Opioid Roundtable Discussion February 19, 2019 Jessica Van Fleet-Green, MD Ross Vogelgesang, MD Kari Lima, MD Lucinda Grande, MD
Agenda • Introduction of Speakers • About PSW • High Level Overview of Washington State Opioid Prescribing Guidelines • Non-Opioid Treatment Options • Expanding Access to Lifesaving Treatments for Opioid Use Disorders • The Olympia Bupe Clinic: A High Capacity “Medication First Clinic”
About Physicians of Southwest WA (PSW) As a population health company, PSW has led healthcare innovation with the guiding principle of supporting the physician – patient relationship to improve the quality of care delivered.
Strategic Priorities
Innovation Model Results
Presentation Goals • Gain understanding and apply Washington State’s Opioid Prescribing Rules • Apply Bree Collaborative Guidelines for prescribing • Demonstrate the utilization of various resources in place for prescribing clinicians
Washington’s Opioid Prescribing Rules • 7 day pill limit for acute prescriptions and 14 days for acute post-operative pain • ( Exemption allowed if clinical judgment is documented) • Care plan and documentation requirements for each phase of pain • Mandated registration and targeted checks of the prescription drug monitoring program
Washington’s Opioid Prescribing Rules • High risk patients require naloxone • (50 MED for ARNP, 90 MED for physicians) • Chronic Pain: Mandatory Consult when >120 MED, written agreement, naloxone • January 1, 2021: ALL controlled substances need electronic transmission (10 or more prescribers)
Why Is This Happening?!?! • Instructed by the legislature as ESHB 1427 • Legislative response due to the doubling of opioid related deaths between 2010 and 2015 • WMC must adopt rules that would establish prescribing requirements with the goals of: • Reduce addiction rates; • Reduce burden to opioid treatment programs; • Opioid Taskforce was created • Meetings were held with expert testimony and public comment; @WAMedCommission WMC.wa.gov
Continuing Medical Education (CME) Requirements • One-time CME regarding best practices in the prescribing of opioids; • At least one hour in length; • Completed by the end of your first full CME reporting period after January 1, 2019 or during the first full CME reporting period after initially being licensed, whichever is later. @WAMedCommission WMC.wa.gov
Bree Collaborative Post-Operative Guidelines • • Type II (Medium Recovery) Type I (Rapid Recovery) NSAIDS/APAP. ≤7 days (up NSAIDS/APAP. If opioids to 42 pills). are necessary, prescribe ≤3 days (8 -12 pills) ✓ cases warranting more than 7 days, surgeon to re-eval the ✓ Oral surgery prior to 3 rd rx, taper within 6 ✓ Lap appy, inguinal hernia, weeks carpal tunnel, breast biopsy, • Type III (Long Term meniscectomy, node biopsy, Vag Hysterectomy Recovery) NSAIDS/APAP. <14 days. ✓ cases warranting more than 14 days, surgeon to re-eval the prior to 3 rd rx, taper within 6 weeks
Resources • Washington State DOH Opioid Prescribing https://www.doh.wa.gov/ForPublicHealthandHealthcare Providers/HealthcareProfessionsandFacilities/OpioidPr escribing • Washington Medical Commission https://wmc.wa.gov/resources/pain-management- resources • WSMA https://wsma.org/WSMA/Resources/Opioids/Prescribin g_Rules_And_Guidelines/prescribing_rules_and_guide lines.aspx • Bree Collaborative
NON-OPIOID TREATMENT OPTIONS IN PAIN MANAGEMENT ROSS E. VOGELGESANG, M.D. ALLIANCE PAIN AND WELLNESS CENTER
EDUCATION AND TRAINING • Graduate of University of Texas Medical School • Internship: Medicine at the University of Tennessee, Bowld Hospital • Residency: Oregon Health Sciences University of Medicine, specializing in Anesthesiology • Board Certified and Specializing in Addiction Medicine and Anesthesiology • Special Concentration in Pain Management
DISCLOSURES Faculty trainer for Medtronic intrathecal pumps used for treatment of pain and spasticity disorders
LEARNING OBJECTIVES • Limitations of opioid medications • Alternative treatment modalities • Non-narcotic pharmacological management • Interventional therapies • Case studies
LIMITATIONS OF OPIOID MEDICATIONS • Pain scale • Addiction, Government oversite and abuse • Assess treatment success
Alternative Treatment Modalities Chiropract Acetaminoph Acupunctur ic en e Medicine Cognitive Physical NSAIDS Behavior Therapy Therapy Interventio Massage Reflexolog n y Therapy Therapy
NON-NARCOTIC PHARMACEUTICAL MANAGEMENT Prescribe medication to treat pain types: • Nerve • Muscle • Structural • Visceral Natural supplements for pain: • Turmeric • Alpha Lipoic Acid
INTERVENTIONAL THERAPIES • Interventional spine procedures • Intraarticular joint injections • Coordinate care with other specialists • Regenerative medicine • Spinal cord stimulation (SCS)
CASE STUDIES 71 Y/O MALE 90 Y/O MALE Diabetic Peripheral Neuropathy Postlaminectomy Syndrome • S/P Aortic Value Replacement • Other Health Comorbidities • A1c 5.8 • Long Standing Opioid Therapy • Opiates: Adverse Effects • Failed Conservative Therapy • Other Treatment Modalities • SCS Trial to Implant
SUMMARY OF PRESENTATION • Opioid Limitations • Alternative Therapies • SCS Today verse Yesterday • Circle the Wagons
"Few things a medical provider does are more important than relieving pain…pain is soul destroying. No patient should have to endure intense pain unnecessarily. The quality of mercy is essential to the practice of medicine; here, of all places, it should not be strained.“ Marcia Angell, American Physician and Author QUESTIONS
EXPANDING ACCESS TO LIFESAVING TREATMENTS FOR OPIOID USE DISORDER KARI LIMA, MD
OBJECTIVES • DESCRIBE MEDICATION-ASSISTED TREATMENT OPTIONS FOR OPIOID USE DISORDER • UNDERSTAND THE PROCESS FOR OBTAINING DATA-2000 WAIVER • IDENTIFY THE MISMATCH BETWEEN AVAILABILITY OF EVIDENCE- BASED TREATMENTS AND NEED • DEVELOP A PLAN TO IMPROVE ACCESS TO EVIDENCE-BASED TREATMENTS IN YOUR OWN SETTING
STATE OF THE CRISIS • 130 OPIOID OVERDOSE DEATHS PER DAY • OPIOIDS ACCOUNT FOR 68% OF ALL DRUG OVERDOSE DEATHS • BETWEEN 1999 AND 2017, OPIOID OVERDOSE DEATH RATES INCREASED BY SIX TIMES • DRUG OVERDOSE DEATHS CONTINUE TO INCREASE
STATE OF THE CRISIS • 130 OPIOID OVERDOSE DEATHS PER DAY • OPIOIDS ACCOUNT FOR 68% OF ALL DRUG OVERDOSE DEATHS • BETWEEN 1999 AND 2017, OPIOID OVERDOSE DEATH RATES INCREASED BY SIX TIMES • DRUG OVERDOSE DEATHS CONTINUE TO INCREASE
STATE OF THE CRISIS • 130 OPIOID OVERDOSE DEATHS PER DAY • OPIOIDS ACCOUNT FOR 68% OF ALL DRUG OVERDOSE DEATHS • BETWEEN 1999 AND 2017, OPIOID OVERDOSE DEATH RATES INCREASED BY SIX TIMES • DRUG OVERDOSE DEATHS CONTINUE TO INCREASE
MEDICATION-ASSISTED TREATMENT OPTIONS • BUPRENORPHINE/NALOXONE • BUPRENORPHINE • METHADONE • NALTREXONE
SUCCESS RATE SIGNIFICANTLY LOWER WITHOUT REPLACEMENT THERAPY Kakko et al, 1-year retention and social function after Sees, et al, Methadone Maintenance vs 180-Day buprenorphine-assisted relapse prevention treatment Psychosocially Enriched Detoxification for Treatment for heroin dependence in Sweden: a randomized, placebo- of controlled trial. Lancet 2003; 361: 662 – 68 Opioid Dependence A Randomized Controlled Trial JAMA 2000 283; 1303-1310
CLEAR MORTALITY BENEFIT FROM MEDICATION ASSISTED TREATMENT • METHADONE MAINTENANCE RESULTS IN AVERAGE OF 25 FEWER DEATHS PER 1,000 PERSON- YEARS • BUPRENORPHINE ALSO REDUCES OVERDOSE DEATH AND ALL-CAUSE MORTALITY
MAT cost savings Mohlman MK et al, 2016
DATA-2000 WAIVER • ALLOWS PROVIDERS TO PRESCRIBE BUPRENORPHINE FOR THE TREATMENT OF OPIOID USE DISORDER • PHYSICIANS – 8 HOURS OF TRAINING (AVAILABLE FOR FREE!) • ARNP/PA – 24 HOURS OF TRAINING (AVAILABLE FOR FREE!) • WAIVER TRAINING OPPORTUNITIES • ONLINE-ONLY TRAINING • HALF-AND-HALF TRAINING (IN PERSON PLUS ONLINE) • FRIDAY, MAY 15, 9AM-1PM AT PSPH 200 ROOM
DATA-2000 • PROVIDERS WILL RECEIVE AN “X” WAIVER DEA NUMBER TO USE • PROVIDERS SHOULD HAVE THE CAPACITY TO SEND PATIENTS TO HIGHER LEVEL OF TREATMENT IF NEEDED • PROVIDERS SHOULD ADHERE TO TREATMENT LIMITS • INITIAL LIMIT = 30 • INCREASE TO 100 AFTER FIRST YEAR (MUST COMPLETE FORM) • INCREASE TO 275 IF ADDITIONAL REQUIREMENTS MET
POINT #1 TREATMENT FOR OPIOID USE DISORDER NEEDS TO BE OFFERED AS PART OF ROUTINE PRIMARY CARE
PRIMARY CARE ATTITUDES TOWARD TREATMENT • SURVEY IN VERMONT AND NEW HAMPSHIRE OF 108 FAMILY PHYSICIANS (10% BUPRENORPHINE PRESCRIBERS) • >80% REGULARLY SAW OPIATE-ADDICTED PATIENTS • 70% FELT THEY SHOULD BE RESPONSIBLE FOR TREATING OPIATE ADDICTION • BARRIERS CITED: DeFlavio et al, 2015
Rosenblatt R et al, 2015
POINT #2 PATIENTS NEED TO BE ENGAGED AT MULTIPLE POTENTIAL ENTRY POINTS AND BARRIERS TO TREATMENT SHOULD BE MINIMIZED
Criminal Psychiatric justice Emergency care / self system departmen help t groups Adolescent case managemen t Initiation of MAT Continuation of MAT Post- operative and pain care Hospital Pregnanc admissio y Emergency n housing
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