1. Southern Oregon Pain Conference 5/9/14 Amit Shah, MD Jackson Care Connect

2. Overview-Epidemiology Most, if not all, aware of opiate inappropriate use, misuse and related high rates of morbidity and mortality with chronic and/or high dose usage It is clear (national, state, and local) that inappropriate prescribing of opiates is not acceptable -JAMA-”Providers inappropriately prescribing are the most significant reason for current epidemic” 2012 Federal study that Oregon physicians only second to “*” in willingness to prescribe opiates Prescribing patterns have changed but not to expected population- public health levels needed 2012 JCC 7 out of top 10 prescriptions were opiates, pain related 2013 JCC 2 out of 10 prescriptions were opiates and unlike 2012 3 out of 10 were antidepressants but 15-17 yo trend continues to rise 2014 JCC 4 out of 10 were opiates and 7 out of 10 were pain related…what happened?

3. Prevalence-One view ICD 9 DiagnosisEncounters 1 Drug Dependence31,959 2 Health Supervision Of Infant Or Child6,631 3 Diabetes Mellitus5,187 4 Other Symptoms Involving Abdomen And Pelvis4,788 5 Symptoms Invlv Resp System&oth Chst Symptoms4,295 6 General Symptoms4,278 7 Alcohol Dependence Syndrome3,471 8 Other And Unspecified Disorders Of Back3,315 9 Acute Uris Of Multiple Or Unspecified Sites3,047 10 Other And Unspecified Disorders Of Joint3,045

4. Prevalence-Another View ICD 9 Diagnosis Encounters Drug Dependence31,959 Persistent Pain18,897 Health Supervision Of Infant Or Child6,631 Diabetes Mellitus5,187 Symptoms Invlv Resp System&oth Chst Symptoms4,295 Acute Uris Of Multiple Or Unspecified Sites3,047

5. Prevalence-Shocking view What do these represent? 25,932 2,149,668 474,420

6. Dark history… Cephalon-Actiq-New Yorker Purdue Pharma, Execs to Pay $634.5 Million Fine in OxyContin Case President, top lawyer and former chief medical officer will pay $634.5 million in fines for claiming the drug was less addictive and less subject to abuse than other pain medications Purdue learned from focus groups with physicians in 1995 that doctors were worried about the abuse potential of OxyContin. The company then gave false information to its sales representatives that the drug had less potential for addiction and abuse than other painkillers

7. Dark History… U.S. Senate panel launches investigation of painkillers, drug companies seeking financial and marketing records from three companies that make opioid drugs, including OxyContin and Vicodin, and seven national organizations

8. Dark History… Pain is the 5 th vital sign Limited to no standards on managing chronic pain Limited to no BH/CD support structures in place Limited to no understanding of the neuro-biology and underlying BH issues If you prescribe controlled substances your license will be reviewed vs. to not prescribe your license will be reviewed Truth? 11 year OMB case review re: opiate prescribing

9. 1:9:35:161:461 “1:9:35:161:461” should be known to all http://jama.ama-assn.org/content/307/8/774.full Morbidity and Mortality Weekly Report JAMA. 2012;307(8):774-776.

10. Overview-High Risk Patients TypeNumberCostInitiative(s) High Utilizers(CMMI)*480$8,800,729 (2% accounting for 25% of cost) CAP work, Providence ED navigator, Community health workers at La Clinica & CHC High Cost (10-50)*2,026 (includes peds)$17,000,000 (10% accounting for 50-60% of cost) Same as High utilizers Opiates*872?OPG-? Polypharmacy (Rx Risk Score >10)* 96$2,923,919 (<1% accounting for 8% of cost) Clinical Pharmacist program development SPMI241$1,751,280 (1% accounting for 5% of cost) Pediatric MH crisis planning with JCMH and Kairos, JCMH primary care clinic; analytics; ACG >0.3*230$6,645,055 (1% accounting for 19% of cost) Same as high utilizer work *=high cross over- correlation with each other

11. Overview-Prescription vs. Chronic Pain Important to think of these as separated but related issues (confusing 2 together has unintended consequences) Must work on provider, patient, community change regarding this “Easy” to address prescription, but find that until this done other critical interventions cannot occur Chronic Pain=Chronic Disease and so must be managed accordingly: “Hey, this is no different than kidney disease or cancer or any other disease” Vermont Governor State of Union Address

12. How to “move the needle” National, state, and local efforts identified the following key strategies: “absolute” adherence to prescribing guidelines-must be policy-not just PCPs but starts here Starts with ceiling dose Build behavioral health and chemical dependence treatment “Upskilling” providers (especially PCPs) Education for provider/staff/ patients/communities IT support

13. Data driving change Hard conversations… Statistics not lie…but often only tell part of the story “What happens in exam room stays in exam room” -pressures to meet visit expectations more and more difficult and often deemed “futile” when opiates in equation

14. Data Opiate Use-Prescribing

15. Members using opiates may belong to one or more risk groups Chronic use risk: > 60 total days supply in 90 days Adverse effect risk (cocktail effect): combination with benzodiazepines, phenothiazines, or muscle relaxants Dental utilization risk: potentially inappropriate dental opiate prescriptions Pain syndrome risk: high morphine equivalent per day > 120mg High risk opioids: methadone or fentanyl Chemical dependency risk: concurrent buprenorphine or chemical dependency visit claim in past year High diversion risk: high pill count of > 10 per day High FWA risk: utilizer of >= 5 pharmacies or >= 5 prescribers in 90 days

16. JCC members using opiates are categorized in these groups JCC members by number of members in risk group * Benzodiazepine claims for clonazepam only, the majority of benzodiazepine claims are paid under DMAP.

17. Regulatory support 42 CFR 431.54(e), 456.3 and 455.1-16: Federal requirement of all Medicaid agencies to have programs to evaluate FWA and over- utilization and allows for lock-in programs. OAR 410-121-0135 and ORS 414.350, 414.360 (c) (a-h): State provision pursuant to above federal requirement for a Pharmacy Management Program limiting clients to a specific pharmacy. DMAP selects clients for the Pharmacy Management Program who used 3 or more pharmacies during the prior 6 months use multiple prescribers to obtain prescriptions of the same or comparable medications have altered a prescription exhibit patterns of prescription drug use 1 1. Oregon Health Authority Pharmaceutical Services Administrative Rulebook Chapter 410, Division 121, effective February 21, 2013

18. Specific interventions Ceiling dose Current Oregon “standard” is 120 MED Study re: 50-200 MED mortality-WA set 120 MED Current trend is 60 MED Portland 120 but moving to 60 CPCCO 120 but considering 60 YCCO 120 Medford-AllCare 120, OPG recommend 120, JCC will adopt community standard 3 groups of high dose patients-Diverter, High Risk, all others Trend is can work on “all others” over time

19. Specific Interventions-Map 3 Core focus areas: What is need in clinic and with providers Guidelines, education, “up skilling” Behavioral Health Chemical Dependency/Addiction Management/Treatment

20. Specific Interventions National (Neighbors) WA furthest along: ECHO, 60 MED, provider education, policy regulatory requirements (licensure, state law refer to specialist, strong evaluation) State EDIE, SBIRT, Screening for Depression, PDMP, less State, “centralized” approach than WA Portland Community adherence to guidelines (forced interventions), ED dental diversion, OCEP adherence, centralized MAT/referral, BH foundation in PCP clinics, ECHO, provider up skilling (EMR protocols, pharmacy protocols), non-medication interventions-OT, PT, CD integration-care coordination, SBIRT, Screening for Depression, just starting jail to community interventions CPCCO Required PIP, Guideline adherence, CCO ongoing opiate oversight-subgroup (as delegated by CAP), CCO red flag patient identification and interventions (lock down, etc.), specific clinical guidelines for high occurring dx (HA, LBP),population analytics, SBIRT, ECHO, Pain Clinic formation in partnership with BH/CD, Mid Valley BH,PCP, Hospital, Dental piloted in coast-”Buy it and Build it” YCCO Moving in CPCCO space but more “build it” model, SBIRT, community adherence to guidelines, moving toward 60

21. What should we do? Pilot and spread Clear outcomes wanting from pilot and “move fast” Once have momentum hard to stop Build BH/CD (in PCP, in ED [e.g. ED navigator ?screens CD], centralized vs. PCP office vs. both) PCP upskilling –IT, ECHO, opiate oversight-some kind of case consultation, support, etc. “real time” Build community resources for non-medication treatments Organization priority-”buy in” support Public Health communications-messaging Regulatory Credentialing Ceiling dose management Build PCP tools to do this (EMR, tapering protocols, etc.) Guideline adherence Ceiling dose-community, multi-payor standard (120?) Clarity on contraindications Clarity on determining appropriate vs. inappropriate for opiates Develop key, highly penetrated diagnosis/ clinical guidelines (HA, dental pain, LBP)

22. How to do? OPG-community clarity on specific concrete outcomes wanting in 90 days, 6 months, 1 year (“bite size”) Pilot to accomplish above Integration with High Utilizer strategy Plan for BH/CD build High penetration diagnosis guidelines Plan for non-medication management strategies Pain clinic services-”build it or buy it,” PCP office focus or centralized like CPCCO? PCP up skilling with concrete tools Education on the neurophysiology of persistent pain IT support EMR optimization ECHO, EDIE, JHIE, Vista Logic CCO analytics (red flag list, lock down, patient lists, utilization analysis, risk) Policy Multipayor ceiling Credentialing Aligning hospitals (e.g. ER guidelines)

23. Questions? “One’s philosophy is not best expressed in words; it is expressed in the choices one makes…and the choices we make are ultimately our responsibility.”