VA HEALTH CARE SYSTEM, DETROIT

INNOVATIVE APPROCH TO FIGHT OPIOID EPIDEMIC

COMPLIMENTARY AND ALTERNATIVE MODALITIES

BASSAM BATARSE, MD. MEDICAL ACUPUNCTURIST

VA HEALTH CARE SYSTEM144 Hospitals1221 OP Centers8.97 Millions Registered ( 2015)20.4 Millions Total Veterans ( 2016)$200 Billions Budget

CHRONIC PAIN IN VA HCSChronic Pain Prevalence30% in Non VA Population55% in Veterans ( 60% in Female Veterans)

CHRONIC PAIN IN VA HCSVeterans' pain is more often severe and complex, and often associated with psychiatric and medical comorbidities

OPIOID USE IN VA HCSPrevalence:2012 (VA Peak) 21.2% (Compared to 14.5 % Non VA)

https://analytics.ncsu.edu/sesug/2015/PH-182.pdf

OPIOID USE IN DETROIT VA QTR 1 - 2014 Detroit VAMC 24.8 % (6874 Veterans)VA Nationally 16.2%

# 2, Highest in the Nation

OPIOID USE IN VA HCS - DETROITHigher Doses 2.2% (150 veterans) over 400 mg MEDD

( compared to 0.3% VA national rate) The highest dose prescribed 3460 mg MEDD

OPIOID SAFETY INITIATIVE BOARD (LATE 2014)( To curb the use of opioids in general and to reduce doses to safe levels)

Multidisciplinary Group Weekly Reviewed all those Veterans on 200mg MEDD or more ( over 500) Sent tailored letters with recommendations to prescribers Re-Reviewed in 6 months for compliance

Created a Multidisciplinary Pain Clinic to support opioid prescribers Quantitative UDS (Ameritox)

And Introduced CAMs

CIM Acupuncture Auricular Acupuncture (BFA and NADA) Yoga Chiropractor Care Aroma Therapy Healing Touch Biofeedback Others ( reiki, Tai Chi, Music therapy, ….)

ACUPUNCTURE2015 1 - 3 providers2017 11 providers

80 Hrs a week pain area

ED/FT, CLC, MH, PC, , Ortho Surgery, OR, Research

ACUPUNCTUREMost Common Indications: Chronic Pain ( spine, joints, fibromyalgia, HA, etc.) PTSD / Anxiety Nausea and vomiting ( Oncology) Paralysis of CVAs Acute pain in the ED/FT ( strains and sprains, sciatica, Migraine and Managing withdrawal symptoms

AURICULAR ACUPUNCTURE

AURICULAR ACUPUNCTURE Battlefield Acupuncture ( BFA) National Acupuncture Detoxification Agency (NADA) Other treatment protocols ( Anxiety, Depression, PTSD etc.

BATTLEFIELD ACUPUNCTURE Limited auricular AP protocol 5 semi permanent needles Quick, safe and effective 85% pain control Inexpensive ( $2-5 in supplies / 2 minutes )

4 hours training for HC providers

BATTLEFIELD ACUPUNCTURE JDD VA MC Over 150 providers are

trained Two, daily walk-in clinics Volunteers providers 20 -30 walk-in visits a day BFA in all areas ED/FT, CLC,PC,

Specialty clinics ( Ortho and RO), MH, Pain Clinics

Train family members

■ Video

NADA PROTOCOLJDD VA MC Several MH providers are trained

in NADA In IOP Detox and rehab Helps reduce reliance on benzos 20 -30 minutes group visits NADA protocol is also used in ED

for management of acute withdrawals.

NADA PROTOCOL Certification in NADA takes a

one day training MH providers, Psychologists,

SW and any one dealing with SUD can be trained and certified

Can be used in both inpatient and outpatient basis

OTHER EAR PROTOCOLS

ACUPUNCTURE & BFA IN OR3 anesthesiologists and 3 CRNs

BFA used for Pre and Post Op pain

Research :Somatic Acupuncture and BFA in THA and TKA peri-op management to reduce opioids used

YOGAFY 2014 FY 2015 FY 2016 FY 2017

YOGA IND 1332 981 1019 1052YOGAEVAL 0 0 463 402YOGA GRP 237 873 1312 1047TOTAL 1569 1854 2794 2501

Sheet1

FY 2014FY 2015FY 2016FY 2017

YOGA IND133298110191052

YOGAEVAL00463402

YOGA GRP23787313121047

TOTAL1569185427942501

YOGA THERAPY DATA TREND

YOGA INDFY 2014FY 2015FY 2016FY 2017133298110191052YOGAEVALFY 2014FY 2015FY 2016FY 201700463402YOGA GRPFY 2014FY 2015FY 2016FY 201723787313121047TOTALFY 2014FY 2015FY 2016FY 20171569185427942501

PAIN SCORE

RESULTSYear Qtr Patients on Opioids (C1-5) VA Patient Population Percentage: National

QTR: 1 2014 6,874.00 27,691.00 24.82% 16.2QTR: 2 2014 6,818.00 27,449.00 24.84% 15.7QTR: 3 2014 6,771.00 27,763.00 24.39% 15.6QTR: 4 2014 6,935.00 27,914.00 24.84% 15.5QTR: 1 2015 6,371.00 27,519.00 23.15% 14.6QTR: 2 2015 6,069.00 27,197.00 22.31% 14.1QTR: 3 2015 5,832.00 27,160.00 21.47% 13.9QTR: 4 2015 5,699.00 27,318.00 20.86% 13.6QTR: 1 2016 5,421.00 27,184.00 19.94% 13.2QTR: 2 2016 5,073.00 27,032.00 18.77% 12.9QTR: 3 2016 4,850.00 26,899.00 18.03% 12.4QTR: 4 2016 4,656.00 26,781.00 17.39% 12QTR: 1 2017 4,515.00 27,636.00 16.34% 11.6QTR: 2 2017 4,304.00 26,732.00 16.10% 11.1QTR: 3 2017 4,166.00 26,585.00 15.67% 10.6QTR: 4 2017 3,960.00 26,404.00 15.00% 10.2QTR: 1 2018 3,737.00 26,316.00 14.20% 9.6QTR: 2 2018 3,437.00 26,372.00 13.03% 9.2

Opiod Utilization VISN Level Report-Detroit VA Medical Center

Sheet1

Opiod Utilization VISN Level Report-Detroit VA Medical Center

Year QtrPatients on Opioids (C1-5)VA Patient PopulationPercentage: National

QTR: 1 20146,874.0027,691.0024.82%16.2

QTR: 2 20146,818.0027,449.0024.84%15.7

QTR: 3 20146,771.0027,763.0024.39%15.6

QTR: 4 20146,935.0027,914.0024.84%15.5

QTR: 1 20156,371.0027,519.0023.15%14.6

QTR: 2 20156,069.0027,197.0022.31%14.1

QTR: 3 20155,832.0027,160.0021.47%13.9

QTR: 4 20155,699.0027,318.0020.86%13.6

QTR: 1 20165,421.0027,184.0019.94%13.2

QTR: 2 20165,073.0027,032.0018.77%12.9

QTR: 3 20164,850.0026,899.0018.03%12.4

QTR: 4 20164,656.0026,781.0017.39%12

QTR: 1 20174,515.0027,636.0016.34%11.6

QTR: 2 20174,304.0026,732.0016.10%11.1

QTR: 3 20174,166.0026,585.0015.67%10.6

QTR: 4 20173,960.0026,404.0015.00%10.2

QTR: 1 20183,737.0026,316.0014.20%9.6

QTR: 2 20183,437.0026,372.0013.03%9.2

Year QtrPercentage:

QTR: 1 201424.8%

QTR: 2 201424.84%

QTR: 3 201424.39%

QTR: 4 201424.84%

QTR: 1 201523.15%

QTR: 2 201522.31%

QTR: 3 201521.47%

QTR: 4 201520.86%

QTR: 1 201619.94%

QTR: 2 201618.77%

QTR: 3 201618.03%

QTR: 4 201617.39%

QTR: 1 201716.34%

QTR: 2 201716.10%

QTR: 3 201715.67%

QTR: 4 201715.00%

QTR: 1 201814.20%

QTR: 2 201813.03%

Percentage:

QTR: 1 2014QTR: 2 2014QTR: 3 2014QTR: 4 2014QTR: 1 2015QTR: 2 2015QTR: 3 2015QTR: 4 2015QTR: 1 2016QTR: 2 2016QTR: 3 2016QTR: 4 2016QTR: 1 2017QTR: 2 2017QTR: 3 2017QTR: 4 2017QTR: 1 20180.248239500198620480.248387919414186310.243885747217519710.248441642186716350.231512772993204690.223149612089568710.214727540500736360.208617029065085280.199418775750441420.187666469369635990.180304100524183050.173854598409320050.163373860182370820.161005536435732450.156704908783148380.149977276170277230.1420048639610883

% Opioid Use-Detroit VAMC

Percentage: QTR: 1 2014QTR: 2 2014QTR: 3 2014QTR: 4 2014QTR: 1 2015QTR: 2 2015QTR: 3 2015QTR: 4 2015QTR: 1 2016QTR: 2 2016QTR: 3 2016QTR: 4 2016QTR: 1 2017QTR: 2 2017QTR: 3 2017QTR: 4 2017QTR: 1 2018QTR: 2 20180.248239500198620480.248387919414186310.243885747217519710.248441642186716350.231512772993204690.223149612089568710.214727540500736360.208617029065085280.199418775750441420.187666469369635990.180304100524183050.173854598409320050.163373860182370820.161005536435732450.156704908783148380.149977276170277230.14200486396108830.13032762020324587

Sheet2

Opiod Utilization VISN Level Report-Detroit VA Medical Center

Year QtrPatients on Opioids (C1-5)VA Patient PopulationPercentage: National

QTR: 1 20146,874.0027,691.0024.82%16.2

QTR: 2 20146,818.0027,449.0024.84%15.7

QTR: 3 20146,771.0027,763.0024.39%15.6

QTR: 4 20146,935.0027,914.0024.84%15.5

QTR: 1 20156,371.0027,519.0023.15%14.6

QTR: 2 20156,069.0027,197.0022.31%14.1

QTR: 3 20155,832.0027,160.0021.47%13.9

QTR: 4 20155,699.0027,318.0020.86%13.6

QTR: 1 20165,421.0027,184.0019.94%13.2

QTR: 2 20165,073.0027,032.0018.77%12.9

QTR: 3 20164,850.0026,899.0018.03%12.4

QTR: 4 20164,656.0026,781.0017.39%12

QTR: 1 20174,515.0027,636.0016.34%11.6

QTR: 2 20174,304.0026,732.0016.10%11.1

QTR: 3 20174,166.0026,585.0015.67%10.6

QTR: 4 20173,960.0026,404.0015.00%10.2

QTR: 1 20183,737.0026,316.0014.20%9.6

QTR: 2 20183,437.0026,372.0013.03%9.2

TOTAL MEDD RELEASED

> 90 MEDD

OPIOIDS IN EDAll ED staff are trained in BFA(3 in somatic acupuncture, as well)Used for• Migraines• Back pain• Joint pains• Chronic pancreatitis pain• Others

NALOXONE • Automatic dispensing by pharmacy• >50mg MEDD• Other known risks

NALOXONE

43

64

33 29 31

184

0

20

40

60

80

100

120

140

160

180

200

Oct Nov Dec Jan Feb Mar

FY2018 Detroit Naloxone Distribution

PDMP

ACUPUNCTURE • COST PER SOMATIC AP VISIT (30-60 Minutes using 2 or more rooms)

• $45-100• COST PER AURICULAR AP VISIT

• 5-15 Minutes ( Group settings)• ~$50

��VA health care system, Detroit� �INNOVATIVE APPROCH TO FIGHT OPIOID EPIDEMIC��COMPLIMENTARY AND ALTERNATIVE MODALITIES��Bassam Batarse, Md. medical acupuncturist VA health care systemChronic pain in vA hcsChronic pain in VA hcsOpioid use in VA hcsOpioid use in Detroit VA Opioid use in VA hcs - DetroitOpioid safety initiative board (Late 2014)cIMAcupunctureAcupunctureAuricular acupunctureAuricular acupuncture�Battlefield Acupuncture �Battlefield Acupuncture Slide Number 16 NADA PROTOCOL NADA PROTOCOL�other ear protocolsAcupuncture & BFA in oryogaPain scoreresultsTotal medd released> 90 medd Opioids in edNaloxone Naloxone PDMPAcupuncture Slide Number 31