Clinical Track National Rx Drug Abuse Summit Dr. Robert DuPont and Dr. William Johnson

1. 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

2. 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.

3. 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.

4. 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

5. 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

6. PrescripAon
Drug
Abuse
–
Opioids
• Opioids
dominate
the
prescripAon
drug
abuse
problem
• Virtually
all
opioid
use
among
PHP
parAcipants
is
from
prescripAon
opioids

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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)

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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”

25. 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

26. Thank
you!

27. 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.

28. 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

29. • 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.

30. Drug
overdose
deaths
increased
eighold
from
1991
to
2007.
According
to
the
CDC

31. 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

32. 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

33. • 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.

34. • 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.

35. • 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%.

36. Effec<ve
Implementa<on
of
Interven<ons
to
Prevent
Prescrip<on
Drug
Abuse

37. 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).

38. 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

39. 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

40. 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

41. 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

42. Problems
with
controlled
substances
Misuse
Abuse
Diversion

43. Provider
shopping:
Controlled
substances
are
acquired
by
decep<on.

44. 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.

45. 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

46. 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

47. Impact
of
House
Bill
1
on
Narco<c
Rx
Paderns
Select
Narco<c
Trend
900
850 800 810
800
741
750 695
700
628
650
593
600 545
529
550
500
450 407
384 382
400 353 368
350 323 325
300 255
250
July Aug Sept Oct Nov Dec Jan Feb
Oxycodone/Generics Hydrocodone/Generics Oxycodone/Generic Trend Hydrocodone/Generic Trend

48. 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

49. Impact
of
House
Bill
1
on
Narco<c
Rx
Paderns
Narco<c
Rx
Refills
600 569 564
542
550 527
501
500 477
450 408
385
400
350
300 271
237 226 234
250
196 204 194
185
200
150
100 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

50. THANK
YOU!
Ques<ons?