A Paradigm Shift of Payer        Strategy         April 10-12, 2012  Walt Disney World Swan Resort
Learning Objectives:1.  Analyze the scope of the payers’ role in the    prescription drug abuse problem.2.  Identify speci...
Disclosure Statement•  All presenters for this session, Dr.   Kathryn Mueller, Dr. Brian K. Solow and   Beverly Franklin-T...
Changing                             Opioid                             Practice   Kathryn Mueller, MD, MPH, FACOEMProfess...
Topics Discussed•  Brief Overview of the problem•  Medical Guideline Recommendations-   e.g. Colorado Div of WC and ACOEM•...
FROM THE NATIONAL CENTER FOR HEALTH STATISTICSMMWR / August 6,2010 / Vol. 59 / No. 30              6
FROM THE NATIONAL CENTER FOR HEALTH STATISTICSMMWR / August 20,2010 / Vol. 59 / No. 32               7
Morphine Equivalents per Case                                8
Use of Opioids•  Use of an opioid treatment   agreement or opioid contract -   Recommended (I)•  Routine use of urine drug...
Recommendations for Opioid Use  Therapeutic Trial Indications   a) The failure of pain      management alternatives by   ...
Starting Opioids•  Acetaminophen, NSAIDS, ASA used first and   should be continued when stronger agents   added•  Start wi...
Criteria for Initiation•  No evidence of psychopathology or   elevated abuse risk, addiction, or   adverse outcome (Relati...
Opioid Trial•  When active therapies, pain self-   management techniques have been   tried•  Psychosocial assessment for a...
Cautions and               Contraindications   •  Relative contraindications       –  Hx of EtOH, benzodiazepine, or other...
Recommendations for Opioid Use   i.  On-Going, Long-Term Management        should include:       a) Prescriptions from a s...
Recommendations for Opioid Use         d)  Contract detailing the             following:               Side effects      ...
Recommendations for Opioid Use               Contract Language         Reasons for tapering opioids –            Lack of...
Recommendations for Opioid Use                  Use of drug screening initially, randomly at                   least once...
What does it look like in real     world practice?                                 19
MMWR 2012            20
FACTORS INFLUENCING WORK         INTERFERENCE IN PATIENTS WITH      CHRONIC LOW BACK PAIN: A RESIDENCY       RESEARCH NETW...
(RRNeT) STUDY               continuedAll Subjects           Depression            Depression              Screening       ...
Interstate Variation in Use of    Narcotics – 17 states studied•  Large variation among the states for   morphine equivale...
Can Clinicians predict misuse?•  Urine drug test results using drug testing   protocols•  In clinician predicted misuse – ...
Rates of Inappropriate Drug Use in            Chronic Pain •    938,586 urine drug screens •    38% no detectable prescrib...
What has prevented change?•  Education of providers and patients    –  Unaware of risk    –  Not aware of current medical ...
Context - Seatbelts                      27
Chronic Opioid Use•  Leads to death for some•  Significantly increases premiums•  Does not necessarily increase return   t...
Solutions•  Education for the public on the rate of   deaths and ways to prevent them•  Education for doctors –  –  curren...
Solutions•  Drug testing  –  Needs to be viewed as a necessary part     of management, similar to tests to     continue ot...
Alcohol and Marijuana          e)  Marijuana: Marijuana use is illegal under              federal guidelines and cannot be...
Colorado Drug Monitoring code         Rule 18 -6 G (5) New code to encourage physicians to  periodically review drug comp...
new code implementation            2010 1st year•  Used in 350 cases•  2/3 of the claims had dates of injury from   2001-2...
Hurdles•  Should all high dose opioid   patients be referred to   specialists?•  Could low-dose patients   have only minim...
References•  Washington State Guidelines http://   www.opioidrisk.com/node/212•  American College of Occupational and   En...
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A Paradigm Shift of Payer Strategy
National Rx Drug Abuse Summit 4-11-12

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Kathryn Mueller

  1. 1. A Paradigm Shift of Payer Strategy April 10-12, 2012 Walt Disney World Swan Resort
  2. 2. Learning Objectives:1.  Analyze the scope of the payers’ role in the prescription drug abuse problem.2.  Identify specific best practice methodologies that can be implemented by payers to reduce fraud, waste and abuse through member and prescriber interventions/ education and support3.  Describe the “drug seeker” profile and how it has changed.
  3. 3. Disclosure Statement•  All presenters for this session, Dr. Kathryn Mueller, Dr. Brian K. Solow and Beverly Franklin-Thompson have disclosed no relevant, real or apparent personal or professional financial relationships.
  4. 4. Changing Opioid Practice Kathryn Mueller, MD, MPH, FACOEMProfessor, School of Public Health & Department of Emergency Medicine University of Colorado Vice-President - American College ofOccupational and Environmental Medicine 4
  5. 5. Topics Discussed•  Brief Overview of the problem•  Medical Guideline Recommendations- e.g. Colorado Div of WC and ACOEM•  Current Practice•  Solutions and Directions for the future 5
  6. 6. FROM THE NATIONAL CENTER FOR HEALTH STATISTICSMMWR / August 6,2010 / Vol. 59 / No. 30 6
  7. 7. FROM THE NATIONAL CENTER FOR HEALTH STATISTICSMMWR / August 20,2010 / Vol. 59 / No. 32 7
  8. 8. Morphine Equivalents per Case 8
  9. 9. Use of Opioids•  Use of an opioid treatment agreement or opioid contract - Recommended (I)•  Routine use of urine drug screening for patients on chronic opioids - Recommended (C)•  Attempts to wean patients on opioids to lowest clinically effective dose or completely from opioids - Recommended, Insufficient Evidence (I) 9
  10. 10. Recommendations for Opioid Use  Therapeutic Trial Indications a) The failure of pain management alternatives by a motivated patient including: a)  active therapies b)  cognitive behavioral therapy c)  pain self-management techniques d)  other appropriate medical techniques. Colorado CP 10
  11. 11. Starting Opioids•  Acetaminophen, NSAIDS, ASA used first and should be continued when stronger agents added•  Start with therapeutic trial with clear understanding of limited use•  Contingent on patient goals and obligations —return to work, agreement that drug screening may be used•  Do not begin opioids until patient has begun a pain rehabilitation program Colorado CP 11
  12. 12. Criteria for Initiation•  No evidence of psychopathology or elevated abuse risk, addiction, or adverse outcome (Relative rather than absolute contraindications) –  Note some studies noted elevated risk of abuse with any prior substance use 12
  13. 13. Opioid Trial•  When active therapies, pain self- management techniques have been tried•  Psychosocial assessment for abuse potential and untreated depression, anxiety, etc.•  Treatment of identified issues and referral to pain specialist if history of addiction•  Informed, written, witnessed consent by the patient•  Frequent (q 2-4 wk) follow-up to document pain control and functional gains such as RTW 13
  14. 14. Cautions and Contraindications •  Relative contraindications –  Hx of EtOH, benzodiazepine, or other substance abuse –  Off work more than 6 months –  Severe personality disorder •  General contraindications –  Active EtOH or substance abuse –  Untreated mood or psychotic disorder –  Decreased mental or physical function with opioid useColorado CP 14
  15. 15. Recommendations for Opioid Use i.  On-Going, Long-Term Management should include: a) Prescriptions from a single practitioner; b) Ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects; c) Ongoing effort to gain improvement of social and physical function as a result of pain relief;Colorado CP 15
  16. 16. Recommendations for Opioid Use d)  Contract detailing the following:   Side effects anticipated from the medication;   Requirements to continue active therapy;   Need to achieve functional goals;Colorado CP 16
  17. 17. Recommendations for Opioid Use Contract Language   Reasons for tapering opioids –   Lack of functional effect at higher doses and for apparent hyperalgesia   Non-compliance with other drug use   Drug screening showing use of drugs outside the prescribed treatment   Requests for prescriptions outside of the defined time frames   Lack of adherence identified by pill count, excessive sedation, or lack of functional gains   Excessive dose escalation with no decrease in use of short-term medicationsColorado CP 17
  18. 18. Recommendations for Opioid Use   Use of drug screening initially, randomly at least once a year and as deemed appropriate by the prescribing physician. (Rolfs R 2010); Canadian Guidelines 2010; Chou R 2009).   PDMP review   Use limited to two opioids: a long-acting opioid for maintenance of pain relief and a short-acting opioid for limited rescue use.   Sleep Apnea Testing: type of testing required unclear. Type 3 portable units with 2 airflow samples and 02 saturation device may be useful for monitoring respirator depression secondary to opioids.Colorado CP
  19. 19. What does it look like in real world practice? 19
  20. 20. MMWR 2012 20
  21. 21. FACTORS INFLUENCING WORK INTERFERENCE IN PATIENTS WITH CHRONIC LOW BACK PAIN: A RESIDENCY RESEARCH NETWORK OF TEXAS STUDY (RRNeT) STUDYSubjects: Three hundred sixty outpatients with CLBPfor more than 3 months.Predictors of Work Interference Screened positive for depression Number and magnitude of flare - upsYoung. RA JABFM Sept.-Oct. 2011Vol.24, No.5, pp 503-509 21
  22. 22. (RRNeT) STUDY continuedAll Subjects Depression Depression Screening Screening Negative PositiveN=360 N=61 N=292---------------------------------------------------------------------------------------Does pain interfere withYour normal work (including both 215 (61.4)housework and paid work)?Takes Opioid medication 210 (58.5)Takes daily scheduled Opioid medication 94(26.1)Patient has written pain Contract 67(18.6)JABFM Sept.-Oct. 2011 Vol.24, No.5, pp 503-509 22
  23. 23. Interstate Variation in Use of Narcotics – 17 states studied•  Large variation among the states for morphine equivalents per case - 4000 NY to 1000 IA•  Psychological evaluation – median 4% of long term user cases•  Drug screening – median 7% of long term user cases Wang,D Workers Compensation Research Institute, 2011 23
  24. 24. Can Clinicians predict misuse?•  Urine drug test results using drug testing protocols•  In clinician predicted misuse – 79% +•  Non-predicted misuse – 72% +•  Other drug tests – 71% +•  Because these are based at least 50% on non-verified cutoffs, true results may be less•  Poster - Bronstein K, Vanderbilt U, Ameritox sponsored 24
  25. 25. Rates of Inappropriate Drug Use in Chronic Pain •  938,586 urine drug screens •  38% no detectable prescribed drug •  29% non-prescribed drug detectable •  11% illicit drugs Couto J , Population Health Management, vol 12 #4 2009 25
  26. 26. What has prevented change?•  Education of providers and patients –  Unaware of risk –  Not aware of current medical guidelines•  Historical medical teaching –  Sanction by medical boards and JCHO for not treating pain•  Patient resistance –  Doctor, don t you trust me•  Provider s time – done outside of visit•  PDMP difficulty accessing – state specific 26
  27. 27. Context - Seatbelts 27
  28. 28. Chronic Opioid Use•  Leads to death for some•  Significantly increases premiums•  Does not necessarily increase return to work•  Most physicians don t follow standard protocol 28
  29. 29. Solutions•  Education for the public on the rate of deaths and ways to prevent them•  Education for doctors – –  currently available on line through AAFP (family practice), Washington state, and others including University of Colorado –  REMS – pharmaceutical based with government requirements 29
  30. 30. Solutions•  Drug testing –  Needs to be viewed as a necessary part of management, similar to tests to continue other long term medications –  Example: Providers are encouraged to check all sexually active adults for HIV yet <2% are + •  Unlikely to be positive if >50 y/o – not necessarily 30
  31. 31. Alcohol and Marijuana e)  Marijuana: Marijuana use is illegal under federal guidelines and cannot be recommended for use in this guideline. The Colorado statute also states that insurers are not required to pay for marijuana. f)  Alcohol Screening: It is appropriate to screen for alcohol use and have a contractual policy regarding alcohol use during chronic opioid management as alcohol use in combination with opioids is more likely to contribute to death or accidents than marijuana. 31Colorado CP
  32. 32. Colorado Drug Monitoring code Rule 18 -6 G (5) New code to encourage physicians to periodically review drug compliance Reports review  Random drug testing review – annually and before chronic opioids are used  Access the State Prescription Drug Monitoring Program (records all opioid Rx from any Pharmacy in CO) Describe function and make recommendation Anecdotally docs are saying about 20% of patients have surprises on drug testing 32
  33. 33. new code implementation 2010 1st year•  Used in 350 cases•  2/3 of the claims had dates of injury from 2001-2009•  No claims were identified with 1-2 opioid Rxs and use of the code•  We hope to identify number of claims where it should have been used and look at psych evals and drug screen for those 33
  34. 34. Hurdles•  Should all high dose opioid patients be referred to specialists?•  Could low-dose patients have only minimal screening, e.g. completing validated office questionnaires for depression, anxiety, abuse•  Who will pay? Hint: Right now physicians are unlikely to continue to prescribe medications with a significant hepatic or renal risk unless lab tests are completed. 34
  35. 35. References•  Washington State Guidelines http:// www.opioidrisk.com/node/212•  American College of Occupational and Environmental Guidelines www.acoem.org chronic pain guides•  Colorado Div of Workers Compensation http://www.colorado.gov go to Div of WC then chronic pain treatment guideline 35
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