management
 Addiction Specialists
 PharmacyAssociation
 HospitalAssociation
 Dental Association
 PsychiatricAssociation
 Pediatric Association
 Kaiser
 Scripps
 Sharp
 Community Clinics
 VA
 Military
 Palomar Pomerado
 Indian Health
 Methadone Clinic

9.  ME Data
• 254 deaths with
prescriptions as cause of
death
• Could be with alcohol, illicit,
over the counter
 PDMP Data
• Does Not Include
 VA
 Balboa Naval Hospital
 Methadone Clinics
 Inpatient hospitals
186
68
254 Prescription Related Deaths
in San Diego 2013
CURES Data
No CURES

10. 10
20%
80%
Single Medication (51)
Multiple Medication (203)

11. 11
2.8
1.6
68.8
0
10
20
30
40
50
60
70
80
California San Diego San Diego Deaths
2013 Census 38.3 million 3.2 million 254
Patients with Rx 7,057,000 816,372 186
Chronic Use 200,080 13,567 128

12. 12
PDMP Match (3)
6%
PDMP Match + Doctor
Shopper (3)
7%
PMDP Match + Doctor
Shopper + Illicit (1)
2%
No Recent
Methadone Rx (3)
7%
No Methadone on
PDMP (24)
52%
No PDMP Data (12)
26%
PDMP Match (3)
PDMP Match + Doctor Shopper
(3)
PMDP Match + Doctor Shopper
+ Illicit (1)
No Recent Methadone Rx (3)
No Methadone on PDMP (24)
 46 deaths
 Number One drug to cause a single medication related death
 85% (39) of Deaths Rx from outside PDMP system
 100% deaths (7) from PDMP system from primary care

13.  All PDMP Reports – 54% (100 patients)
 ME Deaths – 21% (55)
39
16
Opioids + Benzodiazepines
ME Reports – 55 patients
PDMP Match
No Match
100
86
PDMP Reports with
Opioid + Benzodiazepine
Combination
Opioid + Benzo
No Combination
13

14.  52 Patients (28% of all PDMP Reports)were Doctor
Shoppers
 “The Heavy Half” = Received 51% of all Rx
 50/50 Male/Female
28%
72%
% Doctor Shoppers
Doctor Shopper
Regular Patient
14

15.  Emergency Department Guidelines
 Urgent Care Guidelines
 Medication Agreements
 Treatment Guidelines
 Interdisciplinary Conferences
 Educational Outreach
 Magazine Publications
 Case Discussions
 Media Outreach
 Further Research
 Medical Examiner Feedback to Physicians

16.  Lev, R et al “A description of Medical Examiner prescription –related
deaths and prescription drug monitoring program data” American
Journal of Emergency Medicine. December 2015.
 Lev, R et al “Methadone Deaths Compared to All Prescription Related
Deaths” Forensic Science International.2015
 Lev, R et al “Who is prescribing controlled medications to patients who
die from prescription drug abuse?” AmericanJournal of Emergency
Medicine.Oct 2015.
16

17. SanDiegoRxAbuseTaskForce.Org

18. Daniel Calac, MD
Chief Medical Officer
Indian Health Council, Inc
Funded by the National Institutes
for Health and the Indian Health
Service

21. RINCON SITE SANTAYSABEL SITE

24. Study Goal: to reduce availability and misuse of
prescription pain pills in a rural tribal community
Hypotheses: To use focused community interventions to:
 1) Create convenient options for community members to reduce
availability of non-prescribed use;
 2) Demonstrate feasibility of a culturally tailored and environmentally
sound drug disposal system in American Indian communities; and
 3) Change norms around giving away one’s prescription pain pills to
family members or friends.

25.  Created in 2008 to address rising prescription
pain medication misuse/abuse
 Use a multidisciplinary approach which
addresses the physical, psychological and
social issues associated with chronic pain
conditions
 Hold patient and provider accountable for use of
opioid medications for chronic health

26.  Updated prescribing practices and
policies in IHC medical manual
 Implement a Pain Agreement
 Conduct a initial assessment
▪ Formulate a treatment plan
 Treatment plan includes other modalities
▪ Acupuncture, group therapy, chiropractics,
physical therapy, nutrition education

27.  Set a maximum number of 200mg pill/month
of any one opioids; set a maximum daily
morphine equivalent dosage at 200mg
 Conduct Urine Drug Screens
 Conduct a CURES report
 Administer pain questionnaires

28. Conduct initial
evaluation
• History and physical examination
• Lab work ordered
• Screen for abuse potential using SOAAP-R
• Run CURES report to check for recent opioid activity elsewhere
Pain
Agreement
• Provider creates a plan that includes other modalities
• Acupuncture, group therapy, chiropractics, physical therapy, nutrition education
• Patient and provider sign agreement, and a copy of the agreement is given to the patient
• Patient conducts additional assessments with other modalities
Follow up
• At subsequent visits, patient leaves a urine specimen for a drug screen
• Pain questionnaire
• Review Pain Agreement

29.  Training IHC providers on safe prescribing
 No longer prescribing soma (Carisoprodol)
 Limit opioid formulary to MS Contin,
Oxycontin, combination analgesics

30.  Interviewing tribal leaders about prescription drug
disposal practices and barriers to implementation
 Conducting focus groups on disposal methods
 Conducting pill take-back events
 Establishing permanent drop-boxes

31.  Daniel Calac, MD, dcalac@indianhealth.com
 Tony Luna, MA, tluna@indianhealth.com
 Roland Moore, PhD, roland@prev.org
 Rick Mcgaffigan, MA, rmcgaffigan@prev.org

32. Margaret Mendes, Pharm.D.
Director, VISN 22 Academic Detailing Service

33.  Discuss risks with opioids and benzodiazepines
 RecognizeVeteran patients at increased risk
 DescribeVA policies and processes to reduce combination
 Show success inVA
 Discuss future education on benzodiazepine safety
33

34.  After opioids, benzodiazepines are drug class most commonly involved
in pharmaceutical OD deaths (30%) 1
 In the general population benzodiazepines are class most commonly
involved in an opioid-related death (30%) 1
 In theVA, 50% of opioid OD deaths are on concurrent
benzodiazepines2
 Among opioid users, risk of death goes up with benzodiazepines in a
dose-response fashion
1. Jones CM, et al. JAMA 2013;309 (70):657-659.
2. Park TW, et al. BMJ. 2015;350:h2698.

35. 0
10
20
30
40
50
60
70
Opioid
prescription
Highest
quintile of
avg daily
opioid use
Duration of
opioid use >2
months
Concurrent
opioids
Concurrent
sedative
hypnotics
Early opioid
refills
Percent(%)
No MH diagnosis MH diagnosis w/o PTSD PTSD
JAMA 2012; 307:940-7

36. Veterans are twice as likely to die from accidental overdose compared to
the non-Veteran population
 Assessment of risk factors is important in ourVeteran population
especially in returning combatVeterans
 Psychological distress may lead to inappropriate use of opioid
medications
 Caution should be used in this population
Bohnert AS, et al. Med Care 2011;49: 393–396

37. VISN 22 Network Policy N.:2015-05: Chronic Opioid Use for Non-Malignant Pain

39.  Education on risks of
overdose
 Offer naloxone kits to
patients at risk of
overdose

40.  Patient resistance
 Provider resistance
 Visit time constraints and follow up
 Different prescribers of the medications
 Primary Care – Opioids
 Mental Health – Benzodiazepines

42.  Benzodiazepines in the elderly
 Associated with significant risks: falls1, hip fractures2,3,4, sedation1,
CI,1,5,6 MVA7,8, OD9,10
 Benzodiazepines in dementia
 Generally not recommended due to side effects. Lorazepam and
oxazepam do not require oxidative metabolism in the liver and have
no active metabolites therefore many clinicians prefer these agents.11
 Benzodiazepines in PTSD
 No efficacy to support core symptoms. Cognitive effects are
concerning.12
 Insomnia education
 50% increase in overall mortality rates associated with long-term
benzodiazepine use.13
 Promoting non-pharmacological treatment first
 Cognitive BehavioralTherapy (CBT), CBT for Insomnia, relaxation
therapy, supportive therapy

43. 1. Glass J, et al. BMJ. 2005;331(7526):1169.
2. Ray WA, et al. JAMA. 1989. 262(23):3303-3307.
3. Wang PS, et al. Am J Psychiatry. 2001;158(6):892-8.
4. Chang CM, et al. Am J Geriatr Psychiatry. 2008;16(8):686-92.
5. Paterniti S, et al. J Clin Psychopharmacol. 2002;22(3):285-93.
6. Billoti de Gage S, et al. BMJ. 2012. 345:e6231.
7. Ray WA, et al. Am J Epidemiology.1992;136(7):873-83.
8. Hemmelgarn B, et al. JAMA. 1997;278(1):27-31.
9. Jones CM, et al. JAMA 2013;309(70):657-659.
10. ParkTW, et al. BMJ. 2015;350:h2698.
11. Rabins PV, et al. APA Practice Guideline forTreatment of Patients with Alzheimer’s
Disease and other dementias.
12. VA/DoD 2010 Practice Guidelines for Management of PTSD. www.healquality.va.gov
13. Kripke DF, et al. 2012 BMJ open 2 , e000850.

44. George Scolari, Behavioral Health Program Manager
Community Health Group
Chair, Healthy San Diego Behavioral HealthWork Group

45.  Formed in 1998, Healthy San Diego is the
umbrella in which 5 Medicaid (Medi-Cal)
Managed Care Plan’s operate in San Diego.
 Care1st, Community Health Group, Health Net,
Kaiser Permanente & Molina Healthcare.
 The Healthy San Diego Behavioral Health Work
Group was formed in 1998 when Specialty
Mental Health was contractually carved out of
Medi-Cal Managed Care Plans in California.

46.  Dr. Roneet Lev, Chair of the San Diego
Prescription Drug Abuse MedicalTask Force,
presented “San Diego Death Diaries” to
Community Health Group’s Pharmacy and
Therapeutics Committee Meeting.
 The Committee elected to look at “Red Flag”
medications and combinations within
Community Health Group’s utilization data.

47.  HolyTrinity (opioid, benzodiazepine, and
carisoprodol)
 Benzodiazepines Plus Opioids
 Soma (carisoprodol)
 Ambien (Zolpidem) – long term
 Xanax – long term
 Long Acting Opioids – by ED provider
 Methadone – by Primary Care

49.  Community Health Group is in the process of
implementing a pain management specialty
restriction on methadone prescriptions.
 CHG’s Chief Medical Officer and Pharmacy Director
had a conversation with an “outlier” prescriber who is
not a pain management specialist.
 CHG’s P&T voted to remove Soma from formulary.
 Safe Prescribing Guide developed by the Healthy San
Diego Behavioral HealthWork Group.

50.  Chronic, non-cancer pain management
by pain management specialists or in
consultation with pain management
specialists
 Prior authorization and utilization
management edits such as:
 Quantity and fill limits,
 Formulary management,
 Provider restrictions
 Concurrent use edits.

51.  Use of treatment plans to include
assessment of pain; treatment modalities
considered, tried, failed; treatment goals;
medication necessary to manage pain.
 Use of a pain contract between prescriber
and member.
 Restrict members to one prescriber.
 Restrict members to one pharmacy.
 Random drug screens.
 Regular review of utilization management
reports based on members, prescribers,
and pharmacies.
 Recommend providers check CURES.

52.  Review utilization of the “HolyTrinity” use among
CHG members.
 Review data by prescribers.
 Address utilization with “outliers”.
 Work on utilization management edits – will have to
address strategically since this is likely to affect
many providers and members.
 Collaborate with other San Diego Medi-Cal
Managed Care Plan’s (Healthy San Diego) .

54. Promote PDMP Use Promote Utilization of Drug Screens
Use Medication Agreements
Education
Formulary Changes
Prior Authorization
Provider Restriction
Alternate PainTreatment Modality
Join One San DiegoVision

55. One Provider,One Pharmacist
Use CURES (PDMP)
MedicationAgreement
No Opioid + Benzodiazepines
Honor EmergencyGuidelines

56.  Benzodiazepine plus Opioids – avoid combination
 Soma (Carisoprodol) – off formulary
 Methadone– restricted provider
 Xanax – non formulary
 High Dose Morphine Equivalent- prior authorization for
new start > 90 MME
 New Start Opioids – prior authorization for > 2-3 months
 Acute Prescriptions – limit to 30 tablets
 Feedback to providers after EmergencyVisit

57.  Federal
 Patient Satisfaction is Obstacle to Safe Prescribing
 Do not link money with satisfaction scores for doctors
 CURES gold standard: Universal, RealTime, Actively Managed
 State
 Data comparison for state
 Education Databank
 Law enforcement allowed to assist with court mandated
rehabilitation, allow PDMP access
 Pain CME, not biased towards pharmaceutical
 Local
 Health Plan Best Practices
 Feedback from Medical Examiner to Provider
 Pediatrician involved in prevention
 Unified Media Message

58. Turning Off the Faucet from Above:
Health Plan Involvement
in Safe Prescribing
Presenters:
• Roneet Lev, MD, Director of Operations, Scripps Mercy Hospital Emergency
Department, and Chair, San Diego County (CA) Rx Drug Abuse Medical Task
Force
• Daniel Calac, MD, FAAP, Chief Medical Officer, Indian Health Council, Inc.
• Margaret Mendes, PharmD, Program Director, Academic Detailing Service, VA
Desert Pacific Healthcare Network
• George Scolari, Behavioral Health Program Manager, Community Health Group
Third-Party Payer Track
Moderator: Mark D. Birdwhistell, MPA, Vice President for
Administration and External Affairs, University of Kentucky HealthCare