Turning Off the Faucet from Above: Health Plan Involvement

in Safe PrescribingPresenters:• Roneet Lev, MD, Director of Operations, Scripps Mercy Hospital Emergency

Department, and Chair, San Diego County (CA) Rx Drug Abuse Medical Task Force

• Daniel Calac, MD, FAAP, Chief Medical Officer, Indian Health Council, Inc.• Margaret Mendes, PharmD, Program Director, Academic Detailing Service, VA

Desert Pacific Healthcare Network• George Scolari, Behavioral Health Program Manager, Community Health Group

Third-Party Payer Track

Moderator: Mark D. Birdwhistell, MPA, Vice President for Administration and External Affairs, University of Kentucky HealthCare

Disclosures

Daniel Calac, MD, FAAP; Roneet Lev, MD; Margaret Mendes, PharmD; George Scolari; and Mark D. Birdwhistell, MPA, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest:

Starfish Health (spouse)– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center

Learning Objectives

1. Describe strategies to engage health plans in safe prescribing efforts.

2. Identify some red flag medications and combinations that are key to safe prescribing.

3. Outline some health plan policies that can be used for safe prescribing.

4. Provide accurate and appropriate counsel as part of the treatment team.

Turning off the Faucet from Above

Health Plan Involvement in Safe Prescribing

Roneet Lev, MD, Director of Operations, Scripps Mercy Hospital San DiegoChair, San Diego Prescription Drug Abuse Medical Task Force

Daniel Calac, MD, Chief Medical Officer, Indian Health Council, IncMargaret Mendes Pharm D, Program Director, VA San Diego Healthcare SystemGeorge Scolari, Behavioral Health Program Manager, Community Health Group

Turning off the Faucet from Above

VA Health Care

The San Diego Medical Task Force and Death Diaries

Community Health Group

1

3

4

2 Indian Health Council

5 Health Plan Recommendations

San Diego County Prescription Drug Abuse

Medical Task Force

San Diego Death DiariesMedical Examiner and

PDMP Data Results

The PDA Medical Task Force Facilitator DEA Emergency

Physicians Primary Care Pain Management Addiction Specialists Pharmacy

Association Hospital Association Dental Association Psychiatric

Association

Pediatric Association Kaiser Scripps Sharp Community Clinics VA Military Palomar Pomerado Indian Health Methadone Clinic

San Diego Death Diaries

ME Data• 254 deaths with

prescriptions as cause of death

• Could be with alcohol, illicit, over the counter

PDMP Data• Does Not Include

VA Balboa Naval Hospital Methadone Clinics Inpatient hospitals

186

68

254 Prescription Related Deaths in San Diego 2013

CURES Data

No CURES

Number Medications on Medical Examiner Toxicology Report

10

20%

80%

Single Medication (51)

Multiple Medication (203)

Chronic Use3 or More Consecutive Months For Same Rx

69% of Deaths were Chronic Users; 96% of all Rx

11

California San Diego San Diego Deaths0

10

20

30

40

50

60

70

80

2.81.6

68.8

2013 Census 38.3 million 3.2 million 254Patients with Rx 7,057,000 816,372 186Chronic Use 200,080 13,567 128

Methadone Deaths

12

PDMP Match (3)7%

PDMP Match + Doctor

Shopper (3)7%

PMDP Match + Doctor

Shopper + Il-licit (1)

2%No Recent Methadone

Rx (3)7%

No Methadone on PDMP (24)

52%

No PDMP Data (12)

26%

PDMP Match (3)PDMP Match + Doctor Shopper (3)PMDP Match + Doctor Shopper + Illicit (1)No Recent Methadone Rx (3)No Methadone on PDMP (24)No PDMP Data (12)

46 deaths Number One drug to cause a single medication related

death 85% (39) of Deaths Rx from outside PDMP system 100% deaths (7) from PDMP system from primary care

Opioids + Benzodiazepines All PDMP Reports – 54% (100

patients) ME Deaths – 21% (55)

3916

Opioids + Benzodi-azepines

ME Reports – 55 patients

PDMP MatchNo Match 10

086

PDMP Reports with Opioid + Benzodiazepine

Combination

Opioid + Benzo

13

Doctor Shopping4 providers + 4 pharmacies in 12 months

52 Patients (28% of all PDMP Reports)were Doctor Shoppers

“The Heavy Half” = Received 51% of all Rx

50/50 Male/Female

28%

72%

% Doctor Shoppers

Doctor ShopperRegular Patient

14

Emergency Department Guidelines Urgent Care Guidelines Medication Agreements Treatment Guidelines Interdisciplinary Conferences Educational Outreach Magazine Publications Case Discussions Media Outreach Further Research Medical Examiner Feedback to Physicians

Data Driven Advocacy

References Lev, R et al “A description of Medical Examiner prescription

–related deaths and prescription drug monitoring program data” American Journal of Emergency Medicine. December 2015.

Lev, R et al “Methadone Deaths Compared to All Prescription Related Deaths” Forensic Science International.2015

Lev, R et al “Who is prescribing controlled medications to patients who die from prescription drug abuse?” American Journal of Emergency Medicine. Oct 2015.

16

SanDiegoRxAbuseTaskForce.Org

SanDiegoSafePrescribing.org

Safe Prescribing in Tribal

Communitiesa multidisciplinary

approachDaniel Calac, MDChief Medical Officer

Indian Health Council, Inc

Funded by the National Institutes for Health and the Indian Health Service

Indian Health Council, Incorporated (IHC) established on January 19, 1970 

IHC Service Area

Indian Health Council, Inc.

RINCON SITE SANTA YSABEL SITE

IHC services

Safe Prescribing in Tribal Communities

The Pill Take Back Project

Study Goal: to reduce availability and misuse of prescription pain pills in a rural tribal community

Hypotheses: To use focused community interventions to:

1) Create convenient options for community members to reduce availability of non-prescribed use;

2) Demonstrate feasibility of a culturally tailored and environmentally sound drug disposal system in American Indian communities; and

3) Change norms around giving away one’s prescription pain pills to family members or friends.

Pain Management Program

Created in 2008 to address rising prescription pain medication misuse/abuse

Use a multidisciplinary approach which addresses the physical, psychological and social issues associated with chronic pain conditions Hold patient and provider accountable

for use of opioid medications for chronic health

Prescribing policies

Updated prescribing practices and policies in IHC medical manual Implement a Pain Agreement Conduct a initial assessment

▪ Formulate a treatment plan Treatment plan includes other

modalities▪ Acupuncture, group therapy, chiropractics,

physical therapy, nutrition education

Prescribing policies

Set a maximum number of 200mg pill/month of any one opioids; set a maximum daily morphine equivalent dosage at 200mg

Conduct Urine Drug Screens Conduct a CURES report Administer pain questionnaires

Pain Management Practices and Policies

Conduct initial evaluation •History and physical examination•Lab work ordered•Screen for abuse potential using SOAAP-R•Run CURES report to check for recent opioid activity elsewhere

Pain Agreement •Provider creates a plan that includes other modalities•Acupuncture, group therapy, chiropractics, physical therapy, nutrition education•Patient and provider sign agreement, and a copy of the agreement is given to the patient•Patient conducts additional assessments with other modalities

Follow up •At subsequent visits, patient leaves a urine specimen for a drug screen•Pain questionnaire•Review Pain Agreement

Additional changes in past year Training IHC providers on safe

prescribing

No longer prescribing soma (Carisoprodol)

Limit opioid formulary to MS Contin, Oxycontin, combination analgesics

Interviewing tribal leaders about prescription drug disposal practices and barriers to implementation

Conducting focus groups on disposal methods

Conducting pill take-back events Establishing permanent drop-boxes

Plans for the coming year:

Contact

Daniel Calac, MD, dcalac@indianhealth.com

Tony Luna, MA, tluna@indianhealth.com

Roland Moore, PhD, roland@prev.org Rick Mcgaffigan, MA,

rmcgaffigan@prev.org

ReducingOpioid and Benzodiazepine

Combinationat the VA

Margaret Mendes, Pharm.D.Director, VISN 22 Academic Detailing Service

Objectives Discuss risks with opioids and benzodiazepines Recognize Veteran patients at increased risk Describe VA policies and processes to reduce combination Show success in VA Discuss future education on benzodiazepine safety

33

Benzodiazepines and Overdose Deaths After opioids, benzodiazepines are drug class most

commonly involved in pharmaceutical OD deaths (30%) 1

In the general population benzodiazepines are class most commonly involved in an opioid-related death (30%) 1

In the VA, 50% of opioid OD deaths are on concurrent benzodiazepines2

Among opioid users, risk of death goes up with benzodiazepines in a dose-response fashion

1. Jones CM, et al. JAMA 2013;309 (70):657-659.2. Park TW, et al. BMJ. 2015;350:h2698.

Opioid Use in Our Veterans

010203040506070

Opioidprescription

Highestquintile ofavg daily

opioid use

Duration ofopioid use >2

months

Concurrentopioids

Concurrentsedativehypnotics

Early opioidrefills

Perc

ent (

%)

No MH diagnosis MH diagnosis w/o PTSD PTSD

JAMA 2012; 307:940-7

Veterans are at Increased RiskVeterans are twice as likely to die from accidental overdose compared to the non-Veteran population

Assessment of risk factors is important in our Veteran population especially in returning combat Veterans

Psychological distress may lead to inappropriate use of opioid medications Caution should be used in this population

Bohnert AS, et al. Med Care 2011;49: 393–396

Policies for reducing combination

VISN 22 Network Policy N.:2015-05: Chronic Opioid Use for Non-Malignant Pain

Order Check Developed for Combination

Overdose Education and Naloxone Distribution Education on risks

of overdose Offer naloxone kits

to patients at risk of overdose

Challenges in reducing opioids and high risk combinations

Patient resistance Provider resistance Visit time constraints and follow up Different prescribers of the

medications Primary Care – Opioids Mental Health – Benzodiazepines

VA success in reducing combination of opioids and benzodiazepines

Educational Initiatives to reduce inappropriate chronic use of benzodiazepines

Benzodiazepines in the elderly Associated with significant risks: falls1, hip fractures2,3,4, sedation1,

CI,1,5,6 MVA7,8, OD9,10

Benzodiazepines in dementia Generally not recommended due to side effects. Lorazepam and

oxazepam do not require oxidative metabolism in the liver and have no active metabolites therefore many clinicians prefer these agents.11

Benzodiazepines in PTSD No efficacy to support core symptoms. Cognitive effects are

concerning.12

Insomnia education 50% increase in overall mortality rates associated with long-term

benzodiazepine use.13

Promoting non-pharmacological treatment first Cognitive Behavioral Therapy (CBT), CBT for Insomnia, relaxation

therapy, supportive therapy

ReferencesVA success in reducing the combination of opioids and benzodiazepines

1. Glass J, et al. BMJ. 2005;331(7526):1169. 2. Ray WA, et al. JAMA. 1989. 262(23):3303-3307. 3. Wang PS, et al. Am J Psychiatry. 2001;158(6):892-8. 4. Chang CM, et al. Am J Geriatr Psychiatry. 2008;16(8):686-92. 5. Paterniti S, et al. J Clin Psychopharmacol. 2002;22(3):285-93. 6. Billoti de Gage S, et al. BMJ. 2012. 345:e6231. 7. Ray WA, et al. Am J Epidemiology.1992;136(7):873-83. 8. Hemmelgarn B, et al. JAMA. 1997;278(1):27-31. 9. Jones CM, et al. JAMA 2013;309(70):657-659.10. Park TW, et al. BMJ. 2015;350:h2698.11. Rabins PV, et al. APA Practice Guideline for Treatment of Patients with Alzheimer’s Disease and other dementias.12. VA/DoD 2010 Practice Guidelines for Management of PTSD. www.healquality.va.gov13. Kripke DF, et al. 2012 BMJ open 2 , e000850.

The Path Towards Safe Pain Medication Prescribing

George Scolari, Behavioral Health Program ManagerCommunity Health Group

Chair, Healthy San Diego Behavioral Health Work Group

Healthy San Diego Overview

Formed in 1998, Healthy San Diego is the umbrella in which 5 Medicaid (Medi-Cal) Managed Care Plan’s operate in San Diego.

Care1st, Community Health Group, Health Net, Kaiser Permanente & Molina Healthcare.

The Healthy San Diego Behavioral Health Work Group was formed in 1998 when Specialty Mental Health was contractually carved out of Medi-Cal Managed Care Plans in California.

In the Summer of 2015 Dr. Roneet Lev, Chair of the San Diego

Prescription Drug Abuse Medical Task Force, presented “San Diego Death Diaries” to Community Health Group’s Pharmacy and Therapeutics Committee Meeting.

The Committee elected to look at “Red Flag” medications and combinations within Community Health Group’s utilization data.

Red Flags Holy Trinity (opioid, benzodiazepine, and

carisoprodol) Benzodiazepines Plus Opioids Soma (carisoprodol) Ambien (Zolpidem) – long term Xanax – long term Long Acting Opioids – by ED provider Methadone – by Primary Care

Action Taken Based on Data

Community Health Group is in the process of implementing a pain management specialty restriction on methadone prescriptions.

CHG’s Chief Medical Officer and Pharmacy Director had a conversation with an “outlier” prescriber who is not a pain management specialist.

CHG’s P&T voted to remove Soma from formulary.

Safe Prescribing Guide developed by the Healthy San Diego Behavioral Health Work Group.

CHG’s Pain Management Strategy

Chronic, non-cancer pain management by pain management specialists or in consultation with pain management specialists

Prior authorization and utilization management edits such as: Quantity and fill limits, Formulary management, Provider restrictions Concurrent use edits.

CHG Pain Management Strategy - Continued

Use of treatment plans to include assessment of pain; treatment modalities considered, tried, failed; treatment goals; medication necessary to manage pain.

Use of a pain contract between prescriber and member.

Restrict members to one prescriber. Restrict members to one pharmacy. Random drug screens. Regular review of utilization

management reports based on members, prescribers, and pharmacies.

Recommend providers check CURES.

Next Steps… Review utilization of the “Holy Trinity” use

among CHG members. Review data by prescribers. Address utilization with “outliers”. Work on utilization management edits – will

have to address strategically since this is likely to affect many providers and members.

Collaborate with other San Diego Medi-Cal Managed Care Plan’s (Healthy San Diego) .

Health Plan Role in SafePrescribing

Health Plan Recommendations

Promote PDMP Use Promote Utilization of Drug Screens

Use Medication Agreements

EducationFormulary Changes Prior AuthorizationProvider RestrictionAlternate Pain Treatment Modality

Join One San Diego Vision

One Provider, One Pharmacist

Use CURES (PDMP)

Medication Agreement

No Opioid + Benzodiazepines

Honor Emergency Guidelines

One San Diego Vision for Safe Prescribing

Benzodiazepine plus Opioids – avoid combination Soma (Carisoprodol) – off formulary Methadone– restricted provider Xanax – non formulary High Dose Morphine Equivalent- prior authorization for

new start > 90 MME New Start Opioids – prior authorization for > 2-3 months Acute Prescriptions – limit to 30 tablets Feedback to providers after Emergency Visit

Health Plan Best Practices

Wish List

Federal Patient Satisfaction is Obstacle to Safe Prescribing

Do not link money with satisfaction scores for doctors CURES gold standard: Universal, Real Time, Actively Managed

State Data comparison for state Education Databank Law enforcement allowed to assist with court mandated

rehabilitation, allow PDMP access Pain CME, not biased towards pharmaceutical

Local Health Plan Best Practices Feedback from Medical Examiner to Provider Pediatrician involved in prevention Unified Media Message

Turning Off the Faucet from Above: Health Plan Involvement

in Safe PrescribingPresenters:• Roneet Lev, MD, Director of Operations, Scripps Mercy Hospital Emergency

Department, and Chair, San Diego County (CA) Rx Drug Abuse Medical Task Force

• Daniel Calac, MD, FAAP, Chief Medical Officer, Indian Health Council, Inc.• Margaret Mendes, PharmD, Program Director, Academic Detailing Service, VA

Desert Pacific Healthcare Network• George Scolari, Behavioral Health Program Manager, Community Health Group

Third-Party Payer Track

Moderator: Mark D. Birdwhistell, MPA, Vice President for Administration and External Affairs, University of Kentucky HealthCare