Transcript A Community Discussion: Prescribing Patterns for Chronic Pain

Second Annual
Pain Summit
September 29th, 2015
A Community Discussion:
Prescribing Patterns for
Chronic Pain
Second Annual
Yamhill County Pain Summit
September 29th, 2015
William J. Koenig II, DO
Welcome
Buffet
Stairs
Restrooms
Front Exit
Stairs
Resource tables
Resource tables
Stage
6:00 – 6:10
Check in, dinner served
Yamhill CCO Staff, McMinnville Physician’s
Organization
6:10 – 6:20
Welcome & Introduction
William Koenig, DO, Physicians’ Medical Center
6:20 – 6:25
Opening remarks
District Attorney, Brad Berry, Yamhill County
6:25 – 6:55
Opioid Use and Misuse
6:55 – 7:05
Yamhill CCO Updates
Discussion
7:05 – 7:15
7:15 – 7:50
Pharmacy Panel
Discussion and Q&A
8:00 – 8:20
Behavioral Health Panel
8:40 – 8:50
8:50 – 8:55
8:55 – 9:00
Discussion
Oral Health
Discussion
Closing remarks
Jim Rickards, MD , Yamhill CCO
Morgan Parker, PharmD, WVMC
Joanna Thompson, Providence Medical Group
BingBing Liang, PharmD, CareOregon
Nicole Winnen, RPh, Mac Pharmacy
Paul Carson, CareOregon
7:50 – 8:00
8:20 – 8:40
John McIlveen, PhD, Oregon Health Authority
Jeri Turgeson, PsyD, Providence
Laura Fisk, PsyD, Yamhill CCO
Laura Fisk, PsyD, Yamhill CCO
Kristi Schmidlkofer, PsyD, PMC
Kristin Garcia, PsyD, Virginia Garcia
Jeri Turgeson, Providence
Syrett Torres, Psy D, Valley Women’s Health Clinic
Dr. Todd Hyder, DDS, Hyder Family Dentristry
William Koenig, DO, Physicians’ Medical Center
The goal is to stay on time.
Why Are We Here?
Patient safety and improved patient care
when administering opioids for chronic
non-cancer pain.
Second Annual Pain Summit
September 29th, 2015
Brad Berry, District Attorney, Yamhill
County
Introductory Remarks:
Thoughts from the DA
Opioid Use and Misuse:
History, Trends, And The
Oregon Opioid Initiative
John W. McIlveen, Ph.D., LMHC, State Opioid
Treatment Authority, Oregon Health Authority,
Addictions and Mental Health Division
Opioids in the United States: Motor Vehicles
and Opioid Deaths: 2006
Opioids in the United States: Motor Vehicles
and Opioid Deaths: 2010
Opioids in the United States: A Historical
Perspective
• Opioid use widespread and common in the US at turn of
19th/20th century – prescribed for a variety of aliments
• Peak usage late 1800’s, by 1910 around 1 in 400 Americans
opioid dependent
• Majority female users (as many as ¾ ths)
• 1914 Harrison Act – to regulate commerce and the opioid
trade
• Drastic changes in the way this population was treated
• Opiates prescribed only in the “course of practice”
(addiction not seen as a disease condition and not included)
Opioids in the United States: A Historical
Perspective
• 1950’s New York City – heroin epidemic
• Drs. Marie Nyswander and the beginning of
methadone treatment
• Nearly 100% relapse rates for abstinence based
treatment for opioid addicts
• Hypothesis – the opioid addicted brain “lacks
something” - opioid endogenous system
Opioids in the United States: A Historical
Perspective
• DATA 2000: Office‐based treatment of opioid
dependence
• Act of Congress – any schedule III, IV, or V
controlled substance with FDA approval for
treatment of opioid dependence could be
prescribed by a “qualified” physician
• Buperenorphine – Schedule III
• Expanding office based treatment options
Opioids in the United States: Current Trends
• 2009 - nonmedical use of prescription pain
medications; 4.8% of those aged 18‐25; 1.9 million
prescription narcotic users/ diagnostic criteria for
opioid abuse or dependence (second only to
marijuana (4.3 million)
• 2.1 million people in the United States with
substance use disorders related to prescription
opioid pain relievers in 2012; estimated 467,000
addicted to heroin (SAMHSA, 2012)
Prescription opioid sales, deaths and
treatment: 1999-2010
National Vital Statistics System, 1999-2008; Automation of Reports and Consolidated Orders
System (ARCOS) of the Drug Enforcement Administration (DEA), 1999-2010; Treatment
Episode Data Set, 1999-2009
First Use of Opioids: By
Decade
Cicero et al., 2014
Age of First Heroin Usage: By
Decade
Cicero et al., 2014
DEA: Heroin Seizures from
2010 – 2014
Institute for Defense
Analysis/ONDCP: Average
Heroin Prices
Opioids in the United
States: Heroin Facts
• Publicly funded facilities in 2012, opioid admission second
only to marijuana (TEDS, 2012)
• User population increasing more rapidly than any other
drug of abuse, despite overall numbers being vastly lower
than virtually all other illicit drugs; doubled between 2007
(161,000) and 2013 (289,000) (NSDUH, 2013)
• Cocaine users five times that of heroin users but double
the amount of deaths associated with it’s use (CDC, 2014)
• Wide variances in methods of reporting heroin realted
deaths (Warner et al., 2013)
Opioids in the United
States: Treatment
Considerations
in a Medicaid Population
• SUDs and Medicaid clients – appx. 12%
(SAMHSA, 2013)
• Opioid overdose rates much higher among
Medicaid population (Kuehn, 2014)
• Approximately 4.4% of Medicaid clients receive
SUD treatment any given year (SAMHSA, 2013)
• 1.4% of Medicaid programs budgets go towards
SUD treatment (SAMHSA, 2013)
Opioids in the United
States: Infectious Disease
• 2006-2012; 364% increase in HCV infection among young
adults (<30) in Appalachia; coincides with similar rates of
admission for opioid dependence (MMWR, 5/8/15)
• 2007 – HCV surpasses HIV as cause of death (Ly et al.,
2012)
• 2015 – Indiana HIV outbreak; directly related to IV drug
use
• Wide variance in rates of infection for IV drug users in
different areas of the country; from appx. 65% to as low as
10%, strongly correlated with access to public health
services (Fatseas et al., 2011)
Overview
• Opioid prescribing for pain has generated an epidemic of drug
overdose, opioid use disorder, and unstable pain care over the
last 15 years
• Policy and practice solutions have emerged
• Oregon is implementing strategies on the levels of:
 Health systems
 Community
 Public policy
23
24
Goals
• Decrease drug overdose deaths, hospitalizations,
emergency department visits, and misuse
• Increase use of medication assisted treatment for opioid use
disorder
• Decrease health care costs
25
Oregon Opioid Initiative
Align and coordinate Oregon Health Authority Programs:





Medicaid funded care
CDC funded injury epidemiology and prevention programs
SAMHSA funded prevention and treatment
CDC funded chronic disease self management
Pain Commission
26
Oregon Opioid Initiative Partnership
Federal
Partners:
CDC
SAMHSA
Health
Leadership
Council
Health
Systems
BJA
Pain
Managemen
t Clinics
Emergency
Department
s
Public
Safety
Oregon
Coalition
for the
Responsibl
e Use of
Meds
State Policy
Makers &
Statues
Oregon
Health
Authority
Local
Public
Health
Departmen
ts
Opioid
Use
Disorder
Treatment
Programs
OHSU & NW
Addictions
Technology
Transfer Center
Coordinated
Care
Organization
s
27
Interventions on 3 Levels
Communi
ty
Interventi
ons
Data identify and
leverage
Metrics guide quality
improvement
Public
Policy
Health
Systems
28
Health Systems Interventions
• Removed methadone as a preferred drug from the state formulary
• Adoption of opioid management by Medicaid Coordinated Care Organizations (CCOs) as a
Statewide Performance Improvement Project
• Implement opioid prescribing guidelines for practitioners
 Oregon Pain Guidance
 Emergency department guidelines
• Target the most frequent prescribers for PDMP enrollment
• Expand medication assisted treatment, non-opioid treatment reimbursement
• Establish and monitor metrics; use data to monitor progress
29
Targeted PDMP Registration and Use
• 23% of prescribers write 81% of controlled substance prescriptions
• Targeted enrollment has the support of the Oregon Medical
Association and the Oregon Hospital Association
30
Oregon Pain Guidance
Dr. Jim
Shames,
Jackson
County Public
Health
www.oregonpainguidance.com
31
Medication Assisted Treatment Programs in Oregon
1
7
1
2
2
1
32
Opioids in the United States: Data 2000
Naloxone Rescue
• 467 naloxone rescues were reported in 2014 in
Multnomah County
• Heroin deaths dropped 30% in Multnomah County
since 2011 (unpublished data)
34
Oregon Emergency Department
Opioid Prescribing Guidelines
• Oregon Chapter of Emergency Department Physicians have developed
guidelines
• Includes:
 single medical provider to provide all opioids for chronic pain,
 long acting or controlled release opioids should not be prescribed
from the emergency department,
 encourages prescribers to check the PDMP
Sharon Meieran, MD at ocep.org/
35
Community Interventions
• Establish pain guidance groups for health care provider
community
• Implement coordinated community based specialized pain
care
• Convene community action workgroups
• Increase naloxone rescue projects and distribution to at-risk
patients
• Implement public education
36
Oregon Coalition for the Responsible Use of Meds
Summits
Dwight Holton, JD,
Executive Director,
Lines for Life,
OrCrm.org
37
Oregon Legislative Policy
Interventions
• Enhance the Prescription Drug Monitoring Program
Emergency Department Information Exchange (EDIE)
Identified data for research
Automated notifications
Real time data??
• Naloxone statute amendments
38
Oregon Statewide Policy
Directions
• Enhance the Prescription Drug Monitoring Program
• Increase naloxone distribution and usage
• Increase the number of health systems screening
for opioid use disorder and adopt prescribing
guidelines
39
Oregon Statewide Policy
Directions
• Expand health insurance coverage for evidencebased alternative pain management for chronic
non-cancer pain
• Ensure that health insurance covers full spectrum
of services to treat opioid use disorder
• Increase the availability of medication assisted
treatment for opioid use disorders
40
Importance of Data
• Monitor impact of interventions using data
• Link PDMP data with health outcomes
• Establish data dashboards to rapidly disseminate data
to stakeholders
41
Immediate Actions and Potential
Impacts
• Increase registration and use of PDMP
• Reduced high dose opioid prescribing, problematic coprescribing of opioid and benzodiazepines, use of multiple
prescribers for opioids, and reduce the incidence of opioid naive
patients transitioning to chronic episodic and chronic opioid use
• Increase use of non-opioid pain therapies
• Increase use of claims reviews to identify high-risk prescribing
42
Contact
John W. McIlveen, Ph.D., LMHC
State Opioid Treatment Authority
Oregon Public Health Division
Oregon Health Authority
PH: 503.572.8585
Email: [email protected]
43
Second Annual Pain Summit
September 29 2015
Jim Rickards, MD
Supporting Management
of Chronic Pain
and Opiate Prescribing
Overview
Future work?
What is the Yamhill CCO?
Current efforts and strategy?
What?
16 Coordinated Care Organizations (CCOs)
in Oregon
Medicaid/Oregon Health Plan Benefits
Physical, Behavioral, and Dental Care Services
Community Governed Health Plan
501c3 Nonprofit Organization
Why?
Why?
Who?
 Governing Board
 Clinical Advisory Panel (CAP)
 Community Advisory Council (CAC)
 Various Additional Committees
 Administrative Staff
How?
 Integrator
 Platform for Transformation & Innovation
 Build Relationships
 Transformation Funds
 Staff Support
 Access to Outside Expertise
Chronic Pain and Opioid
Prescribing Support
Pain Summit
Opiate Prescribers Group
Controlled Substance
Committee
Yamhill CCO Persistent Pain Program
Data
Community Standards
PCPCPH
Patient Centered Primary
Care Homes
PCPCPH
Patient Centered Primary
Care Homes
Community Standards
Community Standards
PCPCPH
Community Standards
 Persistent Pain & Opiate Prescribing Guidelines
 Adopted 2014 by Clinical Advisory Panel
 Similar to Other CCOs
 < 120 MED Major Component
 Community Wide Support
Data
Data
Community Standards
PCPCPH
Data
Yamhill CCO
Persistent Pain Program
Yamhill CCO Persistent Pain Program
Data
Community Standards
PCPCPH
Yamhill CCO
Persistent Pain Program
 8 Weeks
 Pain School & Movement Therapy Program
 Laura Fisk PsyD - Wellness Center Behaviorist
 Started February 2015
 23 Graduates
 Adding Massage Therapy & Graduate Yoga
Yamhill CCO
Controlled Substance Committee
Controlled Substance
Committee
Yamhill CCO Persistent Pain Program
Data
Community Standards
PCPCPH
Yamhill CCO
Controlled Substance Committee
 Medication & Treatment Service Consultation
 Physicians, Pharmacists, RN, Behaviorist,
Addiction Counselor
 Meets Monthly
 Started April 2015
 Reviewed 10 Cases to Date
Platform for
Discussion and Action
Pain Summit
Opiate Prescribers Group
Controlled Substance
Committee
Yamhill CCO Persistent Pain Program
Data
Community Standards
PCPCPH
Future Work
 Statewide Opiate Performance Improvement
Project
 OHA Expanded Back Pain Treatment Guidelines
and Coverage
 Value Based Payment for Opiate Prescribing
 Dental & ED Strategy
Our Vision Statement:
“A unified healthy community that celebrates physical,
mental, emotional, spiritual, and social well-being.
Our Mission Statement:
“Working together to improve the quality of life and
health of Yamhill Community Care Organization
members by coordinating effective care.
Jim Rickards, MD, MBA
Yamhill CCO Health Strategy Officer
[email protected]
Morgan Parker, WVMC
Johanna Thompson, Providence
BingBing Liang, CareOregon
Nicole Winnen, RPh, Mac Pharmacy
Paul Carson, CareOregon
Pharmacy Panel
Second Annual Pain Summit
September 29th, 2015
BingBing Liang, CareOregon
Prescribing Report
Opioid Alternative
Pain Management Resources
• Acupuncture: No authorization
required when performed by
contracted clinicians affiliated with
PCP office for chemical dependency
treatment.
• Alternative medications: NSAIDs,
gabapentin, amitriptyline,
nortriptyline.
• Biofeedback: Available with
authorization.
• Chiropractic manipulation:
Authorization required for
evaluation and treatment.
• Counseling: Available to all patients
without referral for mental health,
pain management, and alcohol and
drug abuse.
• Massage therapy: Available with
authorization.
• Physical/Occupational therapy: No
authorization for evaluations for
covered diagnoses. Authorization
required for therapy visits. Yamhill
CCO will allow an evaluation and up
to 5 total visits for patients with
below the line diagnoses annually
with authorization.
• Salonpas Pain Relief Patches
(menthol/methyl salicylate): FDAapproved over-the-counter pain
patches available for purchase at
most drug stores.
• TENs units: Available with
authorization.
Yamhill CCO
Opiates Prescribing Report
MED 120mg/Chronic User (%)
Quarter 2, 2015
20.0%
15.0%
16.3%
10.0%
14.1%
13.6%
5.0%
0.0%
Yamhill
All CCOs
MED 120mg/Chronic User (%)
MCHD Clinics
Yamhill CCO
Opiates Prescribing Report
% of Chronic Users (#Mbrs)
Quarter 2, 2015
25.0%
20.0%
24.7%
(69)
21.3%
(56)
15.0%
13.6%
(57)
10.0%
5.0%
0.0%
4th Qrt 2014
1st Qrt 2015
% of Chronic Users (#Mbrs)
2nd Qrt 2015
Top Assigned PCPs
Quarter 2, 2015
Assigned PCP Name
PROVIDENCE MEDICAL GROUP NEWBERG
#Mbrs
% of
Total
23
40.4%
WEST HILLS HEALTHCARE CLINIC
9
15.8%
VIRGINIA GARCIA MCMINNVILLE
4
7.0%
WILLAMETTE HEART & FAMILY WELLNESS YAMHILL
3
5.3%
PHYSICIANS MEDICAL CENTER
2
3.5%
WEST SALEM CLINIC
2
3.5%
43
75.4%
Total
Opiate Utilization Report
MEDS Chart –
Patient-Empowered
Medication
Effectiveness
Paul Carson
CareOregon Pharmacy Team
Overwhelmed by Medications
CareOregon has 12,000 members
who have had 16 or more medication
changes over the last year.
Medication Confusion
• Multiple meds/providers
• Don’t know what they’re taking
or why (purpose for drug not
always spelled-out on label)
Multiple Prescribers
Medication
Prilosec
Zocor
Naproxen
Crestor
Lisinopril
Synthroid
Naproxen
Oxycodone
Glucophage
Hydrochlorothiazide
Amoxicillin
Lipitor
Epogen
Prescribing Physician
Dr. Brown
Dr. Brown
Dr. Brown
Dr. Jaffe
Dr. Jaffe
Dr. Brown
Dr. Willis
Dr. Willis
Dr. Brown
Dr. Jaffe
Dr. Brown
Dr. Brown
Dr. Jaffe
Who Benefits?
Members
Providers
Caregivers
Pharmacists
Available in paper or fillable
.pdf formats
Other languages:
• Spanish
• Chinese
• Vietnamese
• Russian
Take the Chart to
Your Doctor/Pharmacist
Ask patients how their
meds make them feel
Encourage Patient Use
Pilot Site Use Today
• Old Town Clinic – has integrated a version of the
MEDS Chart into their Electronic Health Record
system
• Clackamas Beaver Creek
• YOU can be next!
We want to partner with you!
Paul Carson
Training & Development
Specialist – Pharmacy
[email protected]
503-416-5745
http://www.careoregon.org/meds
Thank you!
Behavioral Health:
Persistent Pain
JERI TURGESEN, PSYD
What is Pain?
“Pain is an unpleasant sensory and
emotional experience that is associated
with actual or potential tissue damage or
described in such terms”
-International Association for the Study of Pain
Chronic Pain
 Brain activity switches when it becomes chronic
 Sensory  Emotional networks
Brain starts devoting more sensory space to pain area
Neuroplasticity
Hurt vs Harm
Pain is output from the brain
Chronic Pain Patients
Frequently, persistent pain symptoms are initially triggered by
biomedical factors
(Skinner, Wilson, & Turk, 2012).
Persistent pain patients experience anxiety and depression at
higher rates than the general population
(Orenius, et al., 2013)
Self-Management?
Tendency towards premature discontinuation of treatment plans
Development of maladaptive self-management strategies for pain management.
(Skinner, Wilson, & Turk, 2012).
Psychosocial Variables: Pain
Beliefs about Pain
Beliefs about Controllability
Self-Efficacy
Cognitive Errors
Coping
(Turf and Monarch, 2002))
Cognitive Behavioral Therapy
CBT: An important component in the treatment of chronic pain.
(Heapy, Stroud, Higgins, & Sellinger, 2006)
CBT has consistently produced positive outcomes in both improvement in
mood and overall functioning for people with chronic pain.
(Burns, Kubilus, et al., 2003)
Chronic pain patients who were treated with CBT:
Return to work
Reduction in perceived pain
Reduction in medication
Improved activity
(Flor, Fydrich, and Turk, 1992)
Cognitive Behavioral Therapy
Pain Education has also demonstrated positive outcomes for
patients:
 Decreasing pain rating
(Van Oosterwijck et al 2011, Meeus et al, 2010, Ryan et al, 2010, Moseley, 2002, 2003, 2004)
 Decreasing in fears related to possible re-injury
(Van Oosterwijck et al 2011, Moseley, 2002, 2003)
 Decreasing pain catastrophizing
(Meeus et al, Moseley 2004)
 Decreasing workmen’s compensation claims
(Buchbinder)
 Improved level of functioning
(Van Oosterwijck et al 2011, Moseley, 2002, 2003
Commonly Utilized Interventions
Cognitive-behavioral therapy
Addressing maladaptive belief systems
Mindfulness/Meditation
Relaxation
Behavioral treatments
Motivational interviewing
Guided imagery
Biofeedback
Wellness Center
Persistent Pain Program
LAURA FISK, PSYD
Wellness Center
Persistent Pain Program
8 week group-based model
1 hour Psychoeducation – “Pain School”
1 hour Movement Therapy – Yoga
Referrals
Referrals: 205
 Members are referred by PCP/Medical Team,
Behavioral Health, Community Partners or Self
Referring Clinics/Organizations
Clinic/Organization
Percentage of
Referrals
Virginia Garcia
42%
A Family Healing Center
13%
Yamhill Adult Behavioral Health
11%
Providence Medical Group
10%
Physicians Medical Center
8%
Willamette Heart
8%
Grande Ronde
2%
Lutheran Community Services
2%
Yamhill CCO Community Health Workers
2%
Community EMS, NSWDS, Provoking Hope, Women's Healthcare
<1%
Attendance (January – August)
Orientation: 87
Intakes: 59
Graduated Program: 23
Outcome Measures
Pre- and Post-measure were collected
Time 1 = 90-minute Intake
Time 2 = Week 8 – Graduation
Demographics
Gender
Femal
e
78%
Male
22%
Ethnicity
74%
Male
13% 4% 0% 0% 0% 9%
Female
Average Age: 45.9 (Min = 26; Max = 63)
Brief Pain Inventory
8
7
6
6.07
5.85
7.07*
6.46
5
4
3
2
1
0
BPI SEVERITY
SCALE PRE-
BPI SEVERITY
SCALE POST-
Note. Significance is indicated * = p<.05
BPI
BPI
INTERFERENCE
INTERFERENCE
*
SCALE PREPOST-
Oswestry Low Back Pain Disability
Questionnaire
52.5
52
52.5
51.5
51
50.5
49.45
50
49.5
49
48.5
48
47.5
PRE-TEST
POST-TEST
Fear of Movement Scale
42
41.5
41.72
41
40.5
39.31
40
39.5
39
38.5
38
PRE-TEST
POST-TEST
Patient Health Questionnaire
(PHQ-9)
18
16
16.04
14
12
12.86
10
8
6
4
2
0
PRE-TEST
Note. Significance is indicated * = p<.05
POST-TEST
DUKE Health Profile
50
39.41
45
40
46.81
43.18 44.54
32.85
35
36.5
30
25
20
15
19.54
15
10
5
0
PHYSICAL PHYSICAL MENTAL
HEALTH HEALTH HEALTH
PREPOSTPRE-
MENTAL
HEALTH
POST-
SOCIAL
HEALTH
PRE-
SOCIAL GENERAL GENERAL
HEALTH HEALTH- HEALTH
POSTPOST-
* (PSEQ)
Pain Self Efficacy Questionnaire
30
28.5
25
20
21.04
15
10
5
0
PRE-TEST
Note. Significance is indicated * = p<.05
POST-TEST
Patient Activation Measure
12
12
10
8
7
6
6
7
6
3
4
2
2
1
0
LEVEL 1
LEVEL 2
Pre-test
LEVEL 3
Post-test
LEVEL 4
Persistent Pain:
Discussion Panel
Persistent Pain Panel
Jeri Turgesen, PsyD: Providence Medical Group, Newberg
Laura Fisk, PsyD: Yamhill CCO Wellness Center; Villa Medical Clinic
Kristi Schmidlkofer, PsyD: Physicians Medical Center
Kristin Garcia, PsyD: Virginia Garcia Clinic, McMinnville
Syrett Torres, PsyD: Women’s Health Care; Valley Women’s Health
Second Annual Pain Summit
September 29th, 2015
Todd Hyder, DMD
Narcotics in Dentistry
Closing
Remarks
Second Annual Pain Summit
September 29th, 2015
William J. Koenig II, DO
Remember to fill out your evaluation to
receive CME credit!
Ongoing
Discussion




Second Annual Pain Summit
September 29th, 2015
William J. Koenig II, DO
Opioid Guidepath Workgroup
Meets monthly
Contact Jenna Harms [email protected] for more information
Presentations available http://yamhillcco.org/for-providers/providerupdates
Remember to fill out your evaluation to receive CME credit!