Trea%ng Pain Dr. Randy Easterling MD, The Street Clinic Medical Director, Marian Hill Chemical Dependence Unit Dr. Daniel Barne2 Medical Director, BlueCross BlueShield Tennessee
DISCLOSURE STATEMENT Randy Easterling has no ﬁnancial rela%onships with proprietary en%%es that produce health care goods and services. Daniel BarneD has no ﬁnancial rela%onships with proprietary en%%es that produce health care goods and services.
RANDY EASTERLING, MD • DIPLOMAT AMERICAN SOCIETY OF ADDICTION MEDICINE • MEDICAL DIRECTOR MARION HILL CHEMICAL DEPENDENCY UNIT RIVER REGION HEALTH SYSTEM, VICKSBURG, MS • PRESIDENT MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE
TREATING PAIN TODAY’S SPEAKER HAS NO DISCLOSURE TO REPORT OF REAL OR APPARENT CONFLICT RELATED TO THE CONTENT OF THIS PRESENTATION.
WHY ALL THE FUSS ? • DRUG OVERDOSED DEATHS INCREASED FOR THE 11TH CONSECUTIVE YEAR IN 2010. • LEADING DRUGS RESPONSIBLE FOR FATALITIES ARE PRESCRIPTION MEDS, MOST OF WHICH ARE OPIOID ANALGESICS.
WHY ALL THE FUSS ? • THE CENTERS FOR DISEASE CONTROL AND PREVENTION FOUND THAT 38,329 DIED FROM DRUG OVERDOSE IN 2010. • THAT’S UP FROM 37,004 DEATHS IN 2009, AND 16, 849 DEATHS IN 1999.
WHY ALL THE FUSS ? • NEARLY 60% OF THE OVERDOSE DEATHS IN 2010 INVOLVED PHARMACEUTICAL DRUGS. • OPIOIDS ACCOUNT FOR 75% OF THESE DEATHS.
WHY ALL THE FUSS ? • IN 2009 ACCIDENTAL OPIOID OVERDOSE BECAME THE #1 LEADING CAUSE OF ACCIDENTAL DEATH IN THE U.S. • ACCIDENTAL OVERDOSE EXCEEDED TRAFFIC ACCIDENTS.
WHY ALL THE FUSS ? • MORE THAN 16,000 AMERICANS DIED LAST YEAR IN THE UNITED STATES FROM ACCIDENTAL OPIOID OVERDOSE. • U.S. HAS 5% OF THE WORLD POPULATION. • USE 99% OF THE HYDROCODONE PRODUCED IN THE WORLD.
WHY ALL THE FUSS ? • ENOUGH HYDROCODONE WRITTEN EACH YEAR IN THE U.S. TO GIVE EVERY MAN, WOMAN, AND CHILD IN THIS COUNTRY 5 MG EVERY 4 HOURS FOR 30 DAYS. • 111 TONS WERE DISPENSED IN 2010: 69 TONS OF PURE OXYCODONE 42 TONS OF PURE HYDROCODONE
WHY ALL THE FUSS ? • IF YOU GIVE A PATIENT HYDROCODONE FOR 90 DAYS – REGARDLESS OF THE REASON …... • 66% OF THOSE PATIENTS WILL BE TAKING HYDROCODONE DAILY 5 YEARS LATER.
WHY ALL THE FUSS ? • VICODAN IS NOW THE MOST WIDELY PRESCRIBED MEDICATION IN THE UNITED STATES … • FOLLOWED BY LISINOPRIL … • THEN, ZOCOR.
WHY ALL THE FUSS ? • 7 MILLION AMERICANS ADDICTED TO PRESCRIPTION OPIOIDS IN THE U.S. • TAKING PRESCRIPTION PAIN KILLERS WITHOUT MEDICAL NEED INCREASED 75% FROM 2002 TO 2010.
WHY ALL THE FUSS ? • IN 2010, 12 MILLION AMERICANS AGE 12 AND OLDER REPORTED NON-‐MEDICAL USE OF PRESCRIPTION PAIN KILLERS IN THE PAST YEAR. • NEARLY ½ MILLION EMERGENCY DEPARTMENT VISITS IN 2009 WERE DUE TO PEOPLE MIS-‐USING OR ABUSING PRESCRIPTION PAIN KILLERS.
WHY ALL THE FUSS ? • NON-‐MEDICAL USE OF PRESCRIPTION PAIN KILLERS COSTS HEALTH INSURORS UP TO $72.5 BILLION ANNUALLY FOR DIRECT HEALTH CARE. • 98 OF THE TOP 100 DOCTORS IN THE COUNTRY DISPENSING OXYCODONE DO SO IN THE STATE OF FLORIDA.
PHYSICIAN PROFILE QUESTION: • WHAT TYPE OF DOCTOR PRESCRIBES EXCESSIVE AMOUNTS OF OPIOIDS? ANSWER: • GOOD CLINICIAN
PHYSICIAN PROFILE • TYPICALLY, WELL TRAINED PAIN MANAGEMENT PHYSICIANS. • PROCEDURELESS • OFTEN WRITE LARGE VOLUMES OF PAIN MEDICATION.
PHYSICIAN PROFILE • WELL-‐INTENTIONED PHYSICIANS WHO BELIEVE PEOPLE ARE NOT SUPPOSED TO HURT. • DO NOT PRACTICE EVIDENCE BASED MEDICINE. • WRITE LARGE QUANTITIES OF OPIOIDS WITH REFILLS.
CHEMICAL COPING TYPICAL PRESCRIPTION: • LORCET PLUS #90 OR #120 • ONE P.O. T.I.D. OR … • ONE P.O. Q.I.D. WITH 5 REFILLS.
WHEN MONEY DRIVES MEDICINE • CRIMINALS WITH A MEDICAL DEGEREE AND LICENSE TO PRACTICE MEDICINE • STATE BOARD OF MEDICAL LICENSURE • SMALL COHORT OF PHYSICIANS
MONITORING PRESCRIBING PATTERNS • HOW DO YOU IDENTIFY PHYSICIANS WHO WRITE TOO MANY OPIOIDS?
MONITORING PRESCRIBING PATTERNS PHARMACISTS • EXCELLENT SOURCE OF INFORMATION. • KNOW WHICH DOCTORS HAVE A LOOSE PEN. • KNOW THE PRESCRIBING HABITS OF EACH PROVIDER IN THEIR COMMUNITY.
PRESCRIPTION MONITORING PROGRAM • CAN BE RUN ON INDIVIDUAL PATIENTS AND INDIVIDUAL PRESCRIBERS. • EXCELLENT TOOL FOR IDENTIFYING DRUG SEEKING PATIENTS AND PRESCRIBERS WHO WRITE TOO MANY SCHEDULED DRUGS.
PRESCRIPTION MONITORING PROGRAM DRAWBACKS – NOT REAL TIME – NOT INTERSTATE – LACK OF FUNDING
PHYSICIAN DRIFT • OUT-‐OF-‐SPECIALTLY PHYSICIANS PRACTICING IN PAIN CLINICS
BUSINESS OF MEDICINE • PAIN CLINICS OWNED BY NON-‐PHYSICIANS AS BUSINESS VENTURES. • EMPLOY PHYSICIANS • CASH ONLY PILL MILLS
• RETIRED OR OLDER PHYSICIAN. • LIKES PRACTICING MEDICINE AGAIN. • RESIDENTS WHO MOONLIGHT. • PRESCRIPTIVE PATTERN THAT IS OUT OF THE ORDINARY
NEW CME REQUIREMENT • EVERY LICENSEE • 40 HOURS IN A 2-‐YEAR CYCLE • 5 HOURS RELATED TO “PRESCRIBING MEDICATIONS” • EMPHASIS ON CONTROLLED SUBSTANCES.
THE SCIENCE OF OPOIDS • PROVEN EFFICACY FOR USE OF OPIOIDS FOR SHORT TERM NON-‐CANCER PAIN. • VERY LITTLE SCIENTIFIC EVIDENCE THAT LONGTERM USE OF OPIOIDS FOR NON-‐ CANCER PAIN IS EFFECTIVE.
THE SCIENCE OF OPOIDS • SIGNIFICANT EVIDENCE THAT LONG TERM OPIOID USE FOR NON-‐CANCER PAIN WILL RESULT IN OPIOID HYPERALYGESIA SYNDROME.
QUESTIONS ? • ANSWERS … $5 • CORRECT ANSWERS … $10 • CORRECT ANSWERS YOU CAN UNDERSTAND … $25
TREATING PAIN Randy Easterling, M.D. Dan BarneD, M.D., J.D. April 2, 2013
Disclosures Daniel BarneD has no ﬁnancial rela%onships with proprietary en%%es that produce health care goods and services.
Where Tennessee Stands • 2nd Most Medicated State (Forbes Magazine, August 16, 2010) • 5th in Average Mg. Opioids/Resident (Oct. 2012 Journal of Pain)
Controlled Substances in Tennessee • Just over 18 million prescrip%ons for controlled substances dispensed in 2012. • Increase of 1.5 % from 2011 (compared to a 23% rise from 2010 – 2011). • Increased use of TN Controlled Substance Database/State Registra%on of Pain Clinics.
PEER REVIEW • Other Physicians Reviewing the Records and Management of Physicians with Possible Quality Problems • Used in Hospitals for years • Why not in Health Plans?
PLANS ARE IN A GOOD POSITION TO ASSESS QUALITY OF CARE OF NETWORK PROVIDERS • We pay claims (and have claims data). • We have audit rights in provider contracts. • We review medical records. • We are in providers’ oﬃces. • No “compe%tors out to get me” in Plan peer review.
The BCBST CRM Program Reviews All Quality of Care Complaints and Concerns • Required to review member complaints by accredi%ng agencies (NCQA, URAC) and state Medicaid program. • Liability/Risk reduc%on method.
The BCBST CRM Program is staﬀed by clinical professionals • 4 RNs review cases. • Support from BCBST Pharmacy Department staﬀed by 12 Pharmacists. • Support from Analy%cs Area to Review Prescribing Data.
How Do We Get RX Cases? • Referrals from Pharmacy Department. • Pharmacists iden%fy outliers in their areas of responsibility and contact the providers to try to determine why they are outliers. • If no explana%on and no change in prac%ce aser contact, refer to CRM.
Also from Member Complaints Mbr wants complaint ﬁled against provider (prv). On one visit, mbr didn’t want his shot b/c they were administering it where it was making mbrs back swell up. Aser he declined the shot, the prv ripped up his rx for Valium. Once the rx was ripped up, mbr had no choice but to take the shot. Then aser they gave him the shot, they rewrote his rx for Valium. Per mbr, it was as if prv was blackmailing him: if he didn’t take the shot, they wouldn’t write his rx.
The CRM Process 1. Obtain medical records from dates of service when pain meds. prescribed. 2. Review medical records internally. 3. Refer suspect records for specialty matched review (through Independent Review Organiza%ons).
Standard of Care That level of care below which no reasonable medical provider would prac%ce.
Medical Correc%ve Ac%on Plan • Specialty matched review shows standard of care not met for controlled substance prescribing. • LeDer with reviewer’s comments giving examples of why standard not met. • Provider advised to take whatever steps are necessary to correct prac%ce.
Model Policy for the Use of Controlled Substances for the Treatment of Pain Medical Records – The physician should keep accurate and complete records to include: 1. the medical history and physical examina%on, 2. diagnos%c, therapeu%c and laboratory results, 3. evalua%ons and consulta%ons, 4. treatment objec%ves, 5. decision of risks and beneﬁts, 6. informed consent, 7. treatments, 8. medica%ons (including date, type, dosage and quan%ty prescribed), 9. instruc%ons and agreements and 10. periodic reviews. Records should remain current and be maintained in an accessible manner and readily available for review.
Reasons for MCAP Failure 1. Lack of Provider Knowledge 2. TIME = MONEY
Consequences of MCAP Failure 1. Creden%aling CommiDee – Creden%als Revoked. 2. Formal Hearing – Due Process 3. Report Filed with Healthcare Integrity and Protec%on Data Bank (HIPDB)