A Paradigm Shift of Payer Strategy

April 10-12, 2012 Walt Disney World Swan Resort

Learning Objectives: 1.  Analyze the scope of the payers’ role in the

prescription drug abuse problem.

2.  Identify specific best practice methodologies that can be implemented by payers to reduce fraud, waste and abuse through member and prescriber interventions/education and support

3.  Describe the “drug seeker” profile and how it has changed.

Disclosure Statement

•  All presenters for this session, Dr. Kathryn Mueller, Dr. Brian K. Solow and Beverly Franklin-Thompson have disclosed no relevant, real or apparent personal or professional financial relationships.

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Changing Opioid Practice

Kathryn Mueller, MD, MPH, FACOEM Professor, School of Public Health & Department of

Emergency Medicine University of Colorado

Vice-President - American College of Occupational and Environmental Medicine

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Topics Discussed

•  Brief Overview of the problem •  Medical Guideline Recommendations-

e.g. Colorado Div of WC and ACOEM •  Current Practice •  Solutions and Directions for the future

6 MMWR / August 6,2010 / Vol. 59 / No. 30

FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

7 MMWR / August 20,2010 / Vol. 59 / No. 32

FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

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Morphine Equivalents per Case

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Use of Opioids •  Use of an “opioid treatment

agreement” or “opioid contract” - Recommended (I)

•  Routine use of urine drug screening for patients on chronic opioids - Recommended (C)

•  Attempts to wean patients on opioids to lowest clinically effective dose or completely from opioids - Recommended, Insufficient Evidence (I)

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Recommendations for Opioid Use   Therapeutic Trial Indications

a) The failure of pain management alternatives by a motivated patient including: a)  active therapies b)  cognitive behavioral

therapy c)  pain self-management

techniques d)  other appropriate

medical techniques.

Colorado CP

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Starting Opioids

•  Acetaminophen, NSAIDS, ASA used first and should be continued when stronger agents added

•  Start with therapeutic trial with clear understanding of limited use

•  Contingent on patient goals and obligations—return to work, agreement that drug screening may be used

•  Do not begin opioids until patient has begun a pain rehabilitation program

Colorado CP

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Criteria for Initiation

•  No evidence of psychopathology or elevated abuse risk, addiction, or adverse outcome (Relative rather than absolute contraindications)

– Note some studies noted elevated risk of abuse with any prior substance use

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Opioid Trial •  When active therapies, pain self-

management techniques have been tried

•  Psychosocial assessment for abuse potential and untreated depression, anxiety, etc.

•  Treatment of identified issues and referral to pain specialist if history of addiction

•  Informed, written, witnessed consent by the patient

•  Frequent (q 2-4 wk) follow-up to document pain control and functional gains such as RTW

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Cautions and Contraindications

•  Relative contraindications –  Hx of EtOH, benzodiazepine, or other substance

abuse –  Off work more than 6 months –  Severe personality disorder

•  General contraindications –  Active EtOH or substance abuse –  Untreated mood or psychotic disorder –  Decreased mental or physical function with

opioid use

Colorado CP

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Recommendations for Opioid Use

i.  On-Going, Long-Term Management should include:

a) Prescriptions from a single practitioner; b) Ongoing review and documentation of

pain relief, functional status, appropriate medication use, and side effects;

c) Ongoing effort to gain improvement of social and physical function as a result of pain relief;

Colorado CP

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Recommendations for Opioid Use

d)  Contract detailing the following:   Side effects

anticipated from the medication;

  Requirements to continue active therapy;

  Need to achieve functional goals;

Colorado CP

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Recommendations for Opioid Use Contract Language

  Reasons for tapering opioids –   Lack of functional effect at higher doses and

for apparent hyperalgesia   Non-compliance with other drug use   Drug screening showing use of drugs outside

the prescribed treatment   Requests for prescriptions outside of the

defined time frames   Lack of adherence identified by pill count,

excessive sedation, or lack of functional gains   Excessive dose escalation with no decrease

in use of short-term medications

Colorado CP

Recommendations for Opioid Use

  Use of drug screening initially, randomly at least once a year and as deemed appropriate by the prescribing physician. (Rolfs R 2010); Canadian Guidelines 2010; Chou R 2009).

  PDMP review   Use limited to two opioids: a long-acting

opioid for maintenance of pain relief and a short-acting opioid for limited rescue use.

  Sleep Apnea Testing: type of testing required unclear. Type 3 portable units with 2 airflow samples and 02 saturation device may be useful for monitoring respirator depression secondary to opioids.

Colorado CP

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What does it look like in real world practice?

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MMWR 2012

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FACTORS INFLUENCING WORK INTERFERENCE IN PATIENTS WITH

CHRONIC LOW BACK PAIN: A RESIDENCY RESEARCH NETWORK OF TEXAS STUDY

(RRNeT) STUDY Subjects: Three hundred sixty outpatients with CLBP for more than 3 months.

Predictors of Work Interference Screened positive for depression Number and magnitude of flare - ups

Young. RA JABFM Sept.-Oct. 2011 Vol.24, No.5, pp 503-509

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(RRNeT) STUDY continued All Subjects Depression Depression

Screening Screening Negative Positive

N=360 N=61 N=292 --------------------------------------------------------------------------------------- Does pain interfere with Your normal work (including both 215 (61.4) housework and paid work)?

Takes Opioid medication 210 (58.5) Takes daily scheduled Opioid medication 94(26.1) Patient has written pain Contract 67(18.6)

JABFM Sept.-Oct. 2011 Vol.24, No.5, pp 503-509

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Interstate Variation in Use of Narcotics – 17 states studied

•  Large variation among the states for morphine equivalents per case - 4000 NY to 1000 IA

•  Psychological evaluation – median 4% of long term user cases

•  Drug screening – median 7% of long term user cases

Wang,D Workers Compensation Research Institute, 2011

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Can Clinicians predict misuse? •  Urine drug test results using drug testing

protocols •  In clinician predicted misuse – 79% + •  Non-predicted misuse – 72% + •  Other drug tests – 71% + •  Because these are based at least 50% on

non-verified cutoffs, true results may be less •  Poster - Bronstein K, Vanderbilt U, Ameritox

sponsored

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Rates of Inappropriate Drug Use in Chronic Pain

•  938,586 urine drug screens •  38% no detectable prescribed drug •  29% non-prescribed drug detectable •  11% illicit drugs

Couto J , Population Health Management, vol 12 #4 2009

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What has prevented change? •  Education of providers and patients

– Unaware of risk – Not aware of current medical guidelines

•  Historical medical teaching –  Sanction by medical boards and JCHO for not

treating pain

•  Patient resistance –  ‘Doctor, don’t you trust me’

•  Provider’s time – done outside of visit •  PDMP difficulty accessing –

state specific

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Context - Seatbelts

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Chronic Opioid Use

•  Leads to death for some •  Significantly increases premiums •  Does not necessarily increase return

to work •  Most physicians don’t follow

standard protocol

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Solutions

•  Education for the public on the rate of deaths and ways to prevent them

•  Education for doctors – – currently available on line through AAFP

(family practice), Washington state, and others including University of Colorado

– REMS – pharmaceutical based with government requirements

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Solutions

•  Drug testing – Needs to be viewed as a necessary part

of management, similar to tests to continue other long term medications

– Example: Providers are encouraged to check all sexually active adults for HIV yet <2% are + •  Unlikely to be positive if >50 y/o – not

necessarily

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Alcohol and Marijuana

e)  Marijuana: Marijuana use is illegal under federal guidelines and cannot be recommended for use in this guideline. The Colorado statute also states that insurers are not required to pay for marijuana.

f)  Alcohol Screening: It is appropriate to screen for alcohol use and have a contractual policy regarding alcohol use during chronic opioid management as alcohol use in combination with opioids is more likely to contribute to death or accidents than marijuana.

Colorado CP

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Colorado Drug Monitoring code Rule 18 -6 G (5)

 New code to encourage physicians to periodically review drug compliance

 Reports review  Random drug testing review – annually

and before chronic opioids are used  Access the State Prescription Drug

Monitoring Program (records all opioid Rx from any Pharmacy in CO)

 Describe function and make recommendation

 Anecdotally docs are saying about 20% of patients have “surprises” on drug testing

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new code implementation 2010 1st year

•  Used in 350 cases •  2/3 of the claims had dates of injury from

2001-2009 •  No claims were identified with 1-2 opioid Rxs

and use of the code •  We hope to identify number of claims where

it should have been used and look at psych evals and drug screen for those

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Hurdles

•  Should all high dose opioid patients be referred to specialists?

•  Could low-dose patients have only minimal screening, e.g. completing validated office questionnaires for depression, anxiety, abuse

•  Who will pay? Hint: Right now physicians are unlikely to continue to prescribe medications with a significant hepatic or renal risk unless lab tests are completed.

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References •  Washington State Guidelines http://

www.opioidrisk.com/node/212 •  American College of Occupational and

Environmental Guidelines www.acoem.org chronic pain guides

•  Colorado Div of Workers Compensation http://www.colorado.gov go to Div of WC then chronic pain treatment guideline

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