“Indiana’s Prescription Drug Abuse Epidemic” Education Subcommittee Update

1. “Indiana’s Prescription Drug Abuse Epidemic” Education Subcommittee Update Indiana Rural Health Association Deborah A. McMahan, MD August 8, 2013

2. Agenda • Education Subcommittee • Healthcare Provider Toolkit • Process for Development • Ten Key Prescribing Recommendations • Recommendations for Medical Licensing Board • Collaboration for Dissemination of Information

3. Education Subcommittee

4. Education Subcommittee Shelly Symmes Natalie Robinson Michelle Sybesma Cynthia Stone Michael Whitworth Cindy Vaught Tamara Weaver Sharon Blair Dr. Joan Duwve Dr. Deb McMahan Dr. Palmer Mackie Abby Kuzma Dr. Amy LaHood Pam Pontones Jim Mowry, PharmD Dr. Mark Gentry

5. Goal Raise awareness of the dangers of prescription drug abuse and misuse through the education of parents, youth, patients, and healthcare providers.

6. Subcommittees • Healthcare Provider Educational Subcommittee • General Education Subcommittee • Data and Outcomes Subcommittee • Legislative Subcommittee

7. Community Education Subcommittee Objective is to develop a state wide public awareness campaign to increase awareness and prevention of prescription drug abuse among specific populations. • Specific populations include parents, youth. Teachers, pregnant women and the elderly. • Considering a Teacher’s Toolkit for student education. We have to change the paradigm with which we view chronic pain as a community, state and nation.

8. Community Education Working Group Tamara Weaver Natalie Robinson John Silcox Abby Kuzma Lori Croasdell Sharon Blair Phil Zahm

9. Data and Outcomes Subcommittee Objective: to support the educational subcommittee and it’s working groups in identifying relevant data and statistics to both describe the issue as well as to evaluate the impact of the interventions recommended. • This subcommittee is charged with identifying relevant available data sets in Indiana • Developing and implementing a healthcare provider survey to assess current provide prescribing practices • Identify variables to monitor for new aberrant behaviors (e.g. heroin use) • Obtain a data set to describe current prescription drug use among vulnerable populations including youth, elderly, pregnant women, etc.

10. Data and Outcomes Working Group Providing and researching recent and current data to evaluate the overall goal of reducing prescription drug abuse and the death and illness associated with that abuse  Pam Pontones Dr. Joan Duwve Dr. Deb McMahan Dr. Todd Rumsey Jim Mowry, PharmD Marion Greene Cynthia Stone, DrPH

11. Healthcare Provider Educational Subcommittee Objective is to ensure adequate training to prescribers regarding appropriate prescribing and dispensing of controlled substances. • This subcommittee is developing an educational toolbox for providers: First Do No Harm: The Indiana Healthcare Providers Guide to the Safe, Effective Management of Non-Terminal Pain. • This committee will also partner with other subcommittees to identify the most effective methods of dissemination of these materials and outcomes to measure the successful implementation of the standards presented in the toolbox.

12. Process for Development

13. Healthcare Provider Working Group • Our goal was to have geographic, professional and specialty diversity represented in our group. • Formed a “working group” with folks that were already working with this issue in the private sector as well as academics. • We have met a number of times with two all day work meetings to discuss issues. • All recommendations have been vetted through this group.

14. Education Toolbox Working Group Developing user friendly guidelines and tools for primary care providers to use in the management of noncancerous pain. Dr. Joan Duwve Dr. Deb McMahan Dr. Palmer Mackie Abby Kuzma Dr. Amy LaHood Jim Mowry, PharmD Dr. Mark Gentry Dr. Eric Schrier Tracy Brooks, PharmD Cynthia Stone Dr. Greg Eigner Dr. Dan Roth Natalie Robinson Michelle Sybesma Michael Whitworth Dr. Kalyan Rao Alicia Elliot Pat Weicher, RN Ersin H. Özlem, PhD Dr. Tim King

15. Compared our Recommendations with Other Respected Guidelines

16. Healthcare Provider Toolkit

19. Key Statistic A national survey of medical residency programs in 2000 found that, of the programs studied, only 56 percent required substance use disorder training, and the number of curricular hours in the required programs varied between 3 to 12 hours. http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/rx_abuse_plan.pdf Key Statistic A national survey of medical residency programs in 2000 found that, of the programs studied, only 56 percent required substance use disorder training, and the number of curricular hours in the required programs varied between 3 to 12 hours.

21. Ten Key Prescribing Recommendations

22. Recommendations • 1. Do your own evaluation. • Perform a detailed history/physical exam and obtain appropriate tests, as indicated. • Obtain and review records from previous caregivers • Ask your patient to complete a Brief Pain Inventory (BPI) survey to document and better understand their specific pain concerns. • After completing your initial evaluation, attempt to establish a working diagnosis and tailor a treatment plan to functional goals that your patient identifies with you, reviewing them from time to time.

23. Recommendations • 2.Risk Stratification for all. • Assess both the mental health status and risk for substance abuse in each patient with a diagnosis of chronic pain. • Mental health metrics such as PHQ-2 or PHQ-9 (for depression) and GAD-7 (for anxiety), are useful screening tools. • Ask patients about any past or current history of substance abuse (alcohol, prescription medications or illicit drugs) prior to initiating treatment for chronic pain. • A risk assessment survey (e.g. Opioid Risk Tool, SOAPP or COMM) should be completed at intake for every patient seeking treatment for chronic pain. Since risk levels may vary over time, repeat these assessments accordingly at follow-up visits. The use of chronic opioids in “high risk” individuals is strongly discouraged.

24. Recommendations • 3.Set functional goals with your patients that include achievable targets for pain management. • In general, it is unrealistic for patients to expect complete resolution of their chronic pain with any specific treatment or combination of therapies. • Work together towards improving pain control and achieving specific functional goals, as both are key outcomes. • Functional goals might include increasing physical activity level, resuming a job/hobby or improving the quality of sleep.

25. Recommendations • 4.Utilize evidence based treatments, including non-opioid options initially, where possible. • Refer to the flowchart entitled “An Approach to Managing Chronic Pain in Primary Care” for detail regarding a broad range of possible treatment options for your patients, based on their specific pain diagnosis. • Give strong consideration to non-pharmacologic therapies, in addition to the various medications available. • Also utilize available first-line pharmacologic options before prescribing opioids. • When you believe that an opioid trial is warranted, use the lowest dose of medication required to reduce pain and improve functioning. This will help to reduce the risk of overuse and also minimize the adverse effects that typically arise with this class of medication. Also explain from the outset that opiates will be discontinued if pain does not improve or if functional goals are not met. • Don’t begin a treatment that you are not prepared to stop.

26. Recommendations • 5.Discuss the potential risks and benefits of opioid treatment for chronic pain, as well as expectations related to prescription requests and proper medication use. • Provide a simple and clear explanation to help patients understand the key elements of their treatment plan. • Together, review and sign a “Treatment Agreement”, which includes the details of this discussion for all patients that are prescribed controlled substances (opioids, benzodiazepines, stimulants) on an ongoing basis. Refer to the sample “Opioid Consent Form and Treatment Agreement” included in the Tool Box.

27. Recommendations • 6. Avoid prescribing for patients without periodic scheduled visits.  • Evaluate patient progress and compliance with their treatment plan regularly and set clear expectations along the way (e.g. attending PT, counseling or other treatment options).  • Follow-up visits for patients with a stable treatment plan and receiving regular controlled substance prescriptions should probably occur at least once every 3-4 months.  • For patients working with you to achieve optimal management, more frequent visits would be appropriate.

28. Recommendations • 7. Remember the 5 A’s when managing your chronic pain patients with opioids: • Assess Affect (and screen for mental illness in general), ask about Activities of Daily Living (ADL’s), provide Analgesia to assist patients in meeting their functional goals, minimize Adverse effects of treatment, and monitor for Aberrant drug use behaviors.

29. Recommendations • 8. INSPECT: Indiana’s prescription drug monitoring program, helps us all.  • Use INSPECT regularly for both new and established patients.  This system tracks all controlled substance prescriptions filled by patients state-wide. • Links have been established with neighboring states as well. INSPECT is easy to use and there is no cost, so please register with the state at  www.in.gov/inspect • INSPECT reports should be run at least once every 3-6 months; or more often as desired or appropriate. 

30. Recommendations • 9. Urine drug monitoring (UDM) protects you and your patients.  • Urine drug monitoring has evolved to become a standard of care when prescribing opioids for chronic pain.  • UDM should be used at the initiation of an opioid trial and also periodically thereafter. 

31. Recommendations • 10. Action is required when a patient’s opioid dose reaches high levels (Morphine Equivalent Dose, or MED 50mg/day) and the patient is still reporting intolerable pain and/or no functional improvement.  See your patient for a complete review.  Then based on your assessment, consider these possible actions: • a) Institute a slow, compassionate therapeutic wean of the opioid or rotate to another opioid, if appropriate. • b) Refer patients to an addiction specialist for evaluation when a substance use disorder is suspected. • c) Enhance mental health support and physical well-being with a modified treatment plan that you monitor. • d) Refer to a pain management specialist for consultation and/or ongoing care.

32. Toolkit Resources • Resources • Screening tools • Sample informed consent • Sample treatment agreement • Follow-up tools • Great articles • Great websites • Videos

33. Recommendations for Medical Licensing Board

34. Medical Licensing Board and ISMA • Partnering with both agencies to incorporate our recommendations into the rules that MLB are required to draft.

35. Collaboration for Dissemination of Information

36. Dissemination of Information • Partnering with ISMA to create CME modules and educational materials to facilitate changes in practice required by rules and outlined in toolkit. • Hard copy, web version, maybe some apps

37. Summary

38. Summary • Adverse outcomes have created a need to examine our approach to chronic, non-terminal pain. • The MLB has been required to create prescribing rules. • Our toolkit will be an important resource for prescribers to utilize to facilitate changes in their practice.