Southern Oregon Pain Conference 5/9/14
Amit Shah, MD
Jackson Care Connect
Overview-Epidemiology
 Most, if not all, aware of opiate inappropriate use, misuse and related
high rates of morbidity and mortality with chronic and/or high dose
usage
 It is clear (national, state, and local) that inappropriate prescribing of
opiates is not acceptable
 -JAMA-”Providers inappropriately prescribing are the most significant
reason for current epidemic”
 2012 Federal study that Oregon physicians only second to “*” in
willingness to prescribe opiates
 Prescribing patterns have changed but not to expected population-
public health levels needed
 2012 JCC 7 out of top 10 prescriptions were opiates, pain related
 2013 JCC 2 out of 10 prescriptions were opiates and unlike 2012 3 out of
10 were antidepressants but 15-17 yo trend continues to rise
 2014 JCC 4 out of 10 were opiates and 7 out of 10 were pain
related…what happened?
Prevalence-One view
ICD 9 Diagnosis
Encounters
1
Drug Dependence
2
Health Supervision Of Infant Or Child
6,631
3
Diabetes Mellitus
5,187
Other Symptoms Involving Abdomen And Pelvis
4,788
Symptoms Invlv Resp System&oth Chst Symptoms
4,295
6
General Symptoms
4,278
7
Alcohol Dependence Syndrome
3,471
8
Other And Unspecified Disorders Of Back
3,315
9
Acute Uris Of Multiple Or Unspecified Sites
3,047
10
Other And Unspecified Disorders Of Joint
3,045
31,959
4
5
Prevalence-Another View
ICD 9 Diagnosis
Encounters
Drug Dependence
31,959
Persistent Pain
18,897
Health Supervision Of Infant Or Child
6,631
Diabetes Mellitus
5,187
Symptoms Invlv Resp System&oth Chst Symptoms
4,295
Acute Uris Of Multiple Or Unspecified Sites
3,047
Prevalence-Shocking view
What do these represent?
 25,932
 2,149,668
 474,420
Dark history…
 Cephalon-Actiq-New Yorker
 Purdue Pharma, Execs to Pay $634.5 Million Fine
in OxyContin Case
 President, top lawyer and former chief medical officer
will pay $634.5 million in fines for claiming the drug was
less addictive and less subject to abuse than other pain
medications
 Purdue learned from focus groups with physicians in
1995 that doctors were worried about the abuse potential
of OxyContin. The company then gave false information
to its sales representatives that the drug had less
potential for addiction and abuse than other painkillers
Dark History…
 U.S. Senate panel launches investigation of painkillers,
drug companies
 seeking financial and marketing records from three
companies that make opioid drugs, including
OxyContin and Vicodin, and seven national
organizations
Dark History…
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Pain is the 5th vital sign
Limited to no standards on managing chronic pain
Limited to no BH/CD support structures in place
Limited to no understanding of the neuro-biology and
underlying BH issues
 If you prescribe controlled substances your license will
be reviewed vs. to not prescribe your license will be
reviewed
 Truth?
 11 year OMB case review re: opiate prescribing
1:9:35:161:461
 “1:9:35:161:461” should be known to all
 http://jama.ama-assn.org/content/307/8/774.full
 http://jama.ama-assn.org/content/307/8/774.full
 Morbidity and Mortality Weekly Report
 JAMA. 2012;307(8):774-776.
Overview-High Risk Patients
Type
Number
Cost
Initiative(s)
High Utilizers(CMMI)*
480
$8,800,729
(2% accounting for 25% of
cost)
CAP work, Providence ED
navigator, Community
health workers at La
Clinica & CHC
High Cost (10-50)*
2,026 (includes peds)
$17,000,000 (10%
accounting for 50-60% of
cost)
Same as High utilizers
Opiates*
872
?
OPG-?
Polypharmacy (Rx Risk
Score >10)*
96
$2,923,919
(<1% accounting for 8% of
cost)
Clinical Pharmacist
program development
SPMI
241
$1,751,280 (1% accounting
for 5% of cost)
Pediatric MH crisis
planning with JCMH and
Kairos, JCMH primary care
clinic; analytics;
ACG >0.3*
230
$6,645,055 (1% accounting
for 19% of cost)
Same as high utilizer work
*=high cross overcorrelation with each other
Overview-Prescription vs. Chronic
Pain
 Important to think of these as separated but related issues
(confusing 2 together has unintended consequences)
 Must work on provider, patient, community change
regarding this
 “Easy” to address prescription, but find that until this done
other critical interventions cannot occur
 Chronic Pain=Chronic Disease and so must be managed
accordingly:
 “Hey, this is no different than kidney disease or cancer or any
other disease” Vermont Governor State of Union Address
How to “move the needle”
 National, state, and local efforts identified the
following key strategies:
 “absolute” adherence to prescribing guidelines-must be
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policy-not just PCPs but starts here
Starts with ceiling dose
Build behavioral health and chemical dependence
treatment
“Upskilling” providers (especially PCPs)
Education for provider/staff/ patients/communities
IT support
Data driving change
 Hard conversations…
 Statistics not lie…but often only tell part of the story
 “What happens in exam room stays in exam room”
-pressures to meet visit expectations more and
more difficult and often deemed “futile” when
opiates in equation
Data
Opiate Use-Prescribing
% of Opiates Utilizing Members with Chronic Use
80%
70%
75,52
132, 82
60%
54, 27
50%
104, 62
65, 36
77, 40
45, 20
JCCCO Average
40%
63, 25
218, 84
98, 32
351, 104 (The rest)
30%
Benchmark
Clinics
42, 11
63, 14
20%
39, 8
75, 12
10%
JCCCO Average
7, 0
0%
0%
10%
20%
30%
40%
50%
% of Utilizing Members Using Opiates
60%
70%
80%
Members using opiates may belong
to one or more risk groups
 Chronic use risk: > 60 total days supply in 90 days
 Adverse effect risk (cocktail effect): combination with
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benzodiazepines, phenothiazines, or muscle relaxants
Dental utilization risk: potentially inappropriate dental opiate
prescriptions
Pain syndrome risk: high morphine equivalent per day >
120mg
High risk opioids: methadone or fentanyl
Chemical dependency risk: concurrent buprenorphine or
chemical dependency visit claim in past year
High diversion risk: high pill count of > 10 per day
High FWA risk: utilizer of >= 5 pharmacies or >= 5 prescribers
in 90 days
JCC members using opiates are categorized
in these groups
JCC members by number of members in risk group
800
753
Of members categorized into one or
more risk groups, the average number
of risk groups per member is 1.63.
700
600
500
471
400
300
233
204
200
203
148
100
60
18
0
Chronic
Cocktail
Dental
Chem dep
Pain
High risk Diversion FWA risk
syndrome
meds
risk
* Benzodiazepine claims for clonazepam only, the majority of benzodiazepine claims are paid under DMAP.
Regulatory support
 42 CFR 431.54(e), 456.3 and 455.1-16: Federal requirement of all
Medicaid agencies to have programs to evaluate FWA and overutilization and allows for lock-in programs.
 OAR 410-121-0135 and ORS 414.350 , 414.360 (c) (a-h): State provision
pursuant to above federal requirement for a Pharmacy Management
Program limiting clients to a specific pharmacy.
 DMAP selects clients for the Pharmacy Management Program who
 used 3 or more pharmacies during the prior 6 months
 use multiple prescribers to obtain prescriptions of the same or comparable
medications
 have altered a prescription
 exhibit patterns of prescription drug use 1
1. Oregon Health Authority Pharmaceutical Services Administrative Rulebook Chapter 410, Division 121, effective February 21, 2013
Specific interventions
 Ceiling dose
 Current Oregon “standard” is 120 MED
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Study re: 50-200 MED mortality-WA set 120 MED
Current trend is 60 MED
Portland 120 but moving to 60
CPCCO 120 but considering 60
YCCO 120
Medford-AllCare 120, OPG recommend 120, JCC will adopt
community standard
3 groups of high dose patients-Diverter, High Risk, all others
 Trend is can work on “all others” over time
Specific Interventions-Map
 3 Core focus areas:
 What is need in clinic and with providers

Guidelines, education, “up skilling”
 Behavioral Health
 Chemical Dependency/Addiction
Management/Treatment
Specific Interventions
 National (Neighbors)
 WA furthest along: ECHO, 60 MED, provider education, policy regulatory requirements
(licensure, state law refer to specialist, strong evaluation)
 State
 EDIE, SBIRT, Screening for Depression, PDMP, less State, “centralized” approach than WA
 Portland
 Community adherence to guidelines (forced interventions), ED dental diversion, OCEP
adherence, centralized MAT/referral, BH foundation in PCP clinics, ECHO, provider up
skilling (EMR protocols, pharmacy protocols), non-medication interventions-OT, PT, CD
integration-care coordination, SBIRT, Screening for Depression, just starting jail to
community interventions
 CPCCO
 Required PIP, Guideline adherence, CCO ongoing opiate oversight-subgroup (as delegated
by CAP), CCO red flag patient identification and interventions (lock down, etc.), specific
clinical guidelines for high occurring dx (HA, LBP),population analytics, SBIRT, ECHO,
Pain Clinic formation in partnership with BH/CD, Mid Valley BH,PCP, Hospital, Dental
piloted in coast-”Buy it and Build it”
 YCCO
 Moving in CPCCO space but more “build it” model, SBIRT, community adherence to
guidelines, moving toward 60
What should we do?
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Pilot and spread
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Build BH/CD (in PCP, in ED [e.g. ED navigator ?screens CD], centralized vs. PCP office vs. both)
PCP upskilling –IT, ECHO, opiate oversight-some kind of case consultation, support, etc. “real time”
Build community resources for non-medication treatments
Organization priority-”buy in” support
Public Health communications-messaging
Regulatory
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Credentialing
Ceiling dose management
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Clear outcomes wanting from pilot and “move fast”
Once have momentum hard to stop
Build PCP tools to do this (EMR, tapering protocols, etc.)
Guideline adherence
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Ceiling dose-community, multi-payor standard (120?)
Clarity on contraindications
Clarity on determining appropriate vs. inappropriate for opiates
Develop key, highly penetrated diagnosis/ clinical guidelines (HA, dental pain, LBP)
How to do?
 OPG-community clarity on specific concrete outcomes wanting in 90 days, 6 months, 1
year (“bite size”)
 Pilot to accomplish above
 Integration with High Utilizer strategy
 Plan for BH/CD build
 High penetration diagnosis guidelines
 Plan for non-medication management strategies
 Pain clinic services-”build it or buy it,” PCP office focus or centralized like CPCCO?
 PCP up skilling with concrete tools
 Education on the neurophysiology of persistent pain
 IT support
 EMR optimization
 ECHO, EDIE, JHIE, Vista Logic
 CCO analytics (red flag list, lock down, patient lists, utilization analysis, risk)
 Policy
 Multipayor ceiling
 Credentialing
 Aligning hospitals (e.g. ER guidelines)
Questions?
“One’s philosophy is not best expressed in words; it is
expressed in the choices one makes…and the choices we
make are ultimately our responsibility.”