Outreach to Providers as Part of Local Overdose Prevention Plans

1. Outreach to Providers as Part of Local Overdose Prevention Plans Yngvild Olsen, MD, MPH Medical Director, Institutes for Behavior Resources, Inc/REACH Health Services President, MATOD, Inc.

2. Outline • Provider context • Which providers and why • Local experiences • Resources • Key points

3. The Washington Post, May 7, 2001 “The lawsuit against physician Wing Chin, scheduled to go to trial tomorrow in Hayward, Calif., is one of the first U.S. cases in which a doctor has gone on trial for allegedly undertreating a patient's pain. The suit reflects an increasing aggressiveness by patients and advocacy groups eager to improve the treatment of pain in the United States.” Susan Okie

4. Epidemiology of Chronic Pain – Year 2000 • Prevalence • WHO estimates 5.5 - 33%* • Studies in primary care estimate 11-45%** • Leading cause of disability • Costly • Lost productivity • Health care resource utilization *Gureje, JAMA, 1998 **Kumpusalo, Fam Pract 2000; Croft, J Rheumatol 1993; Elliott, Lancet, 1999

5. Problem of Undertreatment • Michigan Chronic Pain Study: 70% had persistent pain* despite treatment • American Pain Society survey: 41% with moderate to severe pain had uncontrolled pain** despite treatment *APS, 2000 **APS, 1999

6. RESPONSES • JCAHO • Pain as “Fifth Vital Sign” • Addressing pain tied to accreditation • Pharmaceutical companies • Marketing • Development of new, potent opioid formulations • WHO Pain Treatment Ladder* *Miller, J Midwifery Womens Health, 2004.

7. BUT……. • Lack of clear, practical practice guidelines • Controversy over opioid effectiveness for chronic non-cancer pain • Limited medical training in effective pain management and appropriate opioid prescribing

8. Epidemiology of chronic pain -Year 2012 • Prevalence • General population estimates 25-30%*,** • Leading cause of disability • Aging population • Costly • Lost productivity • Health care resource utilization *National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain.**Johannes CB et al. J Pain 2010.

9. Problem of overtreatment • The quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices was 4 times larger in 2010 than in 1999. • Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for one month. CDC: http://www.cdc.gov/HomeandRecreationalSafety/rxbrief/index.html

10. Unintended Consequences • Non-medical use • The incidence of non-medical use of prescription opioids increased from 573,000 in 1990 to 2.5 million in 2002.* • Addiction • Admission rates to substance abuse treatment facilities for opioid abuse other than heroin increased from 1% of all admissions in 1997 to 5% in 2007.** • Non-fatal and fatal overdoses *Substance Abuse and Mental Health Services Administration (SAMHSA), 2005 **Substance Abuse and Mental Health Services Administration (SAMHSA), 2009

11. How do we move the pendulum back to the middle? Appropriate management of specific conditions for which controlled medications may be indicated Balanced by Risks of unintended consequences including overdose

12. Why do we need a middle? • Controlled prescription medications have legitimate medical indications • Avoid a return to a time of frequently untreated pain • Need to address all unintended consequences (medication mis-use, addiction, and overdose) to avoid additional unintended consequences

13. Unintended Consequence Pain clinic's patients are upset over closure; doctor suspended for 'improper prescribing‘ Several days after patients got word that the Intractable Pain Clinic in Fallston had closed, those who received care there and from its primary doctor, are feeling abandoned and wondering who will prescribe their medication. [One patient, a man] who is in his 40s, said he is disabled and has several medical issues, including a heart condition that causes heartpalpitations. He said he takes several medications and is worried that withdrawal could cause more problems than his body can take. "The more stressed I get, the [sicker] I get," he said. He said he had been prescribed 1 mg of Xanax three times a day, 10 mg of methadone four times a day and 20 mg ofPercocet four times a day. The man…..said he was unable to get medication from Harford Memorial Hospital and believed he would have the same result from his primary care physician later that day. Chris, a patient who didn't want his last name used for fear of being rejected as a new patient at another clinic, is also concerned about not receiving his medication and the impending withdrawal he'll experience if he doesn't find a doctor who will prescribe them to him. "The only people being affected are the patients," he said. "You're abandoned at this point." Like the Havre de Grace man and, undoubtedly, other patients, Chris has been looking for another clinic to go to since news came Monday that the office had closed. He said he was denied by one office on Wednesday because he doesn't have insurance and the medications he's been taking —oxycodone — that particular doctor doesn't prescribe. Source: The Aegis, BY MARISSA GALLO, February 16, 2012 

14. Source: DHMH, Drug and Alcohol Intoxication Deaths, Maryland, 2007-2011

15. Factors for Consideration in Outreach to Providers Increase Appropriate Prescribing Reduce negative unintended consequences • Prescriber education on effective assessment and management • Pain • Anxiety and Depression • Insomnia • Addiction • Clinical practice guidelines • Screening, Brief Intervention, Referral to Treatment (SBIRT) • Prescriber education on overdose risks and risk mitigation/REMS • Health Care Reform and integrated care delivery models • SBIRT • Addiction treatment • Prescriber education on overdose risks and response with naloxone • Rapid response interventions to assist patients abruptly cut off from controlled medications

16. Impact of behavioral health disorders • Ericsson et al*: • Of 184 chronic pain patients, 42% clinically depressed • Depressed pain patients had 7 times the odds of disability at 2.5 year follow-up compared to non-depressed pain patients. • Fishbain et al**: • Systematic review of 83 studies • Patients with history of substance use disorder have 4 times odds of aberrant drug taking behaviors*** *Ericsson et al, DisabilRehabil 2002;24:334-40 **Fishbain et al, Clin J Pain 1997:13:116-37 ***Reid et al, J Gen Intern Med, 2002

17. Source: Schwartz R et al. AJPH online ahead of print 3/14/13

18. Which Providers for Outreach • Prescribers of controlled medications • Primary care • Specialists (orthopedics, psychiatrists, pain management) • Hospital Emergency Departments • Urgent Care Centers • Dentists • Addiction treatment providers • Local providers • MATOD, Inc. • MDSAM

19. Strategies for Engaging Providers • The message is critical • Solution-focused • Prescribers and treatment providers are integral to long-term solution • Consider the language used in the message • Learning Collaborative and MHA anti-stigma efforts • Build on existing relationships • Provide opportunities for mutual learning between prescribers, treatment providers, and others • Highlight best practices • Develop collaborative networks • Identify local champions

20. More strategies for provider engagement • Consider SBIRT implementation • Include addiction specialist with expertise on opioid addiction treatment medications on local overdose prevention plan team • Collaborate with state and local medical societies • Addiction committee at MedChi

21. RESOURCES • AATOD/MATOD • http://www.aatod.org • ASAM/MDSAM • http://www.asam.org • PCSS – B • http://www.pcssb.org • PCSS – O • http://www.pcss-o.org • SBIRT • http://www.integration.samhsa.gov/clinical-practice/sbirt • NCADD –MD • http://www.ncaddmaryland.org • Local advocacy groups • Torsch Foundation – Baltimore County • Addictions Connections Resource, Inc – Harford/Cecil County • Heroin Action Coalition – Montgomery County and Carroll County

22. Summary of Key Points • Providers as part of the problem but also key to long-term solution • Involve prescribers of controlled medications and addiction treatment providers in local plans • Effective messaging is critical • Identify local champions • Build on existing resources and relationships • Have patience with the process and measure it

23. Critical provider-related local overdose plan components • Develop and distribute clinical practice guidelines and tools for appropriate opioid prescribing • Develop and distribute messages on addiction, treatment, and local resources • Adopt overdose response program with training and naloxone

24. Less Serious Most serious Aggressively complaining about need for medication Asking for specific medications by name Asking for non-generic medication Request to have medication dose increased Taking a few extra, unauthorized doses on occasion Claiming multiple pain medicine allergies Visiting multiple doctors for controlled substances prescription Hoarding medication Frequent calls to clinic Using a controlled substance for non-pain relief purposes (e.g. to enhance mood, sleep aid) Frequent unscheduled clinic visits for early refills Consistent disruptive behavior when arrives in clinic Obtaining controlled substances medications from family members Pattern of lost or stolen prescriptions Anger or irritability when questioned closely about pain Unwilling to consider other medications or non-pharmacologic treatments Frequent unauthorized dose escalations after being told that is inappropriate Injecting an oral formulation Forging prescriptions Unwilling to sign controlled substances agreement Selling medications Use of aliases Refuse diagnostic workup or consultation More concern about the drug than their medical problem that persists beyond the third clinic visit Obtaining controlled substance analgesics from illicit sources Consistently calling outside of clinic hours or when a particular physician is on call who prescribes controlled substances Deterioration at home or work or reduction of social activities because of medication side effects Aberrant drug-taking behaviors

25. ASAM 4 C’s* • Loss of control over the use of opioid medications • Compulsive use of opioid medications • Continued use of opioid medications despite harm • Opioid medication cravings *Savage, 2001