LEGISLATOPLASTY : Nevada Osteopathic Medical Association. 65 th Annual Meeting & Symposium May 2-5, 2018 Las Vegas, NV

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1 LEGISLATOPLASTY : How Nevada Addressed the Opioid Epidemic through Common Sense Nevada Osteopathic Medical Association 65 th Annual Meeting & Symposium May 2-5, 2018 Las Vegas, NV Legislative and Medical Solutions

2 LEGISLATOPLASTY DR. JOHN DIMURO, DO, MBA Former Chief Medical Officer, State of Nevada and co-creator of Nevada AB474 President, DiMuro Pain Management -Reno & Las Vegas Board Certified in Anesthesiology & Pain Medicine

4 Controlled Substance Abuse & Prevention Act THE CREATION OF NEVADA AB474 AND THE PRESCRIBE 365 INITIATIVE Creation of a responsible and rational governmental approach to controlled substance prescribing

5 What is AB474? A bill presented to the 2017 Nevada State Legislature to combat both illicit and licit substance abuse, misuse and diversion. Sponsored by Governor Sandoval Passed unanimously

6 TASK Using State data, determine the problem Develop effective, rational strategies to mitigate the abuse, misuse and diversion of controlled substances Increase communication amongst State agencies

7 Barriers Legislators Lobbyists Public Prescriber groups Time

9 MUST Appease ALL stakeholders

10 The Problem PRESCRIPTION CONTROLLED SUBSTANCES FOR PAIN Misuse Abuse Diversion

11 Why do we have a problem? Increased supply of legal drugs Increased access to illegal drugs Dark Web Provider over-prescribing Surgeons Primary Care Logistics Dental prescriptions Providers not wanting to prescribe due to perception Lack of access to appropriate providers

12 How could this happen? According to State data: 1) NO CHECKING OF THE PDMP PRIOR TO PRESCRIBING!! This is the only mandate in the NRS code! Not all prescribers are even registered for the PDMP All physician prescribers must be compliant or face punitive measures by the Board MD Board issues What the Board of Pharmacy knows

13 How can this happen? According to State data: 1) No checking of the PDMP prior to prescribing 2) HIGH QUANTITY OF PILLS PRESCRIBED Convenience for prescribers Dentist prescriptions Poor knowledge about alternative treatments Poor access to alternative treatments Insurance limitations

14 How can this happen? According to State data: 1) No checking of the PDMP prior to prescribing 2) High quantity of pills prescribed 3) HIGH NUMBER OF POLYPHARMACY PRESCRIPTIONS sedating and lethal combinations of meds -opioid + BZD + sleeper fear of reprisal from patient taking over meds from another provider

15 How can this happen? According to State data: 1) No checking of the PDMP prior to prescribing 2) High quantity of pills prescribed 3) High numbers of polypharmacy prescriptions 4) LACK OF EVIDENCE-BASED DIAGNOSIS Can t just use back pain or chronic pain as a diagnosis No appropriate work-up performed Patient refusal to adhere to recommendations/referrals logistical constraints

16 How can this happen? According to State data: 1) No checking of the PDMP prior to prescribing 2) High quantity of pills prescribed 3) High numbers of polypharmacy prescriptions 4) Lack of evidence-based diagnosis 5) LACK OF PROVIDER FOLLOW-UP logistical constraints inconvenient to provider inconsistent providers ignoring warnings from Board of Pharmacy

17 How can this happen? According to State data: 1) No checking of the PDMP prior to prescribing 2) High quantity of pills prescribed 3) High numbers of polypharmacy prescriptions 4) Lack of evidence-based diagnosis 5) Lack of provider follow-up 6) LACK OF APPROPRIATE SCREENING BY PRESCRIBER not utilizing valid risk screening tools no required or regimented body fluid checks poor understanding of long-term effects of chronic use

18 Who is responsible? Prescribers Patients Insurers Pharmaceutical companies Government payers Pharmacists

19 Current State Mandates 1) MUST check the PDMP prior to prescribing opioids ONLY MANDATE!!!

20 MAJOR POINTS OF NEVADA AB474 1) DOES NOT HANDCUFF THE PHYSICIAN

21 MAJOR POINTS OF NEVADA AB474 1) Does not handcuff the physician 2) MUST REGISTER WITH THE PDMP

22 MAJOR POINTS OF NEVADA AB474 1) Does not handcuff the physician 2) Must register with the PDMP 3) MUST HAVE NORMAL FOLLOW UP

23 Major Points of Nevada AB474 1) Does not handcuff the physician 2) Must register with the PDMP 3) Must have normal follow up 4) EVIDENCE-BASED DIAGNOSIS WORK-UP

24 Major Points of Nevada AB474 1) Does not handcuff the physician 2) Must register with the PDMP 3) Must have normal follow up 4) Evidence-based diagnosis work-up 5) CHANGES IN BOARD OVERSIGHT

25 Major Points of Nevada AB474 1) Does not handcuff the physician 2) Must register with the PDMP 3) Must have normal follow up 4) Evidence-based diagnosis work-up 5) Changes in Board oversight 6) PRESCRIPTION CHANGES

Evidence-based diagnosis work-up 5) Mandatory urine drug screening

26 Major Points of Nevada AB474 1) Does not handcuff the physician 2) Must register with the PDMP 3) Must have normal follow up 4) Evidence-based diagnosis work-up 5) Mandatory urine drug screening 6) Changes in Board oversight 7) Prescription changes 8) PRESCRIBE 365

27 Major Points of Nevada AB474 1) Does not handcuff the physician 2) Must register with the PDMP 3) Must have normal follow up 4) Evidence-based diagnosis work-up 5) Mandatory urine drug screening 6) Changes in Board oversight 7) Prescription changes 8) PRESCRIBE 365 9) URINE TOX SCREENS?

28 MAJOR LOSS FOR NEVADA AB474 Attempt to include at least annual body fluid analysis drug screening for all patients taking controlled substances for pain

29 INITIAL RX CONSIDERATIONS 1) Have bona fide relationship 2) Check PDMP! 3) Initial prescription >15 days 4) Complete Informed Consent 5) Complete Opioid Risk Tool

30 >30 DAYS RX CONSIDERATIONS 1) Need prescription medication agreement

31 >90 DAYS RX CONSIDERATIONS 1) Work-up for evidence-based diagnosis 2) PDMP check every 90 days 3) Consider specialist referral

32 Major Points of Nevada AB474 1) Does not handcuff the physician 2) Must register with the PDMP 3) Must have normal follow up 4) Evidence-based diagnosis work-up 5) Changes in Board oversight 6) Prescription changes 7) Prescribe 365 Initiative 8) BEHAVIORAL HEALTH RISK ASSESSMENT

33 How did we get it done?

34 How did we get it done so quickly?

35 CAN WE REALLY DIAGNOSE AND TREAT PAIN WITHOUT PRESCRIPTION DRUGS?

36 What is my job? To obtain an appropriate PAIN diagnosis and then direct the patient to the best treatment option after presenting the patient all viable options.

37 What is the difference between a medical diagnosis and a pain diagnosis? A medical diagnosis is usually a broad, generalized term that is used to most accurately reflect an appropriate ICD- 10 classification code. A pain diagnosis is a specific diagnosis made using a clinical intuition or factual diagnosis. Example: Low back pain Example: Internal Disk Disruption vs. L4 Radicular Pain

38 How does a physician or non physician clinician typically arrive at a pain diagnosis? 1) Massage Therapist 2) Acupuncturist 3) Athletic Trainer 4) Physical Therapist 5) Chiropractor 6) General Physician 7) Specialist Physician

) MASSAGE THERAPIST Will use palpatory feedback and assessment of somatic structures and

39 HOW DOES A PHYSICIAN OR NON PHYSICIAN CLINICIAN TYPICALLY ARRIVE AT A PAIN DIAGNOSIS? (whether doing it correctly or incorrectly?) MASSAGE THERAPIST Will use palpatory feedback and assessment of somatic structures and assimilate patient history info supporting the diagnosis. If complaint of low back pain, will usually diagnose pulled muscle or some other type of musculoskeletal abnormality.

40 HOW DOES A PROVIDER TYPICALLY ARRIVE AT A PAIN DIAGNOSIS? Patient History Patient Complaint ACUPUNCTURIST Assess for musculoskeletal involvement through physical exam colors, sounds, odors, emotions If patient complains of low back pain, acupuncture diagnosis would likely assess a problem with a specific meridian, acupuncture point or extraordinary channel

41 HOW DOES A PROVIDER TYPICALLY ARRIVE AT A PAIN DIAGNOSIS? ATHLETIC TRAINER Medical history Movement screening Anatomical assessment If patient complaint of low back pain, diagnosis may be hip flexor weakness or lumbar sprain/strain

42 HOW DOES A PROVIDER TYPICALLY ARRIVE AT A PAIN DIAGNOSIS? Patient history PHYSICAL THERAPIST Usually Physician referral Movement screening Palpatory diagnosis If patient complaint of low back pain, diagnosis may be iliopsoas syndrome

43 HOW DOES A PROVIDER TYPICALLY ARRIVE AT A PAIN DIAGNOSIS? Patient history CHIROPRACTOR Movement screening Palpatory diagnosis Imaging slides (X-Ray, MRI) If patient complaint of low back pain, diagnosis may be spinal arthritis this can allow them to continue to treat using H.V.L.A.

44 HOW DOES A PROVIDER TYPICALLY ARRIVE AT A PAIN DIAGNOSIS? Thorough incident history PRIMARY CARE PROVIDER Thorough past medical history including family history, genetic predisposition Palpatory diagnosis Imaging studies: X-Ray, MRI, CT scan, ultra-sound Blood work Systemic physical examination-assessing for aneurysm, ecchymosis, induration If patient complains of low back pain, a physician may say urogenital anomaly or possible angiosarcoma.

45 HOW DOES A PROVIDER TYPICALLY ARRIVE AT A PAIN DIAGNOSIS? INTERVENTIONAL PAIN PHYSICIAN Thorough medical history, incident history, mechanism of injury, family history, surgical history, genetic history, medical implications Review of all prior imaging studies and physician notes including blood work, imaging studies, etc. Thorough physical examination including both a general and focused exam Post-examination consultation and debriefing

46 HOW DOES A PROVIDER TYPICALLY ARRIVE AT A PAIN TREATMENT? Debriefing with patient and family Render my opinion on current diagnosis Discuss treatment options taking into account multiple factors: A) Type of insurance B) Risk vs. reward of treatment C) Financial considerations D) cure vs. band-aid options E) Pertinent medical history

47 TREAMENT OPTIONS 1) Do nothing!!

48 1) Do no harm 2) MEDICATIONS Antibiotics, Sleeping aids, anxiolytics, antidepressants TREAMENT OPTIONS Anti-inflammatories Muscle relaxants Opioids, aka Pain killers

49 1) Do Nothing 2) Medications 3) Physical Rehabilitation Modalities Athletic Trainer Acupuncture Physical Therapy Yoga/Pilates Home Exercise Program Chiropractic 49

50 TREAMENT OPTIONS 4) FURTHER DIAGNOSTIC TESTING Thin slice C.T. Scan Flexion/Extension X-Rays MRI Neurography MRI Angiography C.T. Arthrogram

51 TREAMENT OPTIONS SPECIALIST REFERRAL Endocrinologist Rheumatologist GI Specialist

52 SURGICAL REFERRAL TREATMENT OPTIONS Orthopedic Surgeon Neurosurgeon General Surgeon

53 7) Interventional Pain Physician 1) Do Nothing 2) Medications 3) Physical Rehabilitation Modalities 4) Further Diagnostic Testing 5) Specialist Referral 6) Surgical Referral 7) Diagnostic work-up to prove the diagnosis 53

54 Answer : It depends upon what condition/diagnosis we are trying to prove. 1) Disc 2) Joint 3) Nerve 4) Muscle 5) Bone 6) Tendon 7) Ligament 8) Peripheral nerve 9) Organ 54

55 1) Disc How do we determine if the disc is a source of pain or discomfort? Is it a clinical diagnosis? Is it a movement screening diagnosis? No, it is a scientific diagnosis. Provocation Discography 55

56 Suspected Pain Generator 1) Disk Diagnostic Procedure Discogram A Discogram is a method of stimulating the disc through pressurization with fluid to see if concordant pain is elicited. 56

57 Discogram 57

58 Discogram - Abnormal Tear 58

59 Suspected Pain Generator 1) Disc Interventional Diagnostic Test Discogram Treatment Options If Positive Test Surgery Transdiscal Biacuplasty 2) Joint Joint Injection 59

60 Spinal Joint Injection ( Zygapophyseal or Facet Joint) 60

61 Suspected Pain Generator 1) Disk Interventional Diagnostic Test Discogram Treatment Options If Positive Test Surgery Transdiscal Biacuplasty 2) Joint Joint Injection Surgery Radiofrequency Ablation 3) Nerve Selective Nerve Root Block P.T./Chiro/Trainer 61

62 Selective Nerve Root Block Performed for Suspected Pain in a Dermatomal Distribution 62

63 Dangers of Cervical Injection Therapy 63

64 Suspected Pain Generator 1) Disc 2) Joint Interventional Diagnostic Test Discogram Joint Injection Treatment Options If Positive Test Surgery Transdiscal Biacuplasty Surgery R.F.A. Plus Rehab Modalities 3) Nerve Selective Nerve Surgery Root Block Epidural Steroid Injection Phys rehab modalities 64

65 Pain with Abduction and External Rotation during Hip Flexion 65

66 Suspected Pain Generator 1) Disk Interventional Diagnostic Test Discogram 2) Joint Joint Injection 3) Nerve Selective Nerve Root Block 4) Muscle Intramuscular Injection Under Fluoroscopy 5) Bone Rami communicans block, Imaging studies Treatment Options if Positive Test Surgery Transdiscal Biacuplasty Surgery R.F.A. Plus Rehab Modalities Surgery Epidural Steroid Injection Phys rehab modalities Physical Rehab Modalities Prolotherapy Botox Medication Rami Communicans RF, Meds, Bracing 66

67 Suspected Pain Generator Interventional Diagnostic Test Treatment Options if Positive Test 5) Bone Rami Communicans Block, Imaging studies 6) Tendon Tendon Injection Fluoro Guidance Rami Communicans RF, Meds, Bracing Rest, Brace, P.T., Prolotherapy 7) Ligament Ligamentous injection - Very Hard to Do 8) Peripheral Nerve Rest, Prolotherapy Bracing Surgery Peripheral Nerve Injection Surgery Meds Desensitization Injections 9) Organ Pain Sympathetic Plexus Block Surgery Meds Nutrition 67

68 Sympathetic Block 68

69 What are the take-home points? 1) Realize that sometimes things are not as simple as they seem. 2) If you can t prove it, you can t say it! 3) There really are ways to prove diagnoses. 4) Some people are just broken! 5) Depth of knowledge is not well appreciated. 69

70 LEGISLATOPLASTY : How Nevada Addressed the Opioid Epidemic through Common Sense Legislative and Medical Solutions Nevada Osteopathic Medical Association 65 th Annual Meeting & Symposium May 2-5, 2018 Las Vegas, NV JOHNDIMURO@GMAIL.COM THANK YOU! DIMUROPAINMANAGEMENT@GMAIL.COM

WHAT YOU NEED TO KNOW TO ABOUT AB 474

WHAT YOU NEED TO KNOW TO ABOUT AB 474 PRESENTED BY: NEVADA STATE BOARD OF OSTEOPATHIC MEDICINE 2275 Corporate Circle, Suite 210 Henderson, NV 89074 702-732-2147 Fax 702-732-2079 Web Site: www.bom.nv.gov