Opioid Roundtable Discussion

February 19, 2019

Jessica Van Fleet-Green, MD

Ross Vogelgesang, MD

Kari Lima, MD

Lucinda Grande, MD

Agenda

• Introduction of Speakers

• About PSW

• High Level Overview of Washington State Opioid

Prescribing Guidelines

• Non-Opioid Treatment Options

• Expanding Access to Lifesaving Treatments for

Opioid Use Disorders

• The Olympia Bupe Clinic: A High Capacity

“Medication First Clinic”

About Physicians of Southwest WA (PSW)As a population health company, PSW has led healthcare innovation

with the guiding principle of supporting the physician–patient

relationship to improve the quality of care delivered.

Strategic Priorities

Innovation Model Results

Presentation Goals

• Gain understanding and apply Washington State’s

Opioid Prescribing Rules

• Apply Bree Collaborative Guidelines for prescribing

• Demonstrate the utilization of various resources in

place for prescribing clinicians

Washington’s Opioid Prescribing Rules

• 7 day pill limit for acute prescriptions and 14 days for

acute post-operative pain

• (Exemption allowed if clinical judgment is documented)

• Care plan and documentation requirements for each

phase of pain

• Mandated registration and targeted checks of the

prescription drug monitoring program

Washington’s Opioid Prescribing Rules

• High risk patients require naloxone

• (50 MED for ARNP, 90 MED for physicians)

• Chronic Pain: Mandatory Consult when >120 MED,

written agreement, naloxone

• January 1, 2021: ALL controlled substances need

electronic transmission (10 or more prescribers)

@WAMedCommission WMC.wa.gov

• Instructed by the legislature as ESHB 1427

• Legislative response due to the doubling of opioid related deaths between 2010 and 2015

• WMC must adopt rules that would establish prescribing requirements with the goals of:

• Reduce addiction rates;

• Reduce burden to opioid treatment programs;

• Opioid Taskforce was created• Meetings were held with expert testimony and public

comment;

Why Is This Happening?!?!

@WAMedCommission WMC.wa.gov

• One-time CME regarding best practices in the prescribing of opioids;

• At least one hour in length;

• Completed by the end of your first full CME reporting period after January 1, 2019 or during the first full CME reporting period after initially being licensed, whichever is later.

Continuing Medical Education (CME) Requirements

Bree Collaborative Post-Operative

Guidelines

• Type I (Rapid Recovery)

NSAIDS/APAP. If opioids

are necessary, prescribe

≤3 days (8-12 pills)

✓ Oral surgery

✓ Lap appy, inguinal hernia,

carpal tunnel, breast biopsy,

meniscectomy, node biopsy,

Vag Hysterectomy

• Type II (Medium Recovery)

NSAIDS/APAP. ≤7 days (up

to 42 pills).

✓ cases warranting more than 7

days, surgeon to re-eval the

prior to 3rd rx, taper within 6

weeks

• Type III (Long Term

Recovery) NSAIDS/APAP.

<14 days.

✓ cases warranting more than 14

days, surgeon to re-eval the

prior to 3rd rx, taper within 6

weeks

Resources

• Washington State DOH Opioid Prescribing

https://www.doh.wa.gov/ForPublicHealthandHealthcare

Providers/HealthcareProfessionsandFacilities/OpioidPr

escribing

• Washington Medical Commission

https://wmc.wa.gov/resources/pain-management-

resources

• WSMA

https://wsma.org/WSMA/Resources/Opioids/Prescribin

g_Rules_And_Guidelines/prescribing_rules_and_guide

lines.aspx

• Bree Collaborative

NON-OPIOID TREATMENT OPTIONS IN

PAIN MANAGEMENT

ROSS E. VOGELGESANG, M.D.

ALLIANCE PAIN AND WELLNESS CENTER

EDUCATION AND TRAINING

• Graduate of University of Texas Medical School

• Internship: Medicine at the University of Tennessee, Bowld Hospital

• Residency: Oregon Health Sciences University of Medicine,

specializing in Anesthesiology

• Board Certified and Specializing in Addiction Medicine and

Anesthesiology

• Special Concentration in Pain Management

DISCLOSURES

Faculty trainer for Medtronic intrathecal

pumps used for treatment of pain and

spasticity disorders

LEARNING OBJECTIVES

•Limitations of opioid medications

•Alternative treatment modalities

•Non-narcotic pharmacological management

•Interventional therapies

•Case studies

LIMITATIONS OF OPIOID MEDICATIONS

• Pain scale

•Addiction, Government oversite and

abuse

•Assess treatment success

Alternative Treatment Modalities

Acetaminophen

Acupuncture

Chiropractic

Medicine

Cognitive

Behavior

Therapy

NSAIDSPhysicalTherapy

Massage

Therapy

Reflexology

Intervention

Therapy

NON-NARCOTIC PHARMACEUTICAL MANAGEMENT

Prescribe medication to treat pain types:

• Nerve

• Muscle

• Structural

• Visceral

Natural supplements for pain:

• Turmeric

• Alpha Lipoic Acid

INTERVENTIONAL THERAPIES

• Interventional spine

procedures

• Intraarticular joint injections

• Coordinate care with other

specialists

• Regenerative medicine

• Spinal cord stimulation (SCS)

CASE STUDIES71 Y/O MALE

Diabetic Peripheral Neuropathy

• S/P Aortic Value Replacement

• A1c 5.8

• Opiates: Adverse Effects

• Other Treatment Modalities

90 Y/O MALE

Postlaminectomy Syndrome

• Other Health Comorbidities

• Long Standing Opioid Therapy

• Failed Conservative Therapy

• SCS Trial to Implant

SUMMARY OF PRESENTATION

• Opioid Limitations

• Alternative Therapies

• SCS Today verse Yesterday

• Circle the Wagons

"Few things a medical provider does are more important than relieving pain…pain is soul destroying. No patient should have to endure intense pain unnecessarily. The

quality of mercy is essential to the practice of medicine; here, of all places, it should not be strained.“

Marcia Angell, American Physician and Author

QUESTIONS

EXPANDING ACCESS TO LIFESAVING TREATMENTS FOR

OPIOID USE DISORDER

KARI LIMA, MD

OBJECTIVES

• DESCRIBE MEDICATION-ASSISTED TREATMENT OPTIONS FOR

OPIOID USE DISORDER

• UNDERSTAND THE PROCESS FOR OBTAINING DATA-2000 WAIVER

• IDENTIFY THE MISMATCH BETWEEN AVAILABILITY OF EVIDENCE-

BASED TREATMENTS AND NEED

• DEVELOP A PLAN TO IMPROVE ACCESS TO EVIDENCE-BASED

TREATMENTS IN YOUR OWN SETTING

STATE OF THE CRISIS

• 130 OPIOID OVERDOSE DEATHS PER DAY

• OPIOIDS ACCOUNT FOR 68% OF ALL

DRUG OVERDOSE DEATHS

• BETWEEN 1999 AND 2017, OPIOID

OVERDOSE DEATH RATES INCREASED BY

SIX TIMES

• DRUG OVERDOSE DEATHS CONTINUE TO

INCREASE

STATE OF THE CRISIS

• 130 OPIOID OVERDOSE DEATHS PER DAY

• OPIOIDS ACCOUNT FOR 68% OF ALL

DRUG OVERDOSE DEATHS

• BETWEEN 1999 AND 2017, OPIOID

OVERDOSE DEATH RATES INCREASED BY

SIX TIMES

• DRUG OVERDOSE DEATHS CONTINUE TO

INCREASE

• 130 OPIOID OVERDOSE DEATHS PER DAY

• OPIOIDS ACCOUNT FOR 68% OF ALL

DRUG OVERDOSE DEATHS

• BETWEEN 1999 AND 2017, OPIOID

OVERDOSE DEATH RATES INCREASED BY

SIX TIMES

• DRUG OVERDOSE DEATHS CONTINUE TO

INCREASE

STATE OF THE CRISIS

MEDICATION-ASSISTED TREATMENT OPTIONS

• BUPRENORPHINE/NALOXONE

• BUPRENORPHINE

• METHADONE

• NALTREXONE

SUCCESS RATE SIGNIFICANTLY LOWER WITHOUT REPLACEMENT THERAPY

Sees, et al, Methadone Maintenance vs 180-DayPsychosocially Enriched Detoxification for Treatment ofOpioid Dependence A Randomized Controlled Trial JAMA 2000 283; 1303-1310

Kakko et al, 1-year retention and social function after buprenorphine-assisted relapse prevention treatmentfor heroin dependence in Sweden: a randomized, placebo-controlled trial. Lancet 2003; 361: 662–68

CLEAR MORTALITY BENEFIT FROM MEDICATION ASSISTED TREATMENT

• METHADONE MAINTENANCE RESULTS IN AVERAGE OF 25 FEWER DEATHS PER 1,000 PERSON-

YEARS

• BUPRENORPHINE ALSO REDUCES OVERDOSE DEATH AND ALL-CAUSE MORTALITY

MAT cost savingsMohlman MK et al, 2016

DATA-2000 WAIVER

• ALLOWS PROVIDERS TO PRESCRIBE BUPRENORPHINE FOR THE

TREATMENT OF OPIOID USE DISORDER

• PHYSICIANS – 8 HOURS OF TRAINING (AVAILABLE FOR FREE!)

• ARNP/PA – 24 HOURS OF TRAINING (AVAILABLE FOR FREE!)

• WAIVER TRAINING OPPORTUNITIES

• ONLINE-ONLY TRAINING

• HALF-AND-HALF TRAINING (IN PERSON PLUS ONLINE)

• FRIDAY, MAY 15, 9AM-1PM AT PSPH 200 ROOM

DATA-2000

• PROVIDERS WILL RECEIVE AN “X” WAIVER DEA NUMBER TO USE

• PROVIDERS SHOULD HAVE THE CAPACITY TO SEND PATIENTS TO HIGHER LEVEL

OF TREATMENT IF NEEDED

• PROVIDERS SHOULD ADHERE TO TREATMENT LIMITS

• INITIAL LIMIT = 30

• INCREASE TO 100 AFTER FIRST YEAR (MUST COMPLETE FORM)

• INCREASE TO 275 IF ADDITIONAL REQUIREMENTS MET

POINT #1

TREATMENT FOR OPIOID USE DISORDER NEEDS TO BE OFFERED AS PART OF ROUTINE PRIMARY CARE

PRIMARY CARE ATTITUDES TOWARD TREATMENT

• SURVEY IN VERMONT AND NEW HAMPSHIRE OF 108 FAMILY

PHYSICIANS (10% BUPRENORPHINE PRESCRIBERS)

• >80% REGULARLY SAW OPIATE-ADDICTED PATIENTS

• 70% FELT THEY SHOULD BE RESPONSIBLE FOR TREATING OPIATE

ADDICTION

• BARRIERS CITED:

DeFlavio et al, 2015

Rosenblatt R et al, 2015

POINT #2

PATIENTS NEED TO BE ENGAGED AT MULTIPLE POTENTIAL ENTRY POINTS AND BARRIERS TO

TREATMENT SHOULD BE MINIMIZED

Initiation of MAT Continuation of MAT

Pregnanc

y

Post-

operative

and pain

care

Adolescent

case

managemen

t

Emergency

departmen

t

Criminal

justice

system

Emergency

housing

Hospital

admissio

n

Psychiatric

care / self

help

groups

POINT #3

STRATEGIC COORDINATION IS REQUIRED TO DEVELOP THE WORKFORCE NECESSARY TO COMBAT

THE OPIOID EPIDEMIC.

HUB AND SPOKE

• STARTED IN VERMONT, MANY STATES

IMPLEMENTING

• RECEIVING MAT AT SPOKES WAS VERY SIMILAR TO

RECEIVING ROUTINE MEDICAL CARE

• PER PERSON TREATED, MAT DECREASED INPATIENT

DAYS BY 1.46, ER VISITS BY 1.04, AND IMAGING BY

0.92

SUMMARY: YOUR TO-DO LIST

• STEP 1 – TAKE WAIVER TRAINING ONLINE WAIVER TRAINING

• STEP 2 – APPLY FOR YOUR WAIVER SAMHSA APPLY FOR WAIVER

• STEP 3 – TREAT PATIENTS RESOURCES

• STEP 4 – ASK FOR HELP MENTORS EMAIL KARI

• STEP 5 – HELP OTHER PROVIDERS!

REFERENCES NOT OTHERWISE CITED

DEFLAVIO JR, ROLAND SA, NORDSTROM BR, ET AL. ANALYSIS OF BARRIERS TO ADOPTION OF BUPRENORPHINE MAINTENANCE

THERAPY BY FAMILY PHYSICIANS. RURAL AND REMOTE HEALTH. 2015;15:3019.

MOHLMAN MK, TANZMAN B, FINNISON K, ET AL. IMPACT OF MEDICATION-ASSISTED TREATMENT FOR OPIOID ADDICTION ON

MEDICAID EXPENDITURES AND HEALTH SERVICES UTILIZATION RATES IN VERMONT. J SUBSTANCE ABUSE TREATMENT 2016;67:9-

14.

ROSENBLATT RA, ET AL. GEOGRAPHIC AND SPECIALTY DISTRIBUTION OF US PHYSICIANS TRAINED TO TREAT OPIOID USE

DISORDER. ANN FAM MED 2015;13(1):23-26.

TONG ST, HOCHHEIMER CJ, PETERSEN LE, ET AL. BUPRENORPHINE PROVISION BY EARLY CAREER FAMILY PHYSICIANS. ANN FAM

MED 2018;16:443-446.

WAKEMAN SE, BARNETT ML. PRIMARY CARE AND THE OPIOID OVERDOSE CRISIS – BUPRENORPHINE MYTHS AND REALITIES.

NEJM 2018;379(1):1-4.

WALSH SL, LONG KQ. DEPLOYING SCIENCE TO CHANGE HEARTS AND MINDS: RESPONDING TO THE OPIOID CRISIS. PREV MED

2019;128:105780.

Lucinda Grande, MD

Physicians of Southwest Washington

February 27, 2020

Dr. Grande has no relevant financial relationship with an

ACCME- defined commercial interest.

Off-label use of medication may be discussed.

Describe common barriers to access of medication for opioid

use disorder

Explain the use of harm reduction to improve population

health among patients at high risk of adverse effects of opioid

use disorder

Demonstrate the effectiveness of the Medication First model

AP Photo/Ted S. Warren

Syringe Exchange Health Survey 2017, UW ADAI

Syringe Exchange Health Survey 2017, UW ADAI

Syringe Exchange Health Survey 2017, UW ADAI

Syringes exchanged in Thurston County:

1,060,000

Estimated individuals served: 1,162

Syringe Exchange Health Survey 2017, UW ADAI

Capital Recovery Center

Consequences for missed No appointments, evening

hours appointments

Pharmacy challenges On-site dispensing, no cost

Judgment, expectations Peer-led program,

co-located with

syringe exchange

Not enough waivered Rotating community

prescribers prescribers

Stigma against people Education of community

and

with OUD trainees

Stigma of criminal legal Jail outreach

involvement

Custom Pharmacy

Support

Peer Recovery

Care Navigators

Nurse Care

Manager

2 RNs

2 Peers

2-4 prescribers

Front Desk

Coordinator

The Olympian / Steve Bloom

Average Age: 36 (18-

79)

Male: 58%

Incarceration: 69%

Homeless: 53%

Chronic pain: 40%

OD: 37%

The Olympian / Steve Bloom

751 Patients, January – November, 2019

Number of

Patients

January 2019 – January 2020

Visits

Per Day

January 2019 – January 2020

Visits

Per Month

January 2019 – January 2020

Living on the streets: 7 0

Stable housing: 1825

BEFORE AFTER

“They don't toss you out the door for telling the truth.”

“I'm always made to feel welcome and that I'm important.”

Photos with patient permissionAP Photo/Ted S. Warren

Recidivism

28+ day gaps

Pain relief

Quality Assessment

Overall effectiveness

WWW.METRO.COM

Psych meds, acute care, primary care

Referrals / Transfers

Diversion Risk

Housing / Transportation

Criminal legal system

State Opioid Response Grant

Medicaid Transformation Demonstration

Cascade Pacific Action Alliance

Treatment Sales Tax (Thurston County)

Medicaid Billing

Many people want to quit

Lowering barriers helps

Team-based care

On-site dispensing

Peers create a welcoming environment

Our Nurse Care Manager is a gem