Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Tpp 4 pew bronstein_jordan


Published on

Third-Party Payer: The 411 On a Successful Rx Weaning Program - Dr. Katheryn Bronstein and Dr. Krista Jordan

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Tpp 4 pew bronstein_jordan

  1. 1. The  411  on  a  Successful  Rx  Weaning  Program   Third  Party  Payer  Track   April  23,  2014  
  2. 2. Moderator: Mark Pew, Senior Vice President PRIUM (, Duluth, GA Medical intervention on clinically complex claims Panelists: Kathryn S. Bronstein, PhD, RN, Vice President, Medical Affairs Ameritox, Inc. (, Baltimore, MD Medication monitoring solutions Krista D. Jordan, PhD, ABPP, Program Director RestoreFX (, Austin, TX Interdisciplinary functional restoration clinic
  3. 3. Kathryn S. Bronstein wishes to disclose that she is an employee of Ameritox, Inc. Krista D. Jordan has no financial relationships with proprietary entities that produce health care goods and services.
  4. 4. 1.  Describe the pharmacological and medical process of opioid discontinuation 2.  Evaluate the psychosocial issues and coping skills that impact weaning and recovery 3.  Analyze criteria of successful pain management and functional restoration programs
  5. 5. 2011 study on opioid discontinuance trends •  Almost 30,000 patients (primarily private health plans) prescribed opioids continuously for at least 90 days during a 6-month period •  Approximately 66% were still on opioids after 5 years •  Attributing factors were: •  Intermittent prior opioid exposure •  Daily opioid dose > 120mg MED •  Possible opioid misuse Source: Martin BC, et al. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med. 2011 Dec; 26(12): 1450-1457, http://
  6. 6. •  Opioid dosage > 120mg MED per day •  Acetaminophen dosage > 4000mg per day •  NSAID dosage > 3200mg per day •  Opioids used > 2 contiguous months after injury or surgery •  Muscle relaxants used > 2 contiguous months •  NSAIDs used > 6 contiguous months •  Benzodiazepines used > 4 contiguous weeks •  No exit strategy by the prescriber
  7. 7. •  Topical analgesics •  Anti-narcoleptic drugs •  Hormonal supplements •  Spinal Cord Stimulator and topical / oral analgesics •  Drug regimen that has automatic refills •  More than one prescribing physician •  No opioid treatment agreement •  No urine drug monitoring •  No liver / kidney toxicity tests where applicable •  Prescriber not utilizing the state’s PDMP
  8. 8. •  Insomnia •  Lethargy •  Atrophy •  Depression •  Sexual dysfunction •  Constipation •  Addiction PAIN   zolpidem modafinil carisoprodol duloxetine sildenafil stool softener buprenorphine Opioid All  of  this  makes  the   pain  harder  to   iden2fy  and  treat   Fentanyl?
  9. 9. Per the AMA Guides March/April 2011 Newsletter, “21 of 23 patients in the study reported a significant decrease in pain after detoxification” Iatrogenesis – “inadvertent and preventable induction of disease or complications by the medical treatment or procedures of a physician or surgeon” -- Merriam-Webster
  10. 10. Over 526,000 patients currently being treated for chronic pain Urine Drug Monitoring   35.9% prescribed drug not found or lab results warranting review   32.3% contained a drug not prescribed by the clinician   11.1% contained one or more illicit drugs   Of 105,000 samples with an illicit drug found:   78% THC   19% Cocaine   3% Heroin
  11. 11. Bohnert A, Valenstein M, Bair M, et al. JAMA 2011;305(13):1315-1321.
  12. 12. 1. Krenzischek DA et al. J Perianesth Nurs. 2008;23(Suppl 1):S28-S42. 2. Lordon SP. Curr Pain Headache Rep. 2002;6(3):202-206. 3. Townsend CO et al. J Clin Psychol. 2006;62(11):1433-1443. 4. Patel G et al. Med Clin N Am. 2007;91(1):141-167. 5. Freedman MK et al. Arch Phys Med Rehabil. 2008;89(3 suppl 1):S56-S60. 6. Stanos SP et al. Anesthesiol Clin. 2007;25(4):721-759. Pharmacotherapy1 Interventional Approaches2 Psychological Support3 Complementary and Alternative Medicine4 Physical Medicine and Rehabilitation6 Lifestyle Change5
  13. 13. Medical component of weaning 1.  Determine venue, in- or out-patient 2.  Decide if a specialist is required 3.  Assess co-morbidities and complicating factors 4.  Manage the withdrawal symptoms 5.  Define success
  14. 14. Pharmacological component of weaning 1.  Determine clinical appropriateness for each drug 2.  Separate pain management from disease management drugs 3.  Assess drug cocktail for interactions 4.  Create a taper strategy   Sequence of discontinuance, by classification   Add drugs to take away drugs? 5.  Monitor the process (UDM 101)
  15. 15. Psychological component of weaning 1.  Evaluate psychological and/or physical dependence, anxiety and/or depression, family and other interpersonal factors that may be maintaining dependency 2.  Explain risks and potential benefits of long-term use of opiates
  16. 16. Psychological component of weaning 3.  Motivate the patient to make a life change   Stages of Change Model   CBT 101 4.  Identify how patient will manage pain with less/no dosage   Recovery Lifestyle   Coping skills   Function
  17. 17. Profile of a successful functional restoration program   Is there an inter-disciplinary approach (vs. single discipline or multidisciplinary)?   Do they offer complementary treatments (e.g. yoga, Pilates)?   Do they have in-patient access for significant addiction/ health issues?   Are patients assessed and sometimes denied entry?
  18. 18. Profile of a successful functional restoration program   Are treatment plans customized per patient?   Is progress objectively measured regularly?   If inadequate progress are adjustments made?   Are patients followed for at least one year post-discharge?   Do patients have access to booster sessions? If so, are they charged for these?
  19. 19. Flor, H, Fydrich, T, Turk, DC. Efficacy of multidisciplinary pain treatment program centers: a meta-analytic review. Pain. 1992; 49:221-230. •  Shows that compared to no treatment or single-discipline treatment, functional restoration was superior in achieving return to work and healthcare utilization Turk, DC. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clinical Journal of Pain. 2002; 18;355-365. •  Shows functional restoration yields reductions in pain, increased return to work, reduced medication usage, decreased healthcare utilization, closure of disability claims
  20. 20. Woman enters program for knee pain related to OTJ injury. Physically and psychologically dependent on opiates to manage pain. Marriage is strained to the point of collapse. During the program her husband and children attend weekly family therapy group, the patient is able to discontinue narcotics. Patient returns a year later at the urging of her husband secondary to obtaining a prescription for Vicodin for a back strain. Patient and family resume family groups, patient attends additional group therapy and yoga classes, within 3 weeks is able to feel confident about managing without narcotics (and patient never did take the Vicodin prescribed). At one year follow up after this incident she is still opiate free.
  21. 21.   26 of 41 (63%) patients were on opiates at intake   7 of 41 (17%) were still taking opiates upon discharge   Decrease of 73%   100% of patients interviewed for one-year follow-up were functional and/or working   16 of 48 (33%) program completers