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Ohio Self-Insurers Association 2013

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Narcotic Medication Strategies

Narcotic Medication Strategies

Published in: Education, Health & Medicine

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  • 1. Sedgwick © 2013 Confidential – Do not disclose or distribute.Sedgwick © 2011 Confidential – Do not disclose or distribute.JUNE 12-13, 2013
  • 2. Sedgwick © 2013 Confidential – Do not disclose or distribute.Sedgwick © 2011 Confidential – Do not disclose or distribute.Narcotic MedicationStrategiesTeresa Bartlett, MDSenior Vice PresidentMedical Quality
  • 3. Sedgwick © 2013 Confidential– Do not disclose or distribute. 3Sedgwick © 2011 Confidential– Do not disclose or distribute. 3Objectives• Provide background information regarding opioids• Provide education• Provide tools to assist in the assessment of cases• Screening tools• Opioid Agreement• Timing of follow up• Board of pharmacy reporting• Assessment considerations• Drug Screening guidance• Calculations of Morphine dosages
  • 4. Sedgwick © 2013 Confidential– Do not disclose or distribute. 4Sedgwick © 2011 Confidential– Do not disclose or distribute. 4Education• First step toward Prescription Drug optimization• Addresses:• Overuse• Underuse• Misuse• Drug to drug interactions• Medication reconciliation process• Overall health safety concerns• lab studies
  • 5. Sedgwick © 2013 Confidential– Do not disclose or distribute. 5Sedgwick © 2011 Confidential– Do not disclose or distribute. 5Statistics• Every hour in the USA one baby is born suffering from in opioid withdrawal(NIDA)• 40% increase in employees testing positive for prescription narcotics from2005-2009 (Quest)• A November 18, 2010 report post-accident drug tests are four-times morelikely to find narcotics than pre-employment drug tests (Quest)• Vicodin is the most frequently found narcotic prescription drugabused (Quest)
  • 6. Sedgwick © 2013 Confidential– Do not disclose or distribute. 6Sedgwick © 2011 Confidential– Do not disclose or distribute. 6Background: How did we get here•From the American Pain Society Website:• In late 2000, Congress passed into law aprovision, which the President signed, thatdeclared the ten-year period that beganJanuary 1, 2001, as the:• Decade of Pain Control and Research• The American Pain Society has activelysupported the Decade of Pain Control andResearch and it has been a focal point for thedevelopment of numerous programs to advanceawareness and treatment of pain and fundingfor research
  • 7. Sedgwick © 2013 Confidential– Do not disclose or distribute. 7Sedgwick © 2011 Confidential– Do not disclose or distribute. 7Narcotic Utilization•Fatal overdoses involvingprescribed opioids tripled inthe United States between1999 and 2006•A recent government studydetermined that opioid poisoning wasthe leading cause of death for peopleaged 35-54• This rate was higherthan motor vehicle orfirearm related deathsfor that age group• Since 1990, the medical use of opioids has increase by a factor of 10• According to the CDC, enough opioids were prescribed last year tomedicate every American adult with a standard pain treatmentdose of hydrocodone every 4 hours for a month
  • 8. Sedgwick © 2013 Confidential– Do not disclose or distribute. 8Sedgwick © 2011 Confidential– Do not disclose or distribute. 8Narcotic Medication Management• National Issue• Creates issues for• patients• physicians• employers• * The # 1 prescribed drug in the USA in 2012 was Hydrocodonewith acetaminophen (Vicodin)http://healthland.time.com
  • 9. Sedgwick © 2013 Confidential– Do not disclose or distribute. 9Sedgwick © 2011 Confidential– Do not disclose or distribute. 9Prescription Drug Diversion as a National Issue
  • 10. Sedgwick © 2013 Confidential– Do not disclose or distribute. 10Sedgwick © 2011 Confidential– Do not disclose or distribute. 10Unintended Result• Across the country, there is anincrease in the number of ER visitsdue to non-medical use ofnarcotics• Up to 89% of abused prescriptiondrugs are diverted from legallywritten prescriptionsProblem isn’t just with narcoticprescribing,buthowtheyareusedonceinthehandsofthepublic
  • 11. Sedgwick © 2013 Confidential– Do not disclose or distribute. 11Sedgwick © 2011 Confidential– Do not disclose or distribute. 11Biochemical Physiology of Narcotic UseThe way the brain reacts facilitates the process ofaddiction/abuse:• Endorphins are naturally occurring chemicals thatwork on the nervous system to reduce pain• The endorphins can act on certain parts of the brain toproduce euphoria or a natural “high”• Addiction shuts the endorphin system down• This leads to hyperalgia (increased pain perception)and hypersensitivity• The abuser then seeks higher doses or stronger drugs
  • 12. Sedgwick © 2013 Confidential– Do not disclose or distribute. 12Sedgwick © 2011 Confidential– Do not disclose or distribute. 12Opioid Guideline for Chronic Pain• Use opioid only after other pain relief therapies have been exhausted• Before prescribing a risk assessment screening should be conducted• Opioids should be started at the lowest possible dose• If a patients dosage has increased to 120mg MED without substantialimprovement in function or pain relief a chronic pain specialist should beconsulted• Long acting or controlled release opioids should not be used for acute pain• Fentanyl patches, OxyContin and Methadone are examples
  • 13. Sedgwick © 2013 Confidential– Do not disclose or distribute. 13Sedgwick © 2011 Confidential– Do not disclose or distribute. 13Opioid Contract
  • 14. Sedgwick © 2013 Confidential– Do not disclose or distribute. 14Sedgwick © 2011 Confidential– Do not disclose or distribute. 14Importance of Communication Skills• Medical Literacy• Risks• Self Care• Lifestyle choicesPatientEducation• Better Results• Transfer of specificknowledgeConsultingPhysicianEducationBetterOutcomes
  • 15. Sedgwick © 2013 Confidential– Do not disclose or distribute. 15Sedgwick © 2011 Confidential– Do not disclose or distribute. 15Follow up Care• Failure to progress or demonstrate functional progress or anysigns of compliance should lead to prompt discontinuance ofmedication• Dosage may need to be increased to maximize therapeutic valuenot to exceed 120mg Morphine/day• Random Urine Drug Screen• Weaning should involve a mental health professional whospecializes in addiction• PT, exercise and other medications such as NSAIDS areimportant in this process
  • 16. Sedgwick © 2013 Confidential– Do not disclose or distribute. 16Sedgwick © 2011 Confidential– Do not disclose or distribute. 16Morphine 120mg/day is the MAXIMUM• An electronic dose calculator can be found and downloaded• http://agencymeddirectors.wa.gov/mobile.htmlMORPHINE (reference) 30 mgCodeine 200 mgFentanyl Transdermal 12.5mcg/hrHydrocodone (Vicodin) 30 mgHydromorphone 7.5mgOxycodone 20mgOxymorphone 10mgMethadone** 4mgj BE CAUTIOUSCOMPLICATED
  • 17. Sedgwick © 2013 Confidential– Do not disclose or distribute. 17Sedgwick © 2011 Confidential– Do not disclose or distribute. 17Acetaminophen (Tylenol) Warning• Causes liver toxicity• Many narcotics are combined with acetaminophen so you must also watchfor maximum dosing• Short-term use (<10 days) – 4000 mg/day• Long-term use – 2500mg/day
  • 18. Sedgwick © 2013 Confidential– Do not disclose or distribute. 18Sedgwick © 2011 Confidential– Do not disclose or distribute. 18Opioid Risk Tool ORTDate ______Patient NameOPIOID RISK TOOLMark eachbox that appliesItem ScoreIf FemaleItem ScoreIf Male1. Family History of Substance Abuse Alcohol [ ] 1 3Illegal Drugs [ ] 2 3Prescription Drugs [ ] 4 42. Personal History of Substance Abuse Alcohol [ ] 3 3Illegal Drugs [ ] 4 4Prescription Drugs [ ] 5 53. Age (Mark box if 16 – 45) [ ] 1 14. History of Preadolescent Sexual Abuse [ ] 3 05. Psychological Disease Attention DeficitDisorder [ ] 2 2Obsessive CompulsiveDisorderBipolarSchizophreniaDepression [ ] 1 1TOTAL [ ]Total Score Risk Category Low Risk 0 – 3 Moderate Risk 4 – 7 High Risk > 8
  • 19. Sedgwick © 2013 Confidential– Do not disclose or distribute. 19Sedgwick © 2011 Confidential– Do not disclose or distribute. 19Urine Drug Testing• Purpose• Identify aberrant behavior• Undisclosed drug use and/or abuse• Verify compliance with treatment• Frequency• Based on risk assessment for drug abuse• Low risk once/year• Moderate risk twice/year• High risk three to four times/year• Unusual or suspicious behavior = at time of visit• Losing prescription• Requesting early refills• Multiple prescribers• Demonstrating intoxication• Slurred, slow speech
  • 20. Sedgwick © 2013 Confidential– Do not disclose or distribute. 20Sedgwick © 2011 Confidential– Do not disclose or distribute. 20Urine Drug Testing Result InterpretationThe following UDT results should be viewed as a “red flag”requiring confirmation and intervention:• Negative for opioid(s) prescribed• Positive for drug (benzodiazepines, opioids, etc) NOT prescribed• Positive for amphetamine or methamphetamine• Positive for alcohol• Positive for cocaine or metabolitesIf a confirmatory drug test (MRO) substantiates a “red flag” result AND is:• Positive for prescribed opioid(s)• a controlled taper and a referral to an addiction specialist or drug treatmentprogram should be considered• Negative for prescribed opioid(s)• The physician should stop prescribing opioid(s) and consider a referral to anaddiction specialist or drug treatment program
  • 21. Sedgwick © 2013 Confidential– Do not disclose or distribute. 21Sedgwick © 2011 Confidential– Do not disclose or distribute. 21Assessment of Function• Overall Pain Management• How well is the pain being managed?• Pain rating when asked to consider the past month• Should indicate pain is overall better and able to function at a higherlevel• Function• Daily activities should be listed• Even in WC activities that are healthy should be encouraged
  • 22. Sedgwick © 2013 Confidential– Do not disclose or distribute. 22Sedgwick © 2011 Confidential– Do not disclose or distribute. 22
  • 23. Sedgwick © 2013 Confidential– Do not disclose or distribute. 23Sedgwick © 2011 Confidential– Do not disclose or distribute. 23Suggested Weaning Process• Reduce Morphine mg by 10 to 20% each week• Add Clonopine to help with withdrawal symptoms• Addiction or Pain Management Specialist should be consulted• May require short inpatient stay to assist with initial phase• May require drug rehab program (inpatient and outpatient)
  • 24. Sedgwick © 2013 Confidential– Do not disclose or distribute. 24Sedgwick © 2011 Confidential– Do not disclose or distribute. 24The Role of Claim Managers• Help the physician stay on track• Ask for the Risk assessment (ORT) and provide tool if necessary• Make sure other therapies are tried first• That first RX for opioids should be small doses and improvementsshould be documented in function and pain• Request follow up assessment of patient to see if medication is working(allergic reaction) Does not have to be office visit• Set next appointment with treating physician for 10 to 14 days for nextassessment• Provide an Opioid agreement to any physician prescribing these drugs(ACOEM or State of Washington)• Ask for copies of screening, opioid agreement, drug test results andOARRS report
  • 25. Sedgwick © 2013 Confidential– Do not disclose or distribute. 25Sedgwick © 2011 Confidential– Do not disclose or distribute. 25
  • 26. Sedgwick © 2013 Confidential– Do not disclose or distribute. 26Sedgwick © 2011 Confidential– Do not disclose or distribute. 26OHIO Automated RX Reporting System (OARRS)• Established in 2006• Tool to assist healthcare professionals in providing better treatment forpatients with medical needs• Quickly identifies drug seeking behaviors.• Prescription History Report can assure a patient is getting the appropriatedrug therapy and is taking their medication as prescribedWho can run this history report?• Prescribers (or delegates)• Pharmacists• Officers of law enforcement agencies whose primary mission involvesenforcing prescription drug laws• All must register for an OARRS account
  • 27. Sedgwick © 2013 Confidential– Do not disclose or distribute. 27Sedgwick © 2011 Confidential– Do not disclose or distribute. 27Providers Required to Check OARRS When:Have a drug screen result that is inconsistent withthe treatment plan or refusal to participate in adrug screenForging or altering a prescriptionStealing or borrowing reported drugsArrest, conviction or received diversion, orintervention in lieu of conviction for a drug relatedoffense while under the physicians careIncreasing the dosage of reported drugs inamounts that exceed prescribed amountSelling prescription drugsReceiving reported drugs from multiple prescribers,without clinical basisHave a family member, friend, law enforcementofficer, or health care professional express concernrelated to the patients use of illegal or reporteddrugs
  • 28. Sedgwick © 2013 Confidential– Do not disclose or distribute. 28Sedgwick © 2011 Confidential– Do not disclose or distribute. 28Potential Claim or Clinical Actions• Focus on quality health care and patient safety issues• Use Clinical Resources when needed:• Customized letters to physicians• Request drug screen• Ask physician for contract• Ask Physician to run OARRS Report• Identify red flags• Physician Peer outreach• Independent Medical Exam• Seek a weaning process from the treating physician• Potential point of sale blocks• GOAL: Improve management of the injured workers’medication regime and lower overall claim costs
  • 29. Sedgwick © 2013 Confidential– Do not disclose or distribute. 29Sedgwick © 2011 Confidential– Do not disclose or distribute. 29Role of Pharmacy Benefit Management• Identify adverse trends• Provide point of sale alerts• Customize according to need• Define historic use and potential abuse• Injury specific formulary• Formulary different for acute and chronic phase
  • 30. Sedgwick © 2013 Confidential– Do not disclose or distribute. 30Sedgwick © 2011 Confidential– Do not disclose or distribute. 30Success Stories• Sometimes well intended, high quality physicians fall prey to drug seeking patients– Got narcotic pain RX– Called doctor and indicated they realized they had a negative reaction in thepast asked for different RX• Injured worker who did not want narcotics after learning they may cause erectiledysfunction• Injured worker who did not want to risk the side effect of the medications whennurse explained the medication
  • 31. Sedgwick © 2013 Confidential – Do not disclose or distribute.Sedgwick © 2011 Confidential – Do not disclose or distribute.MAKE A DIFFERENCE!Questions and Discussion