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Ohio Self-Insurers Association 2013
1.
Sedgwick © 2013
Confidential – Do not disclose or distribute. Sedgwick © 2011 Confidential – Do not disclose or distribute. JUNE 12-13, 2013
2.
Sedgwick © 2013
Confidential – Do not disclose or distribute. Sedgwick © 2011 Confidential – Do not disclose or distribute. Narcotic Medication Strategies Teresa Bartlett, MD Senior Vice President Medical Quality
3.
Sedgwick © 2013
Confidential– Do not disclose or distribute. 3Sedgwick © 2011 Confidential– Do not disclose or distribute. 3 Objectives • Provide background information regarding opioids • Provide education • Provide tools to assist in the assessment of cases • Screening tools • Opioid Agreement • Timing of follow up • Board of pharmacy reporting • Assessment considerations • Drug Screening guidance • Calculations of Morphine dosages
4.
Sedgwick © 2013
Confidential– Do not disclose or distribute. 4Sedgwick © 2011 Confidential– Do not disclose or distribute. 4 Education • First step toward Prescription Drug optimization • Addresses: • Overuse • Underuse • Misuse • Drug to drug interactions • Medication reconciliation process • Overall health safety concerns • lab studies
5.
Sedgwick © 2013
Confidential– Do not disclose or distribute. 5Sedgwick © 2011 Confidential– Do not disclose or distribute. 5 Statistics • Every hour in the USA one baby is born suffering from in opioid withdrawal (NIDA) • 40% increase in employees testing positive for prescription narcotics from 2005-2009 (Quest) • A November 18, 2010 report post-accident drug tests are four-times more likely to find narcotics than pre-employment drug tests (Quest) • Vicodin is the most frequently found narcotic prescription drug abused (Quest)
6.
Sedgwick © 2013
Confidential– Do not disclose or distribute. 6Sedgwick © 2011 Confidential– Do not disclose or distribute. 6 Background: How did we get here •From the American Pain Society Website: • In late 2000, Congress passed into law a provision, which the President signed, that declared the ten-year period that began January 1, 2001, as the: • Decade of Pain Control and Research • The American Pain Society has actively supported the Decade of Pain Control and Research and it has been a focal point for the development of numerous programs to advance awareness and treatment of pain and funding for research
7.
Sedgwick © 2013
Confidential– Do not disclose or distribute. 7Sedgwick © 2011 Confidential– Do not disclose or distribute. 7 Narcotic Utilization •Fatal overdoses involving prescribed opioids tripled in the United States between 1999 and 2006 •A recent government study determined that opioid poisoning was the leading cause of death for people aged 35-54 • This rate was higher than motor vehicle or firearm related deaths for that age group • Since 1990, the medical use of opioids has increase by a factor of 10 • According to the CDC, enough opioids were prescribed last year to medicate every American adult with a standard pain treatment dose of hydrocodone every 4 hours for a month
8.
Sedgwick © 2013
Confidential– Do not disclose or distribute. 8Sedgwick © 2011 Confidential– Do not disclose or distribute. 8 Narcotic Medication Management • National Issue • Creates issues for • patients • physicians • employers • * The # 1 prescribed drug in the USA in 2012 was Hydrocodone with acetaminophen (Vicodin) http://healthland.time.com
9.
Sedgwick © 2013
Confidential– Do not disclose or distribute. 9Sedgwick © 2011 Confidential– Do not disclose or distribute. 9 Prescription Drug Diversion as a National Issue
10.
Sedgwick © 2013
Confidential– Do not disclose or distribute. 10Sedgwick © 2011 Confidential– Do not disclose or distribute. 10 Unintended Result • Across the country, there is an increase in the number of ER visits due to non-medical use of narcotics • Up to 89% of abused prescription drugs are diverted from legally written prescriptions Problem isn’t just with narcotic prescribing,buthowtheyare usedonceinthehandsofthe public
11.
Sedgwick © 2013
Confidential– Do not disclose or distribute. 11Sedgwick © 2011 Confidential– Do not disclose or distribute. 11 Biochemical Physiology of Narcotic Use The way the brain reacts facilitates the process of addiction/abuse: • Endorphins are naturally occurring chemicals that work on the nervous system to reduce pain • The endorphins can act on certain parts of the brain to produce euphoria or a natural “high” • Addiction shuts the endorphin system down • This leads to hyperalgia (increased pain perception) and hypersensitivity • The abuser then seeks higher doses or stronger drugs
12.
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Confidential– Do not disclose or distribute. 12Sedgwick © 2011 Confidential– Do not disclose or distribute. 12 Opioid Guideline for Chronic Pain • Use opioid only after other pain relief therapies have been exhausted • Before prescribing a risk assessment screening should be conducted • Opioids should be started at the lowest possible dose • If a patients dosage has increased to 120mg MED without substantial improvement in function or pain relief a chronic pain specialist should be consulted • Long acting or controlled release opioids should not be used for acute pain • Fentanyl patches, OxyContin and Methadone are examples
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Confidential– Do not disclose or distribute. 13Sedgwick © 2011 Confidential– Do not disclose or distribute. 13 Opioid Contract
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Confidential– Do not disclose or distribute. 14Sedgwick © 2011 Confidential– Do not disclose or distribute. 14 Importance of Communication Skills • Medical Literacy • Risks • Self Care • Lifestyle choices Patient Education • Better Results • Transfer of specific knowledge Consulting Physician Education BetterOutcomes
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Confidential– Do not disclose or distribute. 15Sedgwick © 2011 Confidential– Do not disclose or distribute. 15 Follow up Care • Failure to progress or demonstrate functional progress or any signs of compliance should lead to prompt discontinuance of medication • Dosage may need to be increased to maximize therapeutic value not to exceed 120mg Morphine/day • Random Urine Drug Screen • Weaning should involve a mental health professional who specializes in addiction • PT, exercise and other medications such as NSAIDS are important in this process
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Confidential– Do not disclose or distribute. 16Sedgwick © 2011 Confidential– Do not disclose or distribute. 16 Morphine 120mg/day is the MAXIMUM • An electronic dose calculator can be found and downloaded • http://agencymeddirectors.wa.gov/mobile.html MORPHINE (reference) 30 mg Codeine 200 mg Fentanyl Transdermal 12.5mcg/hr Hydrocodone (Vicodin) 30 mg Hydromorphone 7.5mg Oxycodone 20mg Oxymorphone 10mg Methadone** 4mgj BE CAUTIOUS COMPLICATED
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Confidential– Do not disclose or distribute. 17Sedgwick © 2011 Confidential– Do not disclose or distribute. 17 Acetaminophen (Tylenol) Warning • Causes liver toxicity • Many narcotics are combined with acetaminophen so you must also watch for maximum dosing • Short-term use (<10 days) – 4000 mg/day • Long-term use – 2500mg/day
18.
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Confidential– Do not disclose or distribute. 18Sedgwick © 2011 Confidential– Do not disclose or distribute. 18 Opioid Risk Tool ORT Date ______ Patient Name OPIOID RISK TOOL Mark each box that applies Item Score If Female Item Score If Male 1. Family History of Substance Abuse Alcohol [ ] 1 3 Illegal Drugs [ ] 2 3 Prescription Drugs [ ] 4 4 2. Personal History of Substance Abuse Alcohol [ ] 3 3 Illegal Drugs [ ] 4 4 Prescription Drugs [ ] 5 5 3. Age (Mark box if 16 – 45) [ ] 1 1 4. History of Preadolescent Sexual Abuse [ ] 3 0 5. Psychological Disease Attention Deficit Disorder [ ] 2 2 Obsessive Compulsive Disorder Bipolar Schizophrenia Depression [ ] 1 1 TOTAL [ ] Total Score Risk Category Low Risk 0 – 3 Moderate Risk 4 – 7 High Risk > 8
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Confidential– Do not disclose or distribute. 19Sedgwick © 2011 Confidential– Do not disclose or distribute. 19 Urine Drug Testing • Purpose • Identify aberrant behavior • Undisclosed drug use and/or abuse • Verify compliance with treatment • Frequency • Based on risk assessment for drug abuse • Low risk once/year • Moderate risk twice/year • High risk three to four times/year • Unusual or suspicious behavior = at time of visit • Losing prescription • Requesting early refills • Multiple prescribers • Demonstrating intoxication • Slurred, slow speech
20.
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Confidential– Do not disclose or distribute. 20Sedgwick © 2011 Confidential– Do not disclose or distribute. 20 Urine Drug Testing Result Interpretation The following UDT results should be viewed as a “red flag” requiring confirmation and intervention: • Negative for opioid(s) prescribed • Positive for drug (benzodiazepines, opioids, etc) NOT prescribed • Positive for amphetamine or methamphetamine • Positive for alcohol • Positive for cocaine or metabolites If a confirmatory drug test (MRO) substantiates a “red flag” result AND is: • Positive for prescribed opioid(s) • a controlled taper and a referral to an addiction specialist or drug treatment program should be considered • Negative for prescribed opioid(s) • The physician should stop prescribing opioid(s) and consider a referral to an addiction specialist or drug treatment program
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Confidential– Do not disclose or distribute. 21Sedgwick © 2011 Confidential– Do not disclose or distribute. 21 Assessment of Function • Overall Pain Management • How well is the pain being managed? • Pain rating when asked to consider the past month • Should indicate pain is overall better and able to function at a higher level • Function • Daily activities should be listed • Even in WC activities that are healthy should be encouraged
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Confidential– Do not disclose or distribute. 22Sedgwick © 2011 Confidential– Do not disclose or distribute. 22
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Confidential– Do not disclose or distribute. 23Sedgwick © 2011 Confidential– Do not disclose or distribute. 23 Suggested Weaning Process • Reduce Morphine mg by 10 to 20% each week • Add Clonopine to help with withdrawal symptoms • Addiction or Pain Management Specialist should be consulted • May require short inpatient stay to assist with initial phase • May require drug rehab program (inpatient and outpatient)
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Confidential– Do not disclose or distribute. 24Sedgwick © 2011 Confidential– Do not disclose or distribute. 24 The Role of Claim Managers • Help the physician stay on track • Ask for the Risk assessment (ORT) and provide tool if necessary • Make sure other therapies are tried first • That first RX for opioids should be small doses and improvements should be documented in function and pain • Request follow up assessment of patient to see if medication is working (allergic reaction) Does not have to be office visit • Set next appointment with treating physician for 10 to 14 days for next assessment • Provide an Opioid agreement to any physician prescribing these drugs (ACOEM or State of Washington) • Ask for copies of screening, opioid agreement, drug test results and OARRS report
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Confidential– Do not disclose or distribute. 25Sedgwick © 2011 Confidential– Do not disclose or distribute. 25
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Confidential– Do not disclose or distribute. 26Sedgwick © 2011 Confidential– Do not disclose or distribute. 26 OHIO Automated RX Reporting System (OARRS) • Established in 2006 • Tool to assist healthcare professionals in providing better treatment for patients with medical needs • Quickly identifies drug seeking behaviors. • Prescription History Report can assure a patient is getting the appropriate drug therapy and is taking their medication as prescribed Who can run this history report? • Prescribers (or delegates) • Pharmacists • Officers of law enforcement agencies whose primary mission involves enforcing prescription drug laws • All must register for an OARRS account
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Confidential– Do not disclose or distribute. 27Sedgwick © 2011 Confidential– Do not disclose or distribute. 27 Providers Required to Check OARRS When: Have a drug screen result that is inconsistent with the treatment plan or refusal to participate in a drug screen Forging or altering a prescription Stealing or borrowing reported drugs Arrest, conviction or received diversion, or intervention in lieu of conviction for a drug related offense while under the physician's care Increasing the dosage of reported drugs in amounts that exceed prescribed amount Selling prescription drugs Receiving reported drugs from multiple prescribers, without clinical basis Have a family member, friend, law enforcement officer, or health care professional express concern related to the patient's use of illegal or reported drugs
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Confidential– Do not disclose or distribute. 28Sedgwick © 2011 Confidential– Do not disclose or distribute. 28 Potential Claim or Clinical Actions • Focus on quality health care and patient safety issues • Use Clinical Resources when needed: • Customized letters to physicians • Request drug screen • Ask physician for contract • Ask Physician to run OARRS Report • Identify red flags • Physician Peer outreach • Independent Medical Exam • Seek a weaning process from the treating physician • Potential point of sale blocks • GOAL: Improve management of the injured workers’ medication regime and lower overall claim costs
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Confidential– Do not disclose or distribute. 29Sedgwick © 2011 Confidential– Do not disclose or distribute. 29 Role of Pharmacy Benefit Management • Identify adverse trends • Provide point of sale alerts • Customize according to need • Define historic use and potential abuse • Injury specific formulary • Formulary different for acute and chronic phase
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Confidential– Do not disclose or distribute. 30Sedgwick © 2011 Confidential– Do not disclose or distribute. 30 Success Stories • Sometimes well intended, high quality physicians fall prey to drug seeking patients – Got narcotic pain RX – Called doctor and indicated they realized they had a negative reaction in the past asked for different RX • Injured worker who did not want narcotics after learning they may cause erectile dysfunction • Injured worker who did not want to risk the side effect of the medications when nurse explained the medication
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Confidential – Do not disclose or distribute. Sedgwick © 2011 Confidential – Do not disclose or distribute. MAKE A DIFFERENCE! Questions and Discussion