National Council for Behavioral Health

Transcription

1 National Council for Behavioral Health Opioid Intervention and Dependence Prevention Series: The Pivotal Role of Behavioral Health Providers in Addressing Opioid Dependency: From Risk Analysis to Direct Service and Other Innovations October 15, 2014

2 Presenters Carol Clayton, PhD CEO, Care Management Technologies Over 25 years of healthcare experience in the public and private sector. Jack M. Gorman, MD CEO and Chief Scientific Officer Franklin Behavioral Healthcare Consultants Expert guidance to improve CNS drug development and the efficacy and costeffectiveness of mental health care. George L. Oestreich, PharmD, MPA Principal, G.L.O. and Associates G.L.O. provides strategic consulting in Medicaid, public policy, pharmacy and pharmacy regulations. Leigh Steiner, PhD Director, Clinical Applications Care Management Technologies 30 years state government experience; former Commissioner of Mental Health for the State of Illinois. 1

3 Webinar Objectives Understand the underpinnings of the pain experience. Develop awareness of risk factors for opioid dependency. Develop an appreciation for the special expertise that mental health and addiction disorder providers offer. Take away key innovations related to the use of pharmacists in addressing and preventing opioid dependency. Take away two ideas about how your MH/SA agency can be involved in the active treatment of opioid dependency. Leave with an advocacy energy about your value added role as a central contributor to addressing this national health care crisis. 2

4 Reasons for Increased Opioid Administration Recognition in 1990s of pain undertreatment New JCAHO pain management standards in 2000 Pain thermometer Pain society advocacy 259 million opioid prescriptions written in 2012 Evidence for effectiveness in chronic non-cancer pain still sparse REF: Manchikanti et al, Pain Physician,

5 Inappropriate Use of Opioid Analgesics Sharp increase in opioid-related overdose and death Clear signal that evidence-based guidelines for opioid prescription not follow BUT opioids are also underprescribed and adherence is problematic 4

6 An Epidemic of Opioid Misuse Drug overdose death rates in the US have more than tripled since 1990 In 2008 more than 36,000 people died from drug overdoses 42 people die everyday from prescription painkiller overdose in US Most of those deaths were caused by prescription drugs 5

7 Most Cases of Opioid Misuse Start with a Doctor s Prescription 6

8 Opioid Misuse Varies Regionally 7

9 Risk Factors for Opioid Misuse: Demographic Young age (18-25) Misuse rising among elderly Male Rural area Living in south, Maine, New Hampshire Low income, unemployment 8

10 Risk Factors for Opioid Misuse: Clinical Previous or current psychiatric illness Previous alcohol or other substance abuse Benzodiazepine use 9

11 Risks for Misuse of Opioids: Doctor Shopping Multiple pharmacies Multiple prescribers Lost pills or prescriptions Frequent requests for dose increase Frequent requests for early refill 10

12 Risk for Misuse of Opioids: Prescriber Issues Influenced by patient request Inadequate training Ignore PMPs REF: McKinlay et al, Med Care,

13 Evidence-based Use of Opioids Control of post-traumatic pain Control of post-surgical pain Treatment of pain in patients with malignant cancer Palliative, end-of-life care Treatment of opioid addiction (methadone & buprenorphine) 12

14 Contraindications of Opioid Use Migraine headache Cough suppression 13

15 Screening for Possible Opioid Analgesic Misuse SOAPP/SOAPP-R: Screener and Opioid Assessment for Patients with Pain Predicts patients who may need more intensive monitoring 24 item self report; Cut-off Score=7; sensitive, high false positive rate ORT: Opioid Risk Tool Predicts patients at high risk for opioid misuse 10 item self report; High-risk cut-off>7; male and female scores DIRE: Diagnosis, intractability, risk, efficacy Designed for primary care; predicts adherence and long-term efficacy clinician rated; score>13 may be a candidate for long-term opioid therapy COMM: Current Opioid Misuse Measure Helps detect possible current opioid misuse problem 17 item self report; Cut-off>8; sensitive; high false positive rate 14

16 Uncertain Use of Opioid Analgesics Chronic non-malignant pain Defined as: pain lasting more than three months or past the time of normal tissue healing One-third of American adults report chronic pain Neuropathic pain REF: AHRQ,

17 Adverse Side Effects of Opioids Gastrointestinal (esp. constipation) Respiratory depression Falls and fractures Motor vehicle accidents Endocrine disturbance (e.g. low testosterone) Hyperalgesia Cognitive impairment and delirium Psychiatric disturbance (e.g. depression) Withdrawal symptoms Opioid use disorder 16

18 Medication-Assisted Treatment (MAT) for Opioid Addiction Buprenorphine: Partial Opioid Agonist Methadone: Full Opioid Agonist Naltrexone: Opioid Antagonist Used with counseling and behavioral therapies 17

19 Solutions to Opioid Misuse Use Data Based Analytics Prescription Monitoring Programs (PMP); CMT Model Follow practice guidelines Screen for substance abuse and psychiatric illness Limit maximum dose (120 mg MDE vs 200 mg MDE) Tamper-proof formulations Regular clinical follow-up Written agreements Urine monitoring Do not co-prescribe benzodiazepines 18

20 Solutions to Opioid Misuse, Cont d Mandatory PMP use Regulate pain clinics Evaluate prescribing data on a regular basis, including in ED Increase access to drug abuse treatment programs Ready access to naloxone Disposal of unused medication programs 19

21 Undertreatment of Pain Untreated pain is risk factor for depression, anxiety disorders, and suicide Untreated pain disrupts quality of life (QOL) Untreated or undertreated pain is common among cancer patients Media attention associated with decreased opioid prescribing REF: Goodwin et al, J Clin Oncology, 2014; Borwein et al, J Pain, 2013; Gerrits, BMC Psychiatry,

22 Terminally Ill Patients Avoid Opioids Perhaps as many as 50% of cancer patients Fear of overdose and addiction Stigma Patient misconception about pain relief REF: Liang et al,

23 Improving Opioid Analgesia Adequate dose Long-acting opioids Treat breakthrough pain Opioid rotation 22

24 Non-opioid Analgesics Acetaminophen Aspirin and NSAIDs Corticosteroids Antidepressants Anticonvulsants Biphosphonates Inhibitors of receptor activator of nuclear factor kappa B ligand 23

25 Evaluation of Opioid Effectiveness Is there pain reduction? Is there improvement in level of function? Are there adverse effects? Are there aberrant behaviors or mood? REF: Gourlay et al, Pain Medicine,

26 Conclusions Key is appropriate prescribing and treatment for pain. Combined with integrative medicine Increased role of the behavioral health specialist Educational efforts for physicians, clinicians and consumers. 25

27 National Council for Behavioral Health Opioid Intervention and Dependence Prevention Series: The Pivotal Role of Behavioral Health Providers in Addressing Opioid Dependency: From Risk Analysis to Direct Service and Other Innovations October 15, 2014

28 Role of Data Analytics in Risk Analysis and Treatment Stratification Population Stratification Resource Consumption 5% 25% 70% Poly-chronic BH/SA comorbidities Elderly and disabled At risk for major intervention/dependency Healthy/minor issues 45% 50% 30% 35% 20% ED visits Avoidable events Polypharmacy Higher volume of preventable acute episodes Complications and readmissions Unmanaged and unengaged Opportunities for integrative medicine Opportunities to enhance value through greater BH access and engagement Opportunities to reduce/prevent dependency; Improve quality of life Source: Blended MarketScan Commercial, Medicare 5% LDS, and representative payer Medicare data 27

29 Emerging Evidence for Use of Data to Improve Opioid Dependency/Misuse Lowered rates of doctor shopping Improved clinical decision making Increased discussion with patients about pain/opioid use Increased referrals for SA and brief intervention services *Sproule, B. Prescription Monitoring Programs in Canada: Best Practice and Program Review, CCSA, June

30 Emerging Best Practices Includes ALL drugs Ensure patient, prescriber, pharmacist linkage in data Full patient profile available Unsolicited reports to stakeholders Standard data collection method Patient privacy safeguards Evaluate intended and unintended consequences Allow for encrypted data for research/outcomes analyses 29

31 Evidence-based Decision Support System What gets measured, gets done. Big Data Engine Clinical lnsights 30

32 Core Foundation Team of Clinical Experts Cohort Studies Published Research & Outcomes Expert Consensus Guidelines 200 Evidence based BH Algorithms 31

33 Quality Indicator Overview Behavioral Pharmacy 164 Age Banded Child, Adult, Elderly Opioid Pharmacy 56 Age Banded Child, Adult, Elderly 32

34 Evidence or consensus based. Involve significant cost and/or health and safety. A small proportion of providers responsible for a large proportion of suspected errors. Compelling empirical support for the indicator. Are actionable. CMT s Quality Indicators Common Foundation 33

35 Sample Opioid Clinical Consideration 34

36 Audit and Feedback Cochrane Review: More efficacious than academic detailing Best value when: o Includes peer comparisons o Communicated by a peer-verbally and in writing o Targeted goals and action plans o Patient specific information tied to outcomes Reflective of CMT s Core Quality Indicator Approach 35

37 Peer Comparator Unsolicited Report 36

38 3 cohorts that were newly targeted in January, February and March mailings in 2013 for two Quality Indicators Opioid Analysis: Health Plan Customer QI 890/892 Use of Opioids for 60 or More Days in Absence of a Diagnosis Supporting Chronic Use QI 886/888 Multiple Prescribers of Opioids without a Malignant Cancer Diagnosis. All of the members who are newly messaged on the QI in the given month are assigned to that month s cohort. Newly messaged is defined as all members who have not previously been messaged on that QI from January 2012 forward. The graphs display the percentage of each cohort who continue to trigger the QI month to month with the black diamonds indicating continuing intervention mailings. 37

39 Retrospective Analysis 38

40 Retrospective Analysis 39

41 National Council for Behavioral Health Opioid Intervention and Dependence Prevention Series: The Pivotal Role of Behavioral Health Providers in Addressing Opioid Dependency: From Risk Analysis to Direct Service and Other Innovations October 15, 2014

42 It is more important to know what manner of patient has the disease, than to know what manner of disease the patient has. Sir William Osler 41

43 Challenges with Chronic Pain QUALITY OF LIFE Ability to perform activities of daily living, work, and/or recreation SOCIO ECONOMIC Healthcare costs Loss of income SOCIAL CONSEQUENCES Loss of relationships Isolation PSYCHOLOGICAL CONSEQUENCES Depression Anxiety Sleep disturbances 42

44 How Common is Chronic Pain? Diagnosis Total Unique Total with Chronic Pain % with Chronic Pain Anxiety 72,581 25,006 34% Depression 98,153 31,171 32% Anxiety or Depression 123,020 37,888 31% Schizophrenia 23,207 4,547 20% CMT Data Cohort of Medicaid recipients for CY 2013 Adults aged excluding those with cancer diagnosis 43

45 Challenges with Chronic Pain 44

46 Increasing Knowledge through Assessment PHQ-2 Depression (prescreen) or 9 AUDIT: Alcohol Use Disorder Identification Test (adults) CRAFFT Substance Abuse Screening Test (adolescents and young adults) Dast-10 for drugs SBIRT: Screening, Brief Intervention, and Referral to Treatment 45

47 1. Reducing pain. Managing Pain Has Three Main Goals 2. Separating the sensation from; suffering, anxiety and fear. 3. Understanding the meaning of pain to the patient. Novik, Belinda, Ph.D., M.S.C.P., M.D.; Pain, Part Two: Techniques for Pain Management and the Maintenance of Comfort, The North Carolina Psychologist, Spring

48 Consider Pain Attending to the presence of chronic pain Explore the pain meaning and fear about losing pain control Make sure your client knows you care about their pain Emphasize opportunity to replace pain fear with interest and curiosity about pain Assisting client to become more active and take greater role in direction of their own care and control of their own life Solicit client ideas and opinions Ask clients who are doing well, how they would recommend helping others 47

49 Basic Interventions Biopsychosocial Approach Help client track and give feedback to their pain specialist; working as a team to find the combination of medications that work best for the individual Social Support/Social Integration Positive Psychology Orientation; Acceptance and Commitment Therapy Develop identity not rooted in what was lost but what remains Relaxation therapy; meditation; mindfulness; yoga; biofeedback; hypnosis; exercise; dietary; pets 48

50 Hope lies, not in finding a way out, but a way through. Robert Frost 49

51 References SAMHSA's updated Opioid Overdose Prevention Toolkit equips communities and local governments with material to develop policies and practices to help prevent opioid-related overdoses and deaths. It also addresses issues for first responders, treatment providers, and those recovering from opioid overdose. PublicHealth.org offers free online course materials from the world s best universities on topics including: the effects various substances have on the brain; processes in the brain that lead to physical addictions; and the scientific analysis of addiction, drug abuse, and associated mental disorders. Published by the American Society of Addiction Medicine, the Medicaid Benefits for the Treatment of Opioid Use Disorder Nationwide displays state's Medicaid fee-for-service benefit coverage for medications approved to treat opioid dependence NORC at the University of Chicago. (Substance Abuse, Mental Health, Criminal Justice Studies research unit). 50

52 National Council for Behavioral Health Opioid Intervention and Dependence Prevention Pharmacist Role in Treating Dependency October 15, 2014

53 Pharmacists Roles and Responsibilities Around Opioid Prescribing Rules and regulations Clinically sound practice Electronic tools and product choice Patient aids and counseling Identification of at-risk patients Support treatment paradigms, be part of the solution 52

54 Existing Laws, Guidelines and Regulations DEA State Controlled Substance Board of Pharmacy Regulations Addiction treatment guidelines Best practice pain control guidelines and agreements Hospice guidelines 53

55 DEA s Outreach VIGIL Verification Identification Generalization Interpretation Legalization Patients support clear guidelines to allow legitimate prescription access to opioid use 54

56 Pharmacy Level Strategies Develop clear and concise procedures for handling opioid prescriptions Handling of required information regarding prescription How and when to access PDMP in all states except Missouri Resolution process for conflicting issues Adjust policies to accommodate patients with previous pharmacy relationships 55

57 Patient Level Strategies Pharmacists that are providing MTM like services are well positioned to support opioid pain management Familiar with diagnosis, indications, treatment goals and therapeutic response After prescription pharmacist can assist in monitoring outcomes, ADRs,and misuse Provide structured education 56

58 Recognize Early Abuse Indicators Targeting fill rates Prescriptions from other prescribers (including anxiolytics and muscle relaxants) Indications of patient securing additional medications from family members and friends 57

59 Pharmacist Collaborating with Prescribers In-depth assessment Ongoing monitoring Ongoing relationship/trust Coordinate and reconcile pain management related services Participate/support components of pain control contract 58

60 Use of FDA REMSs REMSs support appropriate use and risk reduction Maximization of benefit of opioids Utilizes communication techniques Specific training for professionals Restricted distribution of specific agents Patient registries and/or monitoring 59

61 Abuse Risk Reduction Consider abuse deterrent medications (and in general long-acting medications) Counseling on proper use Counseling on use of adjunctive agents Use of PDMP and related databases Consistency with accepted treatment guidelines 60

62 Identify Those at Risk Consistency with medical history Treatment history Efficacy of chosen treatment including adjunctive therapy Integration of cognitive behavioral therapy support Integration of biofeedback 61

63 Opioid Prescription Screening Flags Prescription centric Medication on prescription Seemingly inappropriate dosage Filling/refilling prescription too often Filling outside of logical geographic area Multiple prescribers Prescription inconsistent with patient s demeanor Prescription outside the scope of prescriber Non-prescription related Patients physical appearance Paying cash for prescription Patients only prescription is opioid Patient presents several prescriptions for drugs that don t make sense to use together 62

64 Follow and Support Treatment Efforts Recognize indicators of substance abuse treatment efforts Understand treatment guidelines Support patient s efforts to alleviate pain and use of non-opioid medications Recognize and support treatment plans for addiction including medication and CBT 63

65 Dispensing and Use of Overdose Treatment Medications Recognize current medication and non-medication treatment components Interact with patient to support best practice and patient specific treatment components 64

66 Handling the Bad Prescription If you choose not to dispense prescription, provide appropriate feedback to patients (unless you feel at personal risk) If concerns regarding misuse or abuse, provide patient appropriate treatment options Open discussion of pharmacist s concerns allows patient with the opportunity to explain their individual case Use out of stock only if prescription in deemed non-legal and pharmacist feels unsafe 65

67 Support Addiction Treatment List of local available multi-disciplinary pain control resources Know resources available for patient in need referral When abuse is suspected In support of patient, relative, caregiver request Have referral list available 66

68 Pharmacist s Engaged in Patient Care Multidisciplinary team members, partnering with physicians, nurses and others Use ProAct to identify and follow patients at risk Develop patient specific plans of care focusing on impactable areas Pharmacists collaborate within team to increase outcomes Monitor medications for adherence Assist in increasing health literacy Assist in early recognition of disease and adverse drug reactions Monitor vital clinical signs o o o HbA1C Blood pressure Weight

69 Pharmacists Provide Expanded Services Direct patient care Initiate and adjust drug dosages under physician protocol Provide access to immunizations Reconcile medication regimens Participate to achieve warm patient transitions to less restrictive care Support caregiver efficacy Increase awareness of medication treatment issues Train caregivers to monitor for adverse effects and support proper administration

70 Pharmacists Provide Therapy for Opioid Overdose States allow pharmacist to provide emergency doses of naloxone Opportunity expands in multiple states New in California Others states already on board o New Mexico, Washington, New York, Rhode Island and Vermont