Coordinating Multiple Stakeholders National Rx Drug Abuse Summit 4-11-12

1. Coordinating Multiple
Stakeholders
April 10-12, 2012
Walt Disney World Swan Resort

2. Learning Objectives:
1. Describe the relationship between prescription
drug morbidity and mortality and the under-
treatment of pain.
2. Identify measurement-based care as standard
of care in pain medicine and describe how to
measure pain, mood and function in every
clinical encounter.
3. Evaluate how new state and federal policy
changes will likely allow more prudent and safer
use of opioids for chronic, non-cancer pain.

3. Disclosure Statement
• All presenters for this session, Dr. Alex
Cahana and Dr. Gary M. Franklin, have
disclosed no relevant, real or apparent
personal or professional financial
relationships.

4. UW Pain Care Delivery
Program
acahana@uw.edu

5. John
J.
Bonica

6. UW
Division
of
Pain
Medicine
&
Affiliates
APCA
BCNH
MHCS UAA
IIPM
ANMC
Inpatient
Inpatient Inpatient Inpatient Inpatient Inpatient
(Seattle)
Outpatient Outpatient Outpatient Outpatient
Outpatient
Outpatient Outpatient Outpatient (Seattle & Outpatient Outpatient
AL)

7. My disclosures
• I
am
not
opio-­‐phobic
• I
am
not
opio-­‐philic
• I
am
not
needle-­‐phobic
• I
am
not
needle-­‐philic
• I
am
agnos3c
to
chi
gong
and
tai
chi
• ‘I
just
wanna
know
how
my
pa3ents
are
doin’
• Because
if
I
don’t
measure
outcome
I
believe
my
prac3ce
is
not
medically,
financially
or
ethically
sustainable
• Standard
of
Care
needs
to
be
codified

8. Today:
• Situa3on
• Model
of
Care
• Value
• Future

9. Overtreatment
is
the
new
under-­‐treatment

10. 132 to 1775
690 to 1,442

11. Opioid
AddicEon
Treatment

12. Serious Morbidity ICD-9 CM:
"Diagnosis Codes: Respiratory insufficiency or failure: 518.5, 518.81,518.82, 518.5, 786.09; Aspiration pneumonia
507.0; Anoxic encephalopathy: 348.1; Cardiac Arrest: 427.5; Rhabdomyolysis: 728.88, 728.89"Procedure Codes:
Endotracheal administration: 96.04; Mechanical ventilation: 96.70-96.72; CPR: 93.93, 99.60
Data Sources: Comprehensive Hospital Abstract Reporting System (CHARS)
Oregon, State Inpatient Database (SID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare
Research and Quality.

13. Opioid
Related
Deaths
2001- 265 2009- 644

14. Opioid Overdose Risk (fatal & non-fatal) by
Average
Opioid
overdose/death
raEo
Daily Dose of Medically Prescribed Opioids
10 9-fold increase
9 ** in risk relative
to low-dose
8
patients
7 1.79 %
6
5
4 **
3 0.68 % ** Significant
2 increment in
risk p<0.05
1 0.04 % 0.26 %
0.16 %
0
Non-user 1-19 mg. 20-49 mg. 50-99 mg. 100+ mg.
Dunn et al., Annals Int Med, 2010

15. Fracture
Hazard
RaEo
2.5
2-fold increase
** in risk relative
2 to non-users
10.0 %
1.5
7.0 %
1
5.7 %
3.8 % ** Significant
increment in risk
0.5 p<0.05
0
Non-user 1-19 mg. 20-49 mg. 50+ mg.
Saunders et al., JGIM, 2010

16. Adverse
selecEon:
70.0%
61.4%
60.0%
51.7%
50.0%
38.5%
40.0%
30.0% 26.8% Odds ratios
adjusted for
1.0 1.4 2.1 2.6 pain severity
20.0%
and patient
characteristics
10.0%
0.0%
1-19 mg 20-49 mg. 50-119 mg. 120+ mg.
Merrill et al., under review

17. Newborns
with
Drug
Withdrawal
(GeneraEon
Rx)
Washington
State,
1990-­‐2009
5
4
Rate
per
1,000
live
births
3
2
1
0
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
Source: Washington State Department of Health, Comprehensive Hospital Abstract Reporting System

18. WA
State
Healthy
Youth
Survey
Frequency
of
Use
to
Get
High
Past
30
days
Grade
10
Sabel J, Banta-Green C. CSTE
2009

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L$HI"M
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20. More
opioids,
more
addicEon,
more
deaths

21. • People die from Rx
100 Overdoses Every
Day in the US
• Rx Pain Killer
14,800 Deaths in
2008
Source: CDC Vital Signs: overdoses of prescription opioid pain relievers -
1999-2008

22. For Every One Death :
10 Treatment 32 Emergency
admissions for dept visits
abuse
1 Death
130 People who 825 Non-
Misuse/abuse medical users
Source: CDC Vital Signs: overdoses of prescription opioid pain relievers -
1999-2008

23. Cultural Transformation

24. Today:
• Situa3on
• Model
of
Care
• Value
• Future

26. Revise
our
pracEce
model
• System is • Coordinated care
fragmented (PCMH)
Patient activation
• Care is inconsistent
• Collaborative care
(Telepain/ECHO)
• Cost is
unsustainable • Measurement based
care (CPAIN /
PainTracker)

27. Coordinated,
CollaboraEve
Pain
Management
The Patient
Measurement-Based Care Prescription Monitoring Tools
Primary
Care
Providers
Nurse Care
Coordinator
Pain s UDT
Tracker EDIE
CPAIN PMP
DNIC
Pain
Specialists
Structured
2ndOpinion TelePain Interdisciplinary
RX Reviews Consultation & CME Pain
Management
Increasing Level of Care
Lower Costs

28. 1. Care Coordination
Workflow
CPR = Center for Pain Relief
NCC = Nurse Care Coordinator
PCP = Primary Care Provider

29. 2.
ECHO/TelePain/ROAM

30. “MulEplier
Effect”
(&)*$+' 3..#)/$&"'
!&,*,' (&)*$+,'#$'
(-*,*$+*.' (-&%)%*'
+/'0!12'
!"#$#%#&$'
!"#$#%#&$'

31.
3.
PaEent
reported
outcome

36. Today:
• Situa3on
• Model
of
Care
• Value
• Future

37. 1.
Coordinated
Care
n=3500

38. 1.
Coordinated
care:
Pilot
data
Pain Disability Anxiety Depression Opioid use
Well engaged -6% -45% -44% -50% -56%
Minimally
engaged +28% +55% +10% +28% +1%
Not engaged +29% +29% No f/u No f/u -3%

39. 2.
ECHO/TelePain/ROAM
• 40-­‐50
dial-­‐ins
each
session
• 1500
providers
• 76
loca3ons
• 2240
CME
hours
• Regional
‘Pain
champions’
(meta-­‐ECHO)

40. 2.
ECHO/TelePain/ROAM
N = 94
N = 95
6 Mean
=
4.7
Mean = 4.5
N = 94
SD = 0.6 Mean = 4.3
SD = 0.7
SD = 0.7
5
4
Mean Rating
3
2
1
0
Learning best practice Developing clinical Comfortable teaching
care expertise others what I've learned
Participants Rated Level of Agreement on a 5-point Scale: 1 = Not At All, 5 = To a Large Degree

41. 2.
ECHO/TelePain/ROAM
N = 85 N = 84 N = 84 N = 85 N = 86
Mean = 4.6 Mean = 4.4
6 Mean = 4.3 Mean = 4.4 Mean = 4.5
SD = 0.7 SD =0.7 SD = 0.7 SD = 4.5 SD = 0.6
5
4
Mean Rating
3
2
1
0
Reduced Reduced Provider's Decreased Through early
patient travel for emergency appropriate use visits by and effective
specialty care room visits of testing patients to patient
and testing specialists interventions
Providers Rated Agreement on a 5-point Scale: 1 = Strongly Disagree, 5 = Strongly Agree

42. 2.
ECHO/TelePain/ROAM
2007-­‐2009
25
41%
*
20
2008-­‐20010
54%
*
63%
*
15
29%
34%
10
43%
*
5
0
State
Clallam
Grant
Jefferson
Kitsap
Okanogan

43. 3.
PaEent
Reported
Outcome

44. 3.
PaEent
Reported
Outcome

45. 3.
PaEent
Reported
Outcome
Estimated Savings per Claim over Duration of ER Group (N = 373) ID Group (N = 373) DR Group (N = 373)
Disability
Total Cost of Illness per Claim (2010 US $) $66,525 $121,829 $233,600
Average Savings - $55,304 $167,075
% Saved - 45% 72%
Theodore, in press

46. Today:
• Situa3on
• Model
of
Care
• Value
• Future

47. Scalability
and
sustainability
• State
(WA,
AK)
• DoD/VA
• Large
employers
(UW,
GE)
• CMS/CMMI

48. WA
State
legislaEon
(2876):
• Mandates
Educa3on
and
Guidelines
• Mandates
TeleHealth
• Mandates
Opioid
tracking
• Mandates
Measurement
at
each
encounter

49. Most
emphasis

50. NaEonal
legislaEon
• Educa3on
-­‐
7
(CA,
FL,
ME,
NY,
UT,
WA,
WV)
• TeleHealth
-­‐
5
(KS,
ME,
MN,
NM,
WA)
• Monitoring
Program
-­‐
48
(NH,
MS
pending)
• Outcome
tracking
-­‐
1
(WA)

51. Mandatory
guidelines:

52. 2009-­‐2010:
Deaths
from
opioids
decreased
by
50%

53. State
ED
informaEon
exchange
No controlled
Registration Reveals Physician reviews substances
Patient’s ED chart ED care guidelines
Patient on EDIE
flagged for doctor medical screening
Usual Triage exam by ED physician
ED case manager talks to
patient prior to discharge
Patient Discharged

54. State
ED
informaEon
exchange
“Please
review
Jane
Doe”
24 hour referral line compiled and
Reviewed for appropriateness Program Coordinator
researched.
ED Physician calls PCP
PCP
Recommendations
ED Care Guidelines Committee
ED Care Guidelines Chaplin ED Nurse ED Physicians
Patient’s Primary Care Physician
Psych Nurse Pharmacist Medical Director

55. EDIE:
Reducing
Non-­‐Emergent
ED
UElizaEon

56. Revise
our
pracEce
model
• System is • Coordinated care
fragmented (PCMH)
Patient activation
• Care is inconsistent
• Collaborative care
(TelePain/ECHO)
• Cost is
unsustainable • Measurement based
care (CPAIN/
PainTracker)

57. EducaEon
is
important
Rosenblatt, 2011

58. !"#$%&%'#(')$*+$#,-'.*/)(#$")*0',"*+$#,-,"$*/(%1$2*3"45678**
Current Level of Knowledge1 Level of Interest in
Learning 2
Mean (SD)
Mean (SD)
Assessment and management of genetic-biologic-psychological-social components 2.18 (1.0) 4.25 (0.85)
commonly involved in development and maintenance of complex chronic pain
disorders
Pathophysiology of chronic pain versus acute pain 2.34 (1.0) 4.25 (0.85)
Use, interpretation, and application of measurement based tools when completing a 1.72 (0.9) 4.16 (0.88)
comprehensive pain assessment
Multispecialty treatments and approaches for the care of chronic pain 2.12 (1.0) 4.37 (0.75)
Types and roles of medications used for pain, including opioids and non-opioids. 2.29 (1.1) 4.56 (0.63)
Types and role of non-medication treatment for chronic pain 2.23 (1.0) 4.52 (0.70)
Common primary care clinical pain disorders 2.43 (1.0) 4.35 (0.85)
Pain Medicine as a chronic illness specialty with knowledge and skills including 2.02 (1.1) 3.84 (1.06)
diagnosis of complex complaints, complex medical and surgical illnesses, and both
consultative and continuing multidisciplinary treatment.
Learning more about pursuing a Residency in Pain Medicine - 2.85 (1.35)
!
*
1 Scale = 1-Poor, 2-Fair, 3-Good, 4-Very Good, 5-Excellent
2 Scale = 1-Not Interested, 2-Little Interest, 3-Neutral, 4-Somewhat Interested, 5-Very Interested

59. But
not
enough

60. Take
Home
Message:
• Coordinated,
collabora3ve,
measurement
based
model:
• 50%
decrease
in
deaths
from
opioids
• 65%
decrease
in
coun3es
par3cipa3ng
in
TelePain
• 56%
decrease
in
opioid
prescrip3on
rate
• 56%
decrease
in
opioid
related
ER
visits
• 50%
increase
in(see attached, for North American
Spine Society 2012 Outstanding Paper Award)
global
health
ra3ng
1
year
aker
treatment

61. It
ain't
what
you
don't
know
that
gets
you
into
trouble.
It's
what
you
know
for
sure
that
just
ain't
so.
Mark
Twain