Solving America s Prescription Epidemic

Transcription

1 Solving America s Prescription Epidemic February 22, 2017 Marianne Maumus, MD

2 disclosures none

3 objectives Describe origins of the epidemic Review findings from The Louisiana Commission to Prevent Drug Abuse Recall Opioids and the Brain Recognize causes of Chronic pain Review the Care Pathway for the Prevention of Addiction List Provider roles in combating the epidemic Be aware of proper Risk Assessment: ORT Outline Our group and system responsibilities to patients Review Opioid Stewardship at Ochsner

4 History and Attitudes about Pain and Opioids in the USA 1860 s - Civil war Soldier s Disease. Mophinism 1900s Heroin was marketed by the Bayer Corp. as a non-addictive pain reliever., lt led to the Harrison Narcotics Tax Act, 1970s Post Vietnam Heroin epidemic, low utilization of prescription opioids 1986 Dr. Russell Portenoy s retrospective review of 38 chronic pain patients Purdue Pharmacy marketed oxycontin. Federation of State Medical Boards released policy reassuring physicians they wouldn t face regulatory action for prescribing. 2000s Joint Commission published a booklet stating opioids were non addictive. The 5th vital sign became a JC requirement

5 Decade of Pain Control and Research HR 3244

6 We Swung the Pendulum to the Other Side No Opioids for Chronic Pain Goal Help Patients Manage Opioids for All Pain Goal Eliminate Pain

7 2008: Opioid Results - of the Decade of Pain Control and Research Opioids don t work for chronic pain: AAIPP, AAN, Cochrane Review Board, CDC.many more Opioids do work in the short term Well established role in severe forms of acute pain and end of life pain Much less evidence of effectiveness long-term pain relief Higher pain scores versus non-opioid users Decreased quality of life and employment Increase disability and healthcare utilization side effects including hyperalgesia Most people do worse

8 Mortality Data: US, Louisiana, NOLA US OD Deaths ( per CDC) 46,055 52,404 64,070 pending More than 300,000 lives since 2000 Louisiana - More prescriptions written than people in (6 th highest prescribing rate in the US) OD deaths pending New Orleans OD deaths pending

9 Louisiana Commission to Prevent Opioid Addiction April 2017 Opioid abuse costs Louisianans $ 296 million per year in health care cost Louisiana ranks 50 of 50 states in the United Health Care Foundation s report, America s Health Rankings ranking consistent since of the 3 primary drivers of poor health are directly influenced by the opioid epidemic (HIV and drug related mortalities) Over the past six years Louisiana has averaged 122 prescriptions per 100 persons. Six states prescribe more than Louisiana: Mississippi, Alabama, West Virginia, Oklahoma, Tennessee, and Kentucky

10 Louisiana Commission to Prevent Opioid Addiction April 2017 In Louisiana, males outnumber females in the rate of opioid overdose deaths (71%) as compared to females (29%). Whites outnumber all other ethnic groups (84%), African Americans represent the second highest group (12%) overdose deaths In 2015, suburban populations: Livingston, Washington, Plaquemine, Terrebonne, Orleans, and St. Tammany Parishes led the state with overdose rates that were at least 50% higher than the rest of the state. St. Tammany (50/yr) and Jefferson Parishes (55/yr) have the highest # of overdose

11 Worrisome Trends and Associations CDC. MMWR Nov 4, 2011 / 60(43); Tolia VN, et al. N Engl J Med May 28;372(22):

12 Cardinal features of the Epidemic Diversion of tablets Addiction Chronic pain Psychiatric illness Overutilization Marianne Maumus, MD

13 Learning Reward System and Pain Matrix PAG RVM

14 What is the transition to addiction? Acquired disease of the brain that persists long after the last use of the drug, produced by repeated phamacologic insult. Pharmacologic induced change in brain circuitry that strengthens learned drug-associated behaviors at the expense of adaptive responding for natural rewards Drugs usurps the development of normal learning circuitry Affects neuroplasticity in brain circuits and cell function Drug Addiction as a Pathology of Staged Neuroplasticity, Neuropsychopharmacology (2008) 33,

15 Brain Disease Model of Addiction Cortex PFC NA VTA Amygdala

16 Disease Model of Addiction Drug Addiction as a Pathology of Staged Neuroplasticity, Neuropsychopharmacology (2008) 33, September 5, 2007, p Nora, Volkow, MD, George F. Koob PhD, Thomas McLellan, Neurobiologic Advances from the Disease Model of Addiction, NEJM, January 28, 2016

17 Transition Stages of addiction/ stages of normal reward learning Abstinence 1. Social use/ First exposure 2. Regulated relapse (conscious) 3. Compulsive relapse (unconscious) I m adding a forth stage: 4. Palliative non-hospice, then hospice Drug Addiction as a Pathology of Staged Neuroplasticity, Neuropsychopharmacology (2008) 33, Neurobiologic Advances from the Brain Disease Model of Addiction, NEJM, January, 28, 2015: 374:4

18 What is chronic pain? Pain that is greater than 3 months Associated with fear and avoidance behaviors Leads to, and overlaps with opioid dependence Needs attention to psychosocial factors Chronic pain is treated differently than acute pain Needs a non-opioid multi-modal approach for treatment

19 Chronic pain Need to measure functional status rather than the fifth vital sign ( subjective pain scale) The goal of therapy is to improve the patient s functional status in the setting of pain, it is not pain relief. There is no high level evidence that opioids help. There is evidence that opioids worsen chronic pain. The incidence of chronic pain has increased in the last 20 years despite wide use of opioids.

20 Chronic Pain- Pathophysiology Central sensitization in the brain Dysregulation of descending modulation in the spinal cord

21 Pain Matrix: all 3 hierarchal dimensions of Modulation PAG RVM

22 Pain Matrix: Nociceptive input arrives PAG RVM

23 Pain Matrix: attention/perception areas (Conscious Modulation) ACC, INS ppar PFC PAG RVM

24 Pain Matrix: reappraisal-emotional areas (Unconscious Modulation) AL-PFC PGN-ACC ORB-F PAG RVM

25 Pain Matrix: all 3 hierarchal dimensions of Modulation PAG RVM

26 Opioids intensify neuroinflammation in the PAG zone, RVM and dorsal horn causing central sensitization.

27 Opioids re-inforce the memory of the pain matrix signature.

28 The Learning/Reward System and the Pain Matrix PAG RVM

29 Chronic Pain and Mental Health Disorders: Shared Neural Mechanisms, Epidemiology, and Treatment W. Michael Hooten, MD; Mayo Clinic Proceedings, July, 2016 Bidirectional relationship exist between chronic pain and mental health disorders Biopsychosocial Model of Pain Fear and Avoidance Model of Pain

30 Central Pain Syndromes: Parkinson s disease Multiple Sclerosis Phantom limb pain Post stroke pain Spinal injury Hangover

31 Opioid related Central sensitization: Opioid withdrawal pain Hyperalgesia Allodynia opioid induced increased pain sensitivity Analgesia induced Has Chronic pain syndromes back pain, OA, fibromyalgia, etc. Suspect when Opioids fail to bring relief. It is a complication of opioid therapy

32 Proper pharmacologic treatment for Central Sensitization Neurontin tid Trazodone q hs Cymbalta 20 mg bid

33 Proper non-pharm treatment of Central Sensitization (Brain Pain) Conscious mind Education, cognitive behavior therapies, acceptance therapies Teach how to recognize and avoid unconscious impulses Teach coping skills (serial relaxation, deep breathing, etc) Teach to recognize fear and avoidance behaviors (Pain Catastrophizing) Unconscious mind Distraction Biopsychosocial approach Functional Rehabilitation

34 COMMUNITY LEADER INDEPENDENCE Wearables Physical Therapy Non-opioid Medications-TCA Group Therapy Music Therapy Cognitive Behavioral Therapy Pain Education Yoga AA Meetings Prayer Functional Restoration Monitoring Teach Relaxation Techniques Marriage and Family Counseling Tai Chi Exercise Hospital Medicine/ED Certified Pain Educators/ Pain Management Hospital ADDICTION Clinic PREVENTION ED C H R O NI C PA I N Bio- Psychosocial Care/ Primary Care Psychiatry Pet Therapy Psychotherapy Reinforce Boundaries and Limits around Medication Use Mindfulness Fear Reduction Community Engagement Address Fear and Avoidance Behavior Acupuncture Brain Health Social Services Distraction FAMILY ROLE MODEL Massage Psycho Spiritual Care Anti-seizure Meds, SNRIs Occupational Therapy Volunteer SELF-MANAGEMENT

35 COMMUNITY LEADER INDEPENDENCE Wearables Physical Therapy Non-opioid Medications-TCA Group Therapy Music Therapy Cognitive Behavioral Therapy Pain Education Yoga AA Meetings Prayer Functional Restoration Monitoring Teach Relaxation Techniques Marriage and Family Counseling Tai Chi Exercise Hospital Medicine/ED Certified Pain Educators/ Pain Management Hospital ADDICTION Clinic PREVENTION ED C H R O NI C PA I N Bio- Psychosocial Care/ Primary Care Psychiatry Pet Therapy Psychotherapy Reinforce Boundaries and Limits around Medication Use Mindfulness Fear Reduction Community Engagement Address Fear and Avoidance Behavior Acupuncture Brain Health Social Services Distraction FAMILY ROLE MODEL Massage Psycho Spiritual Care Anti-seizure Meds, SNRIs Occupational Therapy Volunteer SELF-MANAGEMENT

36 COMMUNITY LEADER INDEPENDENCE Wearables Physical Therapy Non-opioid Medications-TCA Group Therapy Music Therapy Cognitive Behavioral Therapy Pain Education Yoga AA Meetings Prayer Functional Restoration Monitoring Teach Relaxation Techniques Marriage and Family Counseling Tai Chi Exercise Hospital Medicine/ED Certified Pain Educators/ Pain Management Hospital ADDICTION Clinic PREVENTION ED C H R O NI C PA I N Bio- Psychosocial Care/ Primary Care Psychiatry Pet Therapy Psychotherapy Reinforce Boundaries and Limits around Medication Use Mindfulness Fear Reduction Community Engagement Address Fear and Avoidance Behavior Acupuncture Brain Health Social Services Distraction FAMILY ROLE MODEL Massage Psycho Spiritual Care Anti-seizure Meds, SNRIs Occupational Therapy Volunteer SELF-MANAGEMENT

37 Marianne Maumus, MD

38 Assessing Opioid Risk ORT >3 Current/update Opioid history Pain history Psychiatry history DOSE MEDD >90 benzo PMP Urine drug screen Opioid complications: withdrawal SE overdose gastroparesis hyperalgesia analgesic HAs Narcotic Bowel Syndrome Aberrant Behaviors: Lost script Reluctance to wean Altering a prescription Doctor shopping Multiple pharmacies Multiple allergies Request specific therapy Provider splitting Request anti-histamine Self- inflicted wounds Source of pain changes Reluctant to self-care More. Drug Effects: Dependence Tolerance Addiction Pseudo-tolerance Pseudo-addiction Marianne Maumus, MD

39 Medical Evaluation: Side effects of opioid history: Nausea Vomiting Sweating Constipation Itching Mental cloudiness Fatigue Drowsiness Respiratory suppression Sedation

40 Medical evaluation: Withdrawal symptoms Abdominal pain Nausea Vomiting Diarrhea Dilated pupils

41 Medical evaluation: Late Complications of Opioids Gastroparesis Narcotic Bowel Syndrome Hyperalgesia Analgesic induced Headaches Overdose

42 Medical Evaluation: Aberrant behaviors Unwillingness to cooperate with assessment Manipulative behavior observed Untruthfulness directly observed Splitting health care providers: History of stolen or lost prescriptions Reluctance to wean/ discontinue narcotic once acute illness resolved History of Altering a prescription Doctor shopping or multiple doctors Hospital shopping or multiple hospitals Multiple allergies Request specific therapy Request antihistamines with narcotic

43 Aberrant behaviors Self inflicted wounds Multiple pharmacies Actions and behavior do not match patients description of the pain Source of pain changes Exaggeration of facts Recurrent admissions Reluctant to appropriately self care: wound care, follow directions to prevent deterioration of problem Solicited opioids from another provider Unauthorized dose escalation, abused prescribed drug Abnormal urine drug screen Used additional opioids than those prescribed No show or no follow up

44 Medical Evaluation: MEDD Oral Morphine equivalent dose, 24 hour (7am-7am) = IV drug: Dilaudid 1 mg = 20 mg po morphine Morphine 1 mg = 3 mg po morphine Oral drug: hydrocodone (lortab) 5 mg = 5 mg po morphine oxycodone ( percocet) 5 mg = 5.5 mg po morphine dilaudid 1 mg = 4 mg po morphine Transdermal Fentanyl 25 mg fentanyl patch = 60 mg oral MS

45 Epic MEQ Calculator

46 Medical evaluation: Drug effects Tolerance time reduces drug s effect Physical dependence abrupt cessation produced withdrawal symptoms Addiction impaired control Pseudoaddiction hostility results from true pain, increasing dose reduces aberrant behavior Pseudotolerance progression of underlying med/surg condition reduces drug s effect)

47 What is the Opioid Risk Tool? ORT >3 A discreet method of conveying sensitive information about a patient s past psychiatry history with a number value. Part of overall risk: Included is the opioid risk tool score, a pain history, an opioid history, a psychiatry history, the urine toxicology screen and a check of the prescription monitoring program (PMP) and the OME dose. Addresses 5 elements personal history of substance use family history of substance use history of psychological disease Age history of preadolescent sexual abuse.

48 ORT: an inter-department, intra-system communication tool a stop/pause/think measure alerts the provider whether a full risk/benefit analysis needs to be performed. The score is determined by previous providers Communicates risk in a sensitive fashion from visit to visit from previous physician to present physician from outpatient setting to in-patient setting from the psychiatrist to the ED physician or hospitalist, and vise-versa. ORT >3

49 ORT: Integrating evolving cultural norms into the health care system Failure to screen places that patient at risk for a life time of addiction. Validated evidence based tools are reflective of reality in the population should be routine to any provider who prescribes opioids. It is a minimum standard of care that the risk of addiction should be assessed prior to giving opioids to a patient. The ORT meets that minimum standard. Evolving cultural pathology requires new standards of care and new modes of communication. Health care systems must address gender biases Providers need to develop easy-to-use tools and standard scripts to address their discomfort.

50 Epic Opioid Risk Assessment Banner appears for patients needing assessment Score calculates upon answering questions

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52 Webster LR. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool. Pain Medicine. 2005;6(6): Definitions: Abuse deliberate overuse LOW RISK predicted that 6% would display aberrant behavior unlikely to abuse opioid MEDIUM -predicted that 28% would display aberrant behavior As likely will or won t abuse opioids HIGH- predicted that 91% would display aberrant behavior likely to abuse opioids

53 Marianne Maumus, MD

54 Diagnosis Acute pain Chronic pain syndrome Opioid Dependence Opioid Use Disorder Substance abuse disorder Acute Opioid withdrawal Opioid overdose Add any known psychiatric disorder Noncompliance of medication

55 Opioid Stewardship

56 Education Data Transparency Improving Practice Patient Resources Solving the Opioid Epidemic System Support Leadership and Physician Buy-in

57 Phase 1 Opioid Stewardship Identify At Risk/Addicted Patients Standard Practice of Care Supply Control Create Patient Registry System Standard for Screening Tool Check Registry PMP Check Quantity Potency Standards Narcotic Screen Tool Non Narcotic Short Term Long Term Pain Contract Drug Test Patient Education Naloxone Guidelines Physician Audit/ Feedback Physician Education Epic Alerts Epic Alerts # of Pain Contacts Opioid Utilization, ED Heroin OD, % of population below 200 MS04Eq Project management, Stakeholder communication, Grant Writing Epic Clinician Pharmacy

58 Our obligations Responsible evidence based prescribing Risk assessment on everyone not all patients have the same risk - ORT Knowing what patients are taking PMP Monitoring patient on long term opioid treatment pain contracts, registry, UDS, Physician and provider education Feedback about prescribing habits Patient education

59 Setting Expectations for Our Patients

60 Patient Education Handouts:

61 Increasing awareness Video and presentation at system wide retreat. Ochsner blog, To your health. Patient education handouts Speaking out locally and nationally Physician education

62 Pain Contract Provider prescribing opioids should initiate with chronic opioid users Patient and provider sign contract Contract includes various requirements for the patient Main requirement Can only have opioids prescribed by contract provider List of rules and a list of side effects and potential outcomes Banner to alert other providers patient is on pain contract

63 System-wide Patient Contract

64 Provider feedback about prescribing

65 Rx/Day Total Rx ED Opioid Prescriptions Opioid Prescribing in the ED , , , , Blinded Data Began Un-blinded Data 4, , , Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ,500 Rx/Day Total Rx

66 ED Compliance To Guidelines 90% % % 60% % % 30% 20% Blinded Data Began Un-blinded Data Formally Published Guidelines % 0% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Guideline % Average of MEQ/RX 75.00

67 Using our EHR to Help

68 Opioid Risk Tool (ORT) Assesses patient s risk of abusing opioids Series of yes/no questions Answers can be pulled in from other areas of chart (PMH, problem list, etc.) Access tool Opioid Management activity Banners

69 Opioid Risk Tool Banner A banner will display if the patient s ORT score is > 3 (Moderate/High Risk). A banner does not appear for low risk patients. The banner links to the patient s score, suggestions for treating moderate/high risk patients, and FAQs about the tool. Where Banners Appear: ED Provider-SXS Track Board, Orders and Patient Summary Report, Navigators: Review Visit, Discharge ED Nurse-Orders and Patient Summary Report, Navigators: Quick Look, Disposition Outpatient Encounters-Snapshot and Sidebar Reports, and the Patient Alerts section of the navigator. IP Provider-Summary Report and Discharge Med Rec on the New Orders tab.

70 Opioid Health Maintenance Plan Primary Care Four Opioid Health Maintenance Plans based on patient s risk level Unknown or Low Risk Pain contract Opioid Risk Tool (ORT) Moderate High Above plus Urine drug screen every year Above plus UDS every 6 months Prescribe naloxone

71 Health Maintenance Activity Patients who have been prescribed an opioid for 3 of the last 4 months will be automatically enrolled to an opioid management health maintenance plan depending on their risk of complication category. The Health Maintenance activity tracks the patient s progress on these plans. Health Maintenance can be accessed from the patient header or within the more button:

72 Opioid Management Activity

73 Best Practice Advisory (BPA) If the patient is overdue for any of the topics in a plan, a BPA will appear in the Best Practice Advisory Section alerting the provider that the patient has overdue topics. To access health maintenance, you can click the link in the BPA or select Overdue Health Maintenance from the patient header. Note: This BPA will not appear within Primary Care departments

74 Morphine Equivalent Daily Dose (MEDD) MEDD calculated for opioid outpatient prescriptions Normalizes various opioid potencies and doses Appears in workflows where providers prescribe medications

75 Louisiana Prescription Monitoring Program (PMP) one click

76 Preventing Patient Overdoses Identify High-Risk Patients Epic Alert to Help Identify Patients at High Risk for Overdose: Patient Takes an MEQ >90/day or Patient is Currently Prescribed Both an Opioid and a Benzodiazepine or Patient has a Diagnosis of Substance Abuse or Opioid Dependence. If MD Enters Opioid Rx and Patient Meets Criteria, Epic Alerts Provider to Consider Writing Naloxone Order Increase Naloxone Availability Established Naloxone Standing Orders in All Ochsner Pharmacies At the Time, Only 4 LA Pharmacies Had Naloxone Standing Orders

77 New Treatments for Pain

78 Innovative Approaches to Pain Treatment Healthy Back Program 10 Week Program- Two Times Per Week Patients Reported a 62.5% Decrease in Pain After 10 Weeks of Treatment Medicaid Grants to Provide Services Not Usually Covered: PT Paravertebral Facet Joint Blocks Virtual Reality to Reduce Initial Exposure to Opioids

79 Functional Restoration Program

80 Functional Restoration Program Results after completion so far ( 6 6-week sessions): A 37% decrease in disability due to pain A 29% improvement in sleep A 42% improvement in mood 30 days after the program, our patients are reporting even better results! A 51% decrease in disability due to pain A 32% improvement in sleep. A 63% improvement in mood

81 Opioid Free Surgeries/ procedures Opiate Free Protocol Cases > 2 Hours Pre-operative IV Acetaminophen and IV Ibuprofen Started with Colorectal & Urology Procedures Other Procedures to Limit Opioid Use: Knee & Hip Replacements

82 Safe pain management program $2 million NIH Grant proposal - pending For Primary care Modeled off the Coumadin clinic Managed by APPs and pharmacists Help wean patients expand psychosocial care Refer to a multi-modal approach Start non-opioid therapies

83 Expanding Psychiatry Care

84 Expanding Opioid Use Disorder Treatment Options Our New Psychiatric Hospital- River Place Behavioral Health- Will Open a Dual Diagnosis Unit in Early 2018 Offering Detoxification and Induction with Buprenorphine for Opioid Dependent Patients with Acute Psychiatric Issues Psychiatry's Suboxone Program (OchMAT) is Underway Adding Additional Support to Capture a Greater Range of Disease Severity. Intensive Outpatient Program for Substance Use (Addictive Behavior Unit) is Streamlining its Services for Opioid Dependent patients Providing Easier Access to Outpatient Suboxone Treatment. Collating Psychiatry resources in Ochsner Community Connect ( a web based resource guide)

85 Pregnancy and opioids 16.2% of pregnant teens and 7.4% of pregneant women are usiing illicit drugs 2010 Nat Survey on Drug Use Consequences: Medical MRSA infections, dentla disease, seizure disroders STDs HIV, Heb B and C, gonnhorea, herpes, syphilis Psychiatry problems - 70% of women w SUD have co-existing psychiatric disorder Obstetrical complications pre-term diliveries Neonatal abstinence Syndrome Sudden infant death syndrome Long term sequelae - maternal depression, child neglect, child abuse, developmental delays, behavior and perceptual problems

86 Partnerships on Path to Treatment and Recovery

87 Doing Our Part: Drug Diversion Response Team Pharmacy Use Data Analytics to Audit Internal Controlled Substance Utilization Investigate Any Reports of Drug Diversion or Loss of Controlled Substances Monthly Interdepartmental Meeting Representation from Pharmacy, Nursing, Compliance, Legal, and Pain Management In Pilot Phase- Plan to Expand to All Ochsner Sites in 2018

88 Engaging With Our Community Drug Take-Back Bins Supply Naloxone to Police Departments Education to Middle School & High School Students Future Partnership with LSU Vet School

89 Worked to Successfully Pass Louisiana Legislation Act #76 (Senate Bill 55) Requires Accessing a Patient s PMP Every 90 Days for Patients on Opioids >90 days. Auto Enroll Prescribers into the PMP Who Get a New License and at Renewal (Every 3 years) Require 3 Hours of Continuing Education Prior to License Renewal Act #82 (House Bill 192) Limit Opioid Prescriptions to Seven Days for a Patient s First Prescription Act #88 (House Bill 490) Create an Advisory Council on Heroin and Opioid Prevention and Education

90 CVS Collaboration CVS One Choice Changes Everything presentations Target middle school to high school students Taught by local CVS pharmacists on opioid awareness and the dangers of opioids Opportunity for OHS collaboration ongoing discussions

91 2018 Goals Education Opioid Conference Monroe Hall Educational Series PSO Protection Expand CVS Education into Schools Opioid Stewardship Website Data Transparency Sharing prescribing data throughout Primary Care Establish Routine metrics for Prescribing Multiple Prescribing Letter Develop System Metrics Improving Practice 100% Adoption of the PMP Inpatient MEQ Calculator Pre-Op Opioid Screening Opioid Smart Set Project ECHO Patient Resources Grants Safe Pain Management Program Addiction Treatment and Recovery More integrated (Investigate Referral Center) More non- pharmacological Chronic Pain Options Pediatric Sickle Cell Initiative

92 Call to Action Opioid Risk Tool Prescription Monitoring Program Opioid contracts Functional restoration Naloxone Urine point of care drug testing

93 end