Trea%ng  Pain  

Dr.  Randy  Easterling  MD,  The  Street  Clinic  

Medical  Director,  Marian  Hill  Chemical  Dependence  Unit    

Dr.  Daniel  Barne2  

Medical  Director,  BlueCross  BlueShield  Tennessee  

Randy  Easterling  has  no  financial  rela%onships  with  proprietary  en%%es  that  produce  health  care  goods  and  services.    

Daniel  BarneD  has  no  financial  rela%onships  with  proprietary  en%%es  that  produce  health  care  goods  and  services.    

DISCLOSURE  STATEMENT    

•  DIPLOMAT    AMERICAN  SOCIETY  OF  ADDICTION  MEDICINE  

•  MEDICAL  DIRECTOR    MARION  HILL  CHEMICAL  DEPENDENCY  UNIT    RIVER  REGION  HEALTH  SYSTEM,  VICKSBURG,  MS  

•  PRESIDENT  MISSISSIPPI  STATE  BOARD  OF  MEDICAL  LICENSURE  

 RANDY  EASTERLING,  MD  

TODAY’S  SPEAKER  HAS  NO  DISCLOSURE    TO  REPORT  OF  REAL  OR  APPARENT    

CONFLICT  RELATED  TO  THE    

CONTENT  OF  THIS  PRESENTATION.    

TREATING  PAIN  

CHRISTMAS  STORY  

WHY  ALL  THE  FUSS  ?  

•   DRUG  OVERDOSED  DEATHS  INCREASED    FOR  THE  11TH  CONSECUTIVE  YEAR  IN  2010.      

•  LEADING  DRUGS  RESPONSIBLE                                    FOR  FATALITIES  ARE  PRESCRIPTION  MEDS,  MOST  OF  WHICH  ARE  OPIOID  ANALGESICS.  

WHY  ALL  THE  FUSS  ?  

•  THE  CENTERS  FOR  DISEASE  CONTROL            AND  PREVENTION  FOUND  THAT  38,329            DIED  FROM  DRUG  OVERDOSE  IN  2010.  

•  THAT’S    UP  FROM  37,004    

     DEATHS  IN  2009,  AND          16,  849  DEATHS  IN  1999.  

WHY  ALL  THE  FUSS  ?  

•  NEARLY  60%  OF  THE  OVERDOSE  DEATHS  IN  2010  INVOLVED  PHARMACEUTICAL  DRUGS.  

•  OPIOIDS  ACCOUNT  FOR    75%  OF  THESE  DEATHS.  

WHY  ALL  THE  FUSS  ?  

•   IN  2009  ACCIDENTAL  OPIOID  OVERDOSE  BECAME  THE  #1  LEADING  CAUSE  OF  ACCIDENTAL  DEATH  IN  THE  U.S.  

•  ACCIDENTAL  OVERDOSE  EXCEEDED  TRAFFIC  ACCIDENTS.  

WHY  ALL  THE  FUSS  ?  

•  MORE  THAN  16,000  AMERICANS  DIED          LAST  YEAR  IN  THE  UNITED  STATES          FROM  ACCIDENTAL  OPIOID  OVERDOSE.  

•  U.S.  HAS  5%  OF  THE          WORLD  POPULATION.    

•  USE  99%  OF  THE          HYDROCODONE          PRODUCED  IN  THE  WORLD.  

WHY  ALL  THE  FUSS  ?  

•  ENOUGH  HYDROCODONE  WRITTEN  EACH  YEAR  IN  THE  U.S.  TO  GIVE  EVERY  MAN,  WOMAN,  AND  CHILD  IN  THIS  COUNTRY  5  MG  EVERY  4  HOURS  FOR  30  DAYS.  

•  111  TONS  WERE  DISPENSED  IN  2010:    69  TONS  OF  PURE  OXYCODONE    42  TONS  OF  PURE  HYDROCODONE  

WHY  ALL  THE  FUSS  ?  

•  IF  YOU  GIVE  A  PATIENT          HYDROCODONE    FOR  90  DAYS  –          REGARDLESS  OF  THE  REASON  …...  

•  66%  OF  THOSE  PATIENTS  WILL          BE  TAKING    HYDROCODONE          DAILY  5  YEARS  LATER.  

WHY  ALL  THE  FUSS  ?  

•  VICODAN  IS  NOW  THE  MOST  WIDELY  PRESCRIBED  MEDICATION    

     IN  THE  UNITED  STATES  …  

•  FOLLOWED  BY          LISINOPRIL  …  

•  THEN,  ZOCOR.  

WHY  ALL  THE  FUSS  ?  

•  7  MILLION  AMERICANS            ADDICTED  TO  PRESCRIPTION          OPIOIDS  IN  THE  U.S.  

•  TAKING  PRESCRIPTION          PAIN  KILLERS  WITHOUT          MEDICAL  NEED          INCREASED  75%          FROM  2002  TO  2010.  

WHY  ALL  THE  FUSS  ?  

•   IN  2010,  12  MILLION  AMERICANS            AGE  12  AND  OLDER  REPORTED            NON-­‐MEDICAL  USE  OF  PRESCRIPTION            PAIN  KILLERS  IN  THE  PAST  YEAR.  

•  NEARLY  ½  MILLION  EMERGENCY  DEPARTMENT  VISITS  IN  2009  WERE    

     DUE  TO  PEOPLE  MIS-­‐USING  OR  ABUSING                  PRESCRIPTION  PAIN  KILLERS.  

WHY  ALL  THE  FUSS  ?  

•  NON-­‐MEDICAL  USE  OF          PRESCRIPTION  PAIN  KILLERS        COSTS  HEALTH  INSURORS  UP          TO  $72.5  BILLION  ANNUALLY          FOR  DIRECT  HEALTH  CARE.    

•   98  OF  THE  TOP  100  DOCTORS            IN  THE  COUNTRY  DISPENSING  OXYCODONE                DO  SO  IN  THE  STATE  OF  FLORIDA.  

 NEONATAL  ABSTINENCE  SYNDROME  

HOW  DID  WE  GET  HERE  FROM  THERE  ?  

•  EVOLVED  INTO  A  SOCIETY  THAT  BELIEVES  WE  ARE  SUPPOSED    

     TO  FEEL  GOOD  ALL  THE  TIME.  

•  PAIN  AND          DISCOMFORT          ARE  BAD.  

CHEMICAL  COPING  

•  PHYSICIANS        ARE    EXPECTED          TO  ALLEVIATE  ALL                UNPLEASANTNESS.      

• PRESCRIPTION  OPIOIDS  ARE  PLENTIFUL    

   AND  VERY        INEXPENSIVE.  

STREET  PRICES  

– 10  MG  HYDROCODONE    …  $6  -­‐  $8.  

– OXYCODONE  …  $10  -­‐  $20  

– 4  MG  DILAUDID  …  $60  

– ADDERALL  …  $1  MG    

STREET  PRICES  

– BENZODIAZEPINE  $1  -­‐  $2  MG  

– RITALIN  $10  -­‐    $20  

– SOMA  $3  

MOBILITY  

• HIT  2  OR  3  DOCTORS  OFFICES  PLUS  SEVERAL  EMERGENCY  ROOMS  IN  12  HOURS.  

A  BEAST  THAT  CAN’T  BE  FED  

       THERE  IS  A  NEVER        ENDING  NEED          FOR  THE  DRUG.      

HOLY  TRINITY  

•  HYDROCODONE  IS  EASILY  COMBINED          WITH  OTHER  MOOD-­‐ALTERING  DRUGS.  

•  HYDROCODONE,          XANAX  AND  SOMA          ARE  THE  HOLY  TRINITY.      

DRUG  OF  CHOICE  

ADD  A  LITTLE  BIT  OF  JACK    

DANIELS  AND  YOU  HAVE    

THE  WHITNEY  HOUSTON  COCKTAIL.      

LAW  ENFORCEMENT  

•  VERY  DIFFICULT  TO  STAY  ON          TOP  OF  THIS  EPIDEMIC.      

•  LAW  ENFORCEMENT  IS  OUT-­‐NUMBERED  AND  OUT-­‐FINANCED.  

LAW  ENFORCEMENT  

•  DRUG  DEALERS  USUALLY        DO  NOT  SUFFER  FROM          THE  SAME  BUDGET          CONTRAINTS  AS  LAW  ENFORCEMENT.      

•  CANNOT  “ARREST  OUR  WAY  OUT  OF  THIS  PROBLEM.”  

EPIDEMIC  PROPORTIONS  

•  THIS  EPIDEMIC  HAS  ENGULFED  OUR  COUNTRY,  OUR  PRACTICES,  OUR  SOCIETY,  AND    

   OUR  LIVELIHOODS.      

REAL  ESTATE  STORY  

PHYSICIAN  PROFILE  

QUESTION:  •  WHAT  TYPE  OF  DOCTOR          PRESCRIBES  EXCESSIVE          AMOUNTS  OF  OPIOIDS?  

ANSWER:  •  GOOD  CLINICIAN  

PHYSICIAN  PROFILE  

•  TYPICALLY,  WELL  TRAINED  PAIN  MANAGEMENT  PHYSICIANS.      

•  PROCEDURELESS    

•  OFTEN  WRITE        LARGE  VOLUMES  OF  PAIN  MEDICATION.  

PHYSICIAN  PROFILE  

•  WELL-­‐INTENTIONED  PHYSICIANS  WHO  BELIEVE  PEOPLE  ARE  NOT  SUPPOSED  TO  HURT.      

•  DO  NOT  PRACTICE          EVIDENCE  BASED          MEDICINE.      

•  WRITE  LARGE          QUANTITIES  OF          OPIOIDS  WITH  REFILLS.    

CHEMICAL  COPING  

TYPICAL  PRESCRIPTION:  

•  LORCET  PLUS  #90  OR  #120    •  ONE  P.O.  T.I.D.  OR  …  •  ONE  P.O.  Q.I.D.  WITH  5  REFILLS.      

WHEN  MONEY  DRIVES  MEDICINE  

•  CRIMINALS  WITH  A  MEDICAL  DEGEREE  AND  LICENSE  TO  PRACTICE  MEDICINE  

•  STATE  BOARD  OF          MEDICAL  LICENSURE  

•  SMALL  COHORT        OF  PHYSICIANS  

MONITORING  PRESCRIBING  PATTERNS  

•  HOW  DO  YOU  IDENTIFY          PHYSICIANS  WHO  WRITE          TOO  MANY  OPIOIDS?  

MONITORING  PRESCRIBING  PATTERNS  

PHARMACISTS    

•  EXCELLENT  SOURCE  OF  INFORMATION.      

•  KNOW  WHICH  DOCTORS  HAVE  A  LOOSE  PEN.      

•  KNOW  THE  PRESCRIBING  HABITS  OF  EACH  PROVIDER  IN  THEIR  COMMUNITY.      

PRESCRIPTION  MONITORING  PROGRAM  

•  CAN  BE  RUN  ON  INDIVIDUAL  PATIENTS  AND  INDIVIDUAL  PRESCRIBERS.  

•  EXCELLENT  TOOL  FOR  IDENTIFYING  DRUG  SEEKING  PATIENTS  AND  PRESCRIBERS  WHO  WRITE  TOO  MANY  SCHEDULED  DRUGS.      

PRESCRIPTION  MONITORING  PROGRAM  

DRAWBACKS  

– NOT  REAL  TIME  

– NOT  INTERSTATE  – LACK  OF  FUNDING  

• TAG  CHECK    

• ZIP  CODE  CHECK    

PHYSICIAN  DRIFT  

•  OUT-­‐OF-­‐SPECIALTLY          PHYSICIANS          PRACTICING          IN  PAIN  CLINICS      

BUSINESS  OF  MEDICINE  

•  PAIN  CLINICS  OWNED  BY  NON-­‐PHYSICIANS  AS  BUSINESS  VENTURES.      

•  EMPLOY          PHYSICIANS    

•  CASH  ONLY          PILL  MILLS  

•  RETIRED  OR  OLDER  PHYSICIAN.      

•  LIKES  PRACTICING  MEDICINE  AGAIN.      

•  RESIDENTS          WHO  MOONLIGHT.    

•  PRESCRIPTIVE          PATTERN  THAT  IS          OUT  OF  THE  ORDINARY  

NEW  CME  REQUIREMENT    

•  EVERY  LICENSEE    

•  40  HOURS          IN  A  2-­‐YEAR  CYCLE    

•  5  HOURS  RELATED          TO  “PRESCRIBING          MEDICATIONS”  

•  EMPHASIS  ON          CONTROLLED  SUBSTANCES.      

THE  SCIENCE  OF  OPOIDS  

•  PROVEN  EFFICACY  FOR  USE  OF  OPIOIDS          FOR  SHORT  TERM  NON-­‐CANCER  PAIN.      

•  VERY  LITTLE  SCIENTIFIC  EVIDENCE  THAT  LONGTERM  USE  OF  OPIOIDS  FOR  NON-­‐CANCER  PAIN  IS  EFFECTIVE.      

THE  SCIENCE  OF  OPOIDS  

•  SIGNIFICANT  EVIDENCE  THAT  LONG  TERM  OPIOID  USE  FOR  NON-­‐CANCER  PAIN  WILL  RESULT  IN  OPIOID    

     HYPERALYGESIA          SYNDROME.  

QUESTIONS  ?  

•  ANSWERS  …  $5  

•  CORRECT  ANSWERS    …  $10  

•  CORRECT  ANSWERS        YOU  CAN  UNDERSTAND    …  $25    

TREATING  PAIN  

Randy  Easterling,  M.D.  

Dan  BarneD,  M.D.,  J.D.  April  2,  2013  

Disclosures  

Daniel  BarneD  has  no  financial  rela%onships  with  proprietary  en%%es  that  produce  health  care  goods  and  services.  

Where  Tennessee  Stands  

•  2nd  Most  Medicated  State  (Forbes  Magazine,  August  16,  2010)  

•  5th  in  Average  Mg.  Opioids/Resident  (Oct.  2012  Journal  of  Pain)  

Controlled  Substances  in  Tennessee  

•  Just  over  18  million  prescrip%ons  for  controlled  substances  dispensed  in  2012.  

•  Increase  of  1.5  %  from  2011  (compared  to  a  23%  rise  from  2010  –  2011).  

•  Increased  use  of  TN  Controlled  Substance  Database/State  Registra%on  of  Pain  Clinics.  

The  Source  

Issue:  How  to  Control  the  Source  of  Controlled  Substances?  

•  Solu%on:    Oversight  of  the  Prescribing  Physicians.  

•  But  How?  

Physicians  

1.  Highly  Educated  

2.  Lengthy  Training  

3.  Ongoing  CME  Requirements  

4.  Independent  

PEER  REVIEW  

•  Other  Physicians  Reviewing  the  Records  and  Management  of  Physicians  with  Possible  Quality  Problems  

•  Used  in  Hospitals  for  years  • Why  not  in  Health  Plans?  

PLANS  ARE  IN  A  GOOD  POSITION  TO  ASSESS  QUALITY  OF  CARE  OF  NETWORK  

PROVIDERS  

•  We  pay  claims  (and  have  claims  data).  •  We  have  audit  rights  in  provider  contracts.  •  We  review  medical  records.  •  We  are  in  providers’  offices.  •  No  “compe%tors  out  to  get  me”  in  Plan  peer  review.  

Health  Plans?  

The  BCBST  CRM  Program  Reviews  All  Quality  of  Care  Complaints  and  Concerns  

•  Required  to  review  member  complaints  by  accredi%ng  agencies  (NCQA,  URAC)  and  state  Medicaid  program.  

•  Liability/Risk  reduc%on  method.  

The  BCBST  CRM  Program  is  staffed  by  clinical  professionals  

•  4  RNs  review  cases.  

•  Support  from  BCBST  Pharmacy  Department  staffed  by  12  Pharmacists.  

•  Support  from  Analy%cs  Area  to  Review  Prescribing  Data.  

How  Do  We  Get  RX  Cases?  

•  Referrals  from  Pharmacy  Department.  

•  Pharmacists  iden%fy  outliers  in  their  areas  of  responsibility  and  contact  the  providers  to  try  to  determine  why  they  are  outliers.  

•  If  no  explana%on  and  no  change  in  prac%ce  aser  contact,  refer  to  CRM.  

Also  from  Member  Complaints  

       Mbr  wants  complaint  filed  against  provider  (prv).  On  one  visit,  mbr  didn’t  want  his  shot  b/c  they  were  administering  it  where  it  was  making  mbr's  back  swell  up.  Aser  he  declined  the  shot,  the  prv  ripped  up  his  rx  for  Valium.  Once  the  rx  was  ripped  up,  mbr  had  no  choice  but  to  take  the  shot.  Then  aser  they  gave  him  the  shot,  they  rewrote  his  rx  for  Valium.  Per  mbr,  it  was  as  if  prv  was  blackmailing  him:  if  he  didn’t  take  the  shot,  they  wouldn’t  write  his  rx.    

The  CRM  Process  

1.  Obtain  medical  records  from  dates  of  service  when  pain  meds.  prescribed.  

2.  Review  medical  records  internally.  

3.  Refer  suspect  records  for  specialty  matched  review  (through  Independent  Review  Organiza%ons).  

Standard  of  Care  

That  level  of  care  below  which  no    

reasonable  medical  provider  would    prac%ce.  

Medical  Correc%ve  Ac%on  Plan  

•  Specialty  matched  review  shows  standard  of  care  not  met  for  controlled  substance  prescribing.  •  LeDer  with  reviewer’s  comments  giving  examples  of  why  standard  not  met.  •  Provider  advised  to  take  whatever  steps  are  necessary  to  correct  prac%ce.  

Model  Policy  for  the  Use  of  Controlled  Substances  for  the  Treatment  of  Pain  

Medical  Records  –  The  physician  should  keep  accurate  and  complete  records  to  include:  

1.  the  medical  history  and  physical  examina%on,  2.  diagnos%c,  therapeu%c  and  laboratory  results,  3.  evalua%ons  and  consulta%ons,    4.  treatment  objec%ves,  5.  decision  of  risks  and  benefits,    6.  informed  consent,    7.  treatments,  8.  medica%ons  (including  date,  type,  dosage  and  quan%ty  prescribed),  9.  instruc%ons  and  agreements  and  10. periodic  reviews.  

Records  should  remain  current  and  be  maintained  in  an  accessible    manner  and  readily  available  for  review.  

Reasons  for  MCAP  Failure  

1.         Lack  of  Provider  Knowledge  

2.  TIME    =    MONEY  

Consequences  of  MCAP  Failure  

1.  Creden%aling  CommiDee  –  Creden%als  Revoked.  

2.  Formal  Hearing  –  Due  Process  

3.  Report  Filed  with  Healthcare  Integrity  and  Protec%on  Data  Bank  (HIPDB)  

QUESTIONS  

?