Transcript in an Era of `Opioid Epidemic`

Opioid Prescribing
in an Era of ‘Opioid Epidemic’
and Regulatory Changes
Opiod Prescribing Under Fire
• Paul E. Tatum, III, MD MSPH CMD AGSF FAAHPM — University of Missouri
HMDAC and Past-Chair, AAHPM State Health Policy Issues Working Group
• Content from AAHPM coordinated by Jackie Kocinsky and Jordan
Endecott, JD, and developed in addition to Tatum by:
– Bob Twillman, PhD FAPM,
American Academy of Pain Management/State Pain Policy Advocacy Network
– John Gould, III, DO RPH HMDC FACP — Lutheran Hospice — Columbia , SC
Member, AAHPM Public Policy Committee
– Gregg K. VandeKieft, MD MA FAAHPM — Providence Health and Services — WA
Co-Chair, AAHPM Public Policy Committee
“Diversion of prescription pills
to the street market promotes
the addiction to painkillers
that leads to overdose
deaths. We are focusing on
charging doctors, pharmacists
and the networks that are
putting this poison on the
streets.”
- U.S. Attorney Barbara McQuade
New fix for opioid epidemic
takes aim at doctors' Rx pads
Why are we talking about this today?
• Statistics show prescription opioid-related overdose deaths
are increasing
• Drug overdose is now the leading cause of injury death in U.S.
• Headline-grabbing stories have captured policymakers’
attention and spurred efforts to reduce abuse, misuse and
diversion at the state and federal levels
• Some legislative and regulatory proposals pose serious risks
to patients with legitimate need or allow for intrusion into
medical practice
Goals for this session
• Understand the public health imperative to address
prescription drug abuse and opioid-related death
• Identify legislative and regulatory efforts to restrict opioid
prescribing at the state and federal levels
• Learn strategies for effective advocacy aimed at balanced
prescribing policy
As health care providers,
we cannot ignore the numbers…
Growth in opiod use: 1993 – 2013
This means AAHPM & HPNA
are doing a good job, right?
The problem is there has not
been an overall change in
the amount of pain that
Americans report.
Source: Centers for Disease Control and Prevention
Prescription painkiller sales and deaths
Prescriptions per person by state
However…
variation in
painkiller
prescribing
between states
cannot be
explained by state
differences in
health issues that
cause people pain.
Drug overdose deaths by state, US 2014
Number and age-adjusted rates
Statistics demonstrating abuse and misuse
Just as sobering:
In 2008, there were
14,800 prescription
painkiller deaths.
JAMA, March 2014:
CDC researchers reported that
those at highest risk of
overdose are likely to get the
drugs from a physician.
Overdose by risk group
Where would you like to
see policymakers focus
when they restrict
prescribing?
What’s Going On?
Pain Management Policy Responses
Opiod Abuse and Chronic Pain: Not a Zero-Sum Game
• Often, it feels like any attempt to prevent prescription opioid
abuse must be accomplished by reining in prescribing,
potentially increasing pain and decreasing function
• Similarly, it often seems as though any effort to improve pain
management must involve increased prescribing, which could,
in turn, lead to more adverse outcomes
• It is possible to address both problems without adversely
affecting either—by providing balanced pain management
A Thought
“For every complex problem, there is a solution
that is neat, simple, and wrong”
—H.L. Mencken
Two simplistic assumptions create a zero-sum policy game:
• Opioids are the only available treatment for pain
• Controlling opioid supplies is the only way to address
prescription opioid abuse
Federal and state pain management policy issues
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Prescribing Guidelines
Abuse-Deterrent Opioids
Prescription Monitoring Programs
Prior Authorization/Step Therapy/Specialty Tier
Pain Clinic Regulation
Mandatory CME/CE
Availability of substance abuse treatment
Good Samaritan/Naloxone Distribution and Administration
Reimbursement for services other than
prescribing and procedures
Current status of guideline policy
• Review finds 68 existing laws, regulations, and guidelines
specifically directing physicians’ pain management efforts
bit.ly/1QsG8iY
• Legislation tracker for AAPManagement’s State Pain Policy
Advocacy Network (SPPAN) project 2016: 69 current bills in 23
states and the federal government
sppan.aapainmanage.org
Current status of guideline policy
• National Governors Association is drafting a guideline to
foster greater interstate consistency
• CDC released an opioid prescribing guideline for PCPs treating
chronic pain
• Heavily criticized for process
• Anticipated that this will be adopted as
law/regulation/guideline by many states
Prescribing guidelines and rules: common elements
• Can be developed through:
– Legislation directing licensing boards (IN) or health departments (TN)
– Task forces reporting to legislature and/or regulators (PA)
– Existing authority of health departments or licensing boards
• Common themes for existing rules/guidelines:
– Patients must be seen at designated intervals
– Nature of exam and documentation is specified
– Informed consent, screening for substance abuse, urine drug testing,
PMP checks, treatment agreements all mandated
Prescribing guidelines and rules: common elements
• Threshold doses set, beyond which certain things must be done
– Re-evaluation of patient and treatment plan
– Consideration of, or mandate for, referral to pain specialist
• Use of threshold doses is problematic
– Doses are expressed in “morphine equivalents”
– Equianalgesic conversion tables vary greatly in recommended conversion
factors
– Individuals vary in pharmacodynamic responses to given doses
– Co-morbidities and drug-drug interactions can produce varied effects across
individuals at a given dose
– Some prescribers treat these as limits, not thresholds
Prescribing guidelines and rules: policy needs
• Prefer guidelines vs. rules
– Less restrictive
– Appears to work (Washington experience)
• Prefer task force (Model: 2014 PA HR 659) vs. licensing board
• Prefer that thresholds be based on duration of treatment
• Prefer that post-threshold requirements not include mandatory
consultations
• Prefer that prescriber discretion be maximized and that necessary
resources be provided
• Should cancer survivors, palliative care, and
hospice patients be carved out?
CDC Guideline: Why does it matter?
• Because a guideline issued by CDC will carry considerably more
weight, and will be considered as more valid, because it comes from
CDC
• State health departments and licensing boards will move quickly to
adopt this as official policy
• This guideline will find its way into court and will be seen as reflecting
standard of practice
• Inflexible recommendations can tie our hands
• How would such a policy effectively be limited to PCPs?
What can we do about guidelines?
• Be vigilant for efforts in your states to develop new guidelines, rules
and regulations, and/or laws governing pain management practice
• If those efforts appear, be active in helping to shape them
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Volunteer to sit on task forces or committees
Comment on draft versions
Contact your allies in your state—medical societies, in particular
Work with groups like SPPAN to coalesce around a response
• And always remember: If you’re not at the table, you’re on the menu
Medical Boards get in on the action
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AAPHM assisted the Carolinas Center in distributing a survey to all Academy
members in SC: collected information on prescribing habits by hospice physicians in
the state, with data provided to the Board.
With testimony of providers and the practice data, Board issued a revised advisory
opinion on February 1, 2016.
– A hospice physician can now prescribe up to a 14-day supply of medications prior to
conducting a physical examination to establish a traditional patient-physician relationship.
– The opinion also does not address the role of nurse practitioners, which means state statute
still governs. Statute states that a nurse practitioner who is supervised by the prescribing
physician can conduct the examination to establish a relationship.
• However, the Board still has serious concerns about this practice, and expects
physicians to see patients if they are going to continue prescribing medications on an
ongoing basis.
Providers Taking the Lead
Compassus Medical Director’s role
• Need to follow the law and rules and regulations
• Need to flood the medical journals and the press with articles and opeds
– Explain that the patient-physician relationship is established in concert with the IDT
– Members of the IDT are seeing patients face to face multiple times a week and all
of that information is being shared with the medical director
• Need to continue to be responsible hospice medical directors… this
means keep practicing as-is in most cases
AMA Task Force to Reduce Opiod Abuse
• >25 State, specialty and other health care associations
• “Re-medicalize” the issues surrounding the epidemic of
prescription drug misuse, overdose and death
• The conversation focused on prescribers of controlled
substances accepting ownership of the issue and providing
leadership in promoting solutions
• Attendees worked to identify actions the societies could work
together to promote
Are we asking the right questions?
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Do PDMPs reduce opioid-related mortality?
Does CME have a direct effect on opioid prescribing?
Is every state experiencing a state-wide opioid epidemic?
Has the national focus on opioids improved access to patients’
pain and substance use disorder needs?
• Are state laws to increase access to naloxone working?
AMA Task Force Goals
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Increase registration and use of PDMPs
Ensure safe, evidence-based prescribing
Support comprehensive pain care; reduce the stigma of pain
Reduce the stigma of substance use disorder; increase access
to treatment
• Increase access to naloxone to save lives from overdose;
support broad Good Samaritan protections
Be an Effective Advocate
Why do policymakers need to hear from us?
• Policymakers rarely are experts in any of the topics we deal
with…we’re the specialists – position yourself as their “resident
expert” on the issue
• We can tell the stories about what happens when policy is good
or bad
• We have the ability to project forward to anticipate the impact
of policies, so we can help prevent negative unintended
consequences and offer suggestions for better policy
• Who else will speak for patients? Many
are too ill to speak for themselves.
How can you get involved?
• Read about policy issues, track legislation, & respond to
comment opportunities (see AAHPM Health Policy & Advocacy
Update, SPPAN website/blog)
• Respond to your professional organization's calls to action
• Partner with Craig Jeffries, Compassus Policy expert
• Let AAHPM know if issues arise in your state
Phil Peterson!!!!
How can you get involved?
• Connect with the government affairs folks at your health
system/hospital and say you want to be involved with them
and policymakers on these issues.
• Contact the state medical society in your state, your
professional society, and your state hospice and palliative care
association and say you want to be active in advocacy.
• Use traditional media and social media to advocate for your
position; write op-eds, letters to the editor, blogs posts
How can you get involved?
• Know who the members of the medical board are – in advance
of having an issue
• Monitor agendas for upcoming board meetings and attend
when hospice and palliative care issues, or other issues that
may have an impact, are on the agenda
Making the case for balanced policy
• “The plural of anecdote is policy.” Having data is important, but it is
much more effective if you can pair the data with stories that
illustrate the nature of the problem.
• Some policymakers respond to cognitive arguments, while others
respond to emotional appeals. Use both in the same presentation, if
at all possible.
• Practice your remarks so you can convey your message smoothly in
less than 2-3 minutes.
• Never invite a question to which you don’t have an answer.
• Be specific in what you ask for.
Partnering in efforts to achieve balanced policy
• Be familiar with statutes in your state. Follow them and be prepared
to advocate for changes when necessary.
• Be familiar with statutes — and any exceptions for hospice/palliative
care — in other states.
• Don’t argue that HPM providers and patients should be exempt from
all prescribing restrictions.
• Be willing to acknowledge that hospice and palliative care patients
and families do misuse opioids and be prepared to explain what
steps are taken to try to reduce risks.
• Register for and use the prescription monitoring
database programs!
Resources
AAHPM
• Guidelines for Effective PDMPs
http://aahpm.org/uploads/advocacy/AAHPM_Guidelines_PDMPs.pdf
• Legislative Action Center http://cqrcengage.com/aahpm/
• State Health Policy Discussion Group on AAHPM Connect
State Pain Policy Advocacy Network http://sppan.aapainmanage.org/
• Policy news
• Legislation & regulations by state
American Medical Association
• www.ama-assn.org/go/endopioidabuse
• Educational resources by state
• Links to each state PDMP for registration
• State naloxone and Good Samaritan laws