Clinical Track, National Rx Drug Abuse Summit, April 2-4, 2013. Treating Pain presentation by Dr. Randy Easterling and Dr. Daniel Barnett

1. 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

2. DISCLOSURE
STATEMENT
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.

3. RANDY
EASTERLING,
MD
• 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

4. TREATING
PAIN
TODAY’S
SPEAKER
HAS
NO
DISCLOSURE
TO
REPORT
OF
REAL
OR
APPARENT
CONFLICT
RELATED
TO
THE
CONTENT
OF
THIS
PRESENTATION.

5. CHRISTMAS
STORY

6. 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.

7. 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.

8. WHY
ALL
THE
FUSS
?
• NEARLY
60%
OF
THE
OVERDOSE
DEATHS
IN
2010
INVOLVED
PHARMACEUTICAL
DRUGS.
• OPIOIDS
ACCOUNT
FOR
75%
OF
THESE
DEATHS.

9. 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.

10. 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.

11. 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

12. 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.

13. WHY
ALL
THE
FUSS
?
• VICODAN
IS
NOW
THE
MOST
WIDELY
PRESCRIBED
MEDICATION
IN
THE
UNITED
STATES
…
• FOLLOWED
BY
LISINOPRIL
…
• THEN,
ZOCOR.

14. 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.

15. 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.

16. 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.

17. NEONATAL
ABSTINENCE
SYNDROME

18. 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.

19. CHEMICAL
COPING
• PHYSICIANS
ARE
EXPECTED
TO
ALLEVIATE
ALL
UNPLEASANTNESS.

20. • PRESCRIPTION
OPIOIDS
ARE
PLENTIFUL
AND
VERY
INEXPENSIVE.

21. STREET
PRICES
– 10
MG
HYDROCODONE
…
$6
-­‐
$8.
– OXYCODONE
…
$10
-­‐
$20
– 4
MG
DILAUDID
…
$60
– ADDERALL
…
$1
MG

22. STREET
PRICES
– BENZODIAZEPINE
$1
-­‐
$2
MG
– RITALIN
$10
-­‐
$20
– SOMA
$3

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

24. A
BEAST
THAT
CAN’T
BE
FED
THERE
IS
A
NEVER
ENDING
NEED
FOR
THE
DRUG.

25. HOLY
TRINITY
• HYDROCODONE
IS
EASILY
COMBINED
WITH
OTHER
MOOD-­‐ALTERING
DRUGS.
• HYDROCODONE,
XANAX
AND
SOMA
ARE
THE
HOLY
TRINITY.

26. DRUG
OF
CHOICE
ADD
A
LITTLE
BIT
OF
JACK
DANIELS
AND
YOU
HAVE
THE
WHITNEY
HOUSTON
COCKTAIL.

27. LAW
ENFORCEMENT
• VERY
DIFFICULT
TO
STAY
ON
TOP
OF
THIS
EPIDEMIC.
• LAW
ENFORCEMENT
IS
OUT-­‐NUMBERED
AND
OUT-­‐FINANCED.

28. LAW
ENFORCEMENT
• DRUG
DEALERS
USUALLY
DO
NOT
SUFFER
FROM
THE
SAME
BUDGET
CONTRAINTS
AS
LAW
ENFORCEMENT.
• CANNOT
“ARREST
OUR
WAY
OUT
OF
THIS
PROBLEM.”

29. EPIDEMIC
PROPORTIONS
• THIS
EPIDEMIC
HAS
ENGULFED
OUR
COUNTRY,
OUR
PRACTICES,
OUR
SOCIETY,
AND
OUR
LIVELIHOODS.

30. REAL
ESTATE
STORY

31. PHYSICIAN
PROFILE
QUESTION:
• WHAT
TYPE
OF
DOCTOR
PRESCRIBES
EXCESSIVE
AMOUNTS
OF
OPIOIDS?
ANSWER:
• GOOD
CLINICIAN

32. PHYSICIAN
PROFILE
• TYPICALLY,
WELL
TRAINED
PAIN
MANAGEMENT
PHYSICIANS.
• PROCEDURELESS
• OFTEN
WRITE
LARGE
VOLUMES
OF
PAIN
MEDICATION.

33. 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.

34. 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.

35. WHEN
MONEY
DRIVES
MEDICINE
• CRIMINALS
WITH
A
MEDICAL
DEGEREE
AND
LICENSE
TO
PRACTICE
MEDICINE
• STATE
BOARD
OF
MEDICAL
LICENSURE
• SMALL
COHORT
OF
PHYSICIANS

36. MONITORING
PRESCRIBING
PATTERNS
• HOW
DO
YOU
IDENTIFY
PHYSICIANS
WHO
WRITE
TOO
MANY
OPIOIDS?

37. 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.

38. 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.

39. PRESCRIPTION
MONITORING
PROGRAM
DRAWBACKS
– NOT
REAL
TIME
– NOT
INTERSTATE
– LACK
OF
FUNDING

40. • TAG
CHECK
• ZIP
CODE
CHECK

41. PHYSICIAN
DRIFT
• OUT-­‐OF-­‐SPECIALTLY
PHYSICIANS
PRACTICING
IN
PAIN
CLINICS

42. BUSINESS
OF
MEDICINE
• PAIN
CLINICS
OWNED
BY
NON-­‐PHYSICIANS
AS
BUSINESS
VENTURES.
• EMPLOY
PHYSICIANS
• CASH
ONLY
PILL
MILLS

43. • RETIRED
OR
OLDER
PHYSICIAN.
• LIKES
PRACTICING
MEDICINE
AGAIN.
• RESIDENTS
WHO
MOONLIGHT.
• PRESCRIPTIVE
PATTERN
THAT
IS
OUT
OF
THE
ORDINARY

44. NEW
CME
REQUIREMENT
• EVERY
LICENSEE
• 40
HOURS
IN
A
2-­‐YEAR
CYCLE
• 5
HOURS
RELATED
TO
“PRESCRIBING
MEDICATIONS”
• EMPHASIS
ON
CONTROLLED
SUBSTANCES.

45. 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.

46. THE
SCIENCE
OF
OPOIDS
• SIGNIFICANT
EVIDENCE
THAT
LONG
TERM
OPIOID
USE
FOR
NON-­‐CANCER
PAIN
WILL
RESULT
IN
OPIOID
HYPERALYGESIA
SYNDROME.

47. QUESTIONS
?
• ANSWERS
…
$5
• CORRECT
ANSWERS
…
$10
• CORRECT
ANSWERS
YOU
CAN
UNDERSTAND
…
$25

48. TREATING
PAIN
Randy
Easterling,
M.D.
Dan
BarneD,
M.D.,
J.D.
April
2,
2013

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

50. Where
Tennessee
Stands
• 2nd
Most
Medicated
State
(Forbes
Magazine,
August
16,
2010)
• 5th
in
Average
Mg.
Opioids/Resident
(Oct.
2012
Journal
of
Pain)

51. 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.

52. The
Source

53. Issue:
How
to
Control
the
Source
of
Controlled
Substances?
• Solu%on:
Oversight
of
the
Prescribing
Physicians.
• But
How?

54. Physicians
1. Highly
Educated
2. Lengthy
Training
3. Ongoing
CME
Requirements
4. Independent

55. 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?

56. 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.

57. Health
Plans?

58. 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.

59. 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.

60. 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.

61. 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.

62. 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).

63. Standard
of
Care
That
level
of
care
below
which
no
reasonable
medical
provider
would
prac%ce.

64. 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.

65. 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.

71. Reasons
for
MCAP
Failure
1.
Lack
of
Provider
Knowledge
2.
TIME
=
MONEY

72. 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)

73. QUESTIONS
?