Rx16 tpp tues_330_1_gavin_2saddy_3gastfriend

Advances in Treating
Chronic Pain and Addiction
Presenters:
• Michael Gavin, MBA, President, PRIUM
• Jennifer Saddy, Director of Workers’ Compensation,
American Airlines
• David R. Gastfriend, MD, Scientific Advisor, Treatment
Research Institute
Third-Party Payer Track
Moderator: Michael C. Barnes, JD, Executive Director,
Center for Lawful Access and Abuse Deterrence, and
Member, Rx and Heroin Summit National Advisory Board

Disclosures
• Michael Gavin, MBA; Jennifer Saddy; and
Michael C. Barnes, JD, have disclosed no
relevant, real, or apparent personal or
professional financial relationships with
proprietary entities that produce healthcare
goods and services.
• David R. Gastfriend, MD – Future royalty:
American Society of Addiction Medicine

Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

Learning Objectives
1. Outline mental and behavioral issues and their
influence on chronic pain.
2. Identify strategies to address psychosocial pain
issues when managing chronic pain and claims
involving chronic pain.
3. Explain the basis and impacts of the new federal
requirements for state Medicaid directors to
implement the ASAM Criteria.
4. Describe a tool for implementing the new ASAM
Criteria requirement.

THIRD-PARTY PAYER TRACK: ADVANCES
IN TREATING CHRONIC PAIN AND
ADDICTION
Michael Gavin, PRIUM
5

Disclosure Statement
Michael Gavin, President of PRIUM, wishes to disclose that
PRIUM is a wholly owned subsidiary of Ameritox. Michael
will present this content in a fair and balanced manner.

Comorbid AMI, SUD, CNCP
“ 9 million persons
in the United States
report long-term
medical use of
opioids.”
- CDC MMWR 2012
Each of the individual populations drives significant healthcare costs; the intersections of the
populations represent particularly complex patients that require innovative and focused management

A. Disease impacts mental health
• 30% of those living with a non-communicable disease
report a concurrent mental disorder.1
B. Mental Health impacts physical health
• Conversely, more than two-thirds of people with a
mental disorder have been shown to have at least one
other chronic NCD. 1
C. Psychosocial and Socioeconomic status modify
both effects
• An individual of lesser social and economic status is
more likely to suffer comorbid mental illness with a
non-communicable disease or disorder. 2
1. (Druss BG, Mental disorders and medical comorbidity.)
2. (Marnett K, Epidemiology of multimorbidity and
implications for health care, research, and medical
education: a cross-sectional study.)
9
Bidirectional Association
Physical health and mental health are intrinsically linked. Psychological factors are reciprocally
interactive in the initiation and expression of the pathology of chronic disease.

• Adverse Childhood Exposures
• The most prevalent of the 7 measured exposures was
substance abuse in the household at (~26%)
• Likelihood of childhood exposure:
• 25% chance to have been exposed to 1 category
• 6% chance to have been exposed to 4 or more categories
• Likelihood of illicit drug use:
• 11% with 1 exposure
• 28% with 4 or more exposures
10
Predicting Substance Abuse
The ACE study followed Kaiser patients from 1995-97. While chronic disease and risky health behaviors
are strongly predicted by ACEs, interventions focused on children are far from implementation.

A. Duration1
• 1-year disability risk is doubled by each of:
– Receiving more than 7 day supply of opioids within the first 6 weeks post injury.
– Receipt of 2 opioid prescriptions in 6 weeks post injury.
– Receipt of >150mg MED in 6 weeks post injury.
B. Mortality2,3
• Nationally, persons with anxiety/depression have a 60% higher mortality and die an
average of 8 years earlier than persons without these illnesses.
• Anxiety/depression attribute to 88,000 deaths each year.
• Prescription painkillers killed more than 16,000 in 2013 or 44 people/day.
C. Expenditures4,5
• Employees treated for depression (most commonly occurring) incurred annual per
capita health and disability costs of $5,415.
• Compared with claims not prescribed opioids, claims prescribed SA opioids are 2.8
times more expensive and claims prescribed LA opioids are 9.3 times more expensive.
1. GM Franklin et al., “early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification
Study Cohort.” Spine 33.2 (2008)
2. Pratt, Laura A., et al., “Excess mortality due to depression and anxiety in the United States.” General Hospital Psychiatry (2015)
3. CDC. National Vital Statistics System mortality data. (2015)
4. Druss, BG et al., “Health and disability costs of depressive illness in a major US corporation.” Am. Journal of Psychiatry 157.8 (2000)
5. White, JA., et al., “Thhe effect of opioid use on workers’ compensation claim cost in the state of Michigan. “J. of Occ and Env. Med (2012)
11
Impact on Claims
Comorbid AMI and CNCP are synergistically disabling and treated as a single disease state using
opiates. Co-occurring AMI and CNCP cause greater disability than each condition taken separately.

Primary Care Problem?
Family practice and internal medicine doctors are responsible for about 28 million opioid claims vs. a
little over 3 million for pain management and interventional pain management combined.

• Stigma contributes to a host of adverse
outcomes for people with SUD:
– Poor mental and physical health.1,2
– Non-completion of treatment for SUD.3
– Delayed recovery and reintegration.4,5
• Stigma also presents a barrier to treatment:
– Causing lowered utilization,6,7
– And differential treatment.8
Influence of Stigma
1. Stigma, discrimination and the health of illicit drug users. Ahern J., Stuber J., Galea S. Article Drug Alcohol Depend, 2007
2. On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse
Link B., Struening E. L., Rahav M., Phelan J. C., Nuttbrock L. Article J Health Soc Behav, 1997
3. Perceptions of discriminatory treatment by staff as predictorsof drug treatment completion: utility of a mixed methods approach
Brener L., von Hippel W., von Hippel C., Resnick I., Treloar C. Article Drug Alcohol Rev, 2010
4. The contextual factors that foster and hinder the process of recoveryfor alcohol dependentwomen
Brewer M. K. Article J Addict Nurs, 2006
5. Nowhere to go: how stigma limits the options of female drug users after release from jail
van Olphen J., Eliason M. J., Freudenberg N., Barnes M. Article Subst Abuse Treat Prev Policy, 2009
6. Utilization of drug treatment programs by methamphetamine users: the role of social stigma
Semple S. J., Grant I., Patterson T. L. Article Am J Addict, 2005
7. Equity of access to treatment, and barriers to treatment for illicit drug use in Australia
Digiusto E., Treloar C. Article Addiction, 2007
8. Are drug treatment services only for ‘thieving junkie scumbags’? Drug users and the management of stigmatised identities
Radcliffe P., Stevens A. Article Soc Sci Med, 2008

Havassy BE, Alvidrez J, Mericle AA. Disparities in Use of Mental Health and
Substance Abuse Services by Persons with Co-occurring
Disorders.Psychiatric services (Washington, DC). 2009;60(2):217-223.
doi:10.1176/appi.ps.60.2.217.
14
Comorbid Treatment Rates
Patients with co-occurring disorders need to navigate two systems of care to obtain treatment. Those
who receive treatment in one sector may not receive adequate treatment in the other sector.

Political Hope?
“…we need a revolution in this country in
terms of mental health treatment.“
- Sen. Bernie Sanders
Democratic Presidential Debate, 1/17/16
"We have to move away from treating the
use of drugs as a crime and instead, move
it to where it belongs, as a health issue.”
- Sec. Hillary Clinton
Democratic Presidential Debate, 1/17/16
"You have the most conservative
Republican governors and the most
liberal Democratic governors agreeing"
on the urgent need to get something
done.
- Gov. Pete Shumliin, VT, NY Times, 2/22/16
“The victims of addiction deserve
treatment...“
- Gov. Chris Christie
ABC News, 1/12/16
“It’s very debilitating when you have a
loved one who’s struggling and you can’t
control it. I don’t know what it’s like to
lose a daughter. But I almost did.”
Gov. Jeb Bush
Huffington Post, 11/5/15
“This is a problem that, for me, I
understand firsthand.”
- Sen. Ted Cruz
Republican Presidential Debate, 2/6/16

• Web: www.prium.com
• Blog: www.priumevidencebased.com
• Twitter: @PRIUM1
• LinkedIn:
https://www.linkedin.com/company/prium-
medical-cost-management
16
Connect with PRIUM

THIRD-PARTY PAYER TRACK: ADVANCES
IN TREATING CHRONIC PAIN AND
ADDICTION
Jennifer Saddy, American Airlines
17

• Redesign of the American Airlines Workers’
Compensation (WC) program in 2014 after
merger with US Airways
– Redefined the roles of the WC team
– Program covers over 120,000 employees and 3 wholly
owned subsidiaries.
– At least 15 union groups.
• New program focused on 2 claim tracks:
– New workers’ compensation claims,
– And the legacy on-going existing claims.
American Airlines WC

• Early intervention of the claim process and
additional resources provided for the employee
– Provide more meaningful interaction with the injured
employees
– Employer, Adjuster and Nurse Case Manager
• Direction of care & partner with the treating
physician (to the extent that is allowable per state
law).
• Collaboration and open communication between
all parties in the claims process
New WC Claims

• Early intervention is key to meaningful impact for
the injured employee
– Need to identify early red flags such as unclear
diagnosis and increasing opioid usage
• Provide the additional resources early in the
process to ensure appropriate treatment plan
– Treating physician
– Physician to physician discussions
– Nurse Case Manager
– Utilization Review
Chronic Pain Claims

• 5,874 WC claims open December 2013 some over
20 years old
• Goal was to resolve these claims but chronic pain
and pharmacy usage was a significant challenge
• Significant pharmacy usage in claims 2+ years old
and growing pharmacy trend and ongoing
disability
• Engaged pharmacy experts and physician
resources in attempts to change trajectory of
medical care to allow more function of the
injured employee
Existing WC Claims

• 40% reduction in open Workers Compensation
claims for American Airlines since December
2013
• Reduction in pharmacy costs by 5% (even with
30% more claims with the US Airways merger)
• Reduced disability by an average of 11 days or
25%
Results

Precise Data for Imprecise Behavior:
Why National Standards
Make a Difference
David R. Gastfriend MD
Chief Architect, CONTINUUMTM – The ASAM Criteria Decision Engine
Scientific Advisor – Treatment Research Institute

Disclosure of Relevant Financial Relationships
Name Commercial
Interests
Relevant
Financial
Relationships:
What Was
Received
Relevant
Financial
Relationships:
For What Role
No Relevant
Financial
Relationships
with Any
Commercial
Interests
David Gastfriend Recovery
Search
Alkermes
Kaleo
Indivior
Royalty from
ASAM, Inc.
Stock,Consulting
Consulting
Consulting
Pres. & CEO
Former VP, Sci.
Communications
Adv. Board
Adv. Board

ACA, Parity & Health IT Acts: Huge Implications
The Affordable Care Act (2010)
• Phasing-out fee-for-service
• Penalties now charged for preventable readmissions
• By 2018, 50% of CMS funds will be paid
through alternative payment methods
• Value-based payment, Case-based rates, Pay-for-performance
• Elevates importance of SUD because tens of millions
with higher SUD prevalence become insured
• SUD gets a seat at the table
…but will it be THE HOT SEAT???

The Mental Health Parity and Addiction Equity Act (2008):
• Rules & lawsuits – slow in coming, but THEY’RE HERE
• Published medical necessity criteria, e.g., ASAM Criteria
• Equal coverage for SUD as for medical/surgical care
• No “non-quantitative treatment limits”
if not used for med/surg benefits (e.g., prior authorization)
• Kennedy Forum & TRI Online Appeals Guide
• SUD finally gets a seat at the table
www.thekennedyforum.org
www.tresearch.org

The Health InfoTech (HITECH) Act (2009): Nowhere to hide
• Incentives for EHR adoption in general healthcare
• SUD behind the curve – competitive pressures now driving
• Data integration on the way…HIPAA & 42CFR – being resolved:
• SAMHSA’s Consent to Share (C2S) web-app is coming:
Patient selects which data can be shared
between which providers & systems
• Not only data storage/retrieval,
but also clinical decision support
and quality/outcomes tracking
…for pay-for-performance

PREVALENCE OF CO-MORBIDITY
(Medicaid; Percent with Chronic Medical +/- Behavioral Disease)
29
Hypertension
Diabetes
Coronary Heart
Disease
Congestive Heart
Failure
Asthma and/or
COPD
31.4%
32.1%
26.3%
30.1%
23.8%
68.6%
67.9%
73.7%
69.9%
76.2%
No Behavioral Health Problem With 1 or More Behavioral Health Problem
29
Boyd, C., Clark, R., Leff, B., Richards, T., Weiss, C., Wolff, J. (2011, August).
Clarifying Multimorbidity for Medicaid Programs to Improve Targeting and Delivering Clinical Services. Presented to SAMHSA, Rockville, MD.

IMPACT OF CO-MORBIDITY ON PER CAPITA COSTS
(Medicaid-Only Beneficaries with Co-Occurring Disorders)
30Boyd, C., Clark, R., Leff, B., Richards, T., Weiss, C., Wolff, J. (2011, August).
Clarifying Multimorbidity for Medicaid Programs to Improve Targeting and Delivering Clinical Services. Presented to SAMHSA, Rockville, MD.
30

Addiction Assessment & Treatment Planning:
• Non-standard, “intuitive”, then “find out the rest later…”
• Managed Care wants more data: Telephone tag (90 min – 3 days)
• Most insurers’ medical necessity criteria are proprietary
• Absent precision & validity, emphasis is on cost, not quality
• 1991: ASAM Patient Placement Criteria…a teaching tool
• States create their own Criteria (CASAM, MASAM, NYSAM…)
• “ASAM” in Major US MCO: ~50% of cases were denials
• on appeal: ~50% reversed; on review ~50% reversed again!
• By 2000s, SAMHSA & CSAT called on ASAM for a standard

Modality Matching:
Many studies, e.g., Project MATCH – but few findings
(Gastfriend & McLellan, Med Clin NA, 1997)
Placement Matching:
Multiple studies; ASAM model – consistent signals
(Gastfriend, Addiction Treatment Matching, Haworth Press, 2004)
Support:
• NIDA: Validation - R01-DA08781 & K24-DA00427
• NIAAA: ASAM Software - SBIR grant R44-AA12004
• CSAT: Access to Recovery Initiative - grant 270-02-7120
• Belgian National Fund for Scientific Research
• Belgian American Educational Foundation
• Central Norway Health Trust /Rusbehandling Midt-Norge
• SAMHSA: Open Behavioral Health IT Architecture Program
Advances in Treatment Matching

ASAM Text: Hundreds of Decision Rules
To place patients in the least intensive & restrictive care
that meets the patient’s multi-dimensional needs
and affords optimal treatment outcome
www.ASAMcriteria.org
www.haworthpress.com

Screening Diagnosis Severity Readiness &
Relapse Potential
Patient Placement Criteria
DIMENSIONS
Intoxication
Withdrawal
Biomedical Emotional
Behavioral
Treatment
Acceptance/
Resistance
Relapse
Potential
Recovery
Environment
Decision Rules
LEVEL OF CARE
1. Outpatient 2. Intensive
Outpatient
3. Medically
Monitored
Intensive
Inpatient
4. Medically
Managed
Intensive
Inpatient
ASAM Patient Placement Criteria
21 3
4 5 6

ASAM PLACEMENT CRITERIA
LEVELS OF 1. OUTPT 2. INTENSIVE 3. MED 4. MED
OF CARE OUTPT MON INPT MGD INPT
CRITERIA
Intoxication/
Withdrawal
no risk minimal some risk severe risk
Medical
Complications no risk manageable
medical
monitoring
required
24-hr acute
med. care
required
Psych/Behav
Complications no risk mild severity moderate
24-hr psych.
& addiction
Tx required
Readiness
For Change cooperative
cooperative
but requires
structure
high resist.,
needs 24-hr
motivating
Relapse
Potential
maintains
abstinence
more symptoms,
needs close
monitoring
unable to
control use in
outpt care
Recovery
Environment supportive
less support,
w/ structure
can cope
danger to
recovery,
logistical
incapacity
for outpt

• DSM-5 Substance Use Disorders: Diagnoses & Criteria
• CIWA-Ar & CINA withdrawal scores (alcohol/BZs, opioids)
• Addiction Severity Index (ASI) Composite Scores
• Imminent Risk Considerations
• Access & Support Needs/Capabilities
• ASAM Level of Care recommendations
– All adult admission levels and sub-levels
– Including Withdrawal Management
– Including Biomedically Enhanced Sub-level
– Including Co-occurring Disorder Sub-levels
(Capable, Enhanced)
• Also: If actual placement disagrees with Software,
the clinician gets to justify the discrepancy: Generating needs analysis data
Clinical Decision Support Software

Under-Matching Worsens No Show to Treatment
0%
10%
20%
30%
40%
50%
60%
70%
All Patients (N=700) Cocaine (N=183) Heroin (N=279)
From Inpatient Detox to Either Residential Rehab or Day Treatment:
All patients, High Frequency Cocaine Users and Heroin Users
Mis-matched Matched
p≤.001
p≤.001
p≤.019
Under-matched
patients’
no-show rate:
~25% worse
Under-matched
patients’
no-show rate:
~100% worse
Under-matched
patients’
no-show rate:
~300% worse
PercentNo-ShowstoNextTreatment

3-mo Drop-Out, Improvement & Stepdown Need
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Under- Matched Over-
0
1
2
3
4
5
6
7
% of Patients Ready for
Stepdown at F/U (vs. BL)
# ASI Subscales
Improved at F/U% Drop Out at 3-Mo F/U
0%
10%
20%
30%
40%
50%
60%
70%
Stepdown
Same LOC
Higher LOC
Naturalistic Match Status – According to ASAM Software

0
5
10
15
20
25
30
35
Adequate (II) Matched (III) Lesser LOC (IV)
~24-mos Before
~13 mos After
Bed-day Use Pre- vs. Post-Naturalistic L-III Placements
AnnualizedBed-Days
*


Bed-Day Utilization over 1-Yr in the VA
Bedford MA VA, N = 97

Conclusions
• ASAM Criteria: Parity-ready, published, medical necessity criteria
• The decision rules show face validity
• CONTINUUM™ technology provides good reliability & feasibility
• Good concurrent validity vs. other instruments
• Good Predictive validity overall, w/heroin, cocaine & comorbidity
• Studies show validity for undermatching, AND for overmatching
• Predictive validity found:
– across cultures/systems: public/VA; MA/NYC; Belgium/Norway
– at multiple time-frames: immediate, 30-d, 90-d & 1-year
– with multiple outcomes: no-show, global improvement,
substance use, step-down readiness, rehospitalization

Stakeholders in the Health IT Revolution
Client
Counselor
Supervisor
SystemManaged
Care
Employer/
Payer
Researcher
Accreditation Body,
Government
Society

• Operates 145 sites treating 30,000 people
• Largest behavioral health provider in U.S.
• Devotes significant resources to payer approval
• Each center has 3-5 FTEs dedicated to UR
• ~20% of cases are contested by payers
• ~30% of MD time is lost interacting w/payers
• If this administrative time is reduced only slightly,
the ASAM Software could yield substantial savings.
Case Study: CRC Health (now Acadia)
HARVARD | BUSINESS | SCHOOL

ASAM’s CONTINUUM™:
(compared to usual assessment/placement)
• 25% - 300% reductions in no shows to next stage of treatment
• 30% reduction in dropout from treatment
• 3X improvement in addiction severity outcomes at 3 months
• 25% increase in numbers of patients ready for stepdown
Leading to…
• Increased patient flow & revenues
• Staffing efficiencies (fewer incomplete intakes & UR delays)
• Improved morale & bottom line
Addiction assessment:
A new, state-of-the-art standard

Survey of Addiction Providers with an EHR
83%
14%
3%
Have you asked your EHR technology vendor(s)
if they can provide CONTINUUM™ to you?
No, but I would like them
to have this capability
Yes
No, I am not interested

OPTIONS for States/Counties implementing the 1115 Waiver:
1. Managed care organization vendor contract – at a cost of millions
2. OR, ASAM’s CONTINUUM™ - at a fraction of the cost
July 27, 2015 SMD # 15-003
Re: New Service Delivery Opportunities
for Individuals with a Substance Use Disorder
Dear State Medicaid Director:
…States should use the ASAM Criteria as they develop a residential or inpatient SUD
service continuum…
In order to receive approval…the assessment for all SUD services, level of care
and length of stay recommendations must be performed by an independent third party
that has the necessary competencies to use ASAM Patient Placement Criteria.
Specifically, an entity other than the rendering provider will use the ASAM Criteria...
DEPARTMENT OF HEALTH & HUMAN
SERVICES Centers for Medicare & Medicaid
Services 7500 Security Boulevard, Mail Stop S2-
26-12 Baltimore, Maryland 21244-1850

A National Addictions Patient Registry
Client
Counselor
Supervisor
SystemManaged
Care
Employer/
Payer
Researcher
Accreditation Body,
Government
ASAM’s
National
Coalition
Treatment
Program
Protected
Raw Data
(Identifiers +
Health Info)
Copied Data
(Stripped of Identifiers
but with
Unique Case #)
EHR

Addiction assessment:
A new, state-of-the-art standard
THE PAST…
• Non-standard, intuitive
• Telephone tag
• Proprietary criteria
• Emphasis: cost, not quality
• 1991: ASAM…teaching tool
• State-by-state Criteria
• Managed Care Study:
~50% of denials reversed
• By 2000s, SAMHSA wants
a standard
NOW…
• Standardized, quantitative
• Rapid Prior Authorization
• Published criteria
• Emphasis on cost AND quality
• 2015: ASAM…a decision tool
• A national standard for Criteria
• Managed care: Willing to pilot
AUTOMATIC prior authorization
• 2015, SAMHSA
has a standard

Addiction assessment: A Sea Change
• Enough legislation already: Begin the quality change process!
• Consumers/Providers: Push for parity in managed care UR
e.g., via the Kennedy Forum/TRI Online Appeals Guide
• Payers/States/Accreditors: Measure program services,
e.g., TRI’s ASAM Level of Care Certification Program
• Payers/MCOs: Standardize medical necessity criteria/reform UR
– drop phone prior authorization
– manage by data: via ASAM’s CONTINUUM™ data registry

For more information:
gastfriend@gmail.com
www.ASAMcontinuum.org

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