Successful Endeavors and Outcomes Robert DuPont, M.D. President, Ins<tu<on of Behavior and Health Inc. Ibhinc.org William Johnson, M.D. Chief Medical Oﬃcer, Pikeville Medical Center April 2 – 4, 2013 Omni Orlando Resort at Champions Gate
Learning Objec<ves • Analyze the latest data about the cost of prescripAon drug abuse to hospitals. • Explain the Physician Health Program model’s relevance to the treatment of prescripAon drug abuse. • Prepare strategies that you can implement in your own pracAce to reduce costs.
Disclosure Statement • Robert DuPont has no ﬁnancial relaAonships with proprietary enAAes that produce health care goods and services • William Johnson has no ﬁnancial relaAonships with proprietary enAAes that produce health care goods and services.
Robert L. DuPont, M.D. • Professor of Clinical Psychiatry, Georgetown University School of Medicine • President, InsAtute for Behavior and Health – Non-‐proﬁt organizaAon; one if its main prioriAes is to reduce prescripAon drug abuse • Vice President, Bensinger, DuPont & Associates – NaAonal consulAng ﬁrm dealing with substance abuse • Chairman, PrescripAon Drug Research Center – ConsulAng ﬁrm that develops risk minimizaAon acAon plans and product surveillance programs, conducts special populaAon surveys and forensic drug extracAon studies, and consults with pharmaceuAcal companies reviewing abuse-‐resistant formulaAons to assess or reassess scheduling
Treatment of PrescripAon Drug Abuse Today • Few prescripAon drug abusers want treatment • Dropping out of treatment and relapse are the norm • The treatment challenge: promote lifeAme recovery • Physician Health Programs (PHPs) set the standard with the New Paradigm
PrescripAon Drug Abuse – Opioids • Opioids dominate the prescripAon drug abuse problem • Virtually all opioid use among PHP parAcipants is from prescripAon opioids
Elements of the PHP System of Care Management • Comprehensive evaluaAon • Signed contract for monitoring and consequences • IniAal intensive, high quality treatment for substance use disorders and comorbid disorders • Random tesAng for 5+ years for alcohol and other drugs of abuse with zero tolerance for ANY use
Elements of the PHP System of Care Management • Leaving the PHP or relapse to substance use means risk of losing the license to pracAce medicine • Immersion in recovery fellowships, mostly Alcoholics Anonymous (AA) and NarcoAcs Anonymous (NA)
PHP Long-‐Term Drug Test Results • Over the course of 5 years: – 78% of all physicians had zero posiAve drug tests – 14% had only 1 posiAve drug test – 3% had only 2 posiAve drug tests – 5% had 3 or more
Opioid Users / IV Status • N = 694 parAcipants Opioids/No IV Use 25% (n=176) Opioids/IV Use 10% (n=70) Other Drugs/No IV Use 15% (n=106) Alcohol 48% (n=342) Excluded: 28 physicians treated for primary alcohol or non-‐opioid drugs with histories of IV use; 72 physicians who moved out of their state program’s jurisdicAon with unknown results
The Same Outstanding Results • No signiﬁcant diﬀerences were found among groups related to: – PosiAve drug tests over 5-‐year period – Contract status at follow-‐up – OccupaAonal status at follow-‐up
MedicaAon Assisted Treatment • 46 physicians were treated with Naltrexone and 1 was treated brieﬂy with methadone • Demographics similar to other physicians – 12 in Opioids/No IV group – 22 in Opioids/IV group – 2 in Other Drug/No IV group – 9 in Alcohol group • 67% of these 46 physicians had no posiAve tests, including for opioids (no diﬀerence)
Lessons from the PHPS for PrescripAon Opioid Abusers 1) Zero tolerance for any use of alcohol and other drugs 2) Thorough evaluaAon and paAent-‐focused long-‐term care 3) Frequent random tesAng for both alcohol and other drugs 4) Deﬁning and managing relapses: swio, certain and meaningful consequences for any substance use or other noncompliance 5) Immersion throughout care in community fellowships 6) Goal: lifelong recovery
ImplicaAons for Treatment of PrescripAon Drug Abuse • Outcomes reﬂect the sepngs in which the decision to use or not use drugs is made – When the environment permits or encourages drug use, it usually conAnues – When the environment quickly and eﬀecAvely idenAﬁes any drug use and intervenes swioly with serious consequences, it usually stops – ParAcipaAon in recovery fellowships extends the beneﬁts of treatment for a lifeAme
Applying the PHP Model to Clinical PracAce • Addressing the problems of translaAng the PHP model to everyday clinical pracAce: 1) The populaAon of physicians is unique 2) Most clinical populaAons lack the leverage of PHPs 3) Most clinical sepngs lack the care management capabiliAes of the PHPs
1) PaAent PopulaAon • The New Paradigm has been successfully used in the criminal jusAce system – a populaAon enArely diﬀerent than physicians • Example of Hawaii’s Opportunity ProbaAon with Enforcement (HOPE) – populaAon of mostly poorly educated, high-‐risk oﬀenders with histories of drug use problems
HOPE ProbaAon • Uses intensive random drug tesAng for up to 6 years • Has zero tolerance for any violaAon of probaAon including drug use, missed tests, missed probaAon appointments, etc. • All violaAons lead to brief incarceraAons • Treatment is available but only required when monitoring fails – “Behavioral Triage” • 12-‐Step parAcipaAon is encouraged but not required
HOPE vs. Standard ProbaAon • Randomized control study of HOPE showed that in a one-‐year period, HOPE probaAoners were: • 55% less likely to be arrested for a new crime • 72% less likely to use drugs • 61% less likely to skip appointments with their supervisory oﬃcer • 53% less likely to have their probaAon revoked • HOPE probaAoners were sentenced to, on average, 48% fewer days of incarceraAon than the standard probaAon group
HOPE Drug Test Results • Over the course of one year: – 61% of all HOPE parAcipants never had a single posiAve drug test – 20% had only 1 posiAve – 9% had 2 posiAves – 10% had 3+ posiAves
2) Finding Leverage • Many sources of leverage can be used including conAnued physician prescribing of opioids • Enhanced acAons in treatment programs – IntervenAons with counselors, groups, all staﬀ – Loss of privileges (e.g. take-‐home privileges in opioid-‐ subsAtuAon therapy) – Increase drug tesAng frequency – Required frequent parAcipaAon in specialized group sessions
3) Lack of Care Management • Responsible clinicians can organize eﬀecAve care management: – Random drug and alcohol tesAng – Writen contracts that specify swio, certain, serious consequences for any use – AcAve parAcipaAon in the 12-‐Step fellowships – Monitor workplace and family for evidence of problems
Summary of Findings • Zero tolerance with swio, certain, and meaningful consequences for any use of alcohol and other drugs – contrary to reasonable assumpAons – leads to lower rates of substance use, higher rates of long-‐term success, and lower rates of failure • PHPs produced impressive results previously unseen across the spectrum of drug use, including individuals with opioid-‐ related SUDs • Principles of the PHP model are validated in the criminal jusAce system and are applicable to prescripAon drug abuse in clinical pracAce
The Good News • AdapAng the PHP model to clinical pracAce can be done • Leading clinicians are now invenAng future pracAces for treatment as part of care management • Care management in which treatment occurs is crucial for long-‐term success of these eﬀorts
The Botom Line • The New Paradigm for managing prescripAon drug abuse: 1) Promotes long-‐term recovery 2) Reduces dropping out of treatment, relapses to drug and alcohol use, and paAent “recycling”
www.IBHinc.org • For more informaAon on other new and important ideas to reduce illegal drug use visit the home website of the InsAtute for Behavior and Health
References • Buhl, A., Oreskovich, M. R., Meredith, C. W., Campbell, M. D., & DuPont, R. L. (2011). Prognosis for the recovery of surgeons from chemical dependency. Archives of Surgery, 146(11), 1286-‐1291. • Caulkins, J. P. & DuPont, R. L. (2010). Is 24/7 Sobriety a good goal for repeat driving under the inﬂuence (DUI) oﬀenders? [Editorial]. Addic5on, 105, 575-‐577. • DuPont, R. L. (1999). Biology and the environment: Rethinking demand reducAon. Journal of Addic5ve Diseases, 18(4), 121-‐138. • DuPont, R.L. (2009). Blueprint for las5ng recovery: Physician health programs drug test results. Unpublished manuscript. • Skipper, G. S., DuPont, R. L., Campbell, M. D., & Shea, C. L. (2012). Recovery from opioid dependence: Lessons from the treatment of opioid-‐dependent physicians. Unpublished manuscript. • DuPont, R. L., & Humphreys, K. (2011). A new paradigm for long-‐term recovery. Substance Abuse, 32(1), 1-‐6. • DuPont, R. L., McLellan, A. T., Carr, G., Gendel, M., & Skipper, G. E. (2009). How are addicted physicians treated? A naAonal survey of physician health programs. Journal of Substance Abuse Treatment, 37, 1-‐7. • DuPont R. L., McLellan A. T., White W. L., Merlo L., and Gold M. S. (2009). Sepng the standard for recovery: Physicians Health Programs evaluaAon review. Journal for Substance Abuse Treatment, 36(2), 159-‐171. • DuPont, R. L., Shea, C. L., Talpins, S. K., & Voas, R. (2010). Leveraging the criminal jusAce system to reduce alcohol-‐ and drug-‐ related crime. The Prosecutor, 44(1), 38-‐42. • DuPont, R. L., & Skipper, G. E. (2012). Six lessons from physician health programs to promote long-‐term recovery. Journal of Psychoac5ve Drugs, 44(1), 72-‐78. • Gold, M. S., & Aronson, M. (2004). Physician health and impairment. Psychiatric Annals, 34(10), 739-‐741. • Hawken, A. (2010). Behavioral Triage: A new model for idenAfying and treaAng substance-‐abusing oﬀenders. Journal of Drug Policy Analysis, 3(1), 1-‐5. • Hawken, A., & Kleiman, M. (2009, December). Managing drug involved probaAoners with swio and certain sancAons: EvaluaAng Hawaii’s HOPE. NaAonal InsAtute of JusAce, Oﬃce of JusAce Programs, U.S. Department of JusAce. Award number 2007-‐IJ-‐ CX-‐0033. • Kleiman, M. (2009). When brute force fails: How to have less crime and less punishment. Princeton, NJ: Princeton University Press. • McLellan, A. T., Skipper, G. E., Campbell, M. G. & DuPont, R. L. (2008). Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. Bri5sh Medical Journal, 337:a2038 • Merlo, L. J., & Greene, W. M. (2010). Physician views regarding substance use-‐related parAcipaAon in a state physician health program. American Journal on Addic5ons, 19, 529-‐533.
William Johnson, M.D. • Chief Medical Oﬃcer, Pikeville Medical Center, Pikeville, KY • Fellow, American College of Physicians • Member, Volunteer Teaching FaculAes, University of Kentucky and University of Louisville Medical Schools • Adjunct Clinical Professor, Internal Medicine, Kentucky College of Osteopathic Medicine
• Bipar<san Congressional Caucus was established in 2010 to seek eﬀec<ve policy solu<ons for prescrip<on drug abuse. • Opera<on UNITE’s (Unlawful Narco<cs Inves<ga<ons, Treatment, and Educa<on) goal is to rid communi<es of illegal drug use. • Healthcare costs exceed $70 billion annually for non-‐medical use of prescrip<on drugs.
Drug overdose deaths increased eighold from 1991 to 2007. According to the CDC
Drug diversion costs health insurance over $72.5 billion a year for bogus claims including opioids alone. According to the Coali<on Against Insurance Fraud
Admission for prescrip<on related opioid treatment increased from 8% in 1999 to 33% in 2009. According to reports from Substance Abuse and Mental Health Services Administra<on
• Criminal jus<ce oﬃcials conserva<vely es<mate that 70-‐80% of all criminal arrests are drug related. • Drug increased deaths due to use of addic<ve drugs exceed traﬃc fatali<es for the ﬁrst <me in 30 years. • Opioid addic<on is a chronic lifelong issue.
• The drama<c increase in physician prescribing of narco<cs for chronic pain parallels the increase of deaths from overdose of narco<cs. • This increase is adributed to: a. Manufacturing companies increase spending to market drugs such as Oxycon<n to treat chronic pain. b. Pressure on the Joint Commission to make pain assessment the ﬁfh vital sign through raising awareness to control pain. c. Educa<on of physicians that physical dependence and addic<on are not a problem to worry about when managing chronic pain (erroneously). d. Manufacturers get state medical socie<es to tell physicians that it is ok to prescribe addic<ve medicines and that pain must be controlled.
• In 2003 Eastern Kentucky was iden<ﬁed as the highest in the na<on for Oxycon<n use and 90% of people wai<ng in Florida pill mills were from Kentucky. • Kentucky alone has 82 deaths per month from prescrip<on drug overdose. • In 2010 The Na<onal Center for Health Sta<s<cs reported 38,329 drug overdose deaths in the United States. Most (22,134) involved pharmaceu<cals. Opioids accounted for 75.2%.
Eﬀec<ve Implementa<on of Interven<ons to Prevent Prescrip<on Drug Abuse
State Level: • HB1 Kentucky 2012. Kentucky HB1 passed in a special session to the General Assembly and was signed in to law by the Governor on 4/24/2012 and became eﬀec<ve 7/12/12. The bill placed restric<ons on pain management clinics, set strict new limits on prescribing controlled substances, and increased repor<ng requirements for prescrip<ons using Kentucky’s KASPER (an electronic controlled substances monitoring system).
Impacts of HB1 in the last six months (as of March 5, 2013): • Total doses of all controlled substances dropped 10.4% from the same <me period a year earlier • Hydrocodone down 11.8% • Oxycodone down 11.8% • Oxymorphone (Opana) down 45.5% • Alprazolam (Xanax) down 14.5% March 5, 2013 News Release, Kentucky Governor Steve Beshear
Pain Management Clinics in Kentucky • 2012 – 44 • March 5, 2013 – 25 • 19 closed including 11 since HB1 implementa<on • Another 4 have received cease and desist from OIG March 5, 2013 News Release, Kentucky Governor Steve Beshear
Local Level: 1. Educa<on of physicians to comply with HB 1 (KASPER CME). David Hoskins, KASPER Program Manager, Oﬃce of Inspector General presented at the October 2, 2012 monthly Medical Staﬀ mee<ng an update on the Kentucky All Schedule Prescrip<on Electronic Repor<ng (KASPER). a. The KASPER Program b. Provider shopping c. Controlled substances prescribing in Kentucky (HB1) d. Controlled substances trends in Kentucky. 2. Expand Pain Management services a. Hire an addi<onal physician provider b. Hire two addi<onal mid-‐level providers c. Build to double the oﬃce space d. Expand the hours of opera<on to 7:00am-‐7:30pm M-‐F
Local Level Con<nued: 3. Assistance of Physicians a. Provide physicians with delegates to run KASPER reports. b. Provide physicians with check lists to keep on track with the new <me requirements of HB1 that must be kept. 4. Results – Outcome a. Pain management center visits b. Pain management average monthly visits c. Narco<c Rx volumes by schedule d. Select narco<c trend e. Narco<c Rx f. Narco<c Rx reﬁlls
Problems with controlled substances Misuse Abuse Diversion
Provider shopping: Controlled substances are acquired by decep<on.
KASPER Opera<on: • KASPER tracks most schedule II-‐V substances dispensed in Kentucky (over 11 million prescrip<ons per year). • Reports are available via web typically within 15 seconds for 90% of requests. • eKASPER registra<on is mandatory for Kentucky physicians and pharmacists authorized to prescribe or dispense controlled substances to humans. • Controlled substance prescribing 2011 reports available per zip code areas.
Impact of House Bill 1 on Narco<c Rx Paderns Pain Management Center Visits 5500 5000 4500 4000 3500 3000 2500 2000 1500 1127 1110 1206 1195 900 927 914 946 1000 500 0 July Aug Sept Oct Nov Dec Jan Feb # Visits 2012 July 12 - Feb 13 Visits July 12 - Feb 13 Trend
Impact of House Bill 1 on Narco<c Rx Paderns Narcotic Rx Trend 2,600 2,400 2,200 1,991 1,955 2,000 1,842 1,755 1,800 1,657 1,600 1,490 1,436 1,496 1,400 1,184 1,192 1,200 1,048 1,066 952 961 1,000 883 852 800 600 400 200 - July Aug Sept Oct Nov Dec Jan Feb All Narcotic Rx Select Narcotic Rx All Narcotic Rx Trend Select Narcotic Rx Trend NOTE: All graphs exclude Cancer Physician data
Impact of House Bill 1 on Narco<c Rx Paderns Select Narco<c Trend 900850 800 810800 741750 695700 628650 593600 545 529550500450 407 384 382400 353 368350 323 325300 255250 July Aug Sept Oct Nov Dec Jan Feb Oxycodone/Generics Hydrocodone/Generics Oxycodone/Generic Trend Hydrocodone/Generic Trend
Impact of House Bill 1 on Narco<c Rx Paderns Narco<c Rx Volume by Schedule 50% 45% 45% 45% 43% 41% 41% 38% 38% 40% 37% 35% 38% 30% 32% 33% 30% 28% 29% 29% 25% 28% 25% 24% 24% 20% 23% 22% 21% 21% 15% 18% 10% 5% 6% 6% 7% 6% 6% 6% 6% 5% 0% July Aug Sept Oct Nov Dec Jan Feb Sched 2 (High Abuse Potential) Sched 3 (Some Abuse Potential Relative to Sched 2) Sched 4 (Low Abuse Potential Relative to Sched 3) Sched 5 (Low Abuse Potential Relative to Sched 4) Sched 2 Trend Sched 3 Trend Sched 4 Trend Sched 5 Trend
Impact of House Bill 1 on Narco<c Rx Paderns Narco<c Rx Reﬁlls 600 569 564 542550 527 501500 477450 408 385400350300 271 237 226 234250 196 204 194 185200150100 66 61 63 61 54 42 50 54 50 0 July Aug Sept Oct Nov Dec Jan Feb Sched 3 Sched 4 Sched 5 Sched 3 Trend Sched 4 Trend Sched 5 Trend