PRIUM Educational Services Managing Drugs & Chronic Pain in Work Comp

PRIUM Educational Services Managing Drugs & Chronic Pain in Work Comp

Your Speaker Mark Pew, Senior Vice President of Product Development PRIUM (www.prium.net) Medical Intervention on Clinically Complex Claims Mr. Pew brings over 30 years of expertise in the property and casualty and healthcare industries, strategic planning, and technology to his presentations. He has worked with PRIUM in a variety of roles since 1989 including IT, operations, product and service development, and executive management. Other experience includes CoreSpeed, MedicaView International, ChoicePoint and Equifax. Mr. Pew has been following the prescription drug issue since 2003 and created PRIUM s Medical Intervention Program. Current responsibilities at PRIUM include marketing, product development and educational outreach.

Learning Objectives 1. Review the prescription drug issue in the US and Work Comp 2. Define opioids and clarify when to and how to use them 3. Define other prescription drugs and Polypharmacy 4. Recognize inappropriate treatment patterns and red flags 5. Outline the weaning process 6. Identify methods to identify and implement treatment plan changes Additional Resources: Katrina Disaster Working Group, 2006 FDA Blueprint, 2011 Responding to America s Prescription Drug Abuse Crisis, 2011 Pacing functional restoration, 2013

The Drug Problem U.S. Culture The CDC calls it an epidemic and health crisis The US comprises 4.5% of world population yet consumes: 65% of all illegal drugs 80% of all opioids 49% of all morphine 99% of all hydrocodone Sources: Kuehn BM. Opioid prescriptions soar: increase in legitimate use as well as abuse. JAMA 2007; 297:249-51 Manachikanti, Laxmaiah, and Singh, Angelie, Therapeutic Opioids: A Ten-Year Perspective of the Complexities and Complications of Escalating Use, Abuse, and Nonmedical Use of Opioids. Pain Physician, March 2008 Joint Meeting of the Drug Safety and Risk Management Advisory Committee, Non-prescription Drugs Advisory Committee, and the Anesthetic and Life Support Drugs Advisory Committee Meeting, June 20-30, 2009 Per the AMA Guides March/April 2011 Newsletter, non-compliance (misuse, overuse, non-consumption) occurred in more than 70% of patients According to the National Survey on Drug Use and Health (2009-2010) 70% of America s first-time prescription drug abusers got the drugs from family and friends

The Drug Problem Workers Compensation According to NCCI s Workers Compensation Prescription Drug Study: 2013 Update Prescription drugs are, on average, 18% of medical costs CompPharma estimates 12-14% in 2013 Narcotics account for 25% of drug costs Physician dispensing was 17% of total paid Rx in 2011 Costs are driven more by utilization than price According to CompPharma s 2013 Prescription Drug Survey Employers and insurers will spend $4B on prescription drugs in 2013 According to the National Drug Intelligence Center OxyContin / Opana street price is between $.50 - $1 per milligram

The Drug Problem Physicians It is easier to write a prescription than to come to an understanding with the patient. -- Franz Kafka Physician dispensed drugs creates improper motivations www.dispensingprofit.com ( easy and profitable program ) It s about revenue Per CWCI research paper (February 2013) As of 2011, over half of all prescriptions were physician dispensed Patient had up to 5 pharmacies within 2.2 miles of physician s office

The Drug Problem Opioids 2011 study on opioid discontinuance trends Almost 30,000 patients (primarily private health plans) prescribed opioids continuously for at least 90 days during a 6-month period Approximately 66% were still on opioids after 5 years Attributing factors were: Intermittent prior opioid exposure Daily opioid dose > 120mg MED Possible opioid misuse Source: Martin BC, et al. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med. 2011 Dec; 26(12): 1450-1457, http://www.ncbi.nlm.nih.gov/pubmed/21751058 2009 study of non-specific, low back-pain Work Comp cases Costs escalate as work loss persists Odds 6x greater for chronic (> 90 days) work loss with Schedule II opioids Odds 11-14x greater with opioids of any kind during period of 90 days Post-injury 3 years, costs of claims with Schedule II opioids averaged $19,453 higher Source: Volinn E, et al. Opioid therapy for nonspecific low back pain and the outcome of chronic work loss. PAIN Volume 142, Issue 3 (April 2009), pages 194-201, Abstract

Opioids Defined Opioid (narcotic) Pain Purpose: Relieve pain by acting directly on the central nervous system (oral, topical). Refills are generally prohibited without new script Possible Side Effects: Sedation, drowsiness, impairments, constipation, respiratory depression, nausea, headache, stomach pain. Extremely high potential for abuse, dependence, addiction and diversion On-label Uses: Before/during/immediately after surgery, cancer and AIDS patients Reasonable Off-label Uses: Lowest effective dose to decrease pain, increase function, improve quality of life Red Flags: Used more than 6 contiguous months, aggregate dosage exceeds 120mg MED/day, DOI of more than 3 years, no change in levels of pain or function Examples: Actiq (Fentanyl lollipop), Exalgo (Hydromorphone ER), Avinza / Kadian (Morphine ER), OxyContin (Oxycodone ER), Nucynta (Tapentadol), Duragesic (Fentanyl transdermal), Ultram (Tramadol)

Opioids Defined Risk management before prescribing Prior substance abuse Personal or family substance abuse history Test: Diagnostic Criteria for Substance Dependence DSM-IV from the American Psychiatric Association Potential addiction/dependence issues Adverse childhood experiences (ACE), www.cdc.gov/ace Neglect Physical, emotional, sexual abuse Test: Opioid Risk Tool (ORT), Screener and Opioid Assessment for Patients with Pain (SOAPP) Psychological makeup Mental illness Psychological stress (chemical coping) Test: Patient Health Questionnaire (PHQ-9)

Opioids Defined What Official Disability Guidelines (ODG) say about Opioids Establish a treatment plan Are there reasonable alternatives, is the patient likely to improve, screened for the risk of addiction, therapeutic trial only after non-opioid therapy has failed Determine if pain is nociceptive or neuropathic and any underlying psychological issues, set goals, pain agreement, discussion of risks Initiating therapy For intermittent pain, start with short-acting opioid, one drug at a time For continuous pain, use extended-release opioids Only change one drug at a time Establish opioid treatment agreement If partial analgesia is not obtained, discontinue opioids Ongoing management Only one prescriber and one pharmacy Lowest possible dose to improve pain and function Drug screening Regular pain assessment to gauge improvement (or lack thereof) in pain control and function

Opioids Defined What ODG says about Opioids When to discontinue opioids No overall improvement or decrease in function Continuing pain with lack of significant benefit from opioids If serious non-adherence (to dosage, to opioid treatment agreement, illegal activity) is occurring The patient requests discontinuance Resolution of pain When to continue opioids If the patient has returned to work If the patient has improved functioning and pain

Opioids Defined Morphine Equivalent Dosage (MED) A method developed to adjust for the various potency of opioids into a common measurement (morphine, which would be a 1:1 ratio) Per ODG, the Factor to be used when calculating MED Codeine - 0.15 Fentanyl (Actiq) oral transmucosal - 10 Fentanyl (Duragesic) transdermal (in mcg/hr) - 2.4 Hydrocodone - 1 Hydromorphone - 4 Methadone, 41 to 60mg per day - 10 Methadone, >60mg per day - 12 Morphine - 1 Oxycodone (OxyContin) - 1.5 Oxymorphone (Opana) 3 (Quantity / Day Supply) = Daily Pill Count * Dosage * MED Factor = MED

The Cocktail But Opioids aren t the only problem NSAID (non-steroidal anti-inflammatory drug) Long-term use can cause kidney failure and/or liver failure Prescriptions where OTC would suffice Examples: Flector patches, Voltaren (Diclofenac Sodium), Celebrex (Celecoxib), Ketoprofen, Mobic (Meloxicam), Relafen (Nabumetone) Skeletal Muscle Relaxants Should not be used for more than 2 contiguous months Soma/Carisoprodol metabolize into an addictive drug Examples: Soma (Carisoprodol), Amrix (Cyclobenzaprine), Valium (Diazepam), Lioresal (Baclofen), Skelaxin (Metaxalone), Zanaflex (Tizanidine) Benzodiazepines Weaning can take up to 18 months First time they are prescribed, Case Management should be involved Examples: Alprazolam (Xanax), Clonazepam (Klonopin), Diazepam (Valium), Lorazepam (Ativan), Temazepam (Restoril)

The Cocktail PAIN Oxycontin Fentanyl? Insomnia Lethargy Atrophy Depression Weight gain Sexual dysfunction Constipation Addiction Ambien Provigil Soma Cymbalta Bariatric surgery Viagra Doc-Q-Lase Suboxone All of this makes the pain harder to identify and treat

Inappropriate Treatment Patterns Treatment Red Flags Opioid dosage exceeding 120mg MED (morphine equivalent dosage) per day Acetaminophen dosage exceeding 4000mg per day NSAID dosage exceeding 3200mg per day Opioids used for more than 2 contiguous months after surgery Muscle relaxants used for more than 2 contiguous months NSAIDs used for more than 6 contiguous months Benzodiazepines used for more than 4 contiguous weeks Topical analgesics Anti-narcoleptic drugs (Provigil, Nuvigil) Hormonal supplements Spinal Cord Stimulator / Intrathecal Pump and topical / oral analgesics Drug regimen that has automatic refills More than one prescribing physician involved in the overall drug regimen No opioid treatment agreement No urine drug monitoring No liver / kidney toxicity tests where applicable

The Weaning Process More Art than Science Detox/weaning/FRP has become a four-letter word for Work Comp Two primary contributors to success 1. Motivation of the patient 2. Competence of the provider

The Weaning Process Before Health assessment General medical, psychiatric and surgical history What drugs in addition to opioids are being taken? Risk assessment before the process starts Patient motivation Psychological dependence, anxiety Level of medical oversight required In-patient / out-patient Goals Reduction in dosage or removal of drugs Identify how patient will manage pain with less/no dosage Patient education Explain Risks and potential benefits Develop realistic expectations Per the AMA Guides March/April 2011 Newsletter, 21 of 23 patients in the study reported a significant decrease in pain after detoxification

The Weaning Process Selection Appropriate setting Cognitive Behavioral Therapy (CBT) Functional Restoration / Chronic Pain Management program In- or out-patient detox Can the treating physician facilitate the weaning? Has success been defined? If not, consider the following when selecting a facility: Is there a multi/inter-disciplinary approach? Do they offer alternative treatments (e.g. yoga)? Do they have in-patient access for significant addiction/health issues? Are patients assessed and sometimes denied entry? Are treatment plans customized per patient? Are changes in vital signs and function and pain control objectively measured and recorded daily? If inadequate progress are adjustments made? Are patients followed for at least one year post-discharge?

The Weaning Process During Withdrawal Generally not life threatening but can be very unpleasant Symptoms may include Vomiting, diarrhea, abdominal cramps Anxiety and agitation Muscle twitching and Restlessness Insomnia Flu-like symptoms Increased pain Per ODG, for patients that are not addicted and on relatively low dosage Taper by 20-50% per week Otherwise a slower process is suggested 10% every 2-4 weeks, down to 5% once ⅓ the original dosage There may be greater success if the patient is first switched to ER / LA drugs Each patient is different in response and duration

How to Implement Change Peer-to-peer, collegial, evidence-based Leverage PBM system, customize the formulary Consistent, coordinated, teambased follow up on changes Focus on prescriber, patient & claims professional The goal should be to: Remove impediments for appropriate drugs Discontinue/reduce inappropriate drugs Increase function and quality of life for the patient

Mark Pew Senior Vice President, Product Development (678) 735-7309 Office mpew@prium.net Our Evidence Based blog www.priumevidencebased.com