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Opioid Roundtable Discussion
February 19, 2019
Jessica Van Fleet-Green, MD
Ross Vogelgesang, MD
Kari Lima, MD
Lucinda Grande, MD
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Agenda
• Introduction of Speakers
• About PSW
• High Level Overview of Washington State Opioid
Prescribing Guidelines
• Non-Opioid Treatment Options
• Expanding Access to Lifesaving Treatments for
Opioid Use Disorders
• The Olympia Bupe Clinic: A High Capacity
“Medication First Clinic”
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About Physicians of Southwest WA (PSW)As a population health company, PSW has led healthcare innovation
with the guiding principle of supporting the physician–patient
relationship to improve the quality of care delivered.
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Strategic Priorities
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Innovation Model Results
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Presentation Goals
• Gain understanding and apply Washington State’s
Opioid Prescribing Rules
• Apply Bree Collaborative Guidelines for prescribing
• Demonstrate the utilization of various resources in
place for prescribing clinicians
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Washington’s Opioid Prescribing Rules
• 7 day pill limit for acute prescriptions and 14 days for
acute post-operative pain
• (Exemption allowed if clinical judgment is documented)
• Care plan and documentation requirements for each
phase of pain
• Mandated registration and targeted checks of the
prescription drug monitoring program
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Washington’s Opioid Prescribing Rules
• High risk patients require naloxone
• (50 MED for ARNP, 90 MED for physicians)
• Chronic Pain: Mandatory Consult when >120 MED,
written agreement, naloxone
• January 1, 2021: ALL controlled substances need
electronic transmission (10 or more prescribers)
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@WAMedCommission WMC.wa.gov
• Instructed by the legislature as ESHB 1427
• Legislative response due to the doubling of opioid related deaths between 2010 and 2015
• WMC must adopt rules that would establish prescribing requirements with the goals of:
• Reduce addiction rates;
• Reduce burden to opioid treatment programs;
• Opioid Taskforce was created• Meetings were held with expert testimony and public
comment;
Why Is This Happening?!?!
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@WAMedCommission WMC.wa.gov
• One-time CME regarding best practices in the prescribing of opioids;
• At least one hour in length;
• Completed by the end of your first full CME reporting period after January 1, 2019 or during the first full CME reporting period after initially being licensed, whichever is later.
Continuing Medical Education (CME) Requirements
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Bree Collaborative Post-Operative
Guidelines
• Type I (Rapid Recovery)
NSAIDS/APAP. If opioids
are necessary, prescribe
≤3 days (8-12 pills)
✓ Oral surgery
✓ Lap appy, inguinal hernia,
carpal tunnel, breast biopsy,
meniscectomy, node biopsy,
Vag Hysterectomy
• Type II (Medium Recovery)
NSAIDS/APAP. ≤7 days (up
to 42 pills).
✓ cases warranting more than 7
days, surgeon to re-eval the
prior to 3rd rx, taper within 6
weeks
• Type III (Long Term
Recovery) NSAIDS/APAP.
<14 days.
✓ cases warranting more than 14
days, surgeon to re-eval the
prior to 3rd rx, taper within 6
weeks
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Resources
• Washington State DOH Opioid Prescribing
https://www.doh.wa.gov/ForPublicHealthandHealthcare
Providers/HealthcareProfessionsandFacilities/OpioidPr
escribing
• Washington Medical Commission
https://wmc.wa.gov/resources/pain-management-
resources
• WSMA
https://wsma.org/WSMA/Resources/Opioids/Prescribin
g_Rules_And_Guidelines/prescribing_rules_and_guide
lines.aspx
• Bree Collaborative
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NON-OPIOID TREATMENT OPTIONS IN
PAIN MANAGEMENT
ROSS E. VOGELGESANG, M.D.
ALLIANCE PAIN AND WELLNESS CENTER
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EDUCATION AND TRAINING
• Graduate of University of Texas Medical School
• Internship: Medicine at the University of Tennessee, Bowld Hospital
• Residency: Oregon Health Sciences University of Medicine,
specializing in Anesthesiology
• Board Certified and Specializing in Addiction Medicine and
Anesthesiology
• Special Concentration in Pain Management
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DISCLOSURES
Faculty trainer for Medtronic intrathecal
pumps used for treatment of pain and
spasticity disorders
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LEARNING OBJECTIVES
•Limitations of opioid medications
•Alternative treatment modalities
•Non-narcotic pharmacological management
•Interventional therapies
•Case studies
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LIMITATIONS OF OPIOID MEDICATIONS
• Pain scale
•Addiction, Government oversite and
abuse
•Assess treatment success
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Alternative Treatment Modalities
Acetaminophen
Acupuncture
Chiropractic
Medicine
Cognitive
Behavior
Therapy
NSAIDSPhysicalTherapy
Massage
Therapy
Reflexology
Intervention
Therapy
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NON-NARCOTIC PHARMACEUTICAL MANAGEMENT
Prescribe medication to treat pain types:
• Nerve
• Muscle
• Structural
• Visceral
Natural supplements for pain:
• Turmeric
• Alpha Lipoic Acid
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INTERVENTIONAL THERAPIES
• Interventional spine
procedures
• Intraarticular joint injections
• Coordinate care with other
specialists
• Regenerative medicine
• Spinal cord stimulation (SCS)
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CASE STUDIES71 Y/O MALE
Diabetic Peripheral Neuropathy
• S/P Aortic Value Replacement
• A1c 5.8
• Opiates: Adverse Effects
• Other Treatment Modalities
90 Y/O MALE
Postlaminectomy Syndrome
• Other Health Comorbidities
• Long Standing Opioid Therapy
• Failed Conservative Therapy
• SCS Trial to Implant
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SUMMARY OF PRESENTATION
• Opioid Limitations
• Alternative Therapies
• SCS Today verse Yesterday
• Circle the Wagons
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"Few things a medical provider does are more important than relieving pain…pain is soul destroying. No patient should have to endure intense pain unnecessarily. The
quality of mercy is essential to the practice of medicine; here, of all places, it should not be strained.“
Marcia Angell, American Physician and Author
QUESTIONS
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EXPANDING ACCESS TO LIFESAVING TREATMENTS FOR
OPIOID USE DISORDER
KARI LIMA, MD
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OBJECTIVES
• DESCRIBE MEDICATION-ASSISTED TREATMENT OPTIONS FOR
OPIOID USE DISORDER
• UNDERSTAND THE PROCESS FOR OBTAINING DATA-2000 WAIVER
• IDENTIFY THE MISMATCH BETWEEN AVAILABILITY OF EVIDENCE-
BASED TREATMENTS AND NEED
• DEVELOP A PLAN TO IMPROVE ACCESS TO EVIDENCE-BASED
TREATMENTS IN YOUR OWN SETTING
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STATE OF THE CRISIS
• 130 OPIOID OVERDOSE DEATHS PER DAY
• OPIOIDS ACCOUNT FOR 68% OF ALL
DRUG OVERDOSE DEATHS
• BETWEEN 1999 AND 2017, OPIOID
OVERDOSE DEATH RATES INCREASED BY
SIX TIMES
• DRUG OVERDOSE DEATHS CONTINUE TO
INCREASE
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STATE OF THE CRISIS
• 130 OPIOID OVERDOSE DEATHS PER DAY
• OPIOIDS ACCOUNT FOR 68% OF ALL
DRUG OVERDOSE DEATHS
• BETWEEN 1999 AND 2017, OPIOID
OVERDOSE DEATH RATES INCREASED BY
SIX TIMES
• DRUG OVERDOSE DEATHS CONTINUE TO
INCREASE
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• 130 OPIOID OVERDOSE DEATHS PER DAY
• OPIOIDS ACCOUNT FOR 68% OF ALL
DRUG OVERDOSE DEATHS
• BETWEEN 1999 AND 2017, OPIOID
OVERDOSE DEATH RATES INCREASED BY
SIX TIMES
• DRUG OVERDOSE DEATHS CONTINUE TO
INCREASE
STATE OF THE CRISIS
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MEDICATION-ASSISTED TREATMENT OPTIONS
• BUPRENORPHINE/NALOXONE
• BUPRENORPHINE
• METHADONE
• NALTREXONE
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SUCCESS RATE SIGNIFICANTLY LOWER WITHOUT REPLACEMENT THERAPY
Sees, et al, Methadone Maintenance vs 180-DayPsychosocially Enriched Detoxification for Treatment ofOpioid Dependence A Randomized Controlled Trial JAMA 2000 283; 1303-1310
Kakko et al, 1-year retention and social function after buprenorphine-assisted relapse prevention treatmentfor heroin dependence in Sweden: a randomized, placebo-controlled trial. Lancet 2003; 361: 662–68
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CLEAR MORTALITY BENEFIT FROM MEDICATION ASSISTED TREATMENT
• METHADONE MAINTENANCE RESULTS IN AVERAGE OF 25 FEWER DEATHS PER 1,000 PERSON-
YEARS
• BUPRENORPHINE ALSO REDUCES OVERDOSE DEATH AND ALL-CAUSE MORTALITY
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MAT cost savingsMohlman MK et al, 2016
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DATA-2000 WAIVER
• ALLOWS PROVIDERS TO PRESCRIBE BUPRENORPHINE FOR THE
TREATMENT OF OPIOID USE DISORDER
• PHYSICIANS – 8 HOURS OF TRAINING (AVAILABLE FOR FREE!)
• ARNP/PA – 24 HOURS OF TRAINING (AVAILABLE FOR FREE!)
• WAIVER TRAINING OPPORTUNITIES
• ONLINE-ONLY TRAINING
• HALF-AND-HALF TRAINING (IN PERSON PLUS ONLINE)
• FRIDAY, MAY 15, 9AM-1PM AT PSPH 200 ROOM
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DATA-2000
• PROVIDERS WILL RECEIVE AN “X” WAIVER DEA NUMBER TO USE
• PROVIDERS SHOULD HAVE THE CAPACITY TO SEND PATIENTS TO HIGHER LEVEL
OF TREATMENT IF NEEDED
• PROVIDERS SHOULD ADHERE TO TREATMENT LIMITS
• INITIAL LIMIT = 30
• INCREASE TO 100 AFTER FIRST YEAR (MUST COMPLETE FORM)
• INCREASE TO 275 IF ADDITIONAL REQUIREMENTS MET
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POINT #1
TREATMENT FOR OPIOID USE DISORDER NEEDS TO BE OFFERED AS PART OF ROUTINE PRIMARY CARE
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PRIMARY CARE ATTITUDES TOWARD TREATMENT
• SURVEY IN VERMONT AND NEW HAMPSHIRE OF 108 FAMILY
PHYSICIANS (10% BUPRENORPHINE PRESCRIBERS)
• >80% REGULARLY SAW OPIATE-ADDICTED PATIENTS
• 70% FELT THEY SHOULD BE RESPONSIBLE FOR TREATING OPIATE
ADDICTION
• BARRIERS CITED:
DeFlavio et al, 2015
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Rosenblatt R et al, 2015
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POINT #2
PATIENTS NEED TO BE ENGAGED AT MULTIPLE POTENTIAL ENTRY POINTS AND BARRIERS TO
TREATMENT SHOULD BE MINIMIZED
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Initiation of MAT Continuation of MAT
Pregnanc
y
Post-
operative
and pain
care
Adolescent
case
managemen
t
Emergency
departmen
t
Criminal
justice
system
Emergency
housing
Hospital
admissio
n
Psychiatric
care / self
help
groups
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POINT #3
STRATEGIC COORDINATION IS REQUIRED TO DEVELOP THE WORKFORCE NECESSARY TO COMBAT
THE OPIOID EPIDEMIC.
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HUB AND SPOKE
• STARTED IN VERMONT, MANY STATES
IMPLEMENTING
• RECEIVING MAT AT SPOKES WAS VERY SIMILAR TO
RECEIVING ROUTINE MEDICAL CARE
• PER PERSON TREATED, MAT DECREASED INPATIENT
DAYS BY 1.46, ER VISITS BY 1.04, AND IMAGING BY
0.92
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SUMMARY: YOUR TO-DO LIST
• STEP 1 – TAKE WAIVER TRAINING ONLINE WAIVER TRAINING
• STEP 2 – APPLY FOR YOUR WAIVER SAMHSA APPLY FOR WAIVER
• STEP 3 – TREAT PATIENTS RESOURCES
• STEP 4 – ASK FOR HELP MENTORS EMAIL KARI
• STEP 5 – HELP OTHER PROVIDERS!
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REFERENCES NOT OTHERWISE CITED
DEFLAVIO JR, ROLAND SA, NORDSTROM BR, ET AL. ANALYSIS OF BARRIERS TO ADOPTION OF BUPRENORPHINE MAINTENANCE
THERAPY BY FAMILY PHYSICIANS. RURAL AND REMOTE HEALTH. 2015;15:3019.
MOHLMAN MK, TANZMAN B, FINNISON K, ET AL. IMPACT OF MEDICATION-ASSISTED TREATMENT FOR OPIOID ADDICTION ON
MEDICAID EXPENDITURES AND HEALTH SERVICES UTILIZATION RATES IN VERMONT. J SUBSTANCE ABUSE TREATMENT 2016;67:9-
14.
ROSENBLATT RA, ET AL. GEOGRAPHIC AND SPECIALTY DISTRIBUTION OF US PHYSICIANS TRAINED TO TREAT OPIOID USE
DISORDER. ANN FAM MED 2015;13(1):23-26.
TONG ST, HOCHHEIMER CJ, PETERSEN LE, ET AL. BUPRENORPHINE PROVISION BY EARLY CAREER FAMILY PHYSICIANS. ANN FAM
MED 2018;16:443-446.
WAKEMAN SE, BARNETT ML. PRIMARY CARE AND THE OPIOID OVERDOSE CRISIS – BUPRENORPHINE MYTHS AND REALITIES.
NEJM 2018;379(1):1-4.
WALSH SL, LONG KQ. DEPLOYING SCIENCE TO CHANGE HEARTS AND MINDS: RESPONDING TO THE OPIOID CRISIS. PREV MED
2019;128:105780.
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Lucinda Grande, MD
Physicians of Southwest Washington
February 27, 2020
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Dr. Grande has no relevant financial relationship with an
ACCME- defined commercial interest.
Off-label use of medication may be discussed.
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Describe common barriers to access of medication for opioid
use disorder
Explain the use of harm reduction to improve population
health among patients at high risk of adverse effects of opioid
use disorder
Demonstrate the effectiveness of the Medication First model
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AP Photo/Ted S. Warren
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Syringe Exchange Health Survey 2017, UW ADAI
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Syringe Exchange Health Survey 2017, UW ADAI
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Syringe Exchange Health Survey 2017, UW ADAI
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Syringes exchanged in Thurston County:
1,060,000
Estimated individuals served: 1,162
Syringe Exchange Health Survey 2017, UW ADAI
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Capital Recovery Center
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Consequences for missed No appointments, evening
hours appointments
Pharmacy challenges On-site dispensing, no cost
Judgment, expectations Peer-led program,
co-located with
syringe exchange
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Not enough waivered Rotating community
prescribers prescribers
Stigma against people Education of community
and
with OUD trainees
Stigma of criminal legal Jail outreach
involvement
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Custom Pharmacy
Support
Peer Recovery
Care Navigators
Nurse Care
Manager
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2 RNs
2 Peers
2-4 prescribers
Front Desk
Coordinator
The Olympian / Steve Bloom
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Average Age: 36 (18-
79)
Male: 58%
Incarceration: 69%
Homeless: 53%
Chronic pain: 40%
OD: 37%
The Olympian / Steve Bloom
751 Patients, January – November, 2019
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Number of
Patients
January 2019 – January 2020
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Visits
Per Day
January 2019 – January 2020
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Visits
Per Month
January 2019 – January 2020
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Living on the streets: 7 0
Stable housing: 1825
BEFORE AFTER
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“They don't toss you out the door for telling the truth.”
“I'm always made to feel welcome and that I'm important.”
Photos with patient permissionAP Photo/Ted S. Warren
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Recidivism
28+ day gaps
Pain relief
Quality Assessment
Overall effectiveness
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WWW.METRO.COM
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Psych meds, acute care, primary care
Referrals / Transfers
Diversion Risk
Housing / Transportation
Criminal legal system
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State Opioid Response Grant
Medicaid Transformation Demonstration
Cascade Pacific Action Alliance
Treatment Sales Tax (Thurston County)
Medicaid Billing
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Many people want to quit
Lowering barriers helps
Team-based care
On-site dispensing
Peers create a welcoming environment
Our Nurse Care Manager is a gem