6 th Annual Regional Healthcare Symposium. Mitchell Mutter, M.D. Medical Director for Special Projects

Transcription

1 6 th Annual Regional Healthcare Symposium Mitchell Mutter, M.D. Medical Director for Special Projects

2 Disclosure Informa0on I have no financial rela0onships to disclose I will not discuss off label use and/or inves0ga0onal use in my presenta0on

3 Effec0veness of pain meds (from Cochrane 70 reviews) (References 17,18,19,20) Percent of people ge-ng 50% pain relief (1/NNT) Two 5 mg Percocet pills Ibuprofen 200mg Ibuprofen 400 mg Oxycodone 15 mg Tylenol #3 (2) Ibu acet 500

4 Comparison of Overall MME, MME of Buprenorphine, and MME not Including Buprenorphine Dispensed/Reported to CSMD, ,000,000,000 10,000,000,000 Amount of Morphine Milligram Equivalents 8,000,000,000 6,000,000,000 4,000,000,000 2,000,000, Year Total MME MME from Buprenorphine MME not including Buprenorphine Comparing 2014 with 2012, total MME dropped 5.1%, total MME not including Buprenorphine dropped 10.1%, and MME of Buprenorphine increased 59.3%.

5 2013 Number of Chronic Pain Pa0ent Based on MME Grouping (First 90 days of the year) Represents 28,234 pajents 24.9% 6.6% Represents 7,437 pajents 54.3% 14.3% Represents 16,161 pajents Represents 61,556 pajents <=60 MME >60-90 MME > MME >200 MME

6 2014 Number of Chronic Pain Pa0ent Based on MME Grouping 5,968 pajents (First 90 days of the year) Represents 29,278 pajents 5.1% 25.2% Represents 53.8% 15.9% Represents 20,046 pajents Represents 62,487 pajents <=60 MME >60-90 MME > MME >200 MME

7 2015 Number of Chronic Pain Pa0ent Based on MME Grouping Represents (First 90 days of the year) Represents 26,442 pajents 24.3% 4.0% 4,382 pajents 53.2% 18.4% Represents 20,046 pajents Represents 57,880 pajents 60 > 60 but 90 > 90 but 200 > 200

8 Changes in 2013, 2014 and 2015 Number of Chronic Pain Pa0ents Based on MME Grouping (First 90 days of each year) 24.9% 6.6% 5.1% 4.0% % 24.3% 18.4% 53.2% 53.8% 54.3% 14.3% 15.9% <=60 MME >60-90 MME > MME >200 MME

9 Overall U0liza0on of Pharmaceu0cals by State All Products Rx per A State Comparison: Annual Prescriptions per Capita 2014 Rx per Capita Rank State Capita Rank State 1 West Virginia Delaware Kentucky South Dakota Rhode Island Illinois Tennessee Virginia District of Columbia Florida Louisiana Wisconsin Alabama New Jersey Mississippi New Hampshire Arkansas Texas South Carolina Maryland Ohio Vermont New York Minnesota Pennsylvania Arizona Nebraska Nevada Massachusetts Oregon Missouri New Mexico Iowa Idaho North Carolina Utah Kansas Montana Michigan Washington Indiana Hawaii Maine Wyoming North Dakota California Connecticut Colorado Oklahoma Alaska Georgia Puerto Rico N/A All states = 12.4 annual prescriptions per capita

10 Growth in U0liza0on of Pharmaceu0cals by State Percent Change in Filled Prescriptions, 2014 vs 2013 All Products Rank State % Change Rank State % Change 1 Rhode Island 7.0% 27 District of Columbia 2.7% 2 Kentucky 6.8% 28 South Carolina 2.6% 3 West Virginia 6.6% 29 California 2.4% 4 Arkansas 5.8% 30 Delaware 2.3% 5 Nevada 5.7% 31 Nebraska 2.3% 6 New Mexico 5.5% 32 North Carolina 2.2% 7 Alaska 4.6% 33 Illinois 2.2% 8 Arizona 4.5% 34 Kansas 2.1% 9 New York 4.4% 35 Louisiana 2.0% 10 Washington 4.2% 36 Georgia 2.0% 11 Texas 3.6% 37 Pennsylvania 1.8% 12 Maryland 3.6% 38 South Dakota 1.8% 13 Oregon 3.6% 39 Minnesota 1.8% 14 Connecticut 3.5% 40 North Dakota 1.7% 15 Mississippi 3.4% 41 Hawaii 1.7% 16 Michigan 3.3% 42 New Hampshire 1.6% 17 Wyoming 3.3% 43 Tennessee 1.6% 18 Florida 3.2% 44 Montana 1.2% 19 Missouri 3.1% 45 Virginia 0.7% 20 Idaho 3.1% 46 Maine 0.7% 21 Colorado 3.0% 47 Indiana 0.6% 22 Ohio 2.9% 48 Vermont 0.4% 23 Utah 2.8% 49 Wisconsin 0.3% 24 Massachusetts 2.8% 50 Oklahoma -1.3% 25 New Jersey 2.8% 51 Alabama -1.6% 26 Iowa 2.8% 52 Puerto Rico N/A All states = 2.8% annual percentage of change

11 C- II Controlled Substance U0liza0on by State Rx per A State Comparison: Annual Prescriptions per Capita 2014 CII Products Rx per Capita Rank State Capita Rank State 1 Alabama District of Columbia Tennessee Massachusetts Louisiana Virginia West Virginia Iowa Mississippi Nebraska Kentucky Montana Arkansas Vermont South Carolina Washington Oklahoma Connecticut Michigan Arizona Indiana Maryland North Carolina Wyoming Delaware North Dakota Kansas Colorado Ohio South Dakota Rhode Island Illinois Maine New Mexico Missouri Florida Utah Minnesota Oregon Texas Georgia Alaska Pennsylvania New Jersey New Hampshire New York Idaho California Nevada Hawaii Wisconsin Puerto Rico N/A All states = 0.8 annual prescriptions per capita 2013 USA total CII prescriptions = 257,450,331; TN total = 8,954, USA total CII prescriptions = 249,953,231; TN total = 8,668,742

12 C- II Controlled Substance Growth by State Percent Change in Filled Prescriptions, 2014 vs 2013 CII Products Rank State % Change Rank State % Change 1 South Dakota 3.7% 27 South Carolina -1.5% 2 North Dakota 1.5% 28 Florida -1.5% 3 Vermont 1.4% 29 Alaska -1.7% 4 Nebraska 0.2% 30 North Carolina -1.7% 5 Arkansas 0.0% 31 West Virginia -1.8% 6 Utah -0.1% 32 Pennsylvania -2.0% 7 Wyoming -0.2% 33 Oregon -2.1% 8 Washington -0.2% 34 Missouri -2.1% 9 Idaho -0.2% 35 Mississippi -2.2% 10 Iowa -0.3% 36 Illinois -2.2% 11 Minnesota -0.3% 37 Hawaii -2.8% 12 Delaware -0.3% 38 Ohio -2.9% 13 New Mexico -0.4% 39 Montana -3.0% 14 Connecticut -0.5% 40 Louisiana -3.0% 15 Maryland -0.8% 41 New York -3.2% 16 Nevada -0.8% 42 Tennessee -3.2% 17 Massachusetts -1.0% 43 Georgia -3.5% 18 District of Columbia -1.0% 44 Maine -3.6% 19 Wisconsin -1.0% 45 Virginia -3.7% 20 Arizona -1.1% 46 California -3.7% 21 New Hampshire -1.1% 47 Rhode Island -4.8% 22 Colorado -1.2% 48 Alabama -6.8% 23 Kansas -1.2% 49 Indiana -8.2% 24 New Jersey -1.3% 50 Texas -8.4% 25 Michigan -1.4% 51 Oklahoma -9.7% 26 Kentucky -1.5% 52 Puerto Rico N/A All states = -2.9% annual percentage of change

13 Opioid U0liza0on by State A State Comparison: Annual Prescriptions per Capita 2014 Opioid Products Rank State Rx per Capita Rank State Rx per Capita 1 Alabama Montana West Virginia Arizona Tennessee Wisconsin Arkansas Washington Mississippi Virginia Louisiana Iowa Kentucky New Hampshire Oklahoma Maryland Michigan Wyoming South Carolina South Dakota Indiana Colorado North Carolina New Mexico Ohio Connecticut Missouri Florida Kansas North Dakota Nevada Texas Delaware Vermont Pennsylvania Massachusetts Oregon Illinois Idaho Alaska Georgia Minnesota District of Columbia New Jersey Maine California Utah New York Nebraska Hawaii Rhode Island Puerto Rico N/A All states = 0.77 annual prescriptions per capita

14 Growth in Opioid U0liza0on by State Percent Change in Filled Prescriptions, 2014 vs 2013 Opioid Products Rank State % Change Rank State % Change 1 South Dakota 2.5% 27 Utah -2.4% 2 Arkansas 1.3% 28 Wisconsin -2.4% 3 Nevada 1.3% 29 Minnesota -2.4% 4 New Mexico 1.0% 30 North Carolina -2.6% 5 Arizona -0.2% 31 Pennsylvania -2.6% 6 Vermont -0.6% 32 Missouri -2.7% 7 Washington -0.8% 33 Kansas -2.7% 8 Idaho -0.9% 34 Montana -2.8% 9 Delaware -1.1% 35 Mississippi -3.0% 10 Maryland -1.1% 36 Hawaii -3.2% 11 Colorado -1.1% 37 Illinois -3.2% 12 Iowa -1.2% 38 Texas -3.3% 13 West Virginia -1.3% 39 Massachusetts -3.3% 14 South Carolina -1.4% 40 Tennessee -3.4% 15 Connecticut -1.4% 41 New Hampshire -3.5% 16 New Jersey -1.5% 42 Georgia -3.9% 17 Michigan -1.6% 43 Maine -4.1% 18 Florida -1.6% 44 Ohio -4.1% 19 Nebraska -1.8% 45 Louisiana -4.5% 20 District of Columbia -1.9% 46 New York -4.6% 21 North Dakota -1.9% 47 Virginia -4.7% 22 Oregon -1.9% 48 Rhode Island -5.6% 23 Kentucky -1.9% 49 Alabama -6.2% 24 Wyoming -2.0% 50 Indiana -8.9% 25 Alaska -2.3% 51 Oklahoma -9.1% 26 California -2.3% 52 Puerto Rico N/A All states = -2.9% annual percentage of change

15 Drug Overdose Death, 2014 Total Numbers Source: TN Department of Health

16 Drug Overdose Death, 2014 Rate per 100, Source: TN Department of Health

17 Neonatal Abs0nence Syndrome (NAS)

18 Controlled Substance Monitoring Database Prescrip0on Safety Act 2012 A. Mandatory Sign- up Pharmacy and Prescribers B. Query Database C. Pharmacies filled D. Data 7 days to near real 0me E. Method of Payment

19 Number of Registrants in CSMD, Year Registrants Change (%) , , , , , (as of July 31) 41,

20 Registrants in the CSMD by Role (as of July 31, 2015) Practitioner 18,080 Practitioner Extenders 5,260 Residents/VA 2,746 Advance Practice Nurse 5,743 Physician Assistant 1,335 D.Ph. 7,306 D.Ph. Extenders 1,115

21 Number of DEA Registrants in Tennessee Profession (as July 31, Number 2015) of DEA in TN Pharmacy 1,784 Hospital / Clinic 245 Practitioner 24,584 APN 7,522 Optometrist 919 PA 1,613 All other 487 TOTAL 37,154

22 Public Chapter 898 Ø All APN s and PA s MUST add supervising physicians in their accounts for each prac0ce loca0on and must have their supervising physicians log into their accounts to approve them to complete the process, otherwise, those without supervising physicians will not be able to pull pa0ent requests aher June 15, 2015.

23 Advanced Nurse Prac00oners Across the State 12,000 10,000 11, ,000 7,522 6,000 5,743 4,000 3,984 2,000 0 Total APNs in State Total APNs in State (with prescribing authority) APNs with a TN DEA Number APNs registered in CSMD APNs registered in CSMD with Active supervisor (s) Data as of 7/31/2015 Sources: TN License and Regularly System, Drug Enforcement Agency, Controlled Substance Monitoring Database

24 Supervisor will log into CSMD. As soon as they enter correct username and password this screen appears direc0ng them they have delegates wai0ng for approval. Click the box to go to My Account screen.

25 Once the Supervisor clicks My Account this screen opens. The supervisor will see any approved delegates and any delegates awai0ng approval. As you can see this one is awai0ng approval.

26 Once the Supervisor clicks Approve You can see the successful message at the top. Also when you look at the delegate area the Supervisor now has the ability to Revoke this user if the Supervisor no longer supervises this delegate.

27 APN or PA will now be no0fied of the approval and when they log into the CSMD their My Account show Ac0ve for the Supervisor (s). The APN or PA have the op0on to Delete this supervisor.

28 Ra0o of Number of Prescrip0on to Number of Request in CSMD, * Ratio ( Number of Prescription : Number of Request) : : 1 Prescription Safety Act of 2012 became PC : : 1 Prescribers / dispensers requirement to be registered in CSMD by 1/1/13 Mandatory CSMD check before prescribing opioid / benzodiazepine after 4/1/ : 1 2.8: * VA prescriptions and requests were included. Year

29 Law Enforcement Request Number of Requests from Law Enforcement in CSMD, ,000 Number of Patient Requests 2,500 2,000 1,500 1, Year

30 Number of Prescrip0ons of Controlled Substances Dispensed and Reported to CSMD, ,000,000 Number of Prescriptions 18,500,000 18,000,000 17,500,000 17,000,000 16,500,000 16,000,000 15,500, Year

31 Number of Prescrip0ons of Controlled Substances Reported to CSMD by Class, ,000,000 9,000,000 Number of Prescriptions 8,000,000 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 Opioid Benzodiazepines Muscle Relaxant Other Year

32 Morphine Milligram Equivalents Reported to CSMD * *Note: Morphine Milligram Equivalents (MME) were converted based on CDC MME conversion tables. Above numbers were derived from CSMD data downloaded on January 5, data are subject to change due to database updajng. VA pharmacies were excluded from above analysis.

33 Cumula0ve Morphine Milligram Equivalent for 1 st and 2 nd quarter of each year, * Morphine Milligram Equivalent (Millions) 5,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, ,685 4,887 4,894 4,785 4,489 4, Note: data used in this analysis were downloaded on July 3, 2015; VA pharmacies were excluded from the analysis. MME was derived based on CDC tables.

34 Comparison of Overall Prescrip0ons, Number of Opioid Prescrip0ons and MME Dispensed/Reported to CSMD, ,000,000 10,000,000,000 18,000,000 9,800,000,000 Number of Prescriptions 16,000,000 14,000,000 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000, ,600,000,000 9,400,000,000 9,200,000,000 9,000,000,000 8,800,000,000 8,600,000,000 8,400,000,000 8,200,000,000 Amount of Morphine Milligram Equivalent Year Overall Prescrip0ons of Controlled Substances Prescrip0on of Opioid Morphine Milligram Equivalent

35 Number of Methadone Products and Morphine Milligram Equivalents (MME) Dispensed/Reported to CSMD, , ,000,000 Number of Prescriptions of Methadone 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 Prescriptions of Methadone MME of Methadone ,000, ,000, ,000, ,000, ,000, ,000,000 50,000,000 0 Amount of Morphine Milligram Equivalents Year

36 More PDMP Queries, Fewer High U0liza0on Pa0ents

37 Result of Survey on Doctor Shopping The CSMD is useful for decreasing the incidence of doctor shopping. Disagree 2.8% Strongly disagree 2.4% Neutral 9.3% Agree 23.9% Strongly agree 61.6%

38 Number of Doctor Shopper Iden0fied in CSMD by Quarter, * Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Total Change (%) ,695 2,005 2,127 1,830 7, ,950 2,413 2,515 2,352 9, ,246 2,218 2,261 1,940 8, ,785 1,533 1,533 1,335 6, ,374 1,404 1,278 1,307 5, *Doctor and pharmacy shopper was defined as a person who got his/her prescrip0ons from 5 or more different DEA prescribers and filled the prescrip0ons at 5 or more different DEA pharmacies within 3 months.

39 Number of Doctor and Pharmacy Shoppers" in CSMD * *If pajents in CSMD had same date of birth and same result of soundex first name and last name, we took the pajents as same person. Data used for above analysis were downloaded on Jan. 5, Data are subject to change due to database updajng and the other reasons. VA pharmacies were excluded from the analysis. Doctor and pharmacy shopper was defined as a person who got his/her prescripjons from 5 or more different DEA prescribers and filled the prescripjons at 5 or more different DEA pharmacies within 3 months.

40 Annual Top 50 Prescribers Public Chapter 396 Ø Registered lerer Ø Significant control substances Ø Number of pa0ents Ø Morphine Equivalents prescribed Ø Department may withhold informa0on if ac0ve case in BIV or OGC Ø Prescriber must respond with an explana0on jus0fying the amounts of control substance prescribe within 15 business days.

41 Top 50 Prescribers Iden0fied in 2015 (based on data from Jan Dec 2014 using CDC MME Conversion Tables)

42 Morphine Milligram Equivalents Dispensed by Top 50 Prescribers in 2013, 2014, and 2015* 12% decrease 8% decrease 1,600,000,000 1,400,000,000 Morphine Milligram Equivalents 1,200,000,000 1,000,000, ,000, ,000, ,000, ,000, Year * Note: Time periods of prescripjons fill used for idenjficajon of top 50 were as below: 2013: from 4/1/2012 to 3/31/2013 ; 2014: 4/1/2013 to 3/31/ : 1/1/2014 to 12/31/2014

43 Top 50 Prescribers Iden0fied in 2015 (based on data from Jan Dec 2014) 2% 10% 22% 66% APN PA DO MD

44 Small County Prescribers Iden0fied in 2015 (based on data from Jan Dec 2014) Ø Top 10 prescribers in small coun0es Ø Small defined as <50,000 people Ø Total MMEs for Small Coun0es: 122,671,152

45 Why do you check the CSMD before prescribing? 80.0% 67.3% 60.0% 52.0% 40.0% 20.0% 0.0% 35.3% Mandatory check New patient Other Reason of checking CSMD 13.4% ED Visit 4.6% Planned surgery

46 How has checking the CSMD changed the way you prac0ce medicine? More likely to prescribe controlled substances 0.7% Other 20.5% No change 37.5% Less likely to prescribe controlled substances 41.4%

47 Public Chapter 475 Ø Effec0ve July 1, 2016 Ø New requirements for pain clinic Ø Medical Director must be a physician and pain specialist Ø Pain Specialists are board cer0fied by ABMS, ABPM, ABIPP, or AOA Ø Expected Outcomes

48 Tennessee Pain Clinics per County

49 Public Chapter 623 Naloxone Ø Licensed Healthcare Prac00oner Ø Pa0ent, family member, friend of pa0ent at risk for overdose death Ø Naloxone Educa0on will be available on the Department of Health website on July 1, 2014 Ø Instruc0on how to administer hrp:// informa0on- for- naloxone

50 2015 Legisla0ve Updates Ø PDMP repor0ng window reduced to daily by 2016 Ø Immunity to those who prescribe or administer naloxone to pa0ents Ø January 1, 2015: Prohibit dispensing of opioids and benzodiazepines directly from any clinic Ø Prescrip0on Safety Act of 2012 set to sunset June 30, 2016 Ø Public Chapter 475 will take effect

51 Chronic Pain Guidelines

52 Chronic Pain Guidelines Expert Panel

53 Public Chapter 430 Ø Chronic Pain Guidelines wriren by January 1, 2014 Ø All prescribers with DEA 2 hours CME every 2 years Ø Prescribe 30 days at a 0me Schedule II- IV Ø By January 1, 2014 the commissioner shall develop recommended treatment guidelines for prescribing opioids, benzodiazepines, barbiturates, and carisoprodol. That can be used in the state as guide for caring for pa0ents.

54 Process Began on January 28, 2013 Ø Selected the Panel of Experts Ø Selected the Steering Commiree Ø First Mee0ng Steering Commiree Mee0ng July 1, 2013

55 Chronic Pain Guidelines Steering Commiree: Worker s Compensa0on Abbie Hudgens Board of Medical Examiner Michael Baron, M.D. Office of General Counsel Andrea Huddleston, J.D. Controlled Substance Monitoring Database Andrew Holt, D.Ph. Department of Health Bruce Behringer, MPH David Reagan, M.D. Larry Arnold, M.D. Mitchell Murer, M.D. Department of TennCare Vaughn Frigon, M.D. TN Department of Mental Health Rodney Bragg, M.A., M.Div. Tennessee Medical Founda0on Roland Gray, M.D. Special Thanks To: Ben E. Simpson, J.D. Tracy Bacchus Debora Sanford

56 Chronic Pain Guidelines Panel Members: Autry Parker, M.D. Brer Snodgrass, APN C. Allen Musil, M.D. Carla Saunders, APN Charles McBride, M.D. James Choo, M.D. Jason Carter, D.Ph. Jeffrey Hazlewood, M.D. Jim Montag, PA- C John Culclasure, M.D. Ka0e Liveoak, D.Ph. Michael O'Neil, D.Ph. Paul Dassow, M.D. Raymond McIn0re, D.Ph. Rer Blake, M.D. Stephen Loyd, M.D. Ted Jones, Ph.D. Thomas Cable, M.D. Tracy Jackson, M.D. W. Clay Jackson, M.D. William Turney, M.D John Standridge, M.D. T. Scor Baker, M.D.

57 Chapters in the Chronic Pain Ø Ø Ø Ø Guidelines IntroducJon - Before inijajng chronic opioid therapy (over 90 days) Ø Screening (including TN risk model), non- opioid therapies, referral to MH, others Ø Informed consent Ø Women's special considera0ons IniJaJng chronic opioid therapy - Ø Standard therapy, combina0on therapy Ø Special considera0ons Ø Methadone/suboxone Ø UDS - qualita0ve & quan0ta0ve Ø CSMD Ø Documenta0on in decision making Follow up of therapy - Ø UDS - qualita0ve & quan0ta0ve Ø CSMD Ø ED visits for OD Ø What cons0tutes a failure of standard therapy? Ø Referral to pain specialist Ø Taper / discon0nua0on of opioids Ø Documenta0on of decision making

58 Chronic Pain Guidelines Appendices Ø Pain Medicine Specialist Ø Risk Assessment Tools Ø Pregnant women Ø Use of Opioids in Worker's Compensa0on Medical Claims Ø Tapering protocol Ø Sample Informed consent Ø Sample Pa0ent Agreement Ø Controlled Substance Monitoring Database Ø Medica0on Assisted Treatment Program Ø Morphine equivalents dose Ø Psychological Assessment Tools Ø Prescrip0on Drug Disposal Ø Safety Net Ø Defini0ons Ø Table of Frequently Prescribed Pain Medica0ons Ø Urine Drug Tes0ng Ø Special Considera0on: Women of Child Bearing Age

59 Sec0on I: Prior to Ini0a0ng Opioid Therapy Ø Non Opioid Treatment if Possible Ø All Newly Pregnant Women Should Ø Complete evalua0on: History and Physical Ø Tes0ng documented in medical record prior Ø Chronic Pain shall not be treated via telemedicine Ø Co- Morbid Mental Condi0ons Ø There shall be the establishment of a current diagnosis that jusjfies a need for opioid therapy

60 Sec0on I: Prior to Ini0a0ng Opioid Therapy (cont.) Ø Risk for Abuse Ø Validated Risk Tools Ø CSMD Ø UDT Ø Goals for Treatment Ø Treatment plan for opioid and non- opioid treatment Ø Increase func0on, not to eliminate pain Ø Documenta0on in medical record

61 Sec0on II: Ini0a0ng Opioids Ø Maximum four doses of short- ac0ng opioids per day Ø Non pain medicine specialist should not prescribe methadone Ø Prescribers shall not prescribe buprenorphine in oral or sublingual for chronic pain Ø Avoid benzodiazepines Ø Document reasons for devia0on from guidelines in record

62 Sec0on II: Ini0a0ng Opioids (cont.) Ø Therapeu0c trial Ø Lowest possible dose Ø Opioid Naïve Ø Informed Consent Ø Treatment Agreement female pa0ent Ø Con0nually monitor for abuse, misuse, or diversions Ø CSMD and UDT

63 Sec0on II: Ini0a0ng Opioids (cont.) Ø Women s Health Ø Birth Control Plans Ø Informed Consent Ø Ask regarding pregnancy each visit Ø Before star0ng opioids in women shall have pregnancy test

64 Sec0on III: Treatment with Opioids Ø Single provider and pharmacy Ø Opioids used at lowest effec0ve dose Ø 5 A s Ø Analgesia Ø Ac0vi0es Ø Adverse side effects Ø Aberrant Ø Affect

65 Sec0on III: Treatment with Opioids (cont.) Ø Ongoing Therapy Ø Greater than 120 MEDD (Morphine Equivalent Dose) should refer to Pain Specialists Ø Greater than 120 MEDD shall refer Ø UDT twice/year Ø Con0nual assessment via 5A s UDT, CSMD Ø Emergency Physician, Primary Provider Communica0on Ø Discon0nue when risk greater than benefits

66 ABPM Ø Recognizes boards in the following cer0fica0on as qualified to sit for Board Exam Ø Anesthesia Ø Psychiatry Ø Neurology Ø Neurosurgery Ø Physical Medicine and Rehabilita0on Ø 50 hours CME in Pain Medicine past two (2) years Ø Substan0al, recent and comprehensive clinical prac0ce experience

67 Pain Specialist Ø Board of Medical Special0es (ABMS) primary physician cer0fica0on organiza0on in US Ø ABMS cer0fies pain medicine fellowship programs in Anesthesia, Physical Medicine and Neurology Ø American Board of Pain Medicine (ABPM) is not ABMS and does not oversee fellowship training programs. Ø ABPM offers prac0ce related examina0ons to qualified candidates. Diplomates of ABPM have cer0fica0on in Pain Medicine Ø AOA Cer0fica0on Ø ABIPP

68 Pain Specialist (cont.) Ø Pa0ents requiring less than 120 MEDD a. Must have valid license by respec0ve board and DEA b. CME per0nent to pain management directed by regulatory board c. Recommend (do not require) 3 year residency and be ABMS eligible or cer0fied

69 Pain Specialist (cont.) Ø Patients requiring > 120 MEDD a. 11 times more likely to have adverse event such as overdose death b. Consultation with pain specialists 1. Pain Specialists up to 7/1/2016 shall have unencumbered license with no prior actions unless an exception is approved by the respective board 2. Two year experience 3. Minimum 25 CME hours in pain management every 12 months 4. Pain consultants after 7/1/2016 shall have ABPM diplomate status or ABMS Boards

70 CDC Chronic Pain Prescribing Guidelines Ø Evaluate Tennessee against CDC recommenda0ons Ø Morphine Milligram Equivalent (MME) at which risk of Overdose significantly increases Ø Long vs. Short Ac0ng opioid treatment op0ons Rela0ve efficacy? Rela0ve safety?

71 Websites: Prescrip0on for Success hfp://tn.gov/mental/prescripjonforsuccess/ address for public comments Pain Clinic Website hfp:// board Pain Clinic Guidelines hfp:// ChronicPainGuidelines.pdf 2015 LegislaJve Report hfp:// CSMD_AnnualReport_2015.pdf

72 NSC white papers: Websites: Evidence on the efficacy of pain medica0ons: nsc.org/painmedevidence The Psychological and Physical Side Effects of Pain Medica0ons: safety.nsc.org/sideeffects Prescrip0on Pain Medica0ons: A fatal cure for injured workers: hrp:// Fatal- Cure- For- Injured- Workers.pdf

73 Questions and Contact Information: Mitchell Murer, MD Medical Director for Special Projects Tennessee Department of Health