ryan, chaput, pharm.d. · 2018. 4. 4. · 1. discuss the core recommendations of the new cdc opioid...

Ryan, Chaput, Pharm.D.

Patricia Gray, Pharm.D., FCSHP

Joel Hyatt, M.D.

Kaiser Permanente (KP)

Southern California Region

(SCAL)

Tackling the Opioid Epidemic:

Safe Opioid Use In Pain Management

DISCLOSURE STATEMENT:I nor my family have any significant financial relationships with any commercial interests that might bias the information given today during my presentationThis educational activity has not received commercial support

The speakers have no conflicts of interest

to disclose.

Ryan Chaput, Pharm.D.

Joel Hyatt, M.D.

Learning ObjectivesAfter attending this 2.5 hour session, “Tackling the Opioid Epidemic: Safe Use of Opioids in Pain Management”, the attendee will be able to:

1. Discuss the core recommendations of the new CDC Opioid Guidelines

2. Explain the basic principles of opioid management

3. Choose alternatives to opioid therapy

4. Identify at least three core interventions to reduce overuse, abuse, and overdose of opioids in your patients and community practice

5. Apply at least two data measurement strategies to identify the at risk opioid patients and track progress in your practice

6. Recognize the prescription opioid epidemic is a community health issue and we each have opportunities to take action in many settings

Outline for Today’s Session: “Tackling the Opioid Epidemic”

5October 14,

1 – CDC Opioid Guidelines, Opioid Management and Opioid Alternatives - Ryan Chaput, Pharm.D.

2 minute Easing the Pain- Bio Stretch Break

2 – An Integrated, Population Care Management Approach -Patricia Gray, Pharm.D., FCSHP

3 minute Easing the Pain - Bio Stretch Break

3 – Community Health Improvement Strategies: It Takes a Village – Joel Hyatt, M.D.

4 – Panel Discussion with Q&A

Time for Q&A 5 min.at end of each talk & Panel Q&A Session

serving 10.6 million members across 8Regions nationwide

38 hospitals

630 medical offices

18,652 physicians

189,302 Employees

• 4.2 million members• 13 service areas• Over 7,000 physicians• 135 medical office buildings• 14 Kaiser Foundation

Hospitals• Over 130 licensed pharmacies

CDC Opioid Guideline Update, Opioid Management, and Opioid Alternatives

Ryan Chaput, Pharm.D.Kaiser Permanente

Riverside, CA

a) 50 MME

b) 100 MME

c) 60 MME

d) 37.5 MME

Test Questions

Question 1: What is the approximate MME of fentanyl patch 25mcg/hr?

a) Losing medication

b) Doctor shopping

c) Urine drug screen negative for prescribed opioid

d) Calling in for a refill 2 days before the prescription is due

Test Questions

Question 2:Which of the following would generally NOT be considered a red flag for opioid abuse/misuse?

2016 CDC Opioid Guideline Highlights(excludes cancer, palliative, end-of-life care)

• Nonpharmacologic and nonopioid therapy first

• Establish treatment goals

• Discuss risks/benefits of opioids

• If starting opioids, use immediate-release opioids instead of extended-release opioids/long-acting opioids

• Review patient’s controlled substance prescription history

• Urine Drug Screen (UDS)

• Avoid concurrent use of opioids and benzodiazepines

• Evidence-based treatment for patients with opioid use disorder

• Reassess risk/benefits before increasing dose >50 MME/day

• Avoid increasing dose >90 MME/day

• For acute pain, prescribe the lowest effective dose and do not prescribe greater quantity than needed

• Re-evaluate risks/benefits within 1 to 4 weeks of initiation/escalation and then at least every 3 months thereafter

• Consider naloxone for patients at higher risk for overdose

For more information and tools visit http://www.cdc.gov/drugoverdose• Guidelines for Prescribing Opioids for Chronic Pain• Prescribing Checklist• Tapering Guide• Non-opioid alternatives• Additional tools/resources

Who wants to learn about opioid management…….?

Goals of Chronic Pain Management

• Decrease pain level

• Functional improvement

• Minimize potential medication side effects

• Emphasize non-pharmacologic tools

• Individualize management to each patient and patient’s response

Chronic Pain Management Clinical Pearls

• Medication is only ¼ of the treatment “pie”• Meds: maximize analgesia/function and minimize side

effects

• Activity modification

• Body mechanics

• Managing mental health and general wellness

• You should NOT be working harder than the patient• Emphasize self-care

• Set realistic goals with patient• Cure? Pain-free?

• Multi-modal approach

• Emphasize non-pharmacologic treatments

• Adjuvant medications are key

Pain Pharmacist

• Manage opioid tapers

• Track progress

• Physician education

• Patient education – CBTR

• Treatment coordination

Interdisciplinary CommitteesAnd

Pain Pharmacist

Interdisciplinary Committees

• Triage high risk patients

• Assess/Track progress

• Physician education

• Assist physicians with complicated patient cases

• Development of policies, protocols, practice recommendations

Non-Pharmacologic Management of Chronic Pain

• Cognitive Behavioral Therapy & Rehabilitation (CBTR)

• Physical Therapy

• Acupuncture

• TENS unit

• Exercise/movement

• Pacing

• Heat/Ice

• Deep breathing

• Guided imagery

• Distraction

Initial Medication Considerations• Etiology of pain

• Age

• Renal and Hepatic function

• Substance abuse history

• Co-morbidities

• Allergies or Intolerances

• Drug interactions

• Formulary

• Co-morbidities

Acetaminophen (APAP)

• Analgesic, antipyretic, and anti-inflammatory properties

• Black Box Warnings• Cardiovascular events• Treatment of peri-op pain in setting of CABG• GI events

• Warnings/Precautions• Cardiovascular events• GI events• CABG surgery• Hypertension• Hepatic impairment• Renal impairment

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

• Analgesic and antipyretic properties

• No appreciable anti-inflammatory effects

• Avoid or use with caution in hepatic impairment and/or alcohol use

Topicals

• Capsaicin

• Salicylates

• Menthol

• Topical anesthetics

• NSAIDs

• Compounded creams/gels

Antidepressants: TCAs• Secondary Amines: Nortriptyline, Desipramine

• Tertiary Amines: Amitriptyline, Doxepin

• May be considered for neuropathic pain

• Dosing – generally requires titration

• Side effects• Anticholinergic effects• Orthostatic hypotension• Sedation• Weight gain• QT prolongation

• Cautions• Use of MAOI within 14 days• Acute recovery phase of MI• Elderly• Drug interactions• Suicidal thinking/behavior

Antidepressants: SNRIs• Venlafaxine (Effexor ®), Duloxetine (Cymbalta ®)

• May be considered for neuropathic pain

• Dosing – generally requires titration

• Side effects• HA• Somnolence/dizziness• Insomnia• Hypertension• Tachycardia

• Cautions (Venlafaxine)• Use of MAOI within 14 days• Renal or hepatic impairment • Suicidal thinking/behavior• Cardiovascular disease: hypertension/tachycardia• Drug interactions

Anticonvulsants• Gabapentin (Neurontin ®), Topiramate (Topamax ®), Pregabalin (Lyrica ®)

• Used for neuropathic pain

Gabapentin• Dosing: consider starting at 100-300mg at

bedtime and slow titration at weekly intervals to max of 3600mg/day

• Side effects• Fatigue• Somnolence• Dizziness• Peripheral edema

• Cautions• Renal impairment • Titrate slowly in elderly

Skeletal Muscle Relaxants (SMRs)

• Tizanidine (Zanaflex ®), Baclofen (Lioresal ®), Methocarbamol(Robaxin ®), Cyclobenzaprine (Flexeril ®), Metaxalone (Skelaxin ®)

• May be useful for muscle spasm/spasticity and myofascial pain

• Side effects: In general, all may cause sedation and muscle weakness

• Avoid in the elderly

Opioids

• Alkaloids derived from opium

• Natural and synthetic agents• Mimicks naturally occurring

substances

• 3 major chemical classes• Phenanthrenes: morphine,

codeine, hydrocodone, hydromorphone, oxycodone, oxymorphone

• Phenylpiperidines: meperidine, fentanyl

• Diphenylheptanes: methadone, propoxyphene

Opioid recommendations have swung back and forth over the years….

Lots of OpioidsNo Opioids

Responsible Use of Opioids

American Pain Society – American Academy of Pain MedicineOpioid Guidelines

2009“By panel consensus, a reasonable definition for high dose opioid therapy is >200mg daily of oral morphine (or equivalent), based on maximum opioid doses studied in randomized trials and average opioid doses observed in observational studies”

Centers for Medicare and Medicaid Services (CMS)2012

CMS released memo addressing the public health concern surrounding potential opioid overutilization

• Effort to improve the safe and effective use of opioids in Medicare Part D

• Daily morphine equivalent dose (MED) above 120mg for at least 90 consecutive days w/ >3 prescribers and >3 pharmacies

CDC’s Guideline for Prescribing Opioids for Chronic Pain

2016Earlier this year the CDC released new opioid guidelines that further reduced the recommended dose of opioids to <90 MME/day

US Surgeon General Letter to all US Physicians

Opioid agonists:Class Side Effects

•Respiratory depression

• CNS depression

•Hypotension

•Bradycardia

• Peripheral edema

• Constipation

• GI upset• Pruritis• Diaphoresis• Dry mouth• Sleep Disorders• Hypogonadism• Hyperalgesia

Opioid Agonists: Morphine, Oxycodone, Hydrocodone, Hydromorphone

• Morphine - 2 major metabolites• ~75% metabolized to morphine-3-

glucuronide• Lacks analgesic effect but may cause

neurotoxicity• ~5%-10% metabolized to

morphine-6-glucuronide• Considered more potent analgesic than

parent compound • Hydromorphone - many major/minor metabolites

•Hydromorphone-3-glucuronide•May cause neuroexcitatory effects

•Hydromorphone-6-glucuronide•Accumulation may lead to myoclonus, agitation, and seizure

• In general, similar pharmacokinetic and side effect profile• Different metabolite profile:

•Oxycodone - 2 major metabolites•Oxymorphone

•Potent analgesic but typically low plasma concentrations

•Noroxycodone•Weak analgesic

•Hydrocodone - 2 major metabolites•Hydromorphone

•Much greater affinity for mu receptor than parent compound

•Norhydrocodone

Opioid Agonist: Tramadol•Effective 8/18/14, DEA reclassified tramadol as a Schedule IV controlled substance

• 2 primary MOA• Mu receptor agonist• Inhibits re-uptake of serotonin and norepinephrine

• Active metabolite (O-desmethyl tramadol) t1/2 ~ 7-9 hours

• Cautions• Seizure disorder• Drug interactions• Falls

Opioid Agonist: Fentanyl•Per CDC recommendations, only clinicians familiar with the dosing and absorption properties should consider prescribing it

• Fentanyl 25mcg/hr patch is ~equivalent to 60 MME/day

• Inactive metabolites

• May be useful in opioid TOLERANT patient’s with morphine allergy

• Contraindicated in opioid naïve patients

• Cautions• Proper disposal of patch to prevent accidental

exposure• Administration issues

Opioid Agonist: Methadone• Per CDC recommendations, should not be the first choice for a long-acting opioid and should only be used by clinicians familiar with methadone and it’s unique properties

• Multiple MOA• Mu receptor agonist• NMDA receptor antagonist• Inhibits re-uptake of serotonin and norepinephrine

• Long and variable t1/2• Elimination half-life is considerably longer than the half-life of analgesia• Side effect profile can persist well beyond duration of analgesia

• Cautions• QT prolongation• Generally not recommended for breakthrough pain due to long half-life and

variable pharmacokinetics• Detox/Maintenance restricted to Opioid Treatment Programs

Opioid Agonists to Avoid……in GeneralDarvocet• Withdrawn from market d/t cardiac

effects

Demerol• Recommended to limit use by most

regulatory bodies

• Beers List

Codeine• Some patients are unable to convert

codeine to morphine for analgesic effect

• Ensure legitimate diagnosis

• Recommend history and physical exam prior to opioid trial

• Document 5 A’s• Analgesia

• Activity (function)

• Adverse effects

• Aberrant behaviors

• Affect

• Maximize non-pharmacologic and non-opioid therapy first

• Do not write range orders or PRN orders for long-acting opioids

Opioid Prescribing Pearls

• For chronic opioid patients limit supply to 30 days with no refills

• Opioid agreements

• Urine Drug Screens• Drugs of abuse and opioid screens

• Pill counts randomly and for aberrant behavior

• CURES reports

Opioid Prescribing Pearls

CDC Opioid Tapering Recommendations

• Decrease 10% per week• Coordinate with specialists/experts prn• Psychosocial support• Adjust the rate/duration of taper based on patient’s response• Don’t reverse the taper; slow/pause the rate and manage withdrawal

symptoms• Consider extending dosing interval once smallest available dose is reached

SA Opioids General Tapering Rec Example TaperHydrocodone/APAP (Norco, Vicodin)

Oxycodone (Roxicodone)

Oxycodone/APAP (Percocet, Roxicet)

Hydromorphone (Dilaudid)

Codeine/APAP (T#3, T#4)

Tramadol (Ultram)

LA Opioids General Tapering Rec Example Taper

Fentanyl Patch (Duragesic) Fentanyl 75 mcg patch q72h: decrease by 12 to 25 mcg every 2 to 4 weeks

*Morphine SR/ER (MS Contin)

Morphine SR 60 mg q8h: decrease by 30 mg every 2 to 4 weeks; may consider reducing

dose decrease to 15 mg as the opioid dose gets lower if patient is unable to tolerate 30

mg decreases

Methadone

Methadone 30 mg q8h: decrease by 10 mg every 2 to 4 weeks (methadone may require

longer intervals due to its long half-life); may consider reducing dose decrease to 5 mg

as the opioid dose gets lower

Oxymorphone SR (Opana SR)Oxymorphone SR 20 mg q8h: decrease by 10 mg every 2 to 4 weeks; may consider

reducing dose decrease to 5 mg as the opioid dose gets lower

Oxycodone SR (Oxycontin)Oyxcodone SR 80 mg q12h: decrease by 20 mg every 2 to 4 weeks; may consider

reducing dose decrease to 10 mg as the opioid dose gets lower

General Recommendations:

SCPMG Opioid Tapering Guide for Patients With Chronic Pain(Excludes palliative/hospice/cancer patients)

These guidelines are based on SCPMG and KPSC combined expertise as buttressed by the CDC 1/2016 Draft Guidelines and WA State 2015 AMDG Guidelines. Clinicians should consider individual patient parameters,

current/past drug use, medical history, and withdrawal side effect tolerance

*The majority of patients can be effectively tapered with formulary dosage forms. In general, 30mg tabs may be used at higher doses and 15mg tabs as the dose gets lower. 20mg caps are available if needed but are

non-formulary

^Per CDC Draft Guidelines 1/2016, avoid concurrent use of benzodiazepines with opioids if at all possible (this is a dangerous drug combination)

SCPMG Practice Guide 3/1/2016, SCAL Exec Controlled Substance Committee, RC/PG/ME/SS/KT/DH/MW

Reduce by 10-25% every 2-4 weeks; may

go faster/slower depending on clinic

need; if intolerable side effects consider

temporarily stopping taper and then

resuming at a slower rate once patient is

clinically stable

Reduce by 1 tab/cap of daily dose per

week until desired MED/day achieved;

goal is less than 100 mg MED/day or

discontinuation of opioid

Norco 10/325 mg 2 tabs q8h: decrease by 1 tab of daily dose per week (ie. decrease to 5

tabs/day for 1 week, then 4 tabs/day for 1 week, etc) until desired MED achieved or

opioid discontinued

1) If the patient is on both a Short-Acting (SA) opioid and a Long-Acting (LA) opioid, it is generally acceptable to maintain the current SA opioid dose (assuming it does not exceed the practice

recommendation of 200 tabs/caps max per month) while tapering the LA opioid

2) In general, it is acceptable to taper LA opioids by 10-25% every 2-4 weeks and SA opioids by 1 tab/cap of daily dose per week

3) Opioid tapers may go faster or slower depending on a patient's clinical need or based on a physician's clinical judgement. CDC Guidelines note that tapers slower than 10% per week (e.g.

10% per month), might also be appropriate and better tolerated than more rapid tapers, particularly when patients have been taking opioids for longer durations (e.g. for years)

4) ^If the patient has intolerable symptoms of withdrawal, the dose may need to be held steady, temporarily, until the patient stabilizes; when resuming taper consider smaller dose decreases

or longer intervals between dose decreases; withdrawal symptoms may also be treated with dicyclomine, clonidine, loperamide, and methocarbamol; Addiction Medicine may be contacted for

Dr. Advice if the aforementioned recommendations fail to adequately resolve withdrawal symptoms

6) Consider contacting the Pain Management Specialists for additional guidance if needed

5) Consider naloxone for any patient at high risk for overdose

SCPMG Opioid Tapering Guide

• Created prior to official CDC guidelines

• Reduce opioid dose by 10-25% every 2 to 4 weeks

• Tapers may go faster or slower depending clinical need

• Consider naloxone for any high risk patient

Red Flags for Opioid Abuse• Early refills - overuse, lost/stolen prescriptions, frequent “vacations”

• Requesting med changes constantly….. “nothing works”

• Requesting specific medications, brand name medications, or certain color medications

• Doctor shopping

• Paying cash

• Refusing imaging or other work-up

• Refusing lab tests

• Urine drug screen inconsistencies

Opioid RotationsMay help overcome tolerance and opioid-induced hyperalgesia• May have less utility now with lower MME recommendations

from CDC

May help minimize or eliminate certain side effects

Recommend to reduce new opioid dose by 25% to 75% to account for incomplete cross tolerance

May consider either cross-titrating or a stop-start approach• Stop-start approach may be beneficial in patients with poor

medication compliance, cognitive deficits, or unable to follow instructions

a) 50 MME

b) 100 MME

c) 60 MME

d) 37.5 MME

Test Questions

a) 50 MME

b) 100 MME

c) 60 MME

d) 37.5 MME

Test Questions

b) Doctor shopping

Test Questions

b) Doctor shopping

Test Questions

“Tackling the Opioid Epidemic: An Integrated, Population Care

Management Approach”

Clinical Operations Manager and PGY1 Residency Coordinator

Kaiser Permanente, Southern California

Riverside Service Area

Tackling the Opioid Epidemic: An Integrated, Population Care Management Approach ”

1 – The Big Challenge and Results

2- How We Got in the Game

3. Our Game Plan

A. Use “Red Flags” to determine if a patient’s opioid prescription should be refilled in your pharmacy

B. Establish a multidisciplinary Controlled Substance Committee in your hospital practice to develop initiatives to improve acute and chronic pain management in hospitalized patients

C. Develop opioid dispensing policies to support the pharmacists in using “Corresponding Responsibility”

D. Volunteer at your local law enforcement “ National Take Back Drug Day” to collect unwanted medications and donate them to a local charity

Question 3: Which of the following is NOT an example of a core interventions Pharmacists can apply in their practice to reduce overuse, abuse, and overdose of opioids?

Test Questions

Question 4: Which of the following is NOT an example of a data measurement strategies pharmacist can use to identify the at risk opioid patients, use to make a safety intervention and track results in your practice?

A. Create list of patients in the hospital that are receiving > 50 mg MEDs/day and run a CURES report for each patient to determine if they are receiving medications from multiple providers

B. Run list of the patients receiving 1 or more opioids in combinations with a benzodiazepine in the hospital or community pharmacy practice

C. Recommend ED policy change for patients presenting with exacerbation of chronic pain to give SQ hydromorphone q 4-6 hrs instead via a slow IV drip of hydromorphone

D. Run prescription list of patients on opioids at > 50 mg MEDs/day with no history of naloxone use

Test Questions

National CDC DATA. CDC.gov

Notable Celebrity Deaths Due to Unintentional Overdose, Combination Prescription Drugs and Addiction

2007 2008 2009

National CDC DATA. CDC.gov

How are we or I going to tackle this overwhelming

challenge, manage chronic pain in our

patients and make a difference?

We have to do something!

SCAL Results- Improvements in Opioid Utilization: Since January, 2010 to YE 2015

Data Source: Kaiser Permanente SCAL Drug Use Management

89% reduction in OxyContin (oxycodone LA) prescribing

66% reduction in Opana ER (hydromorphone) prescribing

98% reduction in opioid/acetaminophen combination prescriptions with > 200 tabs- (no Rxs filled in 2016 > 200)

95% reduction in brand opioid prescribing when a generic is available to almost zero Rxs (Brand had greater street value for diversion)

84% reduction in "Trinity" prescribing (opioid + benzodiazepine + carisoprodol- “Soma”)

31% reduction - patients on > 120 MED/day of opioids (2010-2014)

21% reduction - patients on > 100 MEDs/day of opioids (4th Q 2015-3rd Q 2016)

Early 2010

1. Conducted initial data and analysis

“The U.S. and we have a problem”

…SCAL Physician and Pharmacy Leadership

An Integrated, Population Care Management Approach:9 Core Strategies of Success

First clue: We had an opioid problem- SCAL Rx Utilization DATA

We discovered that OxyContin LA (oxycodone) was our most prescribed, non-formulary medication by cost!!

*Source: Kaiser Permanente SCAL Utilization Data- Jan 2010, Drug Utilization Management

Hydrocodone/APAP Volume PMPMk – Jan 2010

*Source: Kaiser Permanente SCAL Utilization Data- Jan 2010, Drug Utilization Management

KP SCAL Utilization Data:1. Prescribers (2007)

25% of patients in the sample received > 4 gms/day from combination APAP opioids prescriptions from 4 or more different prescribers in a 12 month period!

*Based on a SCAL study of 1,276 MRNs in 12 months ending 3/07-

DSB Reports Kaiser Permanente Drug Utilization Management

2. Early Refills/Overlapping Scripts (2007)

In a sample of 1,276 patients, 50% of patients had more than 20 refills in a 12-month

period!

“This is about saving lives, improving quality of care, and protecting our clinicians and the

organization”… SCPMG Quality Leadership 2010

Solution

• CDC 2010 Goal:

• Reduce overuse, abuse, and overdose of opioids (and other controlled prescription drugs) while ensuring patients with pain are safely and effectively treated.

• In 2010-11, High Risk for Overdose/Death: > 120 mg/day MED (Morphine Equiv. Dose)

2. Supported by Bold Leadership – Acknowledge, Call to Action & Priority Commitment:

3. Combined Leadership and Accountability: Change Management

4. Built Collaborative, Multi-Team Infrastructure with Passionate Leadership:

SCAL SCPMG/Pharmacy

Executive Team

Task ForceInfo Systems Workgroup

Pharmacy Subcommittee

Multi-Disciplinary Task ForceLocal Medical

Center Review Teams

Inter-Departmental

Specialty Support Group

Data and analytic support

Project management

Clinical Ops Manager

Drug Utilization Manager

Drug Education Coordinator

Pharmacy Ops Managers

Chronic Pain Management Pharmacists

Drug Information and Formulary

Pharmacy Benefits

Quality Management

Compliance

5. Provided Prescriber and Pharmacist Education: Evidence Based Medicine

The World Has Changed:Chronic Pain Treatment Reconsidered

Opioids have proven efficacy and relative safety for treating acute pain and pain during terminal illness

Opioids do NOT have proven efficacy or safety for treating chronic pain long-term

High dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia (OIH), decreasing patient pain threshold, and potentially masking resolution of a pre-existing pain condition

5. Provided Prescriber and Pharmacist Education: Evidence Based Medicine (Con’t)

Opioids are powerful drugs and should be reserved for severe, acute non-cancer pain

Avoid the 90 Day Cliff- Studies more likely to become lifelong!

- If on >90 days tend to be at a higher-risk for overdose and death!

Doses > 100mg MED/day =

RED FLAG!

5. Provided Prescriber and Pharmacist Education: Evidence Based Medicine (Con’t)

Patients on daily opioid prescription pain medications at discharge: 7%

Decrease in pain severity, despite discontinuing pain meds: 70%

Reduction in pain severity at dismissal: 73%

Greater control over pain: 84%

Mayo Clinic Experience in the Pain Rehabilitation Center

6. Implemented Evidence-Based Best Practices

“Patients receiving high doses of opioids show no worsening of pain scores or aberrant drug behaviors after significant dose reductions compared with patients who do not have dose reductions, a new study suggests.”

7. Developed Professional & Formulary Guidelines, Policies and Agreements

The Medical Board of California

• Guidelines for Prescribing Controlled Substances for Pain http://www.mbc.ca.gov/Licensees/Prescribing/Pain_Guidelines.aspx

• Guidelines on history/physical, treatment plan, informed consent, office visits, consultation, records, etc.

CA Health and Safety Code 11153

• Pharmacists’ Corresponding Responsibility – “The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription….[who must verify that prescriptions are issued for a legitimate medical purpose].”

• Supported by the CA State Board of Pharmacy

Formulary Guidelines, Policies & Procedures, Inter-department Agreements

8. Deployed Decision Support EMR Tools

• Best Practice Alerts• Protocols• Smart Sets• Smart Dot Phrases• On-Line DR.ADVISE• Standardized Order Sets and Coding• Treatment Agreement Letters & Patient Education

9. Provided Timely Data & Tracking : Quarterly Rx and Patient Data & Analysis -To Prescribers and Pharmacists

Early 2010-2012

• High dose patient lists

• Quarterly prescriber utilization #Rxs & Unique Patients Dashboards & Scorecards

• High patient & prescriber utilizer reports > 15 units/day Opioids

• Facility & individual action plans

• High risk of diversion lists- Top 10 by Area in SCAL by 9 categories

• ED and UC Parenteral prescribing reports

• Reports on Patients with lack of prescriber follow-up reports > 6 months

• Quarterly Tracking of Utilization- DUAT

• 2013: Changed metrics to track >120 mg MED/day (CMS)

• 2015: : Changed metrics to track >100 mg MED/day (CMS)

9. Provided Timely Data & Tracking Results : Quarterly Rx and Patient Data & Analysis, By SCAL Medical Center Area

To Prescribers and Pharmacists- example: 4th Q 2011- 1st Q 2012

Data Source: Kaiser Permanente Drug Use Management

9. Timely Data and Tracking Results: Crucial Component of Success!

Data by Drug Use Management, Pharmacy Analytics & Compliance Drug Utilization Action Team (DUAT): Scorecards and

Quarterly Data Tracking of Initiatives: By Area, Prescriber, Prescription and Patient drilldowns

Center for Medicaid and Medicare (CMS)- Claims Data Monitors opioid utilization for Medicare members and

requiring that the prescriber documents follow-up actions for all high risk patients

Pharmacy Adverse Drug Event Reports KP Compliance: Fraud, Waste and Abuse Report- Top 10 by

9 Categories by each Medical Center Area Ad-hoc Reports

2013-2015• KP Outpatient Pharmacist Escalation Policy: Phone calls to prescribers- concerns,

excessive dosing and RED FLAGS:

• Flag high pill count (>200 pills/Rx short-acting > 400 pills long-acting ) and high dose (>120 mg MED/day. Changed to > 100 mg MED/day)

• Identify & avoid “Trinity” combinations = opioid analgesic + benzodiazepine + Soma

• Benefit change- Refill Policy for all Schedule II Opioid Medications – No refills under 30 days, Quantity = 30 day supply

• All Pharmacists Enrollment and Access to CURES

• Decision Support in EMR- Alternative Alerts, Guidelines, order entry questionnaires with hard stops

10. Implemented Various Target Initiatives: (Con’t)

2013 +

10. Implemented Various Target Initiatives: (Con’t)

• First implemented in all EDs in San Diego County, then at KP San Diego

• Spread to LA County EDs & KP SCAL EDs• Handed to all patients at ED Discharge• Follows American Academy of Emergency

Medicine (AAEM) recommendations• Avoid SQ/IM injectable opioids for chronic pain

patients for exacerbations (non-cancer, non-hospice/palliative pain): Use slow IV Drip hydromorphone

• Limit ED/UC discharge prescription quantity, no refills, no lost/stolen replacements

10. Various Targeted Initiatives (Con’t)

KP Fontana Area 2014

and Spread over SCAL 2015

Pharmacist Education: KP Common Drug Seeking Red-Flag Behaviors: 2013

1. Feigns Illness - complains of back/neck pain, headaches, cough without other symptoms

2. Repeated requests for replacement of "lost“, “dog ate it” drugs or prescriptions

3. Insists on specific medication and/or brand-name & early refills

Oxycontin, Opana have very high street value—tablets sell for $100 each

I have to have it now, going on a trip again

5. Abusive or threatening behavior when denied drugs.

6. Does not get appropriate treatment for legitimate medical issues

7. Wants prescriptions to be filled at non-Kaiser Permanente pharmacy

8. Cancels follow-up appointments 9. Won’t fill prescriptions for non-

controlled substances such as antibiotics

10. Frequent Emergency Room / Urgent Care Visits

www.pharmacy.ca.gov

Pharmacist Education: KP Common Drug Seeking Red-Flag Behaviors: Ca Board of Pharmacy (2015)

National DEA Take Back Drug Day- Drop off Sites, Worked with Local Area Law Enforcement biannually

http://www.deadiversion.usdoj.gov/drug_disposal/takeback/

April 29,2016

Implemented Enhanced Tapering Plan: Tools- May 2016

http://www.pharmacy.ca.gov/publications/naloxone_fact_sheet.pdfhttp://www.cdc.gov/drugoverdose/prescribing/resources.html

Working on Safety Initiative: Prescriber Naloxone Prescribing for High Risk Patients and Pharmacist Furnishing Pilot Sites

http://www.cdc.gov/drugoverdose/prescribing/resources.html

Working on Safety Initiative: Combination Opioid and Benzodiazepines

Strategy:In collaboration with PCP, Psych, & Pain Medicine Specialists:1. Identification of patients and 2. Recommend a slow taper off

one or both medications3. With frequent patient follow-

up4. With Cognitive Behavior

Therapy (CBT Classes) and other safer drug and non-drug therapies

“Tackling the Opioid Epidemic: An Integrated, Population Care Management Approach ”

6. Evidence- Based Best Practices

7. Professional Guidelines, Policies, Agreements

8. EMR Decision Support Tools, protocols, etc.

9. Timely Data & Tracking Results

10. Various Targeted Initiatives

1. Initial Data and Analysis

2. Bold Leadership & Call to Action

3. Leadership + Accountability = Change Management

4. Collaborative, Multi-team Infrastructure with Passionate Leadership

5. Prescriber & Pharmacist Education

9 Core Strategies of Success

Game Over?

Tacking the Opioid Epidemic

A. Use “Red Flags” to determine if a patient’s opioid prescription should be refilled in your pharmacy.

D. Volunteer at your local law enforcement “ National Take Back Drug Day” to collect unwanted medications and donate drugs to a local charity

Question 3: Which of the following is NOT an example of a core interventions Pharmacists can apply in their practice to reduce overuse, abuse, and overdose of opioids:

Test Questions

A. Use “Red Flags” to determine if a patient’s opioid prescription should be refilled in your pharmacy

D. Volunteer at your local law enforcement “ National Take Back Drug Day” to collect unwanted medications and donate drugs to a local charity

Question 3: Which of the following is NOT an example of a core interventions Pharmacists can apply in their practice to reduce overuse, abuse, and overdose of opioids?

Test Questions

Community Health Improvement Strategies for

Tackling the Opioid Epidemic:

It Takes a Village

Joel D. Hyatt, MDEmeritus Assistant Regional Medical Director

Community Health Initiatives

Southern California Permanente Medical Group

Kaiser Permanente Southern California

Prescription Opioid Epidemic: Community & Public Health

Building the LA County Prescription Drug Abuse Medical Task Force (PDAMTF)

All 76 ED’s in LA County adopted AAEM Guidelines (2013) and patient handouts

March, 2015

Safer Prescribing Practices

Medication-assisted Treatment ◦ Buprenorphine and other meds

Preventing Overdoses◦ Naloxone access

Goal to Expand from EDs to Urgent Care Clinics

All 76 ED’s in LA County to all

Major Urgent Care Clinics

Medical (Dental) Practice InitiativeHealth Plans

Provider Groups/Delivery Systems

+LA-AFP, LA-ACP,

Increased Awareness & ActivationWhite House

HHS, CDC

Congress

CMS (Medicare, Medicaid, ie, MediCal)

States (DPH, Legislatures, Ags)

PDMP (CURES)

Retail Pharmacy and PBMs

Law Enforcement

Professional Organizations (AAFP, ACP, ADA, AMA, Pharmacy Boards…

Public Health

Health Plans (KP, Cigna, Blue Shield, LA Care, Anthem…)

Surgeon General

CA SWGRO (Cov. CA, CalPERS, DHCS)

NCQA, PQA, HEDIS

And more……..

Need for coordination, collaboration, communication

Pharmacists have a critical role to play in many community settings

It Takes a Village Working Together

A. California Department of Justice

B. White House

C. California Health Care Foundation

D. Coroner’s Office

E. CSHP

F. American Dental Association

G. CA State Legislature

H. You

I. All of the above

Question 5: Which of the following groups are taking action to stem the opioid epidemic?

A. California Department of Justice

B. White House

C. California Health Care Foundation

D. Coroner’s Office

E. CSHP

F. American Dental Association

G. CA State Legislature

H. You

I. All of the above

Question 5: Which of the following groups are taking action to stem the opioid epidemic?

1. Dowell D, Haegerich TM, Chou R, et al. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep 2016; 65

2. www.cdc.gov/drugoverdose/. Web. 21 Aug 2016

3. Tudor CG (2012, Sept 6). Memo: Supplemental Guidance Related to Improving Drug Utilization Review Controls in Part D. Centers for Medicare and Medicaid Services, 1-45

4. www.healthy.ohio.gov/vipp/data/rxdata.aspx. 2015 Ohio Drug Overdose Data: General Findings. Web. 14 Aug 2016

5. McPherson M. “Demystifying Opioid Conversion Calculations – A Guide for Effective Dosing.” Bethesda: ASHP, 2010. Print

6. Tudor CG. “Supplemental Guidance Related to Improving Drug Utilization Review Controls in Part D.” Centers for Medicare & Medicaid Services. 6 Sep 2012

7. www.globalrph.com. Web. 13 Feb 2012

8. Fisch MJ, Cleeland CS: Managing cancer pain. In: Skeel RT, ed.: Handbook of Cancer Chemotherapy. 6th ed. Phil Lippincott Williams & Wilkins, 2003, pp 663

9. Dolophine (Methadone) package insert. bidocs.boehringer-ingelheim.com. N.p. n.d. Web. 21 Sep 2011

References

10. Toombs J. “Oral Methadone Dosing for Chronic Pain.” Pain-Topics.org. N.p. 12 Mar 2008. Web. 14 Sep 2011

11. Walker PW, et al. J Palliat Med 2008; 11: 1103-1108

12. Vallejo R, et al. “Pharmacology of Opioids in the Treatment of Chronic Pain Syndromes.” Pain Physician: July/August 2011; 14:E343-E360

13. Johnson S. “Opioid Safety in Patients with Renal or Hepatic Dysfunction.” Pain-Topics.org. N.p. 30 Nov 2007. Web. 2 May 2012

14. www.lexicomp.com. Web. 5 May 2012

15. Trescot A, et al. “Opioid Pharmacology.” Pain Physician 2008; Opioid Special Issue: 11:S133-S153

16. Krantz M, et al. Ann Intern Med 2009; 150: 387-95, 417-18

17. Ramasubbu C, Gupta A. “Pharmacological Treatment of Opioid-Induced Hyperalgesia: A Review of the Evidence.” J of Pain & Pall Care Pharmacotherapy. 2011; 25: 219-230

18. Chou R, et al. “Clinical Guidelines for the use of Chronic Opioid Therapy in Chronic Noncancer Pain.” J of Pain, Vol 10, No 2 (February), 2009: pp 113-130

19. http://cl.kp.org/pkc/national/topics/adult/chronicpain/index.html. KP intranet. 5 May 2012

References (con’t)

20. Ca Medical Board: 2014 Guidelines for Prescribing Controlled Substances for Pain http://www.mbc.ca.gov/Licensees/Prescribing/Pain_Guidelines.asp

21. 90 Day Cliff references:

22. Ca Board of Pharmacy: http://www.pharmacy.ca.gov/ Naloxone Pharmacist Finishing Protocol, patient fact sheet, press releases, etc. DEA National Take Back Drug Day Information for CURES Corresponding Responsibility brochure http://www.cdc.gov/drugoverdose/prescribing/resources.html

1. Turk DC, Okifuji A. Pain terms and taximonies. In: Fisman SM, Ballantyne JC, Rathmell, JP eds Bonica’s Management of Pain (4th ed) Lippincott Williams and Wilkins pp 14-43. 2010.

2. Braden JB, Fan MY, Edlund MJ, Martin BC, Deviries A, Sullivan MD. Trends in use of opioids by noncancer pain type 2000-2005 among Arkansas Medicaid and HealthCore enrollees: results from the TROUP study. J Pain. Nov 2008;9 (11):1026-1035.

3. Korff MV, Saunders K, Thomas Ray G, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain. Jul-Aug 2008;23(6):521-527.

4. Martin BC. Fan MY, Edlund MJ, Devries A, Branden JB, Sullivan MD. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med. Dec 2011;26(12):1420-1427.

5. Volinn E, Fargo JD, Fine PG. Opioid therapy for nonspecific low back pain and the outcome of chronic work loss. Pain. Apr 2009;142(3):194-201.

23. Surgeon General: http://www.surgeongeneral.gov/priorities/opioids/index.html and

24. http://turnthetiderx.org/

25. DEA National Take Back Drug:http://www.deadiversion.usdoj.gov/drug_disposal/takeback

26. Marc R. Larochelle, Jane M. Liebschutz, et al. Opioid Prescribing After Nonfatal Overdose and Association With Repeated Overdose: A Cohort Study Opioid Prescribing After Nonfatal Overdose. Ann Intern Med. 2016;164(1):1-9.

27. Phillip O. Coffin, Emily Behar, et al. Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain. Ann Intern Med. 2016;165(4):292-293.

28. Physicians For Responsible Opioid Prescribing, May 26, 2011- YouTube Video: Chapter I: Risk of Addiction, Opioid Therapy for Chronic Non-Cancer Pain Myths and Facts:https://www.youtube.com/watch?v=QYWykvy3xDI

28. John Hopkins Bloomberg School of Public Health: The Prescription Opioid Epidemic: An Evidenced Based Approach, Nov. 2015.http://www.jhsph.edu/research/centers-and-institutes/center-for-drug-safety-and-effectiveness/opioid-epidemic-town-hall-2015/2015-prescription-opioid-epidemic-report.pdf

29. Case Studies: Three California Health Plans Take Action Against Opioid Overuse (June, 2016)http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20CaseStudiesHealthPlansOpioid.pdf

30. Changing Course: The Role of Health Plans in Curbing the Opioid Epidemichttp://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20ChangingHealthPlansOpioid.pdf

31. Kate M Dunn, Kathleen W Saunders, JD, et al. Overdose and prescribed opioids: Associations among chronic non-cancer pain patients. Ann Intern Med. 2010 January 19; 152(2): 85–92.

32. Robert M. Califf, Janet Woodcock, Stephen Ostroff. A Proactive Response to Prescription Opioid Abuse, NEJM.org, 2016 Feb 4 ; 1-6.

33. Yuanyuan Liang and Barbara J. Turner. Assessing Risk for Drug Overdose in a National Cohort: Role for Both Daily and Total Opioid Dose? J Pain. 2015 April ; 16(4): 318–325.

34. California SB 482: Controlled substances: CURES database.(2015-2016)https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB482

35. H Ryan, L Girion, and S Glover. A Times Investigation Part 1. “You want a description of Hell?”, Oxycontin’s12-hour problem? LA Times 2016 May 5.http://www.latimes.com/projects/oxycontin-part1,

36. H Ryan, L Girion, and S Glover. A Times Investigation Part 2. More than 1 million OxyContin pills ended up in the hands of criminals and addicts. What the drugmaker knew. LA Times 2016 July 10.http://www.latimes.com/projects/la-me-oxycontin-part2/

Question & AnswersInteractive Panel Discussion

“Tackling the Opioid Epidemic:

Safe Opioid Use In Pain Management”

1. Write down the course code. Space has been provided in the daily program-at-a-glance sections of your program book.

2. To claim credit: Go to www.cshp.org/cpe before December 1, 2016.

Session Code:

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