Transcript II. State Approaches to Improving Opioid

State Approaches to Improving
Opioid Prescribing
Dr. Grant Baldwin, CDC
Dr. Charissa Fotinos, Washington Medicaid Program
Dr. Christopher Pezzullo, MaineCare
Dr. Vaughn Frigon, Bureau of TennCare, Tennessee
Health Care Finance and Administration
Medicaid National Meeting on Prescription Drug Abuse and Overdose
February 1, 2016
State Approaches to Improving
Opioid Prescribing
Medicaid National Meeting
CDC PERSPECTIVE
Grant Baldwin, PhD, MPH
February 1, 2016
National Center for Injury Prevention and Control
Division of Unintentional Injury Prevention
145,000
Rx opioid deaths in 10 years.
4x as many deaths
In 2013 as 1999.
2002
Rapid Increase in Drug Overdose Death
Rates by County
SOURCE: NCHS Data Visualization Gallery
2007
Rapid Increase in Drug Overdose Death
Rates by County
SOURCE: NCHS Data Visualization Gallery
2014
Rapid Increase in Drug Overdose Death
Rates by County
SOURCE: NCHS Data Visualization Gallery
Rise in Rx overdose deaths since 2000 and recent
increase in heroin & fentanyl deaths
Deaths per 100,000 population
5
Commonly Prescribed Opioids
like oxycodone or hydrocodone
4
Heroin
3
Methadone
2
1
Synthetic opioids
like fentanyl
0
2000
2002
2004
SOURCE: National Vital Statistics System Mortality File.
2006
2008
2010
2012
2014
For every
Rx opioid overdose death in 2011,
there were...
12 treatment admissions for opioids
25 emergency department visits for opioids
105 people who abused or were dependent on opioids
659 nonmedical opioid users
0
100
SAMHSA NSDUH, DAWN, TEDS data sets.
200
300
400
500
600
700
Quarter billion
opioid prescriptions in 2012
Sharp increases in opioid prescribing coincides with
sharp increases in Rx opioid deaths
8
7
6
Opioid Sales (kg per 10k)
Rx Opioid Deaths (per 100k)
5
4
3
2
1
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System.
States with more opioid pain reliever sales tend to have more
drug overdose deaths
Death rate, 2013, National Vital Statistics System. Opioid pain reliever sales rate, 2013, DEA’s Automation of Reports and Consolidated Orders
System
RX Opioids
As Dose Goes Up
Risk Goes Up
Source: Bohnert, Amy SB, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. Jama 305.13 (2011): 1315-1321.
Longer durations and higher doses of opioid treatment are
associated with opioid use disorder
140
adjusted OR for opioid use disorder (abuse or dependence) compared with no opioid use
122
120
adusted OR
100
90 or fewer days
more than 90 days
80
60
40
29
15
20
3
3
3
0
Low (36 mg or less)
Medium (36 to 120 MME)
High (120 MME or more)
opioid dose
Edlund, MJ et al.The role of opioid prescription in incident opioid abuse & dependence among individuals with chronic noncancer pain. Clin J Pain 2014; 30: 557-564.
Who is at risk for an overdose?
Risk Factors
 Patients receiving opioids
from multiple prescribers
and/or pharmacies
 Patients taking high daily
doses of opioids
Demographics
 Men
 35-54 year olds
 Whites
 American Indians/Alaska
Natives
Socioeconomics & geography
 Medicaid
 Rural
Trends in Heroin Use &
Health Outcomes
500% Increase in 2014
Fentanyl-Related Deaths in Ohio
225% Percent
Increase in Neonatal Abstinence Syndrome
live births from 2000 to 2009
Schumacher and Benneyworth, 2012
HHS Secretary’s Opioid Initiative
Focus on three priority areas that tackle the opioid crisis and significantly impact
those struggling with substance use disorders to help save lives
1
Providing training and educational resources to
assist health professionals in making informed
prescribing decisions
2
Increasing use of Naloxone
3
Expanding the use of Medication-Assisted Treatment
Three Pillars of CDC’s Work

Improve data quality and track trends

Strengthen state efforts by scaling up effective public
health interventions

Supply healthcare providers with resources to
improve patient safety
Prevention for States (PfS)

Provides states guidance and resources to
prevent prescription drug overdoses by
addressing problematic opioid prescribing

Builds on the success of the Prevention
Boost – Funding Opportunity

16 states funded with average award
ranging from $750K to $1M

Funding to states with high burden and
readiness to act

Focus on high impact, data driven activities
and give states flexibility to tailor their work

Move toward universal PDMP
registration and use

Make PDMPs easier to use and
access

Move toward a real-time PDMP

Expand and improve proactive
reporting

Conduct public health surveillance
with PDMP

Implement or improve opioid prescribing
interventions for insurers, health systems, or
pharmacy benefit managers. This includes:

1
2
Enhance and
Maximize PDMPs
Community or
Health System
Interventions
Prior authorization, prescribing
rules, academic detailing, CCPs,
PRRs,

Enhance adoption of
opioid prescribing
guidelines
Prevention for States Program
COMPONENTS
Rapid Response
Projects

Allow states to move on quick,
flexible projects to respond to
changing circumstances on the
ground and move fast to capitalize
on new prevention opportunities.
4
State Policy
Evaluation
3

Build evidence base for
policy prevention
strategies that work
like pain clinic laws and
regulations, or
naloxone access laws
State-based interventions are
improving outcomes
Opioid Prescribing
Guidelines for Chronic Pain
Outside of Active Cancer, Palliative, & Endof-life Care
PRIMARY CARE
Conclusions

BURDEN: Overdose deaths from prescription
drugs & heroin are at epidemic levels in the U.S.

KEY DRIVERS: Understanding the epidemic
drivers is critical for effective action. Address
prescribing.

SCOPE OF SOLUTION: Multifaceted and multisector approach is needed.

KNOWN EFFECTIVENSS: Interventions must be
evaluated to determine effectiveness and need
for state-specific adaptation.
For more information please contact Centers for
Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-2326348
E-mail: [email protected] Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not
necessarily represent the official position of the Centers for Disease Control
and Prevention.
Special thanks to Noah Aleshire for his assistance preparing this presentation
Strategies to Improve Opioid
Prescribing
Charissa Fotinos
Deputy Chief Medical Officer, Washington Medicaid
Program
Opioid Related Death in Washington
Unintentional Prescription Opioid Overdose Deaths
Washington 1995-2014
Unintentional Opioid Overdose Deaths
Washington 1995-2014
Source: Washington State Department of Health, Death Certificates
Cross Agency Collaboration
Collaborative Efforts
AMDG Guidelines
Division of
Behavioral Health &
Recovery
Health Care
Authority
Cross-Agency
Collaboration
Projects
Department of
Corrections
Chronic Pain Rules
Prescription Monitoring
Program
Policy
Statewide Plan
Medication Assisted
Treatment
Department
of Health
Labor &
Industry
Framework for Washington Statewide
Plan
Priority Goals
GOAL 1:
GOAL 2:
GOAL 3:
Prevent opioid misuse and abuse.
Treat opioid dependence.
Prevent deaths from overdose.
Improve prescribing practices.
Expand access to treatment.
Distribute naloxone to people
who use heroin.
Priority Actions
GOAL 4:
Use data to monitor and
evaluate.
Optimize and expand data
sources.
Provider Education: Pain Management
• Older policy:2007
– Required state
medical, nursing,
dental, osteopathic,
podiatric
boards/commissions
to develop rules
around management
of chronic, non-cancer
pain
• Repealed permissive
pain rules & mandated
new rules addressing:
2010
– Opioid dosing criteria
– Guidance on when to see
pain specialty
consultation
– Guidance on tracking
clinical progress via
assessment tools
– Guidance on tracking
adherent use of opioids
Updating Medical Director Guidelines
Primary Focus
2010 Guidelines
2015 Guidelines
Mostly on chronic, non-cancer
pain
Expands focus to include opioid use in
acute, subacute & perioperative pain
phases & in special populations
• Recommendations for all pain
phases: clinically meaningful
improvement in function; dosing
threshold; non-opioid options
• New section on reducing or
discontinuing COAT
• New section on recognition &
treatment of opioid use disorder
• New section on opioid use disorder
in special populations: pregnancy,
NAS, children, adolescents, older
adults, cancer survivors
• Expanded sections on tapering &
opioid use disorder
http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf
Main Sections
• Initiating, transitioning &
maintaining patients on
chronic opioid analgesic
therapy (COAT) w/
principles on safe
prescribing
• Optimizing treatment for
patients on > 120mg/day
MED
• Brief sections on getting
consultations, aberrant
behaviors, tapering,
discontinuing COAT
Prescription Drug Monitoring Program
• Data Sharing with Medicaid
– WA State Department of Health is authorized under RCW
70.225 to provide prescription data from PDMP to the
Health Care Authority (HCA) for Medicaid recipients
– Monthly updates based on matching records to a recipient
file that HCA provides
• Feeds into Emergency Department Information
System
• Linkages between EPIC and PMP vendor have
been developed
Prescription Drug Monitoring Program:
What did we look at?
•
•
•
•
•
High (120mg+) MED dose
Opiates combined with benzodiazepine &/or muscle relaxants
Previous opioid serious sequella event with current prescription
Pill volume for chronic, non-cancer pain
Clients paying cash
– Clients cross reference
– ID pharmacies
• Results
– 1783 cash pay incidents identified
– Top 13 pharmacies notified
– 88 prescribers received letters of concer
– MCOs notified of patients PMP info to assess for PRC
Prescription Drug Monitoring Program:
Patient Review & Coordination Program
Aimed at over-utilizing clients
Client & provider education, coordination of care
Minimize medically unnecessary services & drug misuse
Assist providers in managing PRC clients by providing resource
information
Targets clients on highest MED and applies authorization as
indicated
Additional Efforts
• Changes to Methadone Access
– Has been on the Medicaid Preferred Drug List & did not
require prior authorization
– As of October 2015, methadone requires prior
authorization approved by WA State Pharmacy &
Therapeutics Committee
• Must have tried and failed 2 other long-acting opioids
• Maximum starting dose restrictions
– Future removal from Medicaid Preferred Drug List is likely
• Emergency Department 7 Best Practices
– Feedback reports to ED physicians about initiating opioids
• Have seen a decrease
Increasing Access to
MAT: Changes to Medicaid Guidelines
Buprenorphine
monotherapy
• Covered only for pregnant women who meet DSM-IV
criteria for opioid dependence or DSM-V criteria for
moderate/severe opioid use disorder
Buprenorphine/
Naloxone
• Covered for all non-pregnant individuals age 16 or older
who meet DSM-IV criteria for opioid dependence or DSMV criteria for moderate/severe opioid use disorder
Treatment
Facilities
• Treatment in a DSHS approved facility is encouraged, but
not required for initiating MAT with buprenorphine
Overdose Prevention
• May 2015, ESHB 1671 Passed
– Allows health care practitioners to prescribe, administer,
distribute opioid OD reversal medication directly or via a
collaborative drug agreement or standing order to anyone who
might witness an overdose. Adds to prior legislation.
– Liability Protection
• Persons possessing & administering these drugs are protected if acting
in good faith & with reasonable care
• Prescribers protected if issued as part of legitimate medical purpose &
as part of usual professional practice
– Increasing Access to Help
• Persons administering drug must encourage person with OD to seek
care
• Persons seeking care for someone with OD, person experiencing OD
are protected from possession charges
Next Steps








Regular monitoring of prescribing patterns/overdose events for
Medicaid population
Regular monitoring of MCO management of patients identified for
the Patient Review and Coordination program
Establish metrics for tracking progress; deaths, overdose ED visits
and hospitalizations
Improve use of PMP
Improve uptake of the Agency Medical Director Guidelines
Incent/develop payment strategies for non-pharmacologic
treatments for chronic pain
Implement State wide Opioid Response Plan
Continue efforts to expand MAT and access to naloxone
Slide 40
An Approach to Pain Management
A New Utilization Pattern for Opioid
Prescribing
2011-2015
Christopher Pezzullo, DO
Chief Health Officer, Maine DHHS
Agenda
• State Overview
• MaineCare Pain Management Policy
• What’s on the Horizon?
Number of drug deaths involving specific
drug types*: 2014**
70
More than one in three
overdose deaths involved
benzodiazepines.
57
43
42
30
24
More than one in four
overdose deaths involved
heroin/morphine.
*Some deaths may be caused by more
than one key drug.
**2014 results are preliminary
***Deaths caused by known
pharmaceutical morphine removed
from total.
Source: Marci Sorg, Margaret Chase Smith Policy Center at University of Maine,
Office of the Chief Medical Examiner
Unintentional Injury Deaths in Maine, by
type: 2009-2014
250
208
200
In 2014, there were
208 drug related
overdose deaths
compared to 131
motor vehicle
150
131
100
50
related deaths.
0
2009
2010
2011
2012
2013
2014
Motor vehicle-related injury
deaths
159
161
136
164
145
131
Drug-related overdose deaths
179
167
155
163
176
208
Source: Office of the Chief Medical Examiner, Maine Bureau of Highway Safety/Maine Department of Transportation
Number of deaths* caused by
pharmaceuticals and/or illicit drugs:
2010–2014
From 2011 to 2014, Maine
observed a 34% increase in
the number of all drug
related overdose deaths.
250
200
150
In 2014, most (89%) drug
overdose deaths involved
pharmaceutical drugs.
100
There was a 340% increase
50
in the number of illicit
drug-related overdose
0
deaths was observed from
Pharmaceutical
2011 to 2014.
*Deaths involving pharmaceuticals
and illicit drugs are not mutually
exclusive.
2010
2011
2012
2013
2014
160
140
140
105
186
Illicit
17
17
39
47
75
All
167
155
163
176
208
Source: Marci Sorg, Margaret Chase Smith Policy Center at University of Maine,
Office of the Chief Medical Examiner
Number of overdose EMS responses
related to drugs/medications*: 2011–2014
From 2011- 2014, Maine EMS
reported a 35% increase in
overdoses from
drugs/medications.
3,465
3,217
2,947
2,189
*Drugs/medication include illicit drugs and
prescription drugs. Data are not broken
down further than this category.
2011
2012
2013
Source: Maine Emergency Medical Services
2014
Heroin related death overdoses, Maine
vs. Nation: 2002-2013
5.0
Rates/100,000
4.3
Maine
4.0
3.3
Nation
2.7
2.8
3.0
2.4
2.2
2.0
2.1
1.9
1.8
1.5
1.4
1.1
1.0
0.7
0.7
0.6
0.7
0.7
0.8
1.0
1.9
1.0
1.0
0.5
0.7
0.0
Source, National Data: USCDC; Multiple Cause of Death Files from the Source, Maine Data: Maine Department of Health and Human
National Vital Statistics System, 2002-2013.
Services, Office od Research, Data and Vital Statistics
Number of drug deaths* involving
specific drug types**: 2010–2014
In 2014, there were 57
deaths involving
heroin/morphine; a 530%
increase since 2011.
80
60
40
Fentanyl related deaths
increased by 377% from
2013 (9) to 2014 (43)
*Deaths caused by known
pharmaceutical morphine
removed from total.
**Some deaths may be
caused by more than one
key drug.
20
0
Methadone
Oxycodone
Benzodiazepines
Heroin/morphine**
Cocaine
Fentanyl
2010
50
48
57
7
10
10
2011
42
36
41
9
13
14
2012
32
45
33
28
13
10
2013
37
32
63
34
10
9
Source: Marci Sorg, Margaret Chase Smith Policy Center at University of Maine,
Office of the Chief Medical Examiner
2014
30
42
70
57
24
43
Number of drug affected baby
notifications*: 2005-2014
In 2014, there were a total of 976
reports of drug affected babies
and 995 in 2015.
1000
927
779
800
667
From 2005 to 2014, the
number of drug affected baby
notifications increased by
480%.
*This measure reflects the number of infants
born in Maine where a healthcare provider
reported to OCFS that there was reasonable
cause to suspect the baby may be affected
by illegal substance abuse or demonstrating
withdrawal symptoms resulting from
prenatal drug exposure (illicit or prescribed
appropriately under a physician’s care for
the mother’s substance abuse treatment) or
who have fetal alcohol spectrum disorders.
572
600
451
343
400
274
200
165
201
0
Source: Office of Child and Family Services (OCFS),
Maine Automated Child Welfare Information System (MACWIS).
976
PMP
•
•
•
•
Updated every 24 hours
Enrollment mandatory
MME threshold letters
Optional utilization
Paulozzi Reports PMP
• 885 Opioid Rx per 1000 people in Maine
• 21.8 Long acting opioid Rx per 100 people in
2012 (#1 in the nation)
Additional Maine facts…
• Maine #1 state per capita long acting extended
release opioids (USCDC 2102)
• 80 million discrete opioid pills rx’d per year
Background
• In 2011, the Maine State Legislature passed legislation
limiting MaineCare coverage of opioid medications to 45
days.
• At that time, the Department determined it would be
necessary to implement a new opioid prescribing policy,
and that would have to have strong support from a broad
base of providers and advocates.
Department of Health and Human Services
53
Background
The stakeholders involved in this process determined that:
• To accomplish decreased utilization of opioids, other more
effective treatment options for chronic pain would need to be
accessible.
• Guidelines needed to be enforced for use of opioid
medications in the management of acute pain, which is pain
that is expected to last less than eight (8) weeks.
• Guidelines needed to be established for use of opioids in
clinical situations where the literature no longer supports their
use( chronic neck pain, chronic back pain, Fibromyalgia
Syndrome & headaches).
Department of Health and Human Services
Background
The stakeholders involved in this process determined
that:
• Exceptions needed to be made for opioid use during
end-of-life care, hospice care and hospital inpatient care.
• There should be a maximum allowable dose.
• There needed to be a shift in treatment goal from painfree to maximum level of function.
Department of Health and Human Services
From Drug Management to Pain
Management
Strategies developed based upon type of pain:
• Acute (new onset)
• Chronic (long term, or poor response to other treatment)
• Diagnoses typically proven not to respond to opioid
treatment
Department of Health and Human Services
Pain Categories
• Acute Pain is expected to last less than 8 weeks
• Chronic Pain is expected to or already has lasted
longer than 8 weeks
• Non-responsive: Headache, Chronic back pain, Chronic
neck pain, Fibromyalgia
Department of Health and Human Services
Acute Pain
• 15 days per 12 month period with no prior authorization
• 14 additional days with Prior Authorization (PA)
• Face-to-face visit for each Rx within 96 hours of
prescription being written
• Up to 3 refills after the first 15 days
• Surgeons: a one time PA for 60 days
Department of Health and Human Services
Acute Pain Treatment Plan
• Return patient to previous level of function as quickly as
possible.
• Minimize long-term use of opioids for pain that is
expected to resolve in the near-term
Department of Health and Human Services
Chronic Pain
• Patient must try one or more interventions from a
treatment plan
• Certain conditions no longer qualify a patient for
treatment with opioid medications without a second
opinion supporting the use of opioid medications
• Limit on total daily dose of opioids
Department of Health and Human Services
Chronic Pain Treatment Goals
• Transition from pain-free expectation to improved level of
function
• Increase access to proven treatment modalities
• Minimize use of opioids where no data supports current
level of use
Department of Health and Human Services
Chronic Pain Treatment Options
•
•
•
•
•
Osteopathic Manipulative Treatment
Chiropractic Services- 12 per year maintenance program
Physical Therapy- 6 visits per year
Cognitive Behavioral Therapy
Acceptance Commitment Therapy
Department of Health and Human Services
Dosing Limits
Minimum:
30mg or less MME/MSE- exempt from PA process
PA Required:
30-300 MSE/MME
Maximum:
300mg MME/MSE is maximum allowed dose
Department of Health and Human Services
Results After First Year
Comparing 2012 to 2013:
• Nearly 10,000 fewer MaineCare members received a
prescription for opioid medications.
• 69,227 fewer prescriptions were filled for MaineCare
members.
• 5,874,109 fewer opioid pills were dispensed to
MaineCare members.
• 1,108,202 fewer days’ supply were dispensed to
MaineCare members.
Department of Health and Human Services
PMP Opioid Data—State of Maine
Statewide Opioid Utilization by All Payer Sources
Recipient
Count typically
Rx Count
Dispensed
Text
Font
Times Qty
New
Roman Days of Supply
TOTAL- 2012
at least
20 point81,743,690
335,990
1,224,629
19,456,079
TOTAL - 2013
Try312,870
to have size
consistent throughout
1,183,452
77,275,507
18,962,450
TOTAL- 2014
Change 2012 to
2013
Percent Change
Change 2013 to
2014
Percent Change
Change 2012 to
2014
Percent Change
324,121
1,223,516
80,323,827
20,202,989
23,120
-7%
41,177
-3%
4,468,184
-5%
493,629
-3%
11,251
4%
40,064
3%
3,048,320
4%
1,240,539
7%
11,869
-4%
1,113
0%
1,419,863
-2%
(746,910)
4%
Department of Health and Human Services
MaineCare
MaineCare Statewide Opioid Utilization
Medicaid- 2012
Medicaid- 2013
Medicaid- 2014
Change 2012
to 20 13
Percent change
Change 2013 to
2014
Percent change
Change 2012 to
2014
Percent change
Recipient Count
Rx Count
Qty Dispensed
Days of Supply
89,559
356,174
22,144,541
5,457,844
74,394
286,947
16,270,432
4,349,642
50,497
218,250
12,236,397
3,389,985
15,165
-17%
69,227
-19%
5,874,109
-27%
1,108,202
-20%
23,897
-32%
68,697
-24%
4,034,034
-25%
959,657
-22%
39,062
-44%
137,924
-39%
9,908,144
-45%
2,067,859
-38%
Over the last three years, MaineCare has seen a 36% decrease in opiate prescriptions. This number incorporates those who are no longer eligible
for MaineCare.
Department of Health and Human Services
Commercial Insurance
Opioid Utilization by All Commercial Payers
Recipient Count
Rx Count
Qty Dispensed
Days of Supply
Commercial
Insurance- 2012
169,173
608,399
41,581,042
9,745,466
Commercial
Insurance- 2013
159,998
574,557
38,424,810
9,162,888
Commercial
Insurance- 2014
178,879
658,365
43,856,430
10,791,020
Change 2012 to
2013
Percent Change
9,175
-5%
33,842
-6%
3,156,232
-8%
582,578
-6%
18,881
12%
83,808
15%
5,431,621
14%
1,628,132
18%
9,706
6%
49,966
8%
2,275,388
5%
1,045,554
11%
Change 2013 to
2014
Percent Change
Change 2012 to
2014
Percent Change
Department of Health and Human Services
2012-2014 Comparison
Department of Health and Human Services
State of Maine
Statewide Opioid Utilization by All Payers, Jan-June
Recipient
Count
Rx Count
Qty Dispensed
Total- 2012
212,354
613,378
41,134,754
9,715,029
Total- 2013
189,569
585,154
38,335,670
9,316,076
Total- 2014
182,640
569,693
36,216,124
9,117,039
Total- 2015
210,757
647,784
44,058,941
11,172,994
Department of Health and Human Services
Days of Supply
MaineCare
MaineCare Statewide Opioid Utilization , Jan-June
Recipient
Count
Rx Count
Qty Dispensed
Medicaid- 2012
57,463
177,813
11,168,229
2,734,405
Medicaid- 2013
51,927
154,885
8,926,455
2,324,907
Medicaid- 2014
30,345
101,110
5,447,593
1,528,870
Medicaid- 2015
30,032
106,121
6,188,596
1,689,989
Department of Health and Human Services
Days of Supply
Commercial Insurance
Statewide Opioid Utilization by all Commercial Payers, Jan-June
Recipient
Count
Rx Count
Qty Dispensed
Commercial
Insurance- 2012
106,473
307,391
21,307,473
4,961,612
Commercial
Insurance- 2013
93,861
268,750
18,039,348
4,267,654
Commercial
Insurance- 2014
100,717
292,898
18,903,615
4,640,753
Commercial
Insurance- 2015
117,317
350,599
23,987,652
5,943,697
Department of Health and Human Services
Days of Supply
What’s on the Horizon?
• Pain Management Policy Modifications (ie mandatory
use for all Rx’ers, tie MME to pain mgmt policy)
• Sharing Pain Policy with Private Insurers in Maine
• New Threshold letters from PMP
• Mandatory use of PMP by MaineCare prescribers
• Align pain management policy with new USCDC Opiate
Guidelines
Christopher Pezzullo, DO
Chief Health Officer
Maine DHHS
[email protected]
Department of Health and Human Services
State Approaches to
Improving Opioid Prescribing
Vaughn Frigon
Chief Medical Officer, Tennessee Health Care Finance
and Administration Bureau, TennCare
Questions
?