© paradigm outcomes, proprietary a panel discussion managing the opioid epidemic: medication use in...

© Paradigm Outcomes, Proprietary

A Panel Discussion

Managing the Opioid Epidemic:Medication Use in Pain Management


■ Steven Moskowitz, MD, Senior Medical Director, Paradigm, panel moderator

■ Carmen Ferguson, Global Risk Manager, Donaldson Company

■ Cheryl Tabbert, Technical Claim Specialist, Liberty Mutual Group

■ Julia Uehling, Workers’ Compensation Consultant, Hays Companies

Today’s Panelists


■ Pain medications are the most commonly prescribed class of drugs in the U. S.

■ Hydrocodone is top prescribed medication in the U.S.

■ Admission rates for abuse of opiates other than heroin—including prescription painkillers—rose by 400% from 1998-2008

■ Drug overdose deaths in the United States have more than tripled since 1990

■ 100 people die from drug overdoses every day in the U. S.

■ 76 million Americans suffer from chronic pain, according to the NIH

■ 80% of physician office visits are due to pain

■ 20% of workers’ compensation medical costs of fully developed claims are spent on prescription drugs; narcotics account for 34% of drug costs

■ The rest of medical costs are non-pharmaceutical

■ Avoid “opioid myopia” when planning solutions

Pain medications are prescribed regularly, and the potential for abuse is significant.

Chronic Pain and Rx Abuse are Chronic Problems

3

Source: Centers for Disease Control Prescription Painkiller Overdoses Policy Impact Brief, 2011


■ To combat the problem, in 2010 the Minnesota Board of Pharmacy implemented the MN Prescription Monitoring Program (MN PMP) to monitor prescription drug use in an effort to promote public health and welfare by detecting diversion, abuse and misuse of certain controlled substances www.pmp.pharmacy.state.mn.us

■ Minnesota is one of 36 states with an operational PMP

■ Per Minnesota PMP, as of November 2012, 7,116,260 controlled substance prescriptions have been collected

■ Minnesota’s 2008 drug overdose rate was 7.2 per 100,000 prescriptions

■ Minnesota has 3.7 to 5.9 kilograms of prescription painkillers sold per 10,000 people

The estimated annual cost in the United States of healthcare, lost income, and lost productivity due to chronic pain is $100 billion, according to the NIH.

The Cost of Chronic Pain in the Workforce

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http://www.pmp.pharmacy.state.mn.us/


www.cdc.gov/homeandrecreationalsafety/rxbrief Nov 2011

In 2008, there were 14,800 prescription painkiller deaths

Opioids Remain a Critical National Problem

5

http://www.cdc.gov/homeandrecreationalsafety/rxbrief

© Paradigm Outcomes, Proprietary6 © Paradigm Outcomes, Proprietary

How do I determine which treatments are effective, which

are hurtful, and which tools can I use to monitor a treatment plan?


Steven Moskowitz, MD Senior Medical Director, Paradigm Outcomes

Why are these medications prescribed?An introduction and investigation


■ Estimated 40-67% incidence of inaccurate or incomplete diagnosis in patient presenting to a pain treatment centers.

■ Effectiveness of many treatments unproven.

– High dose COT

– Polypharmacy

– Spinal fusion

– Spinal Cord Stimulator

■ Behavioral aspects of chronic pain are often not taken properly into account.

Why Do We See So Many Poor Outcomes?

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Intent

■ To help patients

■ To relieve symptoms/quick fix

■ Convenience/simplicity

■ To satisfy desire for quick fix

■ Efficiency-education and coaching take time and resources

Reasons for poor outcome

■ Helping chronic pain patient requires more than prescriptions

■ Symptoms are by nature subjective

■ It is easier to prescribe than talk and negotiate

■ Doctors and patients believe in quick fixes

■ Even a medication prescription requires educations and training

And why intent and outcome are not always in balance.

Why Do Doctors Prescribe Medications for Chronic Pain?

© Paradigm Outcomes, Proprietary9


Illness convictionCatastrophizingFear avoidance

Quick fix seeking

Maladaptive Treatment

Lack of objective measuresQuick fixes

Trial and error approach

Poly-pharmacyEscalating

interventions

Maladaptive Coping

Unrealistic expectations Catastrophizing Quick fix seeking

Quick fixes Trial and error approach Escalating interventions

Patient

Doctor

How Do We Interrupt a Maladaptive Cycle?

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■ The biomedical approach assumes that all pain symptoms have a specific physical cause and attempts to eradicate the cause directly by identifying and rectifying the presumed pathophysiology.

■ The biopsychosocial approach: chronic pain is a complex and dynamic interaction among biological, psychological, and social factors that perpetuates and may even worsen the clinical presentation. It usually includes deconditioning and poor flexibility, fear avoidance, maladaptive coping.

The biopsychosocial model is consistent with rehabilitation principles.

! !

The Story of Two Treatment Philosophies

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Panel Discussion

A Proactive ApproachCase Study #1


■ 40 year old female attacked by patient on 1/24/2012

■ Resulting bilateral shoulder rotator cuff injuries, neck strain, back strain

■ Treated with bilateral arthroscopic shoulder surgeries; findings of bilateral tear and degenerative changes

■ Continued multiple pain complaints in shoulders, headaches, neck, low back. Continues to look for solutions, even surgical.

■ Psychiatric evaluations noted severe depression and “mired in a self-defeating passivity and isolation”.

■ Current medications:

DOI less than 1 year

Case 1


Oxycodone 5/325 2 per day Cymbalta 30 mg daily

Nucytna 200 mg twice per day Fiorinal COD 30-50-325-40 twice per day

Vicoprofen 7.5/200 twice per day Lunesta 2 mg at night

Robaxin 500 mg twice per day Flector patch 1.3% as directed


■ How do you determine effectiveness of the current treatment?

■ How do you influence a change in plan?

■ What tools do you use?

■ What challenges do you encounter with managing these cases?

We have a case where the current medications plan appears unsuccessful

Ask the Panel

14 © Paradigm Outcomes, Proprietary


Panel Discussion

Long Term Chronic Pain TreatmentCase Study #2


■ 45 year old male injured worker

■ >10 years post injury

■ On multiple medications including high dose opioids ; 27,000 daily morphine equivalent

■ On medications to treat opioid complications: Ex, Amitiza, Provigil, Testosterone, Alfuzocin

■ History of infections from spinal cord stimulator, morphine pump

■ In hospital with infection of clavicle

■ Overly solicitous spouse

■ Medications

An old simmering case with complications, side effects

Case 2


HydromorphoneHydrocodoneProzacCelebrex

Wellbutrin XLAlprazolamNortriptyline

FlomaxUrecholine

TylenolLasix

PrilosecDulcolaxLasix


■ How do you determine when the medications are harmful?

– What tools do you use to identify they are harmful?

■ What tools do you use to rectify harmful usage?

■ What challenges do you encounter with managing long-term cases?

– How can you turn around such an old case?

We have a case where medication plan is unsuccessful and harmful

Ask the Panel



Steven Moskowitz, MD Senior Medical Director, Paradigm Outcomes

Conclusion


■ Make a Diagnosis With Appropriate Differential following a comprehensive evaluation

■ Psychological Assessment, Including Risk of Addictive Disorders and stratification.

■ Informed Consent

■ Treatment Agreement

■ Pre- or Post Intervention Assessment of Pain Level and Function.

■ Appropriate Trial of Opioid Therapy With or Without Adjunctive Medication

■ Reassessment of Pain Score and Level of Function

■ Regularly Assess the "A's" of Pain Medicine (analgesia, activities of daily living, adverse side effects, and aberrant drug-taking behaviors); “adherence” and “affect” (observed mood) might also be added.

■ Urine Toxicology

■ Periodically Review Pain Diagnosis and Comorbid Conditions, Including Addictive Disorders

■ Documentation

REF: “Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain,” Douglas L. Gourlay, MD, et al, Volume 6 • Number 2 • 2005.

Universal Precautions in Pain Management

1919


■ What are appropriate reasons for which medications should be prescribed?

– To improve impairment and function (restorative)

– To help relieve specific defined symptoms

– As part of a biopsychosocial plan to help an injured worker manage and relieve their symptoms

■ What are appropriate measures of success/effectiveness?

– Measures of impairment and function (ODG reference)

– Decrease need for other treatments or for more toxic medications

– Measures for toxicity: mental status, lab studies, UDT

■ What are appropriate strategies to influence the prescribing/attending physician?

– Ask specific for outcome measures for a particular RX and how injured worker will measure it

– Help avoid multiple simultaneous interventions so outcome can be measured

– Remind provider of side effects and negative outcomes

– Share any information about inconsistencies

Try to get provider to help define a rational approach

Conclusions


© paradigm outcomes, proprietary a panel discussion managing the opioid epidemic: medication use in...

Documents

paradigm outcomes

proprietary pain medications

pain management slide

cost of chronic pain

prescription drug use

solutions pain medications

pain treatment centers

investigation slide