Chronic Pain _ the Epidemic

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Chronic Pain _ the Epidemic Powered By Docstoc
					Improving Clinical Effectiveness and Risk
  Control in Chronic Pain Management:
      The Berkshire County Experience

              Ronald F. Hayden, MD
              Ann E. McDonald, MN
               John F. Rogers, Esq
                Alex N. Sabo, MD
            Berkshire Health Systems, Inc.
               Pittsfield, Massachusetts
                   Disclosure


The content of this presentation does not relate to
any product of a commercial interest. Therefore,
there are no relevant financial relationships to
disclose for:
                 Ronald F. Hayden, MD
                 Ann E. McDonald, MN
                  John F. Rogers, Esq
                   Alex N. Sabo, MD
Factors Fueling Berkshire Community Pain
          Management Program



              Ann E. McDonald, MN
      Berkshire Community Pain Management Project
              Berkshire Health Systems, Inc.
        Berkshire County—
Including Area Hospitals And Cities
Berkshire County Surface Tranquility
                 Sub-surface Tremors
                    2005 Massachusetts Opioid Poisoning Cases
                            Rates per 100,000, by Town
       Schedule II Opioid Poisonings Per 100,000
                                            2005




             Rates per 100,000 population (quintiles)
           Rates per 100,000 population (quintiles)
                  0
                   0
                  0.01 - 18.01
                  18.02 - 41.63
                   00.01 - 18.01
                  41.64 - 62.73
                   18.02 - 41.63
                  62.74- 225.51
                    41.64 - 62.73
                    62.74- 225.51




BMC has > 40 survived overdoses annually, mostly
oxycodone and hydrocodone combinations
           Sub-surface Tremors
Schedule II Opioid-related Hospitalizations
            Per 100,000 – 2005
                                                Sub-surface Tremors
               Unintentional overdose death rates by state, 2006 –
                          over 16,000 deaths annually
                                 11.6
                                                       7.6                                                                                                10.4
                                                                        1.1
                           9.8                                                           4.5

                                          6.9                           3.1                            8.3                                       7.6
                                                         6.9                                                      9.9
                                                                                           4.9                                         12.1
                                 16.5                                       4.0
                                                                                                                         11.5                            NH       9.4
                                                16.1                                                     9.5    10.0
                                                                                                                                18.6                     VT      10.0
                     8.0                                       10.8                                                                                      MA      13.0
                                                                              7.5              11.0                                       6.2
                                                                                                                      15.3                               RI      15.2
                                                                                                                                          10.2           CT      10.0
                                                                                                                14.1                                     NJ      8.6
                                          12.5                                    14.2                                                                   DE       8.6
                                                         19.4                                    8.9                                11.0
                                                                                                                                                         MD      12.3
                                                                                                         10.7   7.7          7.9                         DC      16.4
                                                                            8.4                                                                          MA – 2006 – 13
                                                                                                  15.4                                                        2005 – 10.6
                                                                                                                                                              2002 – 9.2
                                                                                                                                   12.5

                                    9.9
                                                                                               Rate per 100,000 population
                                                                      6.4

                                                                                               1.1-8.4                 8.5-11.4                    11.5-19.4


Len Paulozzi, MD, MPH, Centers for Disease Control and Prevention, 2009
                              Sub-surface Tremors
Relationship Between Opioid Sales And Drug Poisoning Mortality




                                                                   MA




LJ Paulozzi, GW Ryan , American Journal of Preventive Medicine, 2006
                Sub-surface Tremors
• Increasing reliance on pain specialists for chronic pain
  medication management instead of PCPs
• Pharma industry information suggesting +2 million
  Schedule II doses in 2005 in Berkshire County
• Schools and law enforcement reporting increased discovery
  of diverted pain medication prescribed by local providers
• DA concern about pain medication abuse and opioids as
  gateway to heroin use
• Anecdotal evidence of “doctor shopping”
• Addiction specialists seeing greater use of analgesics
   Doses of Schedule II Opioids Dispensed in
                                        Berkshire County: 1996-2008
                        3,500,000
                                                                                                                       3,168,950
                                                                                                  3,094,911
                        3,000,000
                                                                                    2,851,443
                                                                                                       2,936,420
                        2,500,000
Total Doses Dispensed




                                                                                           2,489,265
                                       1996-2005 an increase of 18% annually                              2006-2008 inc 4% yr
                        2,000,000
                                                                   2,175,883
                                                                               1,806,831
                                                             1,533,600
                        1,500,000

                                                                1,250,047
                                                 1,057,279
                        1,000,000
                                       661,987
                                                 748,463
                         500,000
                                    578,309

                               0
                                                                     Fiscal Year 1996-2008
          Magnitude of Local Pain Management
                  Risk Control Issue
                               Estimated ratio of
                            Schedule II to Schedule III
                              and IV opioids is 1:4.4

              3,168,950 Schedule II opioid pills in 2008

                Total 13,943,380 opioid pills prescribed

        103.3 tabs per each of 135,000 residents

MDPH Prescription Monitoring Program, 2009
Schedule II Opioid Prescriptions in Berkshire
             County 1996-2008
                       60,000




                       50,000




                       40,000
Prescription Numbers




                       30,000




                       20,000




                       10,000




                          0
                                FY 1996-2008
Schedule II Prescriptions per Individual in
      Berkshire County: 1996-2008
                                                            4.00
                                                            4.00

                                                                                                                       3.39
                                                            3.50
                                                            3.50
                      Estimated prescriptions/ individual




                                                                                                           3.02 3.21
Estimated prescriptions /individual




                                                                                                  2.79                     3.33   3.25
                                                            3.00
                                                            3.00
                                                                                          2.69                                           3.19
                                                                                   2.60                                                         3.03
                                                            2.50
                                                            2.50            2.43
                                                                     2.36

                                                            2.00
                                                            2.00   2.22

                                                            1.50
                                                            1.50


                                                            1.00
                                                            1.00


                                                            0.50
                                                            0.50


                                                            0.00
                                                            0.00
                                                                                                  Fiscal Years 1996-2008
                                                                                                 Fiscal Years 1996-2008
                  Questionable Opioid Activity in Berkshire County: 1996-2008

                                                160
                                                160


                                                 140
                                                140                                                                            139
# of of Individualswith Questionable Activity
  # Individuals with Questionable Activity




                                                 120
                                                120

                                                                                                                     95
                                                 100
                                                100
                                                                                                           89
                                                                                                                          94
                                                                                76
                                                 80
                                                80
                                                                                                64              83
                                                 60
                                                60          51
                                                                           53
                                                                                        58

                                                 40
                                                40     39
                                                                 45
                                                                      39
                                                 20
                                                20



                                                 00
                                                                                  Fiscal Years 1996-2008
                                                                                Fiscal Years 1996-2008
Linear Relationship Between Opioids Dispensed
                    and. . .
  • Deaths – tripled in the US between 1999 and 2007, now more than
    1000 deaths each month in US

  • Overdoses – major culprit is oxycodone, most are unintentional
    and occur in relatively young individuals

  • Hospitalizations – secondary to rescue and treatment of addiction,
    risk of addiction after treatment for several months or longer is 35%
    (BMJ, 2011)

  • Impaired Lifestyle – isolation, loss of function, motivation

  • Worse Outcomes - most commonly studied in LBP, leading to high
    rates of long term disability
Prescriber Role in Both Proper Control
             and Misuse


                  Alex N. Sabo, MD
   BMC Department of Psychiatry and Behavioral Sciences
             Berkshire Health Systems, Inc




                                                          18
                   Project Thesis
• Health care entities and clinicians uniquely situated to
  lead effort among community-based stakeholders to:
   – Improve quality/availability of care for patients with
     chronic pain through provider and patient education with
     adoption of strategies to improve safety in prescribing
   – Improve individual and public health and safety by
     reducing misuse and diversion of prescription pain
     medication
   – Reduce expense of care, productivity loss and other
     societal costs of dependence and addiction through
     prevention and early identification
         Twin Project Goals

               Assuring
 safe and effective treatment of those
suffering from acute and chronic pain
      in Berkshire County while
preventing individual and community
   harm from misuse and diversion
    of prescribed pain medication
        Participating Community Organizations

Community Treatment Providers:      Community Stakeholders:
  Physicians and other clinicians     Public and private schools
  Dentists                            Three community coalitions
  Pharmacies
                                    Massachusetts Dept of Public Health:
Criminal Justice:                     Drug Control Program
   MA Probation Services              Prescription Monitoring Program
   BC Sheriff ’s Office
   BC District Attorney             Academic Affiliations:
   Police Departments                 Brandeis University
   BC Drug Task Force                 Tufts University
First Barrier to Safe Prescribing: Lack of Effective
                  Communication

                  Criminal       Substance
                  Justice          Abuse
                  System         Providers

     Regulatory                                Emergency
     Agencies:                                  Medicine
       DPH             Silo’d Treatment         Providers
                              and
                       Communication
                                                 Mental
      Community                                  Health
      Agencies:                                 Providers
       Schools        Primary
                                     Pain
                       Care
                                   Providers
                     Providers
   Goal: An Integrated Community Program
Optimize treatment planning and EMR communication

                              Primary
                               Care



             MA DPH     Berkshire              Mental
              PMP                              Health
                         County
                       Community
                          Pain
                       Management

                   Pain                 Emergency
                 Specialist              Medicine




                                                        23
       Pain Care Resource Manual Tools
• Universal Precautions
   –   Clarify expectations
   –   Improve patient care and patient safety
   –   Reduce stigma
   –   Contain risk
• Diagnosis and Treatment Algorithms
   – Reinforce evidence-based medicine in pain management
• Opioid Medication & Risk Information
• Treatment Agreements
   –   Medication benefits and risk informed consent document
   –   Treatment goals and expectations set
   –   One prescriber/one pharmacy
   –   Appropriate communication among all co-managers of care
       Pain Care Resource Manual Tools

• Urine Drug Screening Advice and Forms – 3x annually
    – Liquid chromatograph/mass spectrometry technology added in
      3Q 2008
    – Improves patient safety by identifying non-compliance
    – Aids prescriber risk assessment
•   Opioid Risk Screening Tools: SOAPP & COMM
•   Multidisciplinary Assessment Program Description
•   Regulatory Information
•   Community Resources, including substance abuse
    services
           Key Project Components

• Provider Education
  – Pain Care Resource Manual
  – Encouragement of BioPsychoSocial Model for Addressing
    Persistent Pain
  – County-wide Medical Conferences: 2005, 2006, 2009-10
  – Introduction of Content into Residency Program Training
  – Education of entire care team, including MAs and practice
    administrators, through biannual meetings on
    implementation
            Key Project Components

• Integration of Care

   –   Information Technology: Optimizing EMR
   –   Monthly Multidisciplinary Treatment Planning Conferences
   –   Integrated Pain Treatment Pilot Program – CBT and Yoga
   –   Psychologist Added to the Pain Treatment Program
   –   Wrap-around Buprenorphine Treatment
   –   Residency QI program to measure and improve use of quality of
       care tools
• Community Assistance and Awareness

• Safe Medication Disposal Initiatives

• Partnerships with MA DPH and Research Institutions
          Information Technology Tools
• Flag Electronic Medical Records
   – Co-management issues with opioid medication
      • Existence of chronic pain and medication contracts are noted
        in Patient Summary Screen
      • Substance Use Alerts on Aberrant Behavior are noted in
        Patient Summary Screen; history/risk of abuse
      • Automatic system for maintaining currency of contract
        notation
• Create Pain Management Plan note to allow more effective co-
  management of care
• Identify “doctor shoppers” through multiple prescribers/visits
• Study e-Prescribing of Controlled Substances in ambulatory
  setting
• Track individual cases and assemble aggregate outcomes
             Monthly Multidisciplinary
              Treatment Conference
• Goal: Efficiently communicate coordinated treatment
  plan for challenging patients across provider network
• Plan identified in EHR problem list as “Pt Specific
  Treatment Plan (See MTP 01/01/11)”
• Participants include:
   –   Interventional Pain Physicians
   –   ED Chair
   –   Psychiatrist with addiction specialty
   –   Psychologist
   –   Ideally – PCPs, neurologists, rheumatologists and mental
       health providers already involved in care
Community Assistance and Awareness:
        Parent Education: 1/5
    Community Assistance and Awareness:
       Partnership with Criminal Justice System

Collaboration with District Attorney’s Office
• Measure local opioid poisonings and deaths,
• Annual “State of the Streets” report
• 3 Drug Take Back Programs

Facilitation of Pre- and Post-trial Substance Abuse treatment

Berkshire Partnership in Care Program
• Pilot program with Probation Services in central and southern county
  to better manage care of probationers at risk for prescription
  medication abuse
          The “Oxy” Free ED:
  An New Approach to Prescribing Controlled
Substances in the BHS Emergency Departments


         Ronald F Hayden, MD, FACEP
        BMC Department of Emergency Medicine
            Berkshire Health Systems, Inc.
    Characteristics Of All EDs That Create
    Environment of Opioid Prescribing Risk
• Open continuously
• Often no existing physician-patient relationship
• Fragmented connection to primary prescriber
• Patients become aware of variance in
  prescribing patterns, plan visits
• Busy environment, easier to write script than
  start education on safety
                Why an Oxy Free ED?

• The “Oxy Free ED” –a much needed concept to help
  EDs manage care effectively but also cope an epidemic
  of opiate misuse, addiction and death occurring over
  past 15 to 20 years.
• Need to prescribe analgesics in manner consistent with
  the medical evidence, mindful of individual and social
  risk.
• The statistics speak for themselves . . .
                 Sources of Opioid Analgesics


          Setting Type                                    % Distribution
Emergency department                                          39%
Primary care office                                           31%
Medical specialty office                                      13%
Surgical specialty office                                     10%
Hospital outpatient                                            7%
department

 Source: National Center for Health Statistics. Medication therapy in
 ambulatory medical care: United States, 2003-04

                                                                           36
                Goals of Oxy-Free ED

• For acute pain complaints: apply accepted guidelines
  to effectively treat pain but avoid medications that pose
  risk of diversion, abuse and addiction.

• For chronic pain complaints: clarify the role of the ED
  at presentation, emphasizing coordinated care,
  information sharing, drug screening and concern for
  addiction and other risk issues.

• Reduce the unnecessary volume of prescription opioids
  in our community…thereby reduce death, overdose and
  addiction
             Principles of “Oxy” Free ED

• Acute pain should be treated promptly and appropriately:
    – Most often non opioid analgesics or schedule III opioids are sufficient
    – If opioids prescribed, limit discharge medications
    – If possible, direct communication with primary doctor, including record of
      visit
• Acute exacerbations of chronic pain: Appropriate for treatment in
  ED?
    – When urgent treatment necessary—urine drug screen and contact with
      primary doctor before any prescriptions (limited) are given.
•   Chronic pain is multifactorial; opioids only small part of care plan
    – Opioids often not indicated or appropriate
    – ED management of one small component of overall treatment regimen often
      ineffective or dangerous
• Writing unnecessary opioid script is easy, addressing issue is
  harder.
 BHS Emergency Department Guidelines for
the Management of Chronic Pain Complaints


We Care: To improve your safety and the quality
of your care, the BHS Emergency Departments
will follow these guidelines in prescribing
medication for the treatment of pain.
                   First Principle


Pain is a significant medical condition warranting
prompt attention and intervention for its relief in
the most effective and safest manner feasible:
   • The Emergency Departments will promptly and
     effectively address complaints of acute and chronic
     pain of all patients and, when drugs are appropriate,
     provide the right drug in the right dosage and for the
     right duration.
                 Second Principle


To prevent the risks of uncoordinated care, one
provider should manage all opioids (narcotics)
prescribed for chronic pain:
   • Opioid medications have risks associated with
     dosage and interaction with other medications,
     therefore, it is critical to patient safety that one
     provider coordinate all prescribing. Any exception
     will require urine drug screen and direct contact with
     your regular doctor.
                 Third Principle

• To avoid the risks associated with the
  administration of injectable opioids, we will
  rarely provide these medications for the
  treatment of chronic pain:
   • Pain specialists discourage the use of pain
     medication shots for the treatment of chronic pain as
     they lead to increase tolerance to the these
     medications.
               Fourth Principle

In order to avoid the risks of overmedication and
other misuse, we will not provide replacement
prescriptions that are lost, destroyed or stolen.
   • Any necessary replacement prescription must be
     obtained from the original prescribing doctor.
                  Fifth Principle

Long-acting or controlled-release opioids (such as
OxyContin, oxycodone, fentanyl patches and methadone)
are designed to be part of plan for managing chronic pain.
We will not prescribe them for managing a chronic pain
complaint. These medications need a primary care or pain
specialist supervision.
    • We can assist in managing acute pain either with
      non-opioid treatment or a short course of opioid
      medication in appropriate situations.
                 Sixth Principle

In order to better assure safe, effective
coordination of care, we will share relevant
information with doctors involved in caring for the
patient.
   • We will appropriately share information with your
     doctors.
              Seventh Principle

Patients with complex pain conditions often
require treatment by many specialists. These
patients are best managed with a coordinated plan
of care. This care plan improves safety and
effectiveness.
  • We may develop a patient treatment plan on your
    condition and record this in the medical record.
         Summary and Rationale

The Departments will rarely prescribe those
medications most associated with abuse or
addiction: e.g., Percocet, OxyContin, Dilaudid,
MS Contin, Duragesic (fentanyl).
               The Oxy Free ED

• Do the right thing and provide acute pain relief
  promptly and in proportion to injury using a short
  course of medications.
• Reduce dependence, addiction and overdose risk with
  less opportunity for diversion and non-medical use.
• Reduce the high utilization of the ED for chronic pain
  complaints and engage primary physicians and pain
  specialists.
• Improve better outcomes for patient, family and the
  community.
            Key Legal Issues
                       ∆
Early Signs of Berkshire Project Impact



             John F. Rogers, Esq
        Vice President and General Counsel
          Berkshire Health Systems, Inc
                   Key Legal Issues


• Patient Privacy and HIPAA Basics
   – Most states recognize that duty of confidentiality exception in
     cases of serious danger to patient or others
       • Narrower exception in psychiatric care (Tarasoff cases)
   – Implied consent in co-management of care
   – HIPAA Privacy Rule
       •   OCHA
       •   NOPP
       •   TOP
       •   Crime on Premises
   – Federally funded treatment programs (“Part 2 Facilities”)
            Key Legal Issues

• Privacy Exception: Reporting Crime on
  Premises
  – All states have laws similar to M.G.L. c. 94, §33
    making it a crime to:

      “knowingly or intentionally acquire or obtain possession of
       a controlled substance by means of forgery, fraud, deception
       or subterfuge, including but not limited to forgery or
       falsification of a prescription or non-disclosure of a material
       fact…..”
      Attempts to commit a crime are also a crime.
                Key Legal Issues

• Patient Autonomy and Limits of Patient-
  Directed Care
  – Most states recognize the patient right to
    give/withhold consent ≠ right to inappropriate or
    futile care, care outside boundaries of accepted
    medical practice

• Liability Coverage
       Early Signs of Project Impact:
           Adoption of Best Practices

• 750 Pain Contracts posted in EMR from 11
  Practices
• Steadily increasing volume of Urine Drug
  Screens
• 166 prescribers participating in EPCS study
• Prescriber and administrator enthusiasm for on-
  going education (“new community ethic”)
• Enrollment in PMP Single Patient Look-up
• ED provider prescribing modifications
         Early Signs of Project Impact
Increased Use of Prescription Monitoring Program

• Prescription Monitoring Program authorized in
  48 states, operating in 35
   – Pharmacies transmit prescribing data to state
     repository—either public health or public safety
   – Operated on state-by-state basis
      • First in 1972 (PA); 36 added since 2000
      • Limited interconnectivity
      • National All Schedules Prescription Electronic Reporting
        Act of 2005—
          – Unfunded 2006-2008; $2M in 2009 and 2010 (grants in 13
            states
          – Would annually collect 673 million prescriptions from
            65,000 DEA-registered pharmacies accessible by 1.2
            million DEA-registered prescribers
          Early Signs of Project Impact
Increased Use of Prescription Monitoring Program

• PMPs Originally Funded through Department of
  Justice
   – Law enforcement focus: “doctor shopping”, prescription
     forgery, indiscriminate prescribing
   – Many state PMPs housed in law enforcement agencies
   – Data base not used to target subjects for investigation and only
     available to law enforcement in connection with existing
     investigation concerning specific prescribers or customers
• More Current Approach, Including NASPER Focuses
  on Public Health Potential of PMPs
         Early Signs of Project Impact
Increased Use of Prescription Monitoring Program

            The Kentucky PMP Experience
     Est. 1999
     CS Dispensers: 1500             Prescribers
     Scripts annually: 8.2 million
                                     Pharmacists
                 92%
                                     Licensing
                                     Boards
                         1% 1%
                           3% 3%     Law
                                     Enforcement
    Internet based
                                     Others
    5,500 report requests per week
    <5 second response time
                      Early Signs of Project Impact:
     Slowing Annual Increase in Total Schedule II Doses




                                                            Slope-1.2%


                              Slope-10%
                                                             Slope-3.69%


                               Slope-18%
                                                  Slope- 9%




2008 PMP data showed statistically significant reductions
in scripts per pt and doses per script.
   Early Signs of Project Impact:
Providers Beginning to Limit Prescriptions and
            Doses Per Prescription




                              The difference
                              between the 05-08
                              projected total doses
                              and the recorded
                              05-08 total doses is
                              491,050 doses.
          Early Signs of Project Impact:
Program Success with Coordinated, Planned Care
          (Buprenorphine Wrap Around Program)

90%
80%
70%
                                 p<0.05
60%
50%
40%                                                 80%
30%
20%                 42%
10%
 0%
               Pretreatment              After Treatment Was Initiated
(Measured as return to work or school)
             Early Signs of Project Impact:
    Individual Patient Success with Coordinated, Planned Care


• Single male, 30’s               • Began drinking age 8
• College graduate                • Misusing opioids > 10
• Unemployed 4 years                years
• Chronic pain syndrome           • Polysubstance
                                    dependence
• 3 + Berkshire doctors
  providing opioids and           • Multiple overdoses; near
  benzodiazepines                   fatal experiences
• 28 hospital visits in 33        • Multiple suicide
  months                            attempts
• Family terrified he will        • Variety of dangerous
  die                               behaviors involving
                                    police
           Early Signs of Project Impact:
  Individual Patient Success with Coordinated, Planned Care



• Care coordinated with Emergency Department, Psychiatry and
  Substance Abuse Services
• Admitted to inpatient psychiatry unit
• Tapered off opioids and benzodiazepines
• Multiple family and treatment meetings
• Seamless transfer to buprenorphine wrap-around program
       Early Signs of Project Impact:
Individual Patient Success with Coordinated, Planned
                        Care

         Average Monthly Cost of Care
        Pre-treatment:               $5258
        During 1st year of treatment: $1566
        During 2nd year of treatment: $700
   Carlen Robinson, 32

August 9, 1973 - November 11, 2005

				
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