MOA: Practice Managers Program Presented by: Kimber Debelak, CMC, CMOM, CMIS May 17, 2018 Pain Management & New Opioid Laws
Objectives and Educational Statement Objectives To understand the need for new guidelines To review the CDC guidelines To review new Michigan laws To translate this to individual practices Educational Statement This is intended for educational purposes only and is not to direct treatment. There is no financial incentive being provided to the speaker. All information is sourceable and available via internet.
Need for Opioid Prescribing Guidelines Previously there were sporadic and inconsistent guidelines under no central source National guidelines were out dated and were not evidence based Providers report insufficient training or schooling Need to clear, consistent guidelines Oversight and recommendations provided by CDC
Chronic Pain and Opioids 11% of Americans experience chronic pain Opioids are given for commonly prescribed for chronic pain Primary care is on the frontline of treatment and is responsible for 50% of all opioid prescriptions Since 1999, there have been more than 165,000 death due to overdose related to opioid prescriptions Nearly 2 million Americans age 14 or older abused or are dependent on opiates
Role of Prescribing Opioids and Overdose Deaths
Purpose, Use and Audience Primary Care Providers Physicians, NPs and Pas Treating patients 18 and older for chronic pain Chronic pain: lasting > 3 months or longer than normal tissue healing time Outpatient settings Does not include cancer treatment, palliative care or end-of-life care
Clinical Research Findings No long term outcomes in pain study No studies documenting pain relief or functional improvement > 1 year Opioid dependence in primary care up to 26% Dose dependence association with risks of overdose or harm Initiation with LA or ER increased risk of overdose Methadone associated with higher mortality No difference in pain or function with increased dose Increased likelihood of long term use of used for acute pain
Contextual Evidence Findings Effective non-pharmacological therapies Exercise, CBT, interventional therapies Effective non-opioid medications Acetaminophen, NSAIDS, anticonvulsants, antidepressants Opioid related overdose risk is dose dependent Factors that increase risk of harm pregnancy, older age, mental health disorder, sleep disorder breathing Providers lack confidence and training and patients are ambivalent about risk/benefit and worry about addiction
Final CDC Recommendations 12 recommendations grouped into 3 focus areas: Determining when to initiate or continue opioids for chronic pain Opioid selection, dosage, duration, follow-up and discontinuation Assessing risk and addressing harms of opioids
Recommendations - Determining when to initiate or continue opioids for chronic pain Opioids are not first line or routine therapy for chronic pain Establish and measure progress towards goals Ensure patients are aware of potential benefits, harms and alternatives
Recommendations - Opioid selection, dosage, duration, follow-up and discontinuation Chose predictable pharmacokinetics to minimie overdose risk Start low and go slow Recognie when opioids are needed for acute pain Follow-up with patients Tapering
Recommendations - Assessing risk and addressing harms of opioids Recognie factors that increase risk for opioid associated harms Look for multiple sources, high dosages or dangerous combinations Use urine drug screens to assess risk Avoid concurrent opioids with benodiaepines whenever possible What to do if you suspect opioid use disorder
Prescription Monitoring Programs (PMP) New system in Michigan used to be MAPS is now PMP AWARxE/NarxCare but still called MAPS Covers CS schedule 2-5 Response time average 0.4-0.8 seconds Gives clinical alerts Tied in to provider licensure
New Michigan Public Acts Acts 246-254 All pertaining to opioid risk, treatment and education All enacted in 2017 All effective in 2018 All tied into physician licensure and monitoring through LARA
Public Act 246 Require the disclosure of prescription opioid information and risks to minors and patients Effective 6/1/18
Public Act 247 Licensed prescriber may not prescribe a controlled substance in Schedules II-V unless the prescriber is in a bona fide prescriber-patient relationship with the patient. Bona fide prescriber-patient relationship means: The prescriber has reviewed the patient s medical or clinical record s and completed a full assessment of the patient s medical history and current medical condition. The prescriber has created and maintained records of the patient s condition in accordance with medically accepted standards. Effective date TBD for 2018
Public Act 248 Before prescribing or dispensing controlled substances to a patient in a quantity that exceeds a 3-day supply, a licensed prescriber must obtain and review a MAPS report concerning that patient. Exception: If the dispensing occurs in a hospital or a freestanding surgical outpatient facility and the controlled substance is administered to the patient in the hospital or facility. Effective 6/1/18
Public Act 249 Provides sanctions for failing to comply with the new MAPS usage mandates, failure to establish bona fide prescriber-patient relationships, and failure to inform patients regarding the risks associated with prescription opioid drugs Effective currently
Public Act 250 A health professional licensee or registrant who treats a patient for an opioid-related overdose is required to provide that patient with information regarding substance use disorder prevention or treatment services. Effective 3/27/18
Public Act 251 If a prescriber is treating a patient for acute pain, the prescriber shall not prescribe the patient more than a 7-day supply of an opioid within a 7 day period. As used in this section, acute pain means pain that is the normal, predicted physiological response to a noxious chemical or a thermal or mechanical stimulus and is typically associated with invasive procedures, trauma, and disease and usually lasts for a limited amount of time. Effective 7/1/18
Public Act 252 Before dispensing or prescribing buprenorphine or a drug containing buprenorphine or methadone to a patient in a substance disorder program, a prescriber must obtain and review a MAPS report on the patient. In certain circumstances, this patient information is protected and not to be reported. The new state law requires a prescriber to report data to MAPs if federal law does not prohibit the reporting of data concerning the patient.
Summary Points A strong physician/patient relationship that encourages transparency, respect, and healthy boundaries supports pain management. Multidimensional pain care that addresses all factors that can impact pain and disability is ethical care. Setting expectations and building resilience are essential tasks in pain management Balancing safety and effectiveness is a critical goal of pain management. Get involved in quality improvement and continuing education in pain management.
Review Unable to continue to avoid must take action Must educate your practice and your providers Review both CDC and state guidelines Opioid use disorder is at epidemic level, so this is not going away Know that the government is watching don t be a test case for them
Resources Provider and patient materials Checklist for prescribing opioids for chronic pain Fact sheets Posters Web banners and badges Social media web buttons and infographics CDC Opioid Overdose Website www.cdc.gov/drugoverdose/index.html
Resources COCA Call Webinar Series Fact sheets New Opioid Prescribing Guideline Assessing Benefits and Harms of Opioid Therapy Prescription Drug Monitoring Programs Calculating Total Daily Dose of Opioids for Safer Prescribing Pregnancy and Opioid Pain Medications
References CDC Guidelines https://www.cdc.gov/drugoverdose/prescribing/guideline.html MAPS https://www.michigan.gov/lara/0,4601,7-154-72600_72603_55478---,00.html New Michigan Laws summary http://www.michiganpa.org/news/385207/opioid-alert---new- Prescribing-Requirements.htm https://www.michigan.gov/documents/lara/bpl_apprissstatewideopioi dassessementmichigan_03-29-2018_620258_7.pdf