Cl 1 anderson lamer

Clinical
Track:

Taking
on
Prescrip2on
Drug
Abuse

Across
the
Care
Con2nuum

Daren
Anderson,
MD

VP/Chief
Quality
Oﬃcer,
Community
Health
Center,
Inc.

Director,
Weitzman
Quality
Ins?tute

Associate
Professor
of
Medicine,
Quinnipiac
University

Melissa
Lamer,
PharmD,
BCPP

Director
of
Behavioral
Health
Pharmacy
Solu?ons

Magellan
Rx
Management

Disclosures

•  Daren
Anderson
has
disclosed
no
relevant,

real
or
apparent
personal
or
professional

ﬁnancial
rela6onships.

•  Melissa
Lamer
PharmD,
BCPP
wishes
to

disclose
she
is
an
employee
and
is
paid
a

salary
form
Magellan.
She
will
present
this

content
in
a
fair
and
balanced
manner.

Learning
Objec6ves

1.  Iden6fy
the
speciﬁc
provider
educa6on

interven6ons
that
can
play
a
role
in
decreasing

prescrip6on
drug
abuse.

2.  Evaluate
how
the
applica6on
of
advanced
health

care
data
analy6cs
enables
the
iden6ﬁca6on
and

targe6ng
of
inappropriate
behaviors
related
to

prescrip6on
drug
abuse.

3.  Analyze
preliminary
results
of
CHCI’s
randomized

trial
of
ECHO
Pain
Management,
discussing
the

impact
of
the
interven6on
on
provider,
pa6ent
and

administra6ve
outcomes.

Strategies for Improving the Quality
and Safety of Chronic Pain
Management in Primary Care
Daren Anderson, MD
VP/Chief Quality Officer
Community Health Center, Inc.
Director, Weitzman Quality
Institute
Associate Professor of Medicine
Quinnipiac University

Goals of Presentation
•  To discuss current challenges in managing pain in primary
care, particularly in medically underserved populations
•  To describe the Stepped Care Model for Pain
Management
•  To describe primary care system interventions to improve
quality of chronic pain management
•  To explore methods to measure quality in chronic pain
management
•  To understand the Project ECHO model and how it can be
used to improve the quality and safety of pain
management in primary care

Our Vision: Since 1972, Community Health Center, Inc. has been
building a world-class primary health care system committed to caring for
underserved and uninsured populations and focused on improving health
outcomes and building healthy communities.
CHC Inc. Profile:
"   Founding Year - 1972
"   Primary Care Hubs–13
"   No. of Service
Locations-218
"   Licensed SBHC locations–
24
"   Organization Staff – 500
"   140,000 patients
"   400,000 visits
"   Medical, dental, behavioral
health

Weitzman Quality
Institute•  Established in 2013 by the
•  Named in honor of Gerald
Weitzman, a community
pharmacist, one of CHC’s
founders, and a long-time board
member
•  Research Institute based in a
large FQHC
•  Promotes innovations in quality
improvement science as well as
critical investigation in primary
care and systems redesign

•  Chronic pain affects approximately 100 million
Americans1
•  Annual cost of $635 billion in medical treatment and
lost productivity1
•  Majority of patients with pain seek care in a primary
care setting2
•  Primary Care Providers express low knowledge and
confidence in pain management and receive little pain
management education3
•  Opioids are heavily relied on for pain management in
primary care4
•  Prescription opioid overdose is a major and growing
public health concern5
Background

•  Increasing demand to identify and manage painful
conditions
•  Increasing rates of opioid abuse and diversion
•  Limited training in pain management
•  Limited access to specialists
•  Limited access to pain management specialty centers
The Challenge for the PCP

CHC’s Stepped Care Model for Pain Management
STEP

1

STEP

2

STEP

3

Primary Care Medical Home
Routine screening for presence & intensity of pain
Comprehensive pain assessment and follow up
Documentation of function status and goals
Management of common painful conditions
Primary care team-care: MA, RN Care managers
Systematic Opioid Risk Assessment/Refill/Monitoring
Complexity
Treatment
Refractory
Comorbidities
RISK

Tertiary Interdisciplinary Pain
Centers
Referrals to community partners

Chronic Pain in Primary Care:
Baseline Data from a large health
system
Chart ReviewData warehouse Provider/Staff
surveys
Data sources:

Source: J Am Med Inform
Assoc. 2013 Dec; 20
(e2):e275-80. doi: 10.1136/
amiajnl-2013-001856.
Epub 2013 Jul 31.

EHR Data:
Chronic Pain Algorithm
•  All patients age 18 and older with at least one medical
visit in the past year who met any of the criteria below:
•  A visit with an ICD9 code specific for chronic pain (e.g.
“chronic pain syndrome” 338.2X, 338.4)
•  Two or more visits separated by 30 days or more with an
ICD9 code for a painful condition
•  Receipt of at least 90 days of opioid medication other
than buprenorphine in one year
•  One visit with an ICD9 code for a painful condition AND
two or more pain scores greater than or equal to 4.
Data
warehous
e
Source: J Am Med Inform Assoc. 2013 Dec; 20(e2):e275-80. doi: 10.1136/amiajnl-2013-001856. Epub 2013 Jul 31.

Demographics
Pa2ents
with
Chronic

Pain
(20%
of
all

pa2ents)

Pa2ents
without

Chronic
Pain
(80%)

p-‐Value
Two-‐
Tail

Total
Patients* 8152
%
32487
%

Sex
Male
2995
37%
13215
41%
<0.0002

Female
5156
63%
19266
59%
<0.0002

Age
Age
18-‐29
856
11%
8679
27%
<0.0002

Age
30-‐39
1483
18%
7163
22%
<0.0002

Age
40-‐49
2319
28%
6758
21%
<0.0002

Age
50-‐59
2243
28%
5644
17%
<0.0002

Age
60-‐69
925
11%
2969
9%
<0.0002

Age
69+
326
4%
1274
4%
0.7482

Race
Caucasian
3624
44%
12433
38%
<0.0002

Black
1005
12%
4147
13%
0.2891

Hispanic
3138
38%
12866
40%
0.0667

Visits

Avg
Visits/Yr
6.54
2.72
<0.0002

Opioids
Any
Opioid
Rx
3280
40%
1870
6%
<0.0002

90+
Days
Opioid
1297
16%
0
0%
<0.0002

Mental
Hlth
Pts
w/
a
CHCI
BH
Visit
1991
24%
3329
10%
<0.0002

Pain
Referrals
Physical
Therapy
1655
20%
953
3%
<0.0002

Pain
Management
573
7%
94
0%
<0.0002

Physical
Med
and
Rehab
700
9%
346
1%
<0.0002

Orthopedic
Surgery
1347
17%
677
2%
<0.0002

Rheumatology
275
3%
159
0%
<0.0002

Insurance
Medicaid
5425
67%
15315
47%
<0.0002

Medicare
1302
16%
3094
10%
<0.0002

Uninsured
780
10%
7814
24%
<0.0002

Data
warehous
e
•  >female
•  Older
•  More
visits
•  More
opioids
•  More BH
Dx
•  More
referrals
•  Less
uninsured
* All adult patients in 2011 with at least one medical visit
Source: J Am Med Inform Assoc. 2013 Dec; 20(e2):e275-80. doi: 10.1136/amiajnl-2013-001856. Epub 2013 Jul 31.

Data
warehous
e
100%
37%
9%
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
All CHCI Chronic Pain Cohort Chronic Opioid Subset
Total Primary Care Medical Visits, 2012
.
Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in
Primary Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community
Health Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.

0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
1%
1%
1%
1%
1%
1%
1%
1%
1%
1%
1%
1%
2%
2%
2%
2%
2%
2%
2%
2%
2%
2%
2%
2%
3%
3%
4%
4%
4%
5%
5%
5%
5%
5%
5%
5%
6%
7%
7%
7%
8%
10%
11%
11%
11%
11%
0% 2% 4% 6% 8% 10% 12%
Dudley MD, Robert-PD
Farb MD, Alan-PD
Kennedy APRN, Michelle
Moemeka MD, Angela
Seagriff APRN, Nicole
Ayubcha MD, Soussan- FP
Mohammadu MD, Fusaini
Bravo MD, Teresa-FP
Kobel PA, Cela
Martin MD, Monique
Quarles APRN, Kristie
Wessling MD, Kathleen
DeMarco APRN, Rachel-FP
Weir MD, Lori
Knoeckel APRN, Sarah
Weischedel MD, Anne-Katrin
Dresden APRN, Debra
Gellrich MD, Gabriella-FP
Doerwaldt MD, Hartmut-FP
Wilson APRN, Laura
Carden APRN, Pamela LOCUM
Lau MD, Wai Lang- IM
Barrow MD, Alvin
Butler MD, Danielle-FP
Lecce MD, Carl-FP
Swan APRN, Amanda
Kamat MD, Leena
Manning DO, Lynne
Rivera Godreau MD, Ivelisse--FP
Patel DO, Dipak--FP
Decker APRN, Patricia-FP
Percent of Panel Prescribed 90 Days of Opioids by
PCP
Provider
Names
Data
warehous
e
Anderson D, Wang S, Zlateva I. Comprehensive Assessment of Chronic Pain Management in Primary
Care- a First Phase of a Quality Improvement Initiative at a Multi-Site Community Health Center. Journal
of Quality in Primary Care. , 2012, 20(6):421-433.

Chart Review Results
Baseline

2011

Chronic
Opioid

Cohort

Presence
of
pain
documented

65.3%

Provider's
func6onal
assessment
documenta6on
6.7%

Provider's
cause/source
documenta6on
64.0%

Diagnos6c

test
reviewed
4.7%

Pain
medica6on
ordered
100%

Pain
consult
10.7%

Documenta6on
of
treatment
plan
96%

Pa6ent
educa6on
provided
16.0%

Diagnos6c
Imaging
ordered
22.0%

Pain
reassessed
20.0%

Chart
review
.

Pain Survey Questions
Item Statement
Mean

Baseline
2011

Skilled chronic pain management is a high priority for me.
3.74*

My management of chronic pain is influenced by experience with
addicted patients.

1.15

My management of chronic pain is influenced by fear of
contributing to dependence.

1.36

I have adequate time to manage most patients with chronic pain.
1.81

Fear of narcotic regulatory agencies/administration influences my
decisions regarding chronic pain management.

2.04

Analgesic side effects hinder my efforts to treat patients with
chronic pain.

2.17

Patients I treat become addicted to opioids.
2.55

I use an opioid agreement with my patients.
4.45

I use a pain assessment or monitoring tool.
3.77

I am confident in my ability to manage chronic pain.
2.77

I am satisfied with the quality of resources available to help me
manage patients with chronic pain.

1.53

Provider/
Staff
surveys

152.49
138
178
150
0.00
50.00
100.00
150.00
200.00
250.00
CHCI
Providers
(n=47)
Davis
et
al.
Valida6on
Cohort:

Internists
(n=84)

Davis
et
al.
Valida6on
Cohort:

Pain
Experts
(n=22)

Davis
et
al.
Valida6on
Cohort:

Academic
Physicians
(n=27)

Avg CHCI KP50 Baseline Score Comparison
Provider/
Staff
surveys
.

Key Findings
•  Chronic pain is extremely common (up to 37% of visits)
•  Patients using opioids have >10 visits per year
•  Documentation of pain care is poor
•  Functional assessments are rarely documented
•  Pain care knowledge is low
•  Providers have low confidence in their pain
management skills
•  Providers feel that pain care is an important skill for
them
.

Problem
Goal
Interven2on

Low
pain
knowledge/self

eﬃcacy

Increase
knowledge
and
self

eﬃcacy

Online,
team-‐based
CME

Poor
documenta6on
of
pain

and
func6onal
status

Poor
documenta6on
of
pain

reassessment

Improve
documenta6on
of

pain
care/func6onal
status

•  EHR
templates
for
pain

management
visits

•  SF8
Pain
interference

form
(PROMIS
tool)

•  Opioid
Risk
Tool

•  COMM®
form

Low
rates
of
opioid

monitoring/high
varia6on
in

prescribing
paherns

Reduce
opioid
prescrip6on

varia6on
and
increase
use
of

opioid
agreements
and
u-‐tox

monitoring

•  Standard
policy
for

opioid
agreements

•  Standard
policy/
procedure
for
utox

•  Opioid
dashboard

•  Opioid
review

commihee

Limited
behavioral
health

co-‐management

Increase
BH-‐Primary
care
co-‐
management

•  Behavioral
health
co-‐
loca6on

•  Pain
group
therapy

•  Project
ECHO

Low
use
of
CAM
Increase
access
to
CAM
Improved
access/Co-‐loca6on

of
chiroprac6c,

mindfulness
program

Limited
access
to
specialty

consulta6on

Increase
PCP
access
to

specialty
advice

Project
ECHO

Pain CME Options
•  Conferences
•  REMS training

CHCI Biannual Pain Management
CME
•  All PCP’s
•  2 hours, biannually
•  Virtual Lecture
Hall®
•  Group format: PCP,
RN, BHP, PharmD

Action Plan
Problem
Goal
Interven2on

Low
pain
knowledge/self

eﬃcacy

Increase
knowledge
and
self

eﬃcacy

Online,
team-‐based
CME

Poor
documenta6on
of
pain

and
func6onal
status

Poor
documenta6on
of
pain

reassessment

Improve
documenta6on
of

pain
care/func6onal
status

•  EHR
templates
for
pain

management
visits

•  SF8
Pain
interference

form
(PROMIS
tool)

•  Opioid
Risk
Tool

•  COMM®
form

Low
rates
of
opioid

monitoring/high
varia6on
in

prescribing
paherns

Reduce
opioid
prescrip6on

varia6on
and
increase
use
of

opioid
agreements
and
u-‐tox

monitoring

•  Standard
policy
for

opioid
agreements

•  Standard
policy/
procedure
for
utox

•  Opioid
dashboard

•  Opioid
review

commihee

Limited
behavioral
health

co-‐management

Increase
BH-‐Primary
care
co-‐
management

•  Behavioral
health
co-‐
loca6on

•  Pain
group
therapy

•  Project
ECHO

Low
use
of
CAM
Increase
access
to
CAM
Improved

of
chiroprac6c,

mindfulness
program

Limited
access
to
specialty

consulta6on

Increase
PCP
access
to

specialty
advice

Project
ECHO

Chronic Pain Follow-Up Templates
•  Click the HPI link and select the category Chronic Pain Follow
Up to document the necessary information:

Pain Follow Up Assessment Forms

CHCI standard policy for chronic
opioid therapy:
•  All patients receiving COT* must have:
–  Signed opioid agreement scanned and
saved in the EHR
–  Utox at least once every 6 months
–  Follow up visit every 3 months
*COT defined as receipt of 90 days or more of prescription opioid analgesic medication

Opioid Management Dashboard
Provider
Names

Opioid Review Committee
•  Committee with oversight over opioid prescribing
–  Formulary
–  High dose opioid oversight
–  Can require review before Rx
–  Can review outliers
–  Establish internal guidelines

•  University of Bridgeport
•  Six CHC sites: 4 Chiropractors + students
•  1-2 days per week
•  Internal referral in ECW
•  ECW custom HPI folders
•  Collaborative management for pain/
musculoskeletal problems
Results
•  Number of Unique Patients Seen – 77
•  98.7% completely satisfied
•  98% stated their condition was improved after
treatment
CHC-University of Bridgeport Integrated
Chiropractic Care

Expanded Access to Chiropractic

Behavioral Health Integration
for Pain Management
•  Co-location of Behavioral health and
primary care
•  Warm handoffs
•  Group therapy
•  BH participation in Project ECHO

COGNITIVE-BEHAVIORAL THERAPY (CBT)
•  GOAL: Move person from passivity, stress-
reactivity and hopelessness to hopefulness,
resourcefulness, and action

METHODS FOR IMPROVED COPING WITH PAIN
–  Cognitive Restructuring
–  Acceptance and Adaptation
–  Reframing
–  Distraction
–  Repetitive movement
–  Relaxation
–  Imagery
–  Motivation
–  Planning and Pacing Daily Activities
–  Goal Setting
–  Medication Management

Action Plan
Problem
Goal
Interven2on

Low
pain
knowledge/self
eﬃcacy
Increase
knowledge
and
self

eﬃcacy

Online,
team-‐based
CME

Poor
documenta6on
of
pain
and

func6onal
status

Poor
documenta6on
of
pain

reassessment

Improve
documenta6on
of
pain

care/func6onal
status

•  EHR
templates
for
pain

management
visits

•  SF8
Pain
interference
form

(PROMIS
tool)

•  Opioid
Risk
Tool

•  COMM®
form

Low
rates
of
opioid
monitoring/
high
varia6on
in
prescribing

paherns

Reduce
opioid
prescrip6on

varia6on
and
increase
use
of

opioid
agreements
and
u-‐tox

monitoring

•  Standard
policy
for
opioid

agreements

•  Standard
policy/procedure

for
utox

•  Opioid
dashboard

•  Opioid
review
commihee

Limited
behavioral
health
co-‐
management

Increase
BH-‐Primary
care
co-‐
management

•  Behavioral
health
co-‐loca6on

•  Pain
group
therapy

•  Project
ECHO

Low
use
of
CAM
Increase
access
to
CAM
Improved
of

chiroprac6c,

mindfulness
program

Limited
access
to
specialty

consulta6on

Increase
PCP
access
to
specialty

advice

Project
ECHO

NEJM 6/2011
•  Prospective cohort study
comparing HCV Rx at
UNM with Rx by primary
care clinicians at 21 ECHO
sites in rural areas and
prisons in NM.
•  407 patients with no
previous treatment
•  Primary endpoint was SVR.
•  57.5% at UNM and 58.2%
at ECHO sites achieved
SVR.
•  Serious adverse events
occurred in 13.7% at UNM
and 6.9% at ECHO sites.

Project ECHO University of New Mexico
“The mission of Project
ECHO is to develop the
capacity to safely and
effectively treat chronic,
common and complex
diseases in rural and
underserved areas and
to monitor outcomes.”
Dr. Sanjeev Arora,
University of New
Mexico

Technological Infrastructure
•  Video
conferencing
system for ECHO
team
•  Mobile
teleconferencing
platform (Vidyo©)
•  Webcam/iPad/
smart phone for
end-users
•  EHR
60

•  2 hour weekly sessions
•  Case submission form
•  Expert specialty team
•  ECHO Project
Coordinator
•  15-20 min didactic
presentation
•  Case presentations
(2-10)
•  Primary care providers
join from anywhere
Structural Features

Unique Features of CHCI Project ECHO
•  Google Sites project
page
•  ECHO blog
•  Twitter for questions/
comments from
participants and
observers
•  Integration of
behavioral health and
primary care through
co-presentation
•  National participation

Project ECHO
Buprenorphine
Primary Care
Marwan Haddad,
MD, MPH
Psychiatry
Richard Feuer, MD
Behavioral Health
Cliff Briggie Psy.D,
LADC, LCSW
Nursing
Jonathan Arocho,
LPN
Medical Assistance
Omar Perez
65

Bup Case Presentation Form
66
Page 1 Page 2

Provider Comments
•  The sessions are “fascinating”, with “great didactic”
presentations and a “collegial feel” that provides
“the opportunity to…inspect my own clinical
reflexes”.
-- ECHO Medical Provider
•  Sessions are “informative and feature helpful
information on the types of patients I see in
everyday practice”.
•  “I have learned a lot and want to find a way to
share this knowledge with the other providers at my
site.”

Connecticut
Community
Health Center,
Inc.
13 primary
care health
centers
across the
state
Over 130,000
medically
underserved
patients
Arizona
El Rio
Community
Health Center
16 practice
locations in
Tucson, AZ
73,000
patients
280,000 visits
per year
Delaware
Westside
Community
Health Center
9 practices in
Delaware
23,000
patients
Affiliation with
University of
Delaware
California
Open Door
Community
Health Center
2 primary
care sites
Northern CA
region
Coming soon:
10 additional sites from Maine
7 additional sites from New Jersey

Improvements in Opioid Agreements
and uTox Screening

2.7
2.7
2.7
2.7
5.4
14.6
14.6
2.7
13.5
5.4
5.4
10.8
10.8
20.6
20.6
18.9
83.8
91.9
91.9
86.5
83.8
64.7
64.7
78.4
0 20 40 60 80 100
spent enough time with me
thoroughly explains the treatment(s) I receive
treats me respectfully
listens to my concerns
answered all my questions
advises me on ways to avoid future problems
gives me detailed instructions regarding my home program
Overall, I am completely satisfied with the services I receive
Percent of Patients
My chiropractor:
Pt satisfaction with chiropractic services
assessment tool
Disagree
Agree

92.1%
50.0%
21.1%
18.4% 18.4%
13.2%
7.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Back Neck Leg Arm Hand/ Wrist Other Foot/ Ankle
PercentageofPatients
CHCI Chiropractic Services
General Area of Treatment

Decrease in average # of visits for
patients with chronic pain

Chronic Pain Cohort
Prescription of any opioid medication in patients with and without
chronic pain

Decrease in Chronic Opioid Prescribing
Prescription of 90+ days of any opioid medication in
patients with and without chronic pain

Next Steps
•  Combine system redesign work with Project ECHO
–  QI Training
–  IHI “Breakthrough Series Collaborative”
•  Population level data
•  Complete controlled trial of Project ECHO
•  Expand access to ECHO

Summary of Pain Management Best
Practices
•  Required pain CME for all PCPs
•  Structured Opioid Risk Assessment
•  Pain management follow up and monitoring frequency
based on risk assessment
•  Routine review of state prescription drug monitoring
website
•  Standard opioid agreement for all patients receiving
chronic opioids
•  uTox q6 months minimum
•  Multimodal care, onsite when possible:
–  Co-management with Behavioral health
–  Chiropractic
–  Acupuncture
–  Mindfulness

Conclusions
•  Chronic pain is highly prevalent in primary care
•  Knowledge and adherence to guidelines for
management of pain is variable
•  Health IT can be used to identify patients with chronic
pain
•  Use of an opioid management dashboard can improve
safety and monitoring
•  A multifaceted QI initiative aimed at improving pain
management in primary care is improving quality at CHC

Comments or Questions?
_________________________

Daren
Anderson,
MD

VP/
Chief
Quality
Oﬃcer

Community
Health
Center,
Inc.,

Director

Weitzman
Quality
Ins?tute

Daren@chc1.com

860.347.6971
ext.3740

_________________________

References
References:
1. Institute of Medicine. Relieving Pain in America: A Blueprint for
Transforming Prevention, Care, Education, and Research.
Washington, DC: National Academy Press, 2011.
2. Breuer B, Cruciani R, Portenoy R. Pain Management by Primary
Care Physicians, Pain Physicians, Chiropractors, and
Acupuncturists: A National Survey. South Med J 2010;103:738-747.
3. Ponte C, Johnson-Tribino J. Attitudes and Knowledge About Pain:
An Assessment of West Virginia Family Physicians. Fam Med
2005;37:477-480
4. Okie, S. 2010. "A Flood of Opioids, A Rising Tide of Deaths." The
New England journal of medicine 363 (21): 1981-5.
5. Centers for Disease Control and Prevention. 2010. Emergency
Department Visits Involving Nonmedical Use of Selected
Prescription Drugs - United States, 2004–2008. Washington, DC:
DHHS.
Anderson D, Wang S, Zlateva I. Comprehensive Assessment of
Chronic Pain Management in Primary Care- a First Phase of a
Quality Improvement Initiative at a Multi-Site Community Health
Center. Journal of Quality in Primary Care. , 2012, 20(6):421-433.

Taking
on
Prescrip6on
Drug
Abuse

Across
the
Care
Con6nuum

Melissa
Lamer,
PharmD,
BCPP

Director
of
Behavioral
Health
Pharmacy
Solu?ons

Magellan
Rx
Management

Financial
Disclosures

•  Melissa
Lamer
PharmD,
BCPP
wishes
to

disclose
she
is
an
employee
and
is
paid
a

salary
form
Magellan.
She
will
present
this

content
in
a
fair
and
balanced
manner.

Learning
Objec6ves

•  Iden6fy
the
speciﬁc
provider
educa6on
interven6ons

that
can
play
a
role
in
decreasing
prescrip6on
drug

abuse.

•  Evaluate
how
the
applica6on
of
advanced
health
care

data
analy6cs
enables
the
iden6ﬁca6on
and

targe6ng
of
inappropriate
behaviors
related
to

prescrip6on
drug
abuse.

Startling
Trends
in
Substance
Use
and

Abuse

Prescrip2on
drug
abuse
is
the

fastest
growing
drug
problem

•  From
2004-‐2011
emergency
room
visits

due
to
the
use
of
non
medical
use
of

opioids
has
increased
183%1

•  Over
54%
of
pa6ents
were
sent
home;

only
2.4%
who
were
referred
to
detox
or

treatment
programs2

11th
consecu2ve
year
of

increasing
drug
overdose
deaths2

•  Higher
morphine
equivalent
dosing

greatly
increases
risk

•  Many
deaths
involve
combined
mental

health
medica6ons
use
such
as

benzodiazepines,
an6depressants,
and

an6psycho6cs2

1

Drug
Abuse
Warning
Network,
2011.

2
Pharmaceu?cal
Overdose
Deaths,
United
States,
2010.”
Journal
of
the
American
Medical
Associa?on.
2012.

Medicaid
is
One
of
the
Most
Vulnerable

Popula6ons
for
Abuse

•  Medicaid
recipients
are
prescribed
pain
killers
at
twice
the
rate
of
non-‐Medicaid

recipients
and
are
at
six
6mes
the
risk
of
overdose1

•  Washington
study
iden6ﬁed
that
45%
of
people
who
died
were
enrolled
in
Medicaid2

•  A
combina6on
of
4
variables
have
been
found
to
predict
increase
risk
for
opioid

dependence3

-‐  Age

-‐  Depression

-‐  Psychotropic
Medica6ons

-‐  Pain
Impairment

•  Medicaid
is
the
largest
payor
for
mental
health
services4

-‐  This
will
con6nue
to
be
of
greater
importance
with
Medicaid
Expansion

1
CDC,
2011

2
Interagency
Guideline
on
Opioid
Dosing
for
Chronic
Non-‐Cancer
Pain

3Pain
Physician,
2012
4CMS
Bulle?n,
2012
hXp://medicaid.gov/Federal-‐Policy-‐Guidance/Downloads/CIB-‐12-‐03-‐12.pdf

Tradi6onal
Management
Methods

•  Controlled
substance
monitoring
to

increase
awareness
of
pa6ent

u6liza6on
paherns

•  Leverages
a
pharmacist
driven

educa6onal
campaign
and
requiring

provider
registra6on
and
checking
for

certain
pa6ents

•  6
months
aper
implementa6on

-  Registra6on
up
from
4.4%
to

86.5%

-  Database
access
up
from
15.8%
to

58.9%

-  Last
quarter
247
unique
provider

ran
a
query
(45.2%)

•  Audits
iden6fy
pharmacies
and
providers

dispensing/prescribing
higher
quan66es
of

controlled
substances
than
peers

•  Medica6on
use
evalua6ons
iden6fy
use
of

medica6ons
with
addi6ve
eﬀects

-‐  Narco6cs
+
muscle
relaxants
+

psychotropic
medica6ons

•  Lock-‐in
high
risk
individuals
to
one

prescriber
or
pharmacy
for
all
controlled

substances

-‐  Prescrip6ons/pa6ent/month
dropped

15%
during
the
lock
and
38%
post-‐lock

-‐  Average
#
of
drugs/pa6ent
dropped

15%
during
and
36%
post-‐lock

Prescrip2on
Drug
Monitoring

Program
Ini2a2ve
(PDMP)

Retrospec2ve
Medica2on

Reviews

While
Tradi6onal
Methods
Are
Needed

They
Are
Not
Enough

•  Despite
the
release
many

community
providers
are
not

accessing
these
important

databases

•  There
is
addi6onal

administra6ve
burden
on
the

providers
by
requiring
them

to
go
online,
register
and

frequently
revisit
the
site

•  Open
it
does
not
account
for

prescrip6on
in
other
states

To
Best
Manage
Opioid
Abuse
We
Need
a

Smarter
Solu6on

•  Maximizes
knowledge
by
leveraging

evidence-‐based
guidelines
to
create

ac6onable
recommenda6ons

•  Works
with
mul6disciplinary
teams

and
industry
leaders
to
iden6fy
high

proﬁle
targets

•  Engages
providers
through
mul6-‐
modal
communica6ons
techniques

including

face-‐to-‐face,
telephonic,

virtual
and
email

•  Push
data
out
to
providers
instead
of

pulling
them
in
to
get
it
saving
6me,

resources
and
increasing
ease

Receipt
of

Medical,
Behavioral,
&

Rx
Data

Evidence-‐Based

Algorithms

Clinical
Outreach
Outcomes

• Medical,

behavioral,
lab,

and/or
pharmacy

data
received
by

our
data
warehouse

• Extract
created,

data
scrubbed

• Leverages
expert

clinicians
to
create

ac6onable

informa6on

• Algorithms
iden6fy

non-‐compliant

prescribing

paherns
and

stra6fy
others

• PCP
&
BH

Providers

- Mul6-‐channel

consulta6on

- Educa6onal

materials

• Quality
indicator

monitoring

• Impact
analysis

• Ac6vity
tracking

Advanced
proprietary
clinical
algorithms
iden6fy
prescribing
paherns
that

are
inconsistent
with
evidence-‐based
guidelines
resul6ng
in

personalized
provider
consulta6ons

Whole
Health
Rx
SM

Integrated
Solu6on
for
Whole
Member
Health
Management

To
See
the
Whole
Pa6ent,
Pharmacy
and

Medical
Claims
Systems
Must
be
Integrated

•  Mul6ple
opioid

prescrip6ons
from
mul6ple

doctors
and
pharmacies

•  High
dose
medica6ons

•  Over
use
of
short
ac6ng

analgesics
without
long-‐
ac6ng
medica6ons

•  Early
reﬁlls

•  Hospital
admissions
for

overdoses
admissions

•  Diagnosis
claims
to

iden6fy
substance
abuse

•  Methadone
opioid

maintenance
claims
are

not
in
pharmacy
data

•  Cancer
diagnosis

requiring
higher
dosing

Pharmacy
Data
Medical
Data

Whole
Pa2ent

Management

•  Suboxone®
u6liza6on
in

combina6on
with
other
opioid

medica6ons

•  High
cumula6ve
diazepam

equivalent
daily
doses

•  Concomitant
benzodiazepine
and

opioid
therapy

•  High
cumula6ve
morphine

equivalent
daily
dosing

•  Opioids
from
mul6ple

prescribers
and
pharmacies

•  Methadone
and
concomitant

medica6on

monitoring

•  Cumula6ve
early
refills

Repor2ng
and
Profiling

Early
Pa6ent
Iden6fica6on
and
Provider

Outreach
is
Cri6cal
to
Improving
Outcomes

Cumula6ve
High
Risk
Report

Combining
mul6ple
ini6a6ves
is
key
to
addressing

poten6al
dangerous
behavior

Cl 1 anderson lamer

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