View
953
Download
3
Embed Size (px)
DESCRIPTION
Coordinating Multiple StakeholdersNational Rx Drug Abuse Summit
Citation preview
Coordinating Multiple Stakeholders
April 10-12, 2012 Walt Disney World Swan Resort
Accepted Learning Objectives: 1. Describe the relationship between prescription drug morbidity and mortality and the under-treatment of pain. 2. Identify measurement-based care as standard of care in pain medicine and describe how to measure pain, mood and function in every clinical encounter. 3. Evaluate how new state and federal policy changes will likely allow more prudent and safer use of opioids for chronic, non-cancer pain.
Disclosure Statement
• All presenters for this session, Dr. Alex Cahana and Dr. Gary M. Franklin, have disclosed no relevant, real or apparent personal or professional financial relationships.
Opioids: A public health emergency -National Rx Summit-
Orlando, FL April 10-12, 2012
Gary M. Franklin, MD, MPH Research Professor
Departments of Environmental Health, Neurology, and Health Services
University of Washington
Medical Director Washington State Department of
Labor and Industries
"To write prescriptions is easy, but to come to an understanding with people is hard." -- Franz Kafka, “A Country Doctor”
!
“We can’t solve problems by using the same kind of thinking we used when we created them”
By the late 1990s, at least 20 states passed new laws, regulations, or policies moving from near prohibition of opioids to use without dosing guidance WA law: “No disciplinary action will be taken
against a practitioner based solely on the quantity and/or frequency of opioids prescribed.” (WAC 246-919-830, 12/1999)
Laws were based on weak science and good experience with cancer pain
Change in National Norms for Use of Opioids for Chronic, Non-cancer Pain
WAC-Washington Administrative Code
7
Portenoy and Foley Pain 1986; 25: 171-186
Retrospective case series chronic, non-cancer pain
N=38; 19 Rx for at least 4 years 2/3 < 20 mg MED/day; 4> 40 mg MED/day 24/38 acceptable pain relief No gain in social function or employment
could be documented Concluded: “Opioid maintenance therapy
can be a safe, salutary and more humane alternative…”
Overall, the evidence for long-term analgesic efficacy is weak
Putative mechanisms for failed opioid analgesia may be related to rampant tolerance
The premise that tolerance can always be overcome by dose escalation is now questioned
100% of patients on opioids chronically develop dependence More than 50% of patients on opioids for 3 months
will still be on opioids 5 years later
Ballantyne J. Pain Physician 2007;10:479-91; Martin BC et al. J Gen Intern Med 2011; 26: 1450-57
Limitations of Long-term (>3 Months) Opioid Therapy
9
10
Opioid-Related Deaths, Washington State Workers’ Compensation, 1992–2005
Franklin GM, et al, Am J Ind Med 2005;48:91-9
0
2
4
6
8
10
12
14
De
ath
s
Definite Probable Possible
Year
‘95 ‘97 ‘00 ‘02 ‘96 ‘98 ‘99 ‘01
Franklin et al, Natural History of Chronic Opioid Use Among Injured Workers with Low
Back Pain-Clin J Pain, Dec, 2009 • 694/1843 (37.6%) received opioid early • 111/1843 (6%) received opioids for 1 yr • MED increased sign from 1st to 4th qtr • Only minority improved by at least 30% in
pain (26%) and function (16%) • Strongest predictor of long term opioid use
was MED in 1st qtr (40 mg MED had OR 6) • Avg MED 42.5 mg at 1 yr; Von Korff 55 mg at
2.7 yrs
12
Age-adjusted rate per 100,000 population
Unintentional and Undetermined Intent Drug Overdose Death Rates by State, 2007
MD MA NH RI CT DE DC VT NJ
12.5 12.5 11.7 11.1 11.1
9.8 8.8 7.9 7.5
National Vital Statistics System, http://wonder.cdc.gov
Evidence linking specific doses to morbidity and mortality
Dunn et al, Ann Int Med 2010; 152: 85-92 Risk of morbidity and mortality increased 8.9 fold
at 100 mg MED Editorial-McLellan-White House Office of National
Drug Control Policy “Smarter, more responsible (prescribing)
practices are the only hope to avoid tragic, avoidable deaths”
Braden et al, Arch Int Med 2010; 170: 1425-32 Opioid doses >120 mg/day MED and use of long acting Schedule II opioids associated with incresed risk of alcohol- or drug- related ER visit
*
Evidence linking specific doses to morbidity and mortality
Bohnert et al, JAMA 2011; 305: 1315-21 • Risk of mortality 7.18 (chronic pain), 6.64 (acute pain)
Gomes et al, Arch Int Med 2011; 171: 686-91 • Risk of mortality 2.04 at 100 mg and 2.88 at 200 mg
15
Unintentional Overdose Deaths Involving Opioid Analgesics Parallel Opioid Sales
United States, 1997–2007
National Vital Statistics System, multiple cause of death data set and Drug Enforcement Administration ARCOS system; 2007 opioid sales figure is preliminary
Distribution by drug companies 96 mg/person in 1997 698 mg/person in 2007
Enough for every American to take 5 mg Vicodin every 4 hrs for 3 weeks
Overdose deaths 2,901 in 1999 11,499 in 2007
Opioid sales * (mg/person)
Opioid deaths
627% increase
296% increase
Year
Year
Paulozzi and Stier, J Publ Health Pol 2010; 31: 422-32 • Per capita usage of opioids in NY 2/3 that in PA • Drug overdose deaths 1.6 fold higher in PA compared to NY • PDMP in NY better funded and uses serialized, tamperproof Rx forms
But mortality rates probably not affected by mandatory education alone
State mortality varies by regulatory environment
Fitzgibbon et al, Anesthesiology 2010; 112: 948-56
ASOA Closed Claims Database-N=8954 – 50/295 medication management issues
for CNCP • 59% inappropriate medication management • 24% high risk of misuse • 57% death
Washington Agency Medical Directors’ Opioid Dosing Guidelines
• Developed with clinical pain experts in 2006
• Implemented April 1, 2007 • First guideline to emphasize dosing
guidance • Educational pilot, not new standard or rule • National Guideline Clearinghouse
– http://www.guideline.gov/content.aspx?id=23792&search=wa+opioids
18 www.agencymeddirectors.wa.gov
• Part I – If patient has not had clear improvement in pain AND function at 120 mg MED (morphine equivalent dose) , “take a deep breath” – If needed, get one-time pain
management consultation (certified in pain, neurology, or psychiatry)
• Part II – Guidance for patients already on very high doses >120 mg MED
19
Washington Agency Medical Directors’ Opioid Dosing Guidelines
www.agencymeddirectors.wa.gov
Establish an opioid treatment agreement Screen for
Prior or current substance abuse Depression
Use random urine drug screening judiciously Shows patient is taking prescribed drugs Identifies non-prescribed drugs
Do not use concomitant sedative-hypnotics Track pain and function to recognize tolerance Seek help if dose reaches 120 mg MED, and pain and
function have not substantially improved
Guidance for Primary Care Providers on Safe and Effective Use of Opioids for Chronic Non-cancer Pain
20
http://www.agencymeddirectors.wa.gov/opioiddosing.asp MED, Morphine equivalent dose
Open-source Tools Added to June 2010 Update of Opioid Dosing Guidelines
CAGE, “cut down” “annoyed” “guilty” “eye-opener”
21
Opioid Risk Tool: Screen for past and current substance abuse
CAGE-AID screen for alcohol or drug abuse
Patient Health Questionnaire-9 screen for depression 2-question tool for tracking pain and function
Advice on urine drug testing
http://www.agencymeddirectors.wa.gov/opioiddosing.asp#DC
New CDC recommendations
For practitioners, public payers, and insurers
Seek help at 120 mg/day MED if pain and function not improving
http://www.cdc.gov/HomeandRecreationalSafety/pdf/poision-issue-brief.pdf
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
Num
ber o
f Opi
oid
Pre
scrip
tions
Yearly Trend of Scheduled Opioids
(Franklin et al, Am J Ind Med Dec 27 2011)
Schedule II Schedule III Schedule IV
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0% 20
00Q
1
2000
Q2
2000
Q3
2000
Q4
2001
Q1
2001
Q2
2001
Q3
2001
Q4
2002
Q1
2002
Q2
2002
Q3
2002
Q4
2003
Q1
2003
Q2
2003
Q3
2003
Q4
2004
Q1
2004
Q2
2004
Q3
2004
Q4
2005
Q1
2005
Q2
2005
Q3
2005
Q4
2006
Q1
2006
Q2
2006
Q3
2006
Q4
2007
Q1
2007
Q2
2007
Q3
2007
Q4
2008
Q1
2008
Q2
2008
Q3
2008
Q4
2009
Q1
2009
Q2
2009
Q3
2009
Q4
2010
Q1
2010
Q2
2010
Q3
2010
Q4
Percent of Timeloss Claimants on Opioids 2000 - 2010
Opioids Highdose Opioids
25
0
20
40
60
80
100
120
140
1996 Q1
1996 Q3
1997 Q1
1997 Q3
1998 Q1
1998 Q3
1999 Q1
1999 Q3
2000 Q1
2000 Q3
2001 Q1
2001 Q3
2002 Q1
2002 Q3
2003 Q1
2003 Q3
2004 Q1
2004 Q3
2005 Q1
2005 Q3
2006 Q1
2006 Q3
2007 Q1
2007 Q3
2008 Q1
2008 Q3
2009 Q1
2009 Q3
2010 Q1
MED
(m
g/d
ay)
Average Daily Dosage for Opioids,
Washington Workers’ Compensation, 1996–2010
Long-acting opioids
Short-acting opioids
Year/Quarter
96-Q
1
96-Q
3
97-Q
1
97-Q
3
98-Q
1
98-Q
3
99-Q
1
99-Q
3
00-Q
1
00-Q
3
01-Q
1
01-Q
3
02-Q
1
02-Q
3
03-Q
1
03-Q
3
04-Q
1
04-Q
3
05-Q
1
05-Q
3
06-Q
1
06-Q
3
07-Q
1
07-Q
3
08-Q
1
08-Q
3
09-Q
1
09-Q
3
10-Q
1
10-Q
3
0
5
10
15
20
25
30
35
Opi
oid-
rela
ted
Dea
th
WA Workers' Compensation Opioid-related Deaths 1995-2010
Possible Probable Definite
Unintentional Prescription Opioid Overdose Deaths Washington 1995-2010
* Tramadol only deaths included in 2009, but not in prior years.
Source: Washington State Department of Health, Death Certificates
0
100
200
300
400
500
600
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
Num
ber o
f dea
ths
Prescription Opioid + alcohol or illicit drug
Prescription Opioid +/- Other Prescriptions
24
420
Repeals current regulation; new expected by June 2011
Provides specific dosing guidance and guidance on consultations, assessments, and tracking
Signed into law by Governor Gregoire March 25, 2010
28
Washington State Opioid Treatment Regulations Final 1/2/2011
• Emphasize tracking patients for improved pain AND function
• Emphasize widely agreed-upon best practices – Screening for substance abuse and other comorbidities – Prudent use of urine drug screens – Opioid treatment agreement – Single pharmacy and single prescriber
• Encourage use of Prescription Monitoring Program-begins 1/1/2012 and Emergency Department Information Exchange, when available
29
What can PCP do to safely and effectively use opioids for CNCP?
Opioid treatment agreement Screen for prior or current substance abuse/
misuse (alcohol, illicit drugs, heavy tobacco use) Screen for depression Prudent use of random urine drug screening
(diversion, non-prescribed drugs) Do not use concomitant sedative-hypnotics or
benzodiazepines Track pain and function to recognize tolerance Seek help if MED reaches 120 mg and pain and
function have not substantially improved
Improving Physician Access to Pain Specialists in Washington State
• Issue – Moderate capacity problem: not enough pain
specialists – Interventional anesthesiologists generally won’t see
these patients to assist with opioid issues • Solution
– Advanced training for primary care to increase proficiency
– Telephonic or video consultation with experts [Project ECHO at UW (http://depts.washington.edu/anesth/care/pain/echo/index.shtml)]
– Public payers working on payment codes to incentivize these activities
31
Components Being Developed for Community-based Treatment of Chronic Pain
• Cognitive behavioral therapy
• Graded exercise • Activity coaching • Interdisciplinary care • Care coordination
32
Other new directions for chronic pain treatment
Incentivize best practices for chronic pain care in community setttings, eg, medical home concept for chronic pain E.g., cognitive behavioral therapy to
Cautious Prescribing Practices When Considering Therapy With Opioids -Physicians for Responsible Opioid Prescribing-
Von Korff M et al. Ann Intern Med 2011;155:325-328
©2011 by American College of Physicians
There is substantial clustering among providers on dosing and mortality
CA CWCI study-Swedlow et al, March, 2011: 3% of prescribers account for 55% of Schedule II opioid Rxs:http://www.cwci.org/research.html
Dhalla et al, Clustering of opioid prescribing and opioid-related mortality among family physicians in Ontario. Can Fam Physician 2011; 57: e92-96 Upper quintile of frequent opioid prescribers associated with last opioid Rx in 62.7% of public plan beneficiary unintentional poisoning deaths
DLI will send letters to all prescribers with any patient on opioid doses at or above 120 mg/day MED
• Call their attention to AMDG Guidelines and new WA state regulations
• Associate medical director will meet with these docs personally
Early opioids and disability in WA WC. Spine 2008; 33: 199-204
Population-based, prospective cohort N=1843 workers with acute low back injury
and at least 4 days lost time Baseline interview within 18 days(median) 14% on disability at one year Receipt of opioids for > 7 days, at least 2 Rxs,
or > 150 mg MED doubled risk of 1 year disability, after adjustment for pain, function, injury severity
38% Increase since 2001
Concrete steps to take • Track high MED and prescribers • Reverse permissive laws and set dosing and best practice standards
for chronic, non-cancer pain • Implement AMDG Opioid Dosing Guidelines (
http://www.agencymeddirectors.wa.gov/opioiddosing.asp) • Implement effective Prescription Monitoring Program • Encourage/incent use of best practices (web-based MED calculator,
use of state PMPs) • DO NOT pay for office dispensed opioids • ID high prescribers and offer assistance • Incent community-based Rx alternatives (activity coaching and
graded exercise early, opioid taper/multidisciplinary Rx later) • Offer assistance (academic detailing, free CME,ECHO)
Unfinished business • Address low capacity in communities to
prevent/Rx chronic pain • Guidelines for peri-operative use of
opioids • Looming large population dependent/
addicted from Rx opioids • Develop guidelines Re tapering
– PCP routine taper; Detox/pain clinic taper +/- buprenorphine
• Rx of opioid use disorder/addiction
It’s an emergency, so move ahead gingerly
If you do something effective to reverse a decade of bad public policy, you will get pushback: Fauber J. Follow the money: Pain, policy, and profit. 2/19/12.
URL:http://www.medpagetoday.com/Neurology/PainManagement/31256
But remember that the docs in the trenches welcome assistance, tools, and best practices -National survey of PCP network for low income
patients: 1/3 reported a severe outcome (death or life-threatening event); 1/3 do not initiate prescribing of opioids
Leverence RR, et al. J Am Board Fam Med 2011; 24: 551-561
For electronic copies of this presentation, please e-mail
Melinda Fujiwara [email protected] For questions or feedback,
please e-mail Gary Franklin
THANK YOU!