AVOIDING PHYSICIAN STRESS IN MEDICAL PAIN MANAGEMENT

Transcription

1 AVOIDING PHYSICIAN STRESS IN MEDICAL PAIN MANAGEMENT OR HOW TO TREAT PATIENTS AND STAY OUT OF TROUBLE AT THE SAME TIME L AYN E E. SUBERA, D O CONTENTS 1. Perspectives on the opioid situation 2. Oklahoma prescribing guideline 3. Treating patients while staying out of trouble 4. Building practice structure for safety 1

2 Policy Impact: Prescription Painkiller Overdoses The unprecedented rise in overdose deaths in the US parallels a 300% increase since 1999 in the sale of these strong painkillers. CDC Accessed march 31,

3 National Landscape 46 Each day, 46 people die from an overdose of prescription painkillers in the U.S. 259 M Health care providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills of highest prescribing states for painkillers are in the South. Source: Centers for Disease Control and Prevention, 2014 DRUG OVERDOSE RATES BY STATE,

4 Rate per 100,000 Population /13/2015 RATE OF UNINTENTIONAL DRUG OVERDOSE DEATH, UNITED STATES, Column Prescription drugs Crack cocaine 0. Heroin Year Source: Len Paulozzi, MD, MPH National Center for Injury Prevention and Control Centers for Disease Control and Prevention In 2008, there were 14,800 prescription painkiller deaths. In 2014, there were 22,700. CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers United States, MMWR 2011; 60: 1-6 4

5 Number of Deaths 8/13/ Accessed June DEATHS INVOLVING PRESCRIPTION DRUGS, ILLICIT DRUGS, OR ALCOHOL BY YEAR OF DEATH, UNINTENTIONAL POISONING, OKLAHOMA, All poisonings Prescription drugs Alcohol Methamphetamine Cocaine Year of Death Source: OSDH, Injury Prevention Service, Unintentional Poisonings Database (Abstracted from Medical Examiner reports) 5

6 Rate per 100,000 Population 8/13/2015 UNINTENTIONAL POISONING AND MOTOR VEHICLE CRASH DEATH RATES, OKLAHOMA, Unintentional Poisoning MVC Source: WISQARS, Centers for Disease Control and Prevention STATE OF OKLAHOMA PHARMACEUTICAL VS STREET 2013 DRUG OVERDOSE DEATHS Pharmaceutical deaths: there are at least one prescription drug or over the counter drug involved 75% 25% Street OBN 6/11/2014 SOURCE : STATE ME 2013 Data is not complete 6

7 Substances Involved in Unintentional Poisoning Deaths, Oklahoma, Source: OSDH, Injury Prevention Service, Unintentional Poisonings Database (Abstracted from Medical Examiner reports) Accessed June

8 Rx SOURCES Prescribed by one doctor 17.3 Bought from stranger or drug dealer 4.4 Took from a friend or relative without asking 4.8 Bought from a friend or relative 11.4 Other source 7.1 Obtained from friend or relative for free. 55% Obtained from friend or relative for free. Bought from a friend or relative Took from a friend or relative without asking Bought from stranger or drug dealer Prescribed by one doctor Other source 76% of opioid abusers obtained them from friends or relatives. Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: volume 1: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; Available from URL: WHO IS OVERDOSING? Of all patients who receive opioids, 80% are prescribed low doses (<100 mg MED) by a single practitioner, and these patients account for an estimated 20% of all prescription drug overdoses. 10% of patients are prescribed high doses ( 100 mg MED) of opioids by single prescribers and account for an estimated 40% of prescription opioid overdoses. 10% of patients seek care from multiple doctors and are prescribed high daily doses, and account for another 40% of opioid overdoses. These data suggest that prevention of opioid overdose deaths should focus on strategies that target: high-dosage medical users persons who seek care from multiple doctors, receive high doses, and those likely involved in drug diversion. Source: Kanny, Dafna; Garvin, William S.; and Balluz, Lina, "Vital Signs: Binge Drinking Prevalence, Frequency, and Intensity Among Adults United States, 2010," Morbidity and Mortality Weekly Report (Atlanta, GA: Centers for Disease Control and Prevention, January 13, 2012) Vol. 61, No. 1, p % 75% 50% 25% 0% % Patients % Overdoses High M High D Low D 8

9 Rate per 100,000 Population 8/13/2015 MORTALITY RATES BY AGE GROUP AND GENDER, UNINTENTIONAL POISONING, OKLAHOMA, Males Females Age Group Source: OSDH, Injury Prevention Service, Unintentional Poisonings Database (Abstracted from Medical Examiner reports) Unintentional Poisoning Death Rates by County of Residence, 1 Oklahoma,

10 OPIOID KG. SOLD PER 10,000 POP. The Solution P REV ENTION & ED UCATION A multi-faceted approach to overdose prevention is required. A comprehensive array of efforts are underway in Oklahoma, including: MONITORING & D IV ERSION CONTROL INTERV ENTION & TREATMENT 10

11 REDUCING PRESCRIPTION DRUG ABUSE IN OKLAHOMA: A STATE PLAN. Commitments to Action 1. Community/Public Education Promote the 211 Addiction Hotline 2. Provider/Prescriber Education Training curriculum for providers Standardized curriculum for students 3. Disposal/Storage for the Public At least 1 Rx drop box per county Increase 50% by Disposal/Storage for Providers Standardized training for support staff 5. Tracking and Monitoring Upgrade server database software Increase PMP use by 10% per year Share PMP data with OHCA and state payers 6. Regulatory/Enforcement Information sharing between entities 7. Treatment/Interventions Naloxone Pilot Increase SBIRT by Primary Care and ER providers by 10% per year TAKEASPRESCRIBED.ORG 11

12 Good Samaritan Laws and Naloxone Access Laws Accessed June

13 CHOCHRANE REVIEW ON CHRONCIC NONCANCER PAIN (2010) 26 studies with 4893 participants. Twenty five of the studies were case series or uncontrolled long-term trial continuations, the other was an RCT comparing two opioids. Signs of opioid addiction were reported in 0.27% of participants in the studies that reported that outcome. All three modes of administration were associated with clinically significant reductions in pain. Findings regarding quality of life and functional status were inconclusive. 13

14 LESSONS OF HOME EC 101 Find a good recipe Follow the instructions HOW TO TREAT PATIENTS AND STAY OUT OF TROUBLE AT THE SAME TIME Use a guideline Specific diagnosis Educational consent Routine monitoring plan Think about crisis management Talk about substance use disorders Be respectable Believe in your patient Know when to change the plan 14

15 KNOW A GUIDELINE Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting (2013) Due for an update Q Federal Guideline Due Q OPIOID PRESCRIBING GUIDELINES FOR OKLAHOMA HEALTH CARE PROVIDERS 15

16 THE OKLAHOMA GUIDELINE Two parts Acute Pain Setting Chronic Management Setting 2 recommendations are present in both sections 9,846 words spread over 24 pages 24 revisions It does not contain the word shall and the word must appears once in a reference to HIPPA obligations. ACCURATE DIAGNOSIS Acute diagnosis Accurate Treatment Back pain, Chronic Pain Syndrome, etc. Avoid nonspecific diagnoses Avoid unnecessary testing Use a pre screening tool Use the safest drugs first 16

17 WHO PAIN LADDER OPIATE RISK TOOL (ORT) A 2-minute, self or staff administered instrument Highly sensitive and specific Low-risk classification 94% of patients DID NOT display aberrant behaviors High-risk classification 91% in the DID display aberrant behaviors Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool. Pain Med. 2005;6(6):

18 EDUCATIONAL CONSENT Patients should learn something Fair agreement Avoid the adhesion contracts Safety education Signs of overdose Risks and benefits Social functions Office policies Legal issues 36 18

19 ROUTINE MONITORING PLAN Random urine testing Timing method Screen outside drugs Recover inside medications Quarterly projects Depression Screening, Revisit Consent, etc. COST IS NOT A BARRIER TO URINE TESTING Test cost is around $4 per test when purchased online. cliawaved.com or Amazon CMS reimburses about $20 CPT G0434,

20 CURRENT OPIOID MISUSE MEASURE Current Opioid Misuse Measure Accessed 1/8/12 CRISIS MANAGEMENT Telephone reports Abnormal drug screens Concerned family Lost prescriptions Early Refills 20

21 SUBSTANCE USE DISORDERS Adverse event Therapeutic dependency Opioid addiction Opioid Substance Use Disorder 8-10% meet criteria BE RESPECTABLE Look out for diverters Don t over load your schedule Avoid the cash temptation Keep good records Think about a certification Pain medicine Buprenorphine waiver 42 21

22 BELIEVE IN THE PATIENT Most people are good people Political environment makes trust difficult Avoid negative attitudes about pain 3 STRIKES POLICY Strike 1 Counseling from the doctor Strike 2 Referral to outside counselor Strike 3 Referral to physician consultant Discontinue participation in care plan 44 22

23 HIPPOCRATES Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate. Q & A? Layne Subera DO lsubera@sbcglobal.net 46 23