Slide deck from FMCC 2016 Curbing Rx Drug Abuse Plenary by Sarah Chouinard

1. Curbing Prescription Medication Abuse:
Stop the Madness
Sarah Chouinard, MD
AAFP FMCC
Washington, DC
April 18, 2016

2. The problem
Prescribing rates per 100 persons (in quartiles) 2012

3. West Virginia Statistics
• West Virginia has the highest drug overdose mortality rate
in the United States, with 28.9 per 100,000 people
suffering drug overdose fatalities. (according to a new report, Prescription Drug
Abuse: Strategies to Stop the Epidemic, 2013)
• Drug Overdose Mortality Rates quadrupled from 1999 to
2010 (www.healthyamericans.org)
• WV clinicians wrote 138 pain prescriptions per every
100 people in 2012

4. Where do the patients get these drugs?
They get them from us.
Providers wrote nearly a quarter of a billion opioid prescriptions in
2013—with wide variation across states. This is enough for every
American adult to have their own bottle of pills.1
Health care providers in the highest prescribing state, Alabama,
wrote almost three times as many of these prescriptions per
person as those in the lowest prescribing state, Hawaii.
Studies suggest that regional variation in use of prescription
opioids cannot be explained by the underlying health status of the
population.
• 1 IMS Health, National Prescription Audit (NPATM). Cited in internal document: Preliminary Update on Opioid Pain Reliever (OPR) Prescription Rates Nationally and by Stae: 2010-2013.
• 2Centers for Disease Control and Prevention. Vital Signs: Variation Among States in Prescribing of Opioid Pain Relievers and Benzodiazepines — United States, 2012. MMWR 2014; 63(26);563-568.
• 3Ossiander EM. Using textual cause-of-death data to study drug poisoning deaths. Am J Epidemiol 2014 Apr 1;179(7):884-94.

5. Why are we writing so many drugs?
• Access to legitimate specialty clinics
• Cultural norms – ―oxy‖ is today’s aspirin
• Prescription coverage issues (copay for small quantity v. a month supply)
• Lack of training
• Lack of access to substance abuse treatment
• HIE limitations
• Communication gaps – doctor/doctor and doctor/patient
• Human misery

6. We are miserable:
WV is #1 for the 6th year on the The Gallup-
Healthways Well-Being Index
• measures the well-being of Americans in 5 categories:
purpose, social, financial, community, and physical
• Poverty rate is 18.5% (10th highest)
• Unemployment 6.5% (18th lowest)
• Obesity rate is 35.1% (tied for highest
• Poor mental health days 4.4/30 (4th)
• http://247wallst.com/special-report/2015/02/20/americas-happiest-and-most-miserable-
states-2/#ixzz45gBt9859

7. •

8. Co-morbid Conditions

9. Is chronic pain a primary care
diagnosis?
• Family physicians’ training in WV consists of rotations spattered
throughout their residency plus 3 hours of mandatory training every 2
years.
• 2012 West Virginia Code CHAPTER 16. PUBLIC HEALTH ARTICLE 5H.
CHRONIC PAIN CLINIC LICENSING ACT.
• §16-5H-4. Operational requirements.Meet one of the following training
requirements: (i) Complete a pain medicine fellowship that is accredited
by the Accreditation Council for Graduate Medical Education or such other
similar program as may be approved by the secretary; or (ii) Hold current
board certification by the American Board of Pain Medicine or current
board certification by the American Board of Anesthesiology or such other
board certification as may be approved by the secretary.

10. Solutions
• 1. Education – patient and doctor
• 2. Changing Financial Incentives -- remove
counterproductive incentives for physicians (pay
for volume & patient satisfaction tied to payment)
• 3. Technology
• 4. Laws

11. Our ―solution‖ to the problem:
Internal Referrals
• All patients requesting long-term pain medications for a non-acute
problem are offered a work-up, a pain contract and an internal,
community-based, specialist
• All patients are referred internally to our anesthesiologist who has
access to the primary care electronic health record.
• Screening with multiple tools that risk stratify problems and
predict likeliness to abuse medications
• Random urine drug screens 4 times annually and at every office
visit
• Behavioral health integration and MAT

12. Solutions:
Regulatory Changes
• WV Code § 16-5H-2 (through 1st Spec. Sess. 2012)
Chronic Pain Clinic Licensing Act
• OHFLAC—Office of Health Facility Licensure and
Certification in any month more than fifty percent of patients of the prescribers
or dispensers are prescribed or dispensed opioids or other controlled substances
specified in rules promulgated pursuant to this article for chronic pain resulting from
non- malignant conditions
• Complete a Pain Medicine fellowship accredited by
ACGME
• PDMP

13. Solutions:
CDC Guidelines
• This guideline provides recommendations for primary care
clinicians who are prescribing opioids for chronic pain outside of
active cancer treatment, palliative care, and end-of-life care. The
guideline addresses 1) when to initiate or continue opioids for
chronic pain; 2) opioid selection, dosage, duration, follow-up, and
discontinuation; and 3) assessing risk and addressing harms of
opioid use. It is important that patients receive appropriate pain
treatment with careful consideration of the benefits and risks of
treatment options. This guideline is intended to improve
communication between clinicians and patients about the risks and
benefits of opioid therapy for chronic pain, improve the safety and
effectiveness of pain treatment, and reduce the risks associated
with long-term opioid therapy, including opioid use disorder,
overdose, and death.

14. CDC’s Checklist

15. Checklist highlights
• When CONSIDERING long-term opioid therapy…
• Set realistic goals for pain and function based on
diagnosis (eg, walk around the block).
• Check that non-opioid therapies tried and optimized.
• Discuss benefits and risks (eg, addiction, overdose)
with patient.
• Evaluate risk of harm or misuse.

16. Checklist Suggestions
• Discuss risk factors with patient.
• Check prescription drug monitoring program (PDMP) data. • Check
urine drug screen.
• Set criteria for stopping or continuing opioids.
• Assess baseline pain and function
• Schedule initial reassessment within 1– 4 weeks.
• Prescribe short-acting opioids using lowest dosage on product
labeling; match duration to scheduled reassessment.

17. Many states and the CDC have established
guidelines for total daily opioid dosages:
Morphine Milligram Equivalent
• Conversion factors: hydrocodone 1;
tramadol 0.1; hydromorphone 4
• • If ≥ 50 MME /day total (≥ 50 mg hydrocodone; ≥
33 mg oxycodone), increase frequency of follow-
up; consider offering naloxone.
• • Avoid ≥ 90 MME /day total (≥ 90 mg
hydrocodone; ≥ 60 mg oxycodone), or carefully
justify; consider specialist referral.

18. Curr Pain Headache Rep. 2016 May;20(5):29. doi:
10.1007/s11916-016-0562-z.
Role of Alternative Therapies for Chronic
Pain Syndromes.
Thomas DA1, Maslin B1, Legler A1, Springer E1, Asgerally A1, Vadivelu N2.
Author information
1Department of Anesthesiology, Yale University School of Medicine,
TMP 3, 333 Cedar Street, New Haven, CT, 06520, USA.

19. Conclusions
This review highlights the key role of psychology in the
treatment of chronic pain. Cognitive behavior therapy
appears to be the most impactful while biofeedback therapy
has also been shown to be effective for chronic pain.
Exercise therapy has been shown to be effective in short-,
intermediate-, and long-term pain states. When compared to
that in sham controls, acupuncture has shown some benefit
for neck pain immediately after the procedure and in the
short term and improvement has also been demonstrated in
the treatment of headaches. The role of smartphones and
whole-body cryotherapy are new modalities and further
studies are needed. Recent literature suggests that several
alternate therapies could play a role in the treatment of
chronic pain, supporting the biopsychosocial model in the
treatment of pain states.

20. Neuromodulation. 2014 Oct;17
Suppl 2:24-30. doi:
10.1111/ner.12078.
Noninvasive and alternative
management of chronic low back
pain (efficacy and outcomes).
Wellington J1.
Author information
1Pain Medicine Center, Indiana
University, Indianapolis, IN, USA.

21. Alternatives to pills for low
back pain
• CONCLUSIONS: Those with the strongest evidence in
the literature for good efficacy and outcomes include
exercise therapy with supervised physical therapy,
multidisciplinary biopsychosocial rehabilitation, and
acupuncture. Therapies with fair evidence or
moderately supported by literature include yoga, back
schools, thermal modalities, acupressure, and
cognitive-behavioral therapy. Those therapies with poor
evidence or little to no literature support include
manipulation, transcutaneous electrical nerve
stimulation, low-level laser therapy, reflexology,
biofeedback, progressive relaxation, hypnosis, and
aromatherapy

22. If opioids are the ―best‖
treatment, monitoring works

23. EDIE
• How does EDIE work?
• When a patient visits an EDIE-participating ED, that
patient’s visit information is automatically sent to CMT
via integration with a facility’s electronic health medical
records system. The system searches for the patient in
our databases, then compares the patient’s history
against the ED’s criteria for Notification—these criteria
may be based on visit frequency and/or mobility, or if the
patient has Care Guidelines in EDIE—and if any criteria
are met, an EDIE Notification is immediately dispatched
to the ED.

24. Interfaces with the
PDMP
• What tools are available within the EDIE Web Application?
• The EDIE Web Application serves as a dynamic care management
care coordination platform where ED staff can closely monitor and
manage their high-utilization and complex-needs patient population.
Within the EDIE Web App, users will have access to a range of
features, including:
• Recent Patient Visit Activity & Utilization Reporting
• Collaborative Shared Patient Record
• Care Guidelines Publisher
• Visit Reduction Analytics

25. Be part of the solution
Questions?
Thank you
Sarah.B.Chouinard@ccwv.org