nevada osteopathic medical association ......nevada osteopathic medical association 65th annual...

LEGISLATOPLASTY :

How Nevada Addressed the Opioid Epidemic through Common Sense

Legislative and Medical Solutions

Nevada Osteopathic Medical Association

65th Annual Meeting & Symposium

May 2-5, 2018Las Vegas, NV

LEGISLATOPLASTY

DR. JOHN DIMURO, DO, MBA• Former Chief Medical Officer,

State of Nevada and co-creator of Nevada AB474• President, DiMuro Pain Management

-Reno & Las Vegas•Board Certified in Anesthesiology &

Pain Medicine

THE CREATION OF NEVADAAB474 AND THE “PRESCRIBE

365” INITIATIVE

Creation of a responsible and rational governmental approach to controlled substance prescribing

Controlled Substance Abuse & Prevention Act

What is AB474?

• A bill presented to the 2017 Nevada State Legislature to combat both illicit and licit substance abuse, misuse and diversion.

• Sponsored by Governor Sandoval• Passed unanimously

TASK

Using State data, determine the problem

1Develop effective, rational strategies to mitigate the abuse, misuse and diversion of controlled substances

2Increase communication amongst State agencies

3

Barriers

• Legislators• Lobbyists• Public• Prescriber groups• Time

MUST…Appease ALL stakeholders

The Problem

PRESCRIPTION CONTROLLEDSUBSTANCES FOR PAIN

MisuseAbuseDiversion

Why do we have a problem?

• Increased supply of legal drugs• Increased access to illegal drugs• Dark Web

• Provider over-prescribing• Surgeons• Primary Care• Logistics

• Dental prescriptions• Providers not wanting to prescribe due

to perception• Lack of access to appropriate providers

How could this happen?

• According to State data:1) NO CHECKING OF THE PDMP PRIOR TO

PRESCRIBING!!This is the only mandate in the NRS code!• Not all prescribers are even

registered for the PDMP• All physician prescribers must

be compliant or face punitive measures by the Board

• MD Board issues• What the Board of Pharmacy

knows …

How can this happen?

• According to State data:1) No checking of the PDMP prior to prescribing2) HIGH QUANTITY OF PILLS PRESCRIBED

• “Convenience” for prescribers• Dentist prescriptions• Poor knowledge about alternative

treatments• Poor access to alternative

treatments• Insurance limitations

How can this happen?

• According to State data:

1) No checking of the PDMP prior to prescribing

2) High quantity of pills prescribed

3) HIGH NUMBER OF POLYPHARMACY PRESCRIPTIONS

• sedating and lethal combinations of meds

-opioid + BZD + sleeper

• fear of reprisal from patient

• taking over meds from another provider

How can this happen?

• According to State data:1) No checking of the PDMP prior to prescribing2) High quantity of pills prescribed 3) High numbers of polypharmacy prescriptions4) LACK OF EVIDENCE-BASED DIAGNOSIS

• Can’t just use “back pain” or “chronic pain” as a diagnosis

• No appropriate work-up performed

• Patient refusal to adhere to recommendations/referrals

• logistical constraints

How can this happen?

• According to State data:1) No checking of the PDMP prior to prescribing2) High quantity of pills prescribed 3) High numbers of polypharmacy prescriptions4) Lack of evidence-based diagnosis5) LACK OF PROVIDER FOLLOW-UP

• logistical constraints• inconvenient to provider• inconsistent providers• ignoring warnings from Board

of Pharmacy

How can this happen?

• According to State data:1) No checking of the PDMP prior to prescribing2) High quantity of pills prescribed 3) High numbers of polypharmacy prescriptions4) Lack of evidence-based diagnosis5) Lack of provider follow-up6) LACK OF APPROPRIATE SCREENING BY

PRESCRIBER

• not utilizing valid risk screening tools• no required or regimented body fluid

checks• poor understanding of long-term

effects of chronic use

Who is responsible?

• Prescribers• Patients• Insurers • Pharmaceutical companies• Government payers• Pharmacists

Current State Mandates

• 1) MUST check the PDMP prior to prescribing opioids• ONLY MANDATE!!!

MAJOR POINTS OF NEVADA AB474

• 1) DOES NOT HANDCUFF THE PHYSICIAN

MAJOR POINTS OF NEVADA AB474

• 1) Does not handcuff the physician

• 2) MUST REGISTER WITH THEPDMP

MAJOR POINTS OF NEVADA AB474• 1) Does not handcuff the

physician• 2) Must register with the PDMP• 3) MUST HAVE NORMAL FOLLOW UP

Major Points of Nevada AB474

• 1) Does not handcuff the physician

• 2) Must register with the PDMP

• 3) Must have normal follow up

• 4) EVIDENCE-BASED DIAGNOSISWORK-UP

Major Points of Nevada AB474

• 1) Does not handcuff the physician• 2) Must register with the PDMP• 3) Must have normal follow up • 4) Evidence-based diagnosis work-up• 5) CHANGES IN BOARD OVERSIGHT

Major Points of Nevada AB474• 1) Does not handcuff the

physician• 2) Must register with the PDMP• 3) Must have normal follow up • 4) Evidence-based diagnosis

work-up• 5) Changes in Board oversight• 6) PRESCRIPTION CHANGES

Major Points of Nevada AB474

• 1) Does not handcuff the physician• 2) Must register with the PDMP• 3) Must have normal follow up • 4) Evidence-based diagnosis work-up• 5) Mandatory urine drug screening• 6) Changes in Board oversight• 7) Prescription changes• 8) PRESCRIBE 365

Major Points of Nevada AB474

• 1) Does not handcuff the physician• 2) Must register with the PDMP• 3) Must have normal follow up • 4) Evidence-based diagnosis work-up• 5) Mandatory urine drug screening• 6) Changes in Board oversight• 7) Prescription changes• 8) PRESCRIBE 365• 9) URINE TOX SCREENS?

MAJOR LOSS FOR NEVADA AB474

• Attempt to include at least annual body fluid analysis drug screening for all patients taking controlled substances for pain

INITIAL RX CONSIDERATIONS

1) Have bona fide relationship2) Check PDMP! 3) Initial prescription >15 days4) Complete Informed Consent5) Complete Opioid Risk Tool

>30 DAYS RX CONSIDERATIONS

1) Need prescription medication agreement

>90 DAYS RX CONSIDERATIONS

1) Work-up for evidence-based diagnosis2) PDMP check every 90 days3) Consider specialist referral

Major Points of Nevada AB474

• 1) Does not handcuff the physician

• 2) Must register with the PDMP

• 3) Must have normal follow up

• 4) Evidence-based diagnosis work-up

• 5) Changes in Board oversight

• 6) Prescription changes• 7) Prescribe 365 Initiative• 8) BEHAVIORAL HEALTH RISK

ASSESSMENT

How did we get it done?

How did we get it done so quickly?

CAN WE REALLY DIAGNOSE AND TREAT PAIN WITHOUT PRESCRIPTION DRUGS?

What is my job?

• To obtain an appropriate PAIN diagnosis and then direct the patient to the best treatment option after presenting the patient all viable options.

What is the difference between a “medical” diagnosis and a “pain” diagnosis?

A medical diagnosis is usually a broad,

generalized term that is used to most accurately

reflect an appropriate ICD-10 classification code.

Example: Low back pain

A pain diagnosis is a specific diagnosis made

using a clinical intuition or factual diagnosis.

Example: Internal Disk Disruption vs. L4 Radicular

Pain

How does a physician or non–physician clinician typically arrive at a pain diagnosis?

1) Massage Therapist

2) Acupuncturist

3) Athletic Trainer

4) Physical Therapist

5) Chiropractor

6) General Physician

7) Specialist Physician

HOW DOES A PHYSICIAN OR NON–PHYSICIANCLINICIAN TYPICALLY ARRIVE AT A PAIN DIAGNOSIS?(whether doing it correctly or incorrectly?)

MASSAGE THERAPIST• Will use palpatory feedback and assessment of somatic structures • and assimilate patient history info supporting the diagnosis.• If complaint of low back pain, will usually diagnose “pulled muscle” or some other type of musculoskeletal abnormality.

HOW DOES APROVIDER

TYPICALLY ARRIVEAT A PAIN

DIAGNOSIS?

ACUPUNCTURIST• Patient History• Patient Complaint• Assess for musculoskeletal involvement through physical exam colors, sounds, odors, emotions• If patient complains of low back pain, acupuncture diagnosis would likely assess a problem with a specific meridian, acupuncture point or extraordinary channel

HOW DOES A PROVIDER TYPICALLY ARRIVE AT A PAINDIAGNOSIS?

ATHLETIC TRAINER

• Medical history

• Movement screening

• Anatomical assessment

• If patient complaint of low back pain, diagnosis may be “hip flexor weakness” or “lumbar sprain/strain”

HOW DOES A PROVIDER TYPICALLYARRIVE AT A PAIN DIAGNOSIS?

PHYSICAL THERAPIST• Patient history

• Usually Physician referral

• Movement screening

• Palpatory diagnosis

• If patient complaint of low back pain, diagnosis may be “iliopsoas syndrome”

HOW DOES A PROVIDER TYPICALLYARRIVE AT A PAIN DIAGNOSIS?

CHIROPRACTOR

• Patient history

• Movement screening

• Palpatory diagnosis

• Imaging slides (X-Ray, MRI)

• If patient complaint of low back pain, diagnosis may be “spinal

arthritis” this can allow them to continue to treat using H.V.L.A.

HOW DOES A PROVIDER TYPICALLYARRIVE AT A PAIN DIAGNOSIS?

PRIMARY CARE PROVIDER

• Thorough incident history

• Thorough past medical history including family history, genetic predisposition

• Palpatory diagnosis

• Imaging studies: X-Ray, MRI, CT scan, ultra-sound

• Blood work

• Systemic physical examination-assessing for aneurysm, ecchymosis, induration

• If patient complains of low back pain, a physician may say “urogenital anomaly” or “possible angiosarcoma.”

HOW DOES A PROVIDER TYPICALLYARRIVE AT A PAIN DIAGNOSIS?

INTERVENTIONAL PAIN PHYSICIAN

• Thorough medical history, incident history, mechanism of

injury, family history, surgical history, genetic history, medical

implications

• Review of all prior imaging studies and physician notes

including blood work, imaging studies, etc.

• Thorough physical examination including both a general

and focused exam

• Post-examination consultation and debriefing

HOW DOES A PROVIDER TYPICALLY ARRIVE AT A PAINTREATMENT?

• Debriefing with patient and family

• Render my opinion on current diagnosis

• Discuss treatment options taking into account multiple factors:A) Type of insuranceB) Risk vs. reward of treatmentC) Financial considerationsD) “cure” vs. “band-aid” optionsE) Pertinent medical history

TREAMENT OPTIONS 1) Do nothing!!

TREAMENT OPTIONS

1) Do no harm2) MEDICATIONS• Antibiotics, Sleeping aids, anxiolytics, anti-

depressants

• Anti-inflammatories

• Muscle relaxants

• Opioids, aka “Pain killers”

1) Do Nothing2) Medications

Athletic Trainer

3) Physical Rehabilitation Modalities

Acupuncture PhysicalTherapy

Yoga/Pilates Home ExerciseProgram

Chiropractic

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TREAMENT OPTIONS 4) FURTHER DIAGNOSTIC TESTING

Thin slice C.T. Scan

Flexion/Extension X-Rays

MRI Neurography

MRI Angiography

C.T. Arthrogram

TREAMENT OPTIONS

SPECIALIST REFERRAL

• Endocrinologist• Rheumatologist• GI Specialist

TREATMENT OPTIONS

SURGICAL REFERRAL

• Orthopedic Surgeon• Neurosurgeon• General Surgeon

7) Interventional Pain Physician

1) Do Nothing2) Medications3) Physical Rehabilitation Modalities

5) Specialist Referral6) Surgical Referral7) Diagnostic work-up to prove the diagnosis

4) Further Diagnostic Testing

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Answer : It depends upon what condition/diagnosis we are trying to prove.

1) Disc

2) Joint

3) Nerve

4) Muscle

5) Bone

6) Tendon

7) Ligament

8) Peripheral nerve

9) Organ

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1) DiscHow do we determine if the disc is a source of pain or discomfort?

Is it a clinical diagnosis?

Is it a movement screening diagnosis?

No, it is a scientific diagnosis.

Provocation Discography

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1) Disk

Suspected Pain Generator

DiagnosticProcedure

Discogram

A Discogram is a method of stimulating the disc through pressurization with fluid to see if concordant pain is elicited.

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Discogram

57

Discogram - Abnormal Tear

58

1) Disc

Suspected Pain Generator

InterventionalDiagnostic

Test

Discogram

2) Joint Joint Injection

Treatment OptionsIf Positive Test

Surgery

TransdiscalBiacuplasty

59

Spinal Joint Injection(“Zygapophyseal” or “Facet” Joint)

60

1) Disk

Suspected

Pain Generator

Interventional

Diagnostic

Test

Discogram

2) Joint Joint Injection

Treatment Options

If Positive Test

Surgery

Transdiscal Biacuplasty

3) Nerve Selective Nerve

Root Block

Surgery

Radiofrequency Ablation

P.T./Chiro/Trainer

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Selective Nerve Root BlockPerformed for Suspected Pain in a Dermatomal Distribution

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Dangers of Cervical Injection Therapy

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1) Disc

Suspected

Pain Generator

Interventional

Diagnostic

Test

2) Joint

Treatment Options

If Positive Test

3) Nerve Surgery

Epidural Steroid Injection

Phys rehab modalities

Selective Nerve

Root Block

Joint Injection Surgery

R.F.A.

Plus Rehab Modalities

Discogram Surgery

Transdiscal Biacuplasty

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Pain with Abduction and External Rotation during Hip Flexion

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1) Disk

Suspected Pain Generator

InterventionalDiagnostic Test

Discogram

2) Joint Joint Injection

Treatment Optionsif Positive Test

• Surgery• Transdiscal Biacuplasty

3) Nerve Selective Nerve Root Block

• Surgery• R.F.A. • Plus Rehab Modalities• Surgery• Epidural Steroid Injection • Phys rehab modalities

4) Muscle Intramuscular InjectionUnder Fluoroscopy

• Physical Rehab Modalities• Prolotherapy• Botox• Medication

5) Bone Rami communicans block,Imaging studies

• Rami Communicans RF, • Meds, Bracing

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Suspected Pain Generator

InterventionalDiagnostic Test

Treatment Optionsif Positive Test

5) Bone Rami Communicans Block,Imaging studies

• Rami Communicans RF, • Meds, Bracing

6) Tendon Tendon Injection Fluoro Guidance

• Rest, Brace, P.T., • Prolotherapy

7) Ligament Ligamentous injection- Very Hard to Do

• Rest, Prolotherapy• Bracing• Surgery

8) PeripheralNerve

Peripheral Nerve Injection • Surgery• Meds • Desensitization Injections

9) Organ Pain Sympathetic Plexus Block • Surgery• Meds • Nutrition

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Sympathetic Block

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What are the take-home points?

1) Realize that sometimes things are not as simple as they seem.

2) If you can’t prove it, you can’t say it!

3) There really are ways to prove diagnoses.

4) Some people are just broken!

5) Depth of knowledge is not well appreciated.

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LEGISLATOPLASTY :

How Nevada Addressed the Opioid Epidemic through Common Sense Legislative and Medical Solutions

THANK YOU!

Nevada Osteopathic Medical Association

65th Annual Meeting & SymposiumMay 2-5, 2018

Las Vegas, NV

JOHNDIMURO@GMAIL.COM

DIMUROPAINMANAGEMENT@GMAIL.COM