Drug Overdoses A Public Health Problem. Marianne Cloeren, MD, MPH, FACOEM, FACP 10/2/2013. Objectives

Transcription

1 Drug Overdoses A Public Health Problem Marianne Cloeren, MD, MPH, FACOEM, FACP 10/2/2013 Objectives O Provide an overview of the trends in opioid prescriptions and impact O Consider implications for the workplace O Propose management and safety actions to mitigate impact 1

2 Oxycodone Hydrocodone Morphine Methadone Rates of opioid pain reliever (OPR) overdose death, OPR treatment admissions, and kilograms of OPR sold United States,

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4 Subacute > Chronic Risk O 2011 study of about 30,000 patients prescribed opioids continuously for at least 90 days during a 6 month period O 66% of those followed for 5 years were still on opioids O Most were private health plan patients; ¼ were Medicaid population O No difference in these populations in long-term use 5 year follow-up after 90+ day prescription Still on opioids Off opiods Prescribed Dose & Risk of Mortality O Canadian study of opioid-related death in patients prescribed opioids for nonmalignant pain O 498 opioid-related deaths in 607,156 people on opioids O Strong correlation between dose and risk with 3 times the risk of death in patients on highest dose (>200 Morphine Equivalent Dose/day) compared to low dose (< 20 Morphine Equivalent Dose/day) O Opioid Dose and Drug-Related Mortality in Patients With Nonmalignant Pain, Gomes T, Arch Intern Med. 2011;171(7): Copyright 2012 ACOEM, All Rights Reserved 4

5 Average Claim Cost by Opioid Prescription Involvement, Michigan Prescriptio n # Claims % of Claims Medical Costs Indemnity Costs Total Costs None 4, ,212 7,050 13,295 Other 4, ,759 9,119 16,918 SA Opioids 3, ,006 28,511 47,742 LA Opioids ,898 95, ,74 8 The Effect of Opioid Use on Workers' Compensation Claim Cost in the State of Michigan White, Jeffrey A. MS; Tao, Xuguang MD, PhD; Talreja, Milan MA, PMP; Tower, Jack MS; Bernacki, Edward MD, MPH Journal of Occupational & Environmental Medicine: August Volume 54 - Issue 8 - p Chronic Opioids Impact Work Disability O Study of back pain WC cases, looking at work disability days in those managed with or without opioids O Compared with no opioid group, odds of chronic work loss were 6X > for claimants with schedule II ( strong ) opioids O Odds of chronic work loss were times greater for claimants with opioid prescriptions of any type during a period of 90 days O 3 years after injury, costs of claims with schedule II opioids averaged $19,453 > costs of no opioid claims 5

6 Chronic Opioids and Lost Work Days Opioid therapy for nonspecific low back pain and the outcome of chronic work loss Chronic Opioids Impact on Function O Study of 1843 workers compensation claimants (6%) received opioids for 1 yr O Daily opioid dose increased significantly over the year O Small minorities improved by 30% in pain (26%) and function (16%) Majority did not have improvements in pain or function! O Franklin et al, Natural History of Chronic Opioid Use Among Injured Workers w Low Back Pain, Clin J Pain, Dec, 2009 Copyright 2012 ACOEM, All Rights Reserved 6

7 In the News WCRI Study: Physician Dispensing in the Maryland Workers Compensation System O Study looked at prevalence and costs of physician dispensing on the Maryland workers compensation system O Found that the average prices paid to physiciandispensers in Maryland were often more than double the prices paid for the same drugs dispensed at a pharmacy. O Prices paid to physician-dispensers for many common drugs increased over the study period, while prices paid to pharmacies for the same drugs typically decreased over the same period. O In the News NCCI Study: WORKERS COMPENSATION PRESCRIPTION DRUG STUDY: 2013 UPDATE O Opioids increased from 21% of costs in 2010 to 25% in O Physician dispensing increased as well, along with the average cost for physician dispensed drugs. O The older the claim, the greater the percentage of total medical costs due to drugs up to 40 percent. O pdf 7

8 In the News WCRI Study: Impact of Banning Physician Dispensing of Opioids in Florida O Florida House Bill 7095 banned physician dispensing of stronger opioids effective July 1, O Study looked at opioid use among newly injured workers after the implementation of the bill. O The average Florida physician-dispenser continued to dispense pain medications after the ban, but increased the use of less addictive pain medications like ibuprofen and Tramadol. O No material change in the pharmacy fill of stronger opioids. O Opioids in WC O Trends summary: O Increasing early prescription O Increasing doses in early prescription O High reimbursement for physician dispensing increases this practice O Higher the early dose, more likely long term use O Opioid prescription associated with more lost time and higher overall claim costs 8

9 Why Is This Happening? O No requirement to follow guidelines O Physician dispensing (repackaging companies) O Lack of incentives for better outcomes O Much pressure on physicians to prescribe opioids for any pain O The system makes it easier to do things wrong than do things right O Biopsychosocial issues complicating recovery Chronic Opioid Management Guidelines What SHOULD doctors be doing? O Screen for appropriateness O Try other treatments first O Educate patients about risks/benefits O Use with other approaches (esp. psychological) O Continue if improving function (measure function) O Use written agreement (contract) O Monitor urine drug screening O STOP if not helping or noncompliance 18 9

10 Risk of Long Term Opioid Use O Tolerance and dependence are expected. O Addiction is NOT rare in people treated with opioids for chronic pain. O Opioid-induced hyperalgesia is also seen (not clear how commonly) INCREASED pain due to the opioids O Depression, sleep disorder, sexual dysfunction, immune system dysfunction Tolerance, Dependence, Addiction O Tolerance refers to needing more opioid over time the same amount no longer relieves pain. It is EXPECTED in chronic opioid use. O Dependence refers to the physical reliance of the body on opioids to feel normal and the symptoms of withdrawal that occur as the opioid wears off. It is EXPECTED in chronic opioid use. O Addiction refers to abnormal behavior seeking drugs lying, going to multiple different doctors, taking medication not as prescribed. 10

11 Who Is At Risk for Addiction? O Personal or family substance abuse history O Adverse childhood experiences (ACE) O Neglect O Physical, emotional, sexual abuse O Mental illness O Psychological stress (chemical coping) Employee Attitudes and Beliefs O Fear of re-injury O Thinking catastrophically O Tendency to feel depressed or anxious O Feeling mistreated O Belief that condition is disabling O Low self-efficacy 22 11

12 Signs of Possible Prescription Opioid Addiction O Decreased reliability O Performance deficits O Financial problems (asking for advances) O Wearing sunglasses inappropriately O Itching, scratching O Frequent absences O Loss of interest in friends and activities O Anger, irritability Implications in the Workplace O Safety concerns in RTW on prescribed opioids O More of an issue in acute use than chronic O Rules in some jobs/functions O Rampant use of OPM (Other People s Medications) O Costs of long-term disability and medical costs when related to WC 12

13 The Situation in Maryland O Free choice in medical care O Physician dispensing permitted, payments high O Most WC claimants are represented O No WC fee schedule reimbursement for opioid management plan activities O Prescription Drug Monitoring Program not yet active (enrollment to start this year) What s a Manager to Do? O Medical care decisions O Employee education O Policies O Drug testing O Partnering with WC insurer for access to treatment, reimbursement for management activities 13

14 Management Actions Medical Provider Choice O Limited opportunities to influence medical treatment decisions O In some states, can select panels or use preferred provider networks O CO, WA reimburse for following opioid management plans O Increase appeal of medical providers who treat responsibly O What do employee surveys tell you about how they feel they are treated? O Can you partner with unions for better outcomes related to opioid use? Management Actions Employee Education O Consider when and how to deliver information O Partner with labor O Possible routes for delivery: Incorporate in wellness messages, injury packets, OH/case management follow-up, pharmacy benefit plan outreach 14

15 Do I understand the alternatives? Do I know the likelihood of various outcomes? Do I know the potential benefits and harms? Do I know the potential consequences of my decision? 29 Acute: What I Want Employees to Understand about Opioids O O O O O They don t work any better than nonopioids for musculoskeletal injuries like low back strains Lots of side effects Worse long-term outcomes in patients who start them There should be a plan for stopping them if not helping function Some people have trouble getting off them once started (some studies -> 1/3 become addicted) 30 15

16 Arm Employee with the Right Questions to Ask Doctor Why do you think I need this medicine? How will opioid medicine help me function better as I recover from this injury? What are the alternatives to taking this medicine? How long will I need this medicine? What can I do to manage my pain so I don t need as much of this medicine? Given my personal health history, what is the risk that I will become addicted? What side effects should I expect in the short run? What about in the long run? How will this medicine affect my ability to work or drive safely? Employee Education Turn this Advice to Doctors into Employee Information O 16

17 Subacute to Chronic: What I Want Employees to Understand Subacute to Chronic: What I Want Employees to Understand 17

18 Subacute to Chronic: What I Want Patients to Understand O At the day point, there should be an informed decision-making process about continuing opioids, with: O Assessment of the clinical value of opioids vs. alternatives O Assessment of the risk of dependence, addiction O and side effects Discussion with the patient about what long-term opioid use will mean in his or her life O If decision is made to continue, there should be written materials, a signed agreement, and a plan for discontinuation if there is not improvement in function and symptoms Chronic Opioid Management: What I Want Employees to Understand O It should be stopped if it has not improved their life and function. O Long-term side effects include sexual dysfunction, depression, sleep disorders and increased pain. O Professional help is needed to stop. O They will need to trigger getting such help in most cases. 18

19 Management Actions Policies O RTW policies stringent enough to protect operations and other employees but not so stringent that they keep people off if able to work in some capacity O Reasonable accommodation considerations if chronic use O Drug-Free workplace include consequences if abnormal results O Consider seeking Occ Med support in developing policies O Types Management Actions Drug Testing O Pre-employment O For cause O Random O Make sure your policies are compliant with state regulations O Keep in mind that a positive result accompanied by a legitimate prescription is interpreted as a negative test but still has safety implications 19

20 Management Actions Access to Care O Work with your WC insurer for access to types of treatment that can be used to reduce need for opioids: O Cognitive behavioral therapy O Exercise based rehabilitation O Case management support O Work with your insurer for access to substance abuse rehab with pain management focus Cognitive Behavioral Therapy O Health and Behavioral Intervention CPT codes (not psychiatric care codes) can be used. O CBT can help manage the cognitive, behavioral and psychosocial factors that interfere with recovery from the physical impairment. O No psychiatric diagnosis is required under this code for a psychologist or psychiatrist to receive authorization and fee schedule re-imbursement to evaluate and treat a patient with a medical condition. O The goal of the CBT program is to facilitate acceptance of pain and not equate chronic pain with disability

21 CBT Approach for Pain and Work Disability Prevention O Brief and time limited O Collaborative effort between the therapist and the client O Structured and directive O Based on an educational model O Work activity focus O Homework is a central feature of CBT 41 Research on Work Focused CBT 21

22 Summary O Plan policies, messages, coordination, training, tools O Educate employees about opioid risks O Collaborate with WC insurer for access to care and interventions to improve care delivery O mcloeren@managedcareadvisors.com 43 22