A Community Discussion:Prescribing Patterns for Chronic

Pain

Second Annual Pain Summit

September 29th, 2015

Welcome

Second Annual

Yamhill County Pain Summit

September 29th, 2015

William J. Koenig II, DO

Reso

urce

tabl

es

Resource tables

Sign-in tableSign-in/CME

Buffet

Stage

StairsRestrooms

Front ExitStairs

The goal is to stay on time.

6:00 – 6:10 Check in, dinner served Yamhill CCO Staff, McMinnville Physician’s Organization

6:10 – 6:20

Welcome & Introduction

William Koenig, DO, Physicians’ Medical Center

6:20 – 6:25 Opening remarks District Attorney, Brad Berry, Yamhill County

6:25 – 6:55 Opioid Use and Misuse John McIlveen, PhD, Oregon Health Authority

6:55 – 7:05 Yamhill CCO Updates Jim Rickards, MD , Yamhill CCO

7:05 – 7:15 Discussion

7:15 – 7:50Pharmacy Panel

Morgan Parker, PharmD, WVMCJoanna Thompson, Providence Medical GroupBingBing Liang, PharmD, CareOregonNicole Winnen, RPh, Mac PharmacyPaul Carson, CareOregon

7:50 – 8:00 Discussion and Q&A

8:00 – 8:20 Behavioral Health Panel Jeri Turgeson, PsyD, ProvidenceLaura Fisk, PsyD, Yamhill CCO

8:20 – 8:40Discussion

Laura Fisk, PsyD, Yamhill CCOKristi Schmidlkofer, PsyD, PMCKristin Garcia, PsyD, Virginia GarciaJeri Turgeson, ProvidenceSyrett Torres, Psy D, Valley Women’s Health Clinic

8:40 – 8:50 Oral Health Dr. Todd Hyder, DDS, Hyder Family Dentristry

8:50 – 8:55 Discussion

8:55 – 9:00 Closing remarks William Koenig, DO, Physicians’ Medical Center

Why Are We Here?

Patient safety and improved patient care when administering opioids for chronic non-cancer pain.

Introductory Remarks:Thoughts from the DA

Second Annual Pain Summit

September 29th, 2015

Brad Berry, District Attorney, Yamhill County

Opioid Use and Misuse: History, Trends, And The Oregon Opioid Initiative

John W. McIlveen, Ph.D., LMHC, State Opioid Treatment Authority, Oregon Health Authority,

Addictions and Mental Health Division

Opioids in the United States: Motor Vehicles and Opioid Deaths: 2006

Opioids in the United States: Motor Vehicles and Opioid Deaths: 2010

Opioids in the United States: A Historical Perspective

• Opioid use widespread and common in the US at turn of 19th/20th century – prescribed for a variety of aliments

• Peak usage late 1800’s, by 1910 around 1 in 400 Americans opioid dependent

• Majority female users (as many as ¾ ths)

• 1914 Harrison Act – to regulate commerce and the opioid trade

• Drastic changes in the way this population was treated

• Opiates prescribed only in the “course of practice” (addiction not seen as a disease condition and not included)

Opioids in the United States: A Historical Perspective

• 1950’s New York City – heroin epidemic

• Drs. Marie Nyswander and the beginning of methadone treatment

• Nearly 100% relapse rates for abstinence based treatment for opioid addicts

• Hypothesis – the opioid addicted brain “lacks something”- opioid endogenous system

Opioids in the United States: A Historical Perspective

• DATA 2000: Office based treatment of opioid ‐dependence

• Act of Congress – any schedule III, IV, or V controlled substance with FDA approval for treatment of opioid dependence could be prescribed by a “qualified” physician

• Buperenorphine – Schedule III

• Expanding office based treatment options

Opioids in the United States: Current Trends

• 2009 - nonmedical use of prescription pain medications; 4.8% of those aged 18 25; 1.9 million ‐prescription narcotic users/ diagnostic criteria for opioid abuse or dependence (second only to marijuana (4.3 million)

• 2.1 million people in the United States with substance use disorders related to prescription opioid pain relievers in 2012; estimated 467,000 addicted to heroin (SAMHSA, 2012)

National Vital Statistics System, 1999-2008; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), 1999-2010; Treatment Episode Data Set, 1999-2009

Prescription opioid sales, deaths and treatment: 1999-2010

Cicero et al., 2014

First Use of Opioids: By Decade

Cicero et al., 2014

Age of First Heroin Usage: By Decade

DEA: Heroin Seizures from 2010 – 2014

Institute for Defense Analysis/ONDCP: Average Heroin Prices

Opioids in the United States: Heroin Facts• Publicly funded facilities in 2012, opioid admission

second only to marijuana (TEDS, 2012)

• User population increasing more rapidly than any other drug of abuse, despite overall numbers being vastly lower than virtually all other illicit drugs; doubled between 2007 (161,000) and 2013 (289,000) (NSDUH, 2013)

• Cocaine users five times that of heroin users but double the amount of deaths associated with it’s use (CDC, 2014)

• Wide variances in methods of reporting heroin realted deaths (Warner et al., 2013)

Opioids in the United States: Treatment Considerations in a Medicaid Population

• SUDs and Medicaid clients – appx. 12% (SAMHSA, 2013)

• Opioid overdose rates much higher among Medicaid population (Kuehn, 2014)

• Approximately 4.4% of Medicaid clients receive SUD treatment any given year (SAMHSA, 2013)

• 1.4% of Medicaid programs budgets go towards SUD treatment (SAMHSA, 2013)

Opioids in the United States: Infectious Disease• 2006-2012; 364% increase in HCV infection among young

adults (<30) in Appalachia; coincides with similar rates of admission for opioid dependence (MMWR, 5/8/15)

• 2007 – HCV surpasses HIV as cause of death (Ly et al., 2012)

• 2015 – Indiana HIV outbreak; directly related to IV drug use

• Wide variance in rates of infection for IV drug users in different areas of the country; from appx. 65% to as low as 10%, strongly correlated with access to public health services (Fatseas et al., 2011)

23

Overview

• Opioid prescribing for pain has generated an epidemic of drug overdose, opioid use disorder, and unstable pain care over the last 15 years

• Policy and practice solutions have emerged

• Oregon is implementing strategies on the levels of:Health systems Community Public policy

24

25

Goals

• Decrease drug overdose deaths, hospitalizations, emergency department visits, and misuse

• Increase use of medication assisted treatment for opioid use disorder

• Decrease health care costs

26

Oregon Opioid Initiative

Align and coordinate Oregon Health Authority Programs:

Medicaid funded care CDC funded injury epidemiology and prevention

programs SAMHSA funded prevention and treatment CDC funded chronic disease self management Pain Commission

27

Oregon Opioid Initiative Partnership

Oregon Health

Authority

Health Leadership

Council Health

Systems

Oregon Coalition for the

Responsible Use of

Meds

State Policy Makers & Statues

OHSU & NW Addictions Technology

Transfer Center

Coordinated Care

OrganizationsOpioid

Use Disorder

Treatment Programs

Local Public Health

Departments

Public Safety

Emergency Department

s

Pain Managemen

t Clinics

Federal Partners:

CDCSAMHSA

BJA

28

Interventions on 3 Levels

Health Systems

Public Policy

Community

Interventions

Data identify and leverage

Metrics guide qualityimprovement

29

Health Systems Interventions• Removed methadone as a preferred drug from the state formulary

• Adoption of opioid management by Medicaid Coordinated Care Organizations (CCOs) as a Statewide Performance Improvement Project

• Implement opioid prescribing guidelines for practitioners Oregon Pain Guidance Emergency department guidelines

• Target the most frequent prescribers for PDMP enrollment

• Expand medication assisted treatment, non-opioid treatment reimbursement

• Establish and monitor metrics; use data to monitor progress

30

Targeted PDMP Registration and Use

• 23% of prescribers write 81% of controlled substance prescriptions

• Targeted enrollment has the support of the Oregon Medical Association and the Oregon Hospital Association

31

Oregon Pain Guidance

Dr. Jim Shames, Jackson County Public Health

www.oregonpainguidance.com

32

Medication Assisted Treatment Programs in Oregon

711

2

2

1

Opioids in the United States: Data 2000

34

Naloxone Rescue

• 467 naloxone rescues were reported in 2014 in Multnomah County

• Heroin deaths dropped 30% in Multnomah County since 2011 (unpublished data)

35

Oregon Emergency Department Opioid Prescribing Guidelines

• Oregon Chapter of Emergency Department Physicians have developed guidelines

• Includes: single medical provider to provide all opioids for chronic pain, long acting or controlled release opioids should not be prescribed

from the emergency department, encourages prescribers to check the PDMP

Sharon Meieran, MD at ocep.org/

36

Community Interventions

• Establish pain guidance groups for health care provider community

• Implement coordinated community based specialized pain care

• Convene community action workgroups

• Increase naloxone rescue projects and distribution to at-risk patients

• Implement public education

37

Oregon Coalition for the Responsible Use of Meds Summits

Dwight Holton, JD, Executive Director, Lines for Life, OrCrm.org

38

Oregon Legislative Policy Interventions

• Enhance the Prescription Drug Monitoring ProgramEmergency Department Information Exchange (EDIE) Identified data for researchAutomated notificationsReal time data??

• Naloxone statute amendments

39

Oregon Statewide Policy Directions• Enhance the Prescription Drug Monitoring Program

• Increase naloxone distribution and usage

• Increase the number of health systems screening for opioid use disorder and adopt prescribing guidelines

40

Oregon Statewide Policy Directions• Expand health insurance coverage for evidence-

based alternative pain management for chronic non-cancer pain

• Ensure that health insurance covers full spectrum of services to treat opioid use disorder

• Increase the availability of medication assisted treatment for opioid use disorders

41

Importance of Data

• Monitor impact of interventions using data

• Link PDMP data with health outcomes

• Establish data dashboards to rapidly disseminate data to stakeholders

42

Immediate Actions and Potential Impacts

•Increase registration and use of PDMP

•Reduced high dose opioid prescribing, problematic co-prescribing of opioid and benzodiazepines, use of multiple prescribers for opioids, and reduce the incidence of opioid naive patients transitioning to chronic episodic and chronic opioid use

•Increase use of non-opioid pain therapies

•Increase use of claims reviews to identify high-risk prescribing

43

Contact

John W. McIlveen, Ph.D., LMHCState Opioid Treatment Authority Oregon Public Health DivisionOregon Health AuthorityPH: 503.572.8585Email: john.w.mcilveen@state.or.us

Supporting Management of Chronic Pain

and Opiate Prescribing

Second Annual Pain Summit

September 29 2015

Jim Rickards, MD

Overview

Current efforts and strategy?

What is the Yamhill CCO?

Future work?

16 Coordinated Care Organizations (CCOs)

in Oregon

Medicaid/Oregon Health Plan Benefits

Physical, Behavioral, and Dental Care Services

Community Governed Health Plan

501c3 Nonprofit Organization

What?

Why?

Why?

Governing Board

Clinical Advisory Panel (CAP)

Community Advisory Council (CAC)

Various Additional Committees

Administrative Staff

Who?

Integrator

Platform for Transformation & Innovation

Build Relationships

Transformation Funds

Staff Support

Access to Outside Expertise

How?

Pain SummitOpiate Prescribers Group

Controlled Substance Committee

Yamhill CCO Persistent Pain Program

Data

Community Standards

PCPCPH

Chronic Pain and Opioid Prescribing Support

Patient Centered Primary Care Homes

PCPCPH

Patient Centered Primary Care Homes

Community Standards

Community Standards

PCPCPH

Persistent Pain & Opiate Prescribing Guidelines

Adopted 2014 by Clinical Advisory Panel

Similar to Other CCOs

< 120 MED Major Component

Community Wide Support

Community Standards

Data

Data

Community Standards

PCPCPH

Data

Yamhill CCO Persistent Pain Program

Yamhill CCO Persistent Pain Program

Data

Community Standards

PCPCPH

8 Weeks

Pain School & Movement Therapy Program

Laura Fisk PsyD - Wellness Center Behaviorist

Started February 2015

23 Graduates

Adding Massage Therapy & Graduate Yoga

Yamhill CCO Persistent Pain Program

Yamhill CCO Controlled Substance Committee

Controlled Substance Committee

Yamhill CCO Persistent Pain Program

Data

Community Standards

PCPCPH

Medication & Treatment Service Consultation

Physicians, Pharmacists, RN, Behaviorist,

Addiction Counselor

Meets Monthly

Started April 2015

Reviewed 10 Cases to Date

Yamhill CCO Controlled Substance Committee

Platform for Discussion and Action

Pain SummitOpiate Prescribers Group

Controlled Substance Committee

Yamhill CCO Persistent Pain Program

Data

Community Standards

PCPCPH

Statewide Opiate Performance Improvement

Project

OHA Expanded Back Pain Treatment Guidelines

and Coverage

Value Based Payment for Opiate Prescribing

Dental & ED Strategy

Future Work

Our Vision Statement: “A unified healthy community that

celebrates physical, mental, emotional, spiritual, and social well-being.

Jim Rickards, MD, MBA Yamhill CCO Health Strategy Officerjrickards@yamhillcco.org

Our Mission Statement:“Working together to improve the quality of life and health of Yamhill Community Care

Organization members by coordinating effective care.

Pharmacy Panel

Morgan Parker, WVMC

Johanna Thompson, Providence

BingBing Liang, CareOregon

Nicole Winnen, RPh, Mac Pharmacy

Paul Carson, CareOregon

Prescribing Report

Second Annual Pain SummitSeptember 29th, 2015

BingBing Liang, CareOregon

Opioid Alternative Pain Management Resources

• Massage therapy: Available with authorization.

• Physical/Occupational therapy: No authorization for evaluations for covered diagnoses. Authorization required for therapy visits. Yamhill CCO will allow an evaluation and up to 5 total visits for patients with below the line diagnoses annually with authorization.

• Salonpas Pain Relief Patches (menthol/methyl salicylate): FDA-approved over-the-counter pain patches available for purchase at most drug stores.

• TENs units: Available with authorization.

• Acupuncture: No authorization required when performed by contracted clinicians affiliated with PCP office for chemical dependency treatment.

• Alternative medications: NSAIDs, gabapentin, amitriptyline, nortriptyline.

• Biofeedback: Available with authorization.

• Chiropractic manipulation: Authorization required for evaluation and treatment.

• Counseling: Available to all patients without referral for mental health, pain management, and alcohol and drug abuse.

Yamhill CCO Opiates Prescribing Report

Yamhill All CCOs MCHD Clinics0.0%

5.0%

10.0%

15.0%

20.0%

13.6%

16.3%

14.1%

MED 120mg/Chronic User (%)

MED 120mg/Chronic User (%)

Quarter 2, 2015

Quarter 2, 2015

4th Qrt 2014 1st Qrt 2015 2nd Qrt 20150.0%

5.0%

10.0%

15.0%

20.0%

25.0%

24.7%(69)

21.3%(56)

13.6%(57)

% of Chronic Users (#Mbrs)

% of Chronic Users (#Mbrs)

Yamhill CCO Opiates Prescribing Report

Top Assigned PCPs

Quarter 2, 2015

Assigned PCP Name #Mbrs% of Total

PROVIDENCE MEDICAL GROUP NEWBERG 23 40.4%

WEST HILLS HEALTHCARE CLINIC 9 15.8%

VIRGINIA GARCIA MCMINNVILLE 4 7.0%

WILLAMETTE HEART & FAMILY WELLNESS YAMHILL 3 5.3%

PHYSICIANS MEDICAL CENTER 2 3.5%

WEST SALEM CLINIC 2 3.5%

Total 43 75.4%

Opiate Utilization Report

MEDS Chart –Patient-Empowered Medication Effectiveness

Paul Carson

CareOregon Pharmacy Team

Overwhelmed by Medications

CareOregon has 12,000 members who have had 16 or more medication changes over the last year.

• Multiple meds/providers• Don’t know what they’re taking

or why (purpose for drug not always spelled-out on label)

Medication Confusion

Multiple PrescribersMedication Prescribing PhysicianPrilosec Dr. BrownZocor Dr. BrownNaproxen Dr. BrownCrestor Dr. JaffeLisinopril Dr. JaffeSynthroid Dr. BrownNaproxen Dr. WillisOxycodone Dr. WillisGlucophage Dr. BrownHydrochlorothiazide Dr. JaffeAmoxicillin Dr. BrownLipitor Dr. BrownEpogen Dr. Jaffe

Who Benefits?

Members

Providers

Caregivers

Pharmacists

Available in paper or fillable .pdf formats

Other languages:

• Spanish

• Chinese

• Vietnamese

• Russian

Take the Chart to Ask patients how their Your Doctor/Pharmacist meds make them

feel

Encourage Patient Use

Pilot Site Use Today• Old Town Clinic – has integrated a version of the

MEDS Chart into their Electronic Health Record system

• Clackamas Beaver Creek• YOU can be next!

We want to partner with you!

Paul CarsonTraining & Development Specialist – Pharmacycarsonp@careoregon.org 503-416-5745

http://www.careoregon.org/meds

Thank you!

Behavioral Health: Persistent PainJERI TURGESEN, PSYD

What is Pain? “Pain is an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage or described in such terms”

-International Association for the Study of Pain

Chronic Pain Brain activity switches when it becomes chronic

Sensory Emotional networks

Brain starts devoting more sensory space to pain area

Neuroplasticity

Hurt vs Harm

Pain is output from the brain

Chronic Pain Patients

Frequently, persistent pain symptoms are initially triggered by biomedical factors

(Skinner, Wilson, & Turk, 2012).

Persistent pain patients experience anxiety and depression at higher rates than the general population

(Orenius, et al., 2013)

Self-Management? Tendency towards premature discontinuation of treatment plans Development of maladaptive self-management strategies for pain management.

(Skinner, Wilson, & Turk, 2012).

Psychosocial Variables: Pain

Beliefs about Pain

Beliefs about Controllability

Self-Efficacy

Cognitive Errors

Coping (Turf and Monarch, 2002))

Cognitive Behavioral Therapy

CBT: An important component in the treatment of chronic pain.(Heapy, Stroud, Higgins, & Sellinger, 2006)

CBT has consistently produced positive outcomes in both improvement in mood and overall functioning for people with chronic pain.

(Burns, Kubilus, et al., 2003)

Chronic pain patients who were treated with CBT:Return to workReduction in perceived painReduction in medicationImproved activity

(Flor, Fydrich, and Turk, 1992)

Cognitive Behavioral Therapy

Pain Education has also demonstrated positive outcomes for patients:

Decreasing pain rating (Van Oosterwijck et al 2011, Meeus et al, 2010, Ryan et al, 2010, Moseley, 2002, 2003, 2004)

Decreasing in fears related to possible re-injury (Van Oosterwijck et al 2011, Moseley, 2002, 2003)

Decreasing pain catastrophizing (Meeus et al, Moseley 2004)

Decreasing workmen’s compensation claims (Buchbinder)

Improved level of functioning(Van Oosterwijck et al 2011, Moseley, 2002, 2003

Commonly Utilized Interventions

Cognitive-behavioral therapyAddressing maladaptive belief systemsMindfulness/MeditationRelaxationBehavioral treatmentsMotivational interviewingGuided imageryBiofeedback

Wellness Center Persistent Pain ProgramLAURA FISK, PSYD

Wellness Center

Persistent Pain Program

8 week group-based model 1 hour Psychoeducation – “Pain School” 1 hour Movement Therapy – Yoga

Referrals Referrals: 205

Members are referred by PCP/Medical Team, Behavioral Health, Community Partners or Self

Referring Clinics/OrganizationsClinic/Organization Percentage of

Referrals

Virginia Garcia 42%

A Family Healing Center 13%

Yamhill Adult Behavioral Health 11%

Providence Medical Group 10%

Physicians Medical Center 8%

Willamette Heart 8%

Grande Ronde 2%

Lutheran Community Services 2%

Yamhill CCO Community Health Workers 2%

Community EMS, NSWDS, Provoking Hope, Women's Healthcare <1%

Attendance (January – August)

Orientation: 87

Intakes: 59

Graduated Program: 23

Outcome Measures

Pre- and Post-measure were collected

Time 1 = 90-minute Intake

Time 2 = Week 8 – Graduation

Demographics

Male 22%

Female 78%

Gender

Male Female

74%

13% 4% 0% 0% 0% 9%

Ethnicity

Average Age: 45.9 (Min = 26; Max = 63)

BPI Severity Scale Pre-

BPI Severity Scale Post-

BPI Interference Scale Pre-

BPI Interference Post-

0

1

2

3

4

5

6

7

8

6.07 5.857.07 6.46

Brief Pain Inventory

*

*

Note. Significance is indicated * = p<.05

Pre-Test Post-Test47.5

48

48.5

49

49.5

50

50.5

51

51.5

52

52.552.5

49.45

Oswestry Low Back Pain Disability Ques-tionnaire

Pre-Test Post-Test38

38.5

39

39.5

40

40.5

41

41.5

42 41.72

39.31

Fear of Movement Scale

Pre-test Post-Test0

2

4

6

8

10

12

14

16

18 16.0412.86

Patient Health Questionnaire(PHQ-9)

Note. Significance is indicated * = p<.05

Physical Health

Pre-

Physical Health Post-

Mental Health

Pre-

Mental Health Post-

Social Health

Pre-

Social Health Post-

General Health-

General Health Post-

0

5

10

15

20

25

30

35

40

45

50

1519.54

39.41 43.18 44.54 46.81

32.85 36.5

DUKE Health Profile

Pre-test Post-test0

5

10

15

20

25

30

21.04

28.5Pain Self Efficacy Questionnaire (PSEQ)*

Note. Significance is indicated * = p<.05

Level 1 Level 2 Level 3 Level 40

2

4

6

8

10

12

67 7

23

6

12

1

Patient Activation Measure

Pre-test Post-test

Persistent Pain: Discussion Panel

Persistent Pain Panel

Jeri Turgesen, PsyD: Providence Medical Group, Newberg

Laura Fisk, PsyD: Yamhill CCO Wellness Center; Villa Medical Clinic

Kristi Schmidlkofer, PsyD: Physicians Medical Center

Kristin Garcia, PsyD: Virginia Garcia Clinic, McMinnville

Syrett Torres, PsyD: Women’s Health Care; Valley Women’s Health

Second Annual Pain Summit

September 29th, 2015

Todd Hyder, DMD

Narcotics in Dentistry

Second Annual Pain Summit

September 29th, 2015

William J. Koenig II, DO

Closing Remarks

Remember to fill out your evaluation to receive CME credit!

Second Annual Pain Summit

September 29th, 2015

William J. Koenig II, DO

Opioid Guidepath Workgroup Meets monthly Contact Jenna Harms jharms@yamhillcco.org for more information Presentations available http://

yamhillcco.org/for-providers/provider-updates

Remember to fill out your evaluation to receive CME credit!

Ongoing Discussion