This document summarizes a presentation on implementing strategies to reduce prescription drug abuse. 1. It discusses analyzing the scope of payers' role in prescription drug abuse and identifying best practices payers can use, such as member education and prescriber interventions, to reduce fraud and abuse. 2. It describes how the "drug seeker" profile has changed and provides an overview of medical guidelines and current opioid prescribing practices. 3. It outlines solutions payers and providers can implement, such as education, use of drug testing and prescription monitoring programs, to curb inappropriate opioid use and change practices.

1. A Paradigm Shift of Payer
Strategy
April 10-12, 2012
Walt Disney World Swan Resort

2. Learning Objectives:
1. Analyze the scope of the payers’ role in the
prescription drug abuse problem.
2. Identify specific best practice methodologies
that can be implemented by payers to
reduce fraud, waste and abuse through
member and prescriber interventions/
education and support
3. Describe the “drug seeker” profile and how it
has changed.

3. Disclosure Statement
• All presenters for this session, Dr.
Kathryn Mueller, Dr. Brian K. Solow and
Beverly Franklin-Thompson have
disclosed no relevant, real or apparent
personal or professional financial
relationships.

4. Changing
Opioid
Practice
Kathryn Mueller, MD, MPH, FACOEM
Professor, School of Public Health & Department of
Emergency Medicine
University of Colorado
Vice-President - American College of
Occupational and Environmental Medicine
4

5. Topics Discussed
• Brief Overview of the problem
• Medical Guideline Recommendations-
e.g. Colorado Div of WC and ACOEM
• Current Practice
• Solutions and Directions for the future
5

6. FROM THE NATIONAL CENTER FOR HEALTH STATISTICS
MMWR / August 6,2010 / Vol. 59 / No. 30 6

7. FROM THE NATIONAL CENTER FOR HEALTH STATISTICS
MMWR / August 20,2010 / Vol. 59 / No. 32 7

8. Morphine Equivalents per Case
8

9. Use of Opioids
• Use of an opioid treatment
agreement or opioid contract -
Recommended (I)
• Routine use of urine drug screening
for patients on chronic opioids -
Recommended (C)
• Attempts to wean patients on
opioids to lowest clinically effective
dose or completely from opioids -
Recommended, Insufficient
Evidence (I)
9

10. Recommendations for Opioid Use
 Therapeutic Trial Indications
a) The failure of pain
management alternatives by
a motivated patient
including:
a) active therapies
b) cognitive behavioral
therapy
c) pain self-management
techniques
d) other appropriate
medical techniques.
Colorado CP
10

11. Starting Opioids
• Acetaminophen, NSAIDS, ASA used first and
should be continued when stronger agents
added
• Start with therapeutic trial with clear
understanding of limited use
• Contingent on patient goals and obligations
—return to work, agreement that drug
screening may be used
• Do not begin opioids until patient has begun
a pain rehabilitation program
Colorado CP 11

12. Criteria for Initiation
• No evidence of psychopathology or
elevated abuse risk, addiction, or
adverse outcome (Relative rather than
absolute contraindications)
– Note some studies noted elevated risk of
abuse with any prior substance use
12

13. Opioid Trial
• When active therapies, pain self-
management techniques have been
tried
• Psychosocial assessment for abuse
potential and untreated depression,
anxiety, etc.
• Treatment of identified issues and referral
to pain specialist if history of addiction
• Informed, written, witnessed consent by
the patient
• Frequent (q 2-4 wk) follow-up to
document pain control and
functional gains such as RTW 13

14. Cautions and
Contraindications
• Relative contraindications
– Hx of EtOH, benzodiazepine, or other substance
abuse
– Off work more than 6 months
– Severe personality disorder
• General contraindications
– Active EtOH or substance abuse
– Untreated mood or psychotic disorder
– Decreased mental or physical function with
opioid use
Colorado CP 14

15. Recommendations for Opioid Use
i. On-Going, Long-Term Management
should include:
a) Prescriptions from a single practitioner;
b) Ongoing review and documentation of
pain relief, functional status,
appropriate medication use, and side
effects;
c) Ongoing effort to gain improvement of
social and physical function as a result
of pain relief;
Colorado CP 15

16. Recommendations for Opioid Use
d) Contract detailing the
following:
 Side effects
anticipated from
the medication;
 Requirements to
continue active
therapy;
 Need to achieve
functional goals;
Colorado CP 16

17. Recommendations for Opioid Use
Contract Language
 Reasons for tapering opioids –
 Lack of functional effect at higher doses and
for apparent hyperalgesia
 Non-compliance with other drug use
 Drug screening showing use of drugs outside
the prescribed treatment
 Requests for prescriptions outside of the
defined time frames
 Lack of adherence identified by pill count,
excessive sedation, or lack of functional gains
 Excessive dose escalation with no decrease
in use of short-term medications
Colorado CP 17

18. Recommendations for Opioid Use
 Use of drug screening initially, randomly at
least once a year and as deemed
appropriate by the prescribing physician.
(Rolfs R 2010); Canadian Guidelines 2010;
Chou R 2009).
 PDMP review
 Use limited to two opioids: a long-acting
opioid for maintenance of pain relief and a
short-acting opioid for limited rescue use.
 Sleep Apnea Testing: type of testing
required unclear. Type 3 portable units with
2 airflow samples and 02 saturation device
may be useful for monitoring respirator
depression secondary to opioids.
Colorado CP

19. What does it look like in real
world practice?
19

20. MMWR 2012
20

21. FACTORS INFLUENCING WORK
INTERFERENCE IN PATIENTS WITH
CHRONIC LOW BACK PAIN: A RESIDENCY
RESEARCH NETWORK OF TEXAS STUDY
(RRNeT) STUDY
Subjects: Three hundred sixty outpatients with CLBP
for more than 3 months.
Predictors of Work Interference
Screened positive for depression
Number and magnitude of flare - ups
Young. RA JABFM Sept.-Oct. 2011
Vol.24, No.5, pp 503-509
21

22. (RRNeT) STUDY continued
All Subjects Depression Depression
Screening Screening
Negative Positive
N=360 N=61 N=292
---------------------------------------------------------------------------------------
Does pain interfere with
Your normal work (including both 215 (61.4)
housework and paid work)?
Takes Opioid medication 210 (58.5)
Takes daily scheduled Opioid medication 94(26.1)
Patient has written pain Contract 67(18.6)
JABFM Sept.-Oct. 2011 Vol.24, No.5, pp 503-509
22

23. Interstate Variation in Use of
Narcotics – 17 states studied
• Large variation among the states for
morphine equivalents per case -
4000 NY to 1000 IA
• Psychological evaluation – median
4% of long term user cases
• Drug screening – median 7% of long
term user cases
Wang,D Workers Compensation Research Institute, 2011
23

24. Can Clinicians predict misuse?
• Urine drug test results using drug testing
protocols
• In clinician predicted misuse – 79% +
• Non-predicted misuse – 72% +
• Other drug tests – 71% +
• Because these are based at least 50% on
non-verified cutoffs, true results may be less
• Poster - Bronstein K, Vanderbilt U, Ameritox
sponsored
24

25. Rates of Inappropriate Drug Use in
Chronic Pain
• 938,586 urine drug screens
• 38% no detectable prescribed drug
• 29% non-prescribed drug detectable
• 11% illicit drugs
Couto J , Population Health
Management, vol 12 #4 2009
25

26. What has prevented change?
• Education of providers and patients
– Unaware of risk
– Not aware of current medical guidelines
• Historical medical teaching
– Sanction by medical boards and JCHO for not
treating pain
• Patient resistance
– Doctor, don t you trust me
• Provider s time – done outside of visit
• PDMP difficulty accessing –
state specific 26

27. Context - Seatbelts
27

28. Chronic Opioid Use
• Leads to death for some
• Significantly increases premiums
• Does not necessarily increase return
to work
• Most physicians don t follow
standard protocol
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29. Solutions
• Education for the public on the rate of
deaths and ways to prevent them
• Education for doctors –
– currently available on line through AAFP
(family practice), Washington state, and
others including University of Colorado
– REMS – pharmaceutical based with
government requirements
29

30. Solutions
• Drug testing
– Needs to be viewed as a necessary part
of management, similar to tests to
continue other long term medications
– Example: Providers are encouraged to
check all sexually active adults for HIV yet
<2% are +
• Unlikely to be positive if >50 y/o – not
necessarily
30

31. Alcohol and Marijuana
e) Marijuana: Marijuana use is illegal under
federal guidelines and cannot be
recommended for use in this guideline. The
Colorado statute also states that insurers are
not required to pay for marijuana.
f) Alcohol Screening: It is appropriate to screen
for alcohol use and have a contractual
policy regarding alcohol use during chronic
opioid management as alcohol use in
combination with opioids is more likely to
contribute to death or accidents than
marijuana.
31
Colorado CP

32. Colorado Drug Monitoring code
Rule 18 -6 G (5)
 New code to encourage physicians to
periodically review drug compliance
 Reports review
 Random drug testing review – annually
and before chronic opioids are used
 Access the State Prescription Drug
Monitoring Program (records all opioid
Rx from any Pharmacy in CO)
 Describe function and make
recommendation
 Anecdotally docs are saying
about 20% of patients have
surprises on drug testing 32

33. new code implementation
2010 1st year
• Used in 350 cases
• 2/3 of the claims had dates of injury from
2001-2009
• No claims were identified with 1-2 opioid Rxs
and use of the code
• We hope to identify number of claims where
it should have been used and look at psych
evals and drug screen for those
33

34. Hurdles
• Should all high dose opioid
patients be referred to
specialists?
• Could low-dose patients
have only minimal screening,
e.g. completing validated
office questionnaires for
depression, anxiety, abuse
• Who will pay? Hint: Right now
physicians are unlikely to continue
to prescribe medications with a
significant hepatic or renal risk
unless lab tests are completed.
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35. References
• Washington State Guidelines http://
www.opioidrisk.com/node/212
• American College of Occupational and
Environmental Guidelines
www.acoem.org chronic pain guides
• Colorado Div of Workers Compensation
http://www.colorado.gov go to Div of WC
then chronic pain treatment guideline
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36. 36

37. 37 37