Ea 3 green weiss_katzman

Educa&on and Advocacy Track: Overview of State Strategies to

Stop the Epidemic Presenters:

Sherry L. Green Joanna Katzman, MD, MSPH

Jennifer Weiss, MBA, BSIT

Moderator: Karen H. Perry,

Disclosures

•  Sherry L. Greenhas disclosed no relevant, real or apparent personal or professional financial rela&onships.

•  Joanna Katzman has disclosed no relevant, real or apparent personal or professional financial rela&onships.

•  Jennifer Weiss has disclosed no relevant, real or apparent personal or professional financial rela&onships.

Learning Objec&ves

1.  Outline implementa&on strategies to reduce prescrip&on drug abuse based on the successes New Mexico has had specifically with prescribers, medical facili&es, legislatures, educators, and other key stakeholders.

2.  Build a statewide coali&on comprised of an academic medical center, state agencies, community coali&ons, legislatures, and key community stakeholders in an effort to reduce overdose death rates.

3.  Iden&fy resources to advocate for change, with specific focus on state strategies.

2014 NATIONAL PRESCRIPTION DRUG ABUSE SUMMIT

EDUCATION & ADVOCACY TRACK: OVERVIEW OF STATE STRATEGIES TO

STOP THE EPIDEMIC APRIL 22, 2014 3:15 P.M. – 4:30 P.M.

SNAPSHOT OF SELECTED STATE PRESCRIPTION DRUG LAWS & POLICIES

SHERRY L. GREEN, CEO NATIONAL ALLIANCE FOR MODEL

STATE DRUG LAWS (NAMSDL)

NAMSDL

● 501(c)(3) non-profit corporation

● Successor to the President’s Commission of Model State Drug Laws

● 20 years

● Congress funds NAMSDL’s services

● Provides legislative and policy services on over 40 types of drug and alcohol laws to stakeholders at the local, state, and federal levels

TYPES OF LAWS & POLICIES USED TO ADDRESS PRESCRIPTION DRUG

PROBLEMS

● State prescription drug monitoring programs (PMPS)

● Regulation of pain clinics/pain management

● Prescribing & dispensing guidelines/practices

● Proper disposal of unused medications

● Education for the public and health care providers

● Treatment & prevention

● Good Samaritan & naloxone access

● Identification of person picking up prescription

● Lock-in programs

● Doctor shopping

SNAPSHOT OF FOUR TYPES

● State PMPs

● Regulation of pain clinics/pain management

● Prescribing & dispensing guidelines/practices

● Good Samaritan & naloxone access

MORE RESEARCH NEEDED

● National Governors Association Reducing Prescription Drug Abuse: Lessons Learned from an NGA Policy Academy, February 2014

● More research needed to determine:

  Effective interventions to reduce abuse

  Effective approaches to change prescribing

  Effective public messaging to change consumer behavior

STATE PRESCRIPTION DRUG MONITORING PROGRAMS (PMPS)

Law and Policy

● Statewide electronic databases that collect prescription controlled substance data

● 49 states and D.C. have laws

● 48 PMP programs operational

● Increase usefulness of PMPs as health care tools

  Allow delegates/authorized agents for prescribers and dispensers

  Expand healthcare professionals who can use PMP data

  Medical examiners/coroners

  Increase frequency of dispenser reporting

 Oklahoma – real-time reporting

 Most states – 7 days/weekly

  Provide interstate data sharing

  Permit proactive alerts

 Mandate registration for prescribers/ dispensers

 No clear consensus about usefulness

 Mandate use by prescribers/dispensers

 No clear consensus about usefulness

Research – surveys, studies, assessments

● State practitioners surveys in OH, KY, OK, and OR suggest that PMPs can enhance patient care and patient safety by:

 Helping practitioners become more informed prescribers, and

 Helping practitioners determine if a patient may have an abuse or addiction problem

Example: Use of OHIO OARRS data by ER physicians (2009)

  41% changed patient prescription plan

  61% of patients received fewer or no opioids

  39% of patients received more pain medication than planned

  Baehren, DF, Marco CA, Droz DE, Sinha S, Callan EM, Akpunonu P. A statewide prescription monitoring program affects emergency department prescribing behaviors. Annuals of Emergency Medicine, 2010 Jul; 45(1):19-23

● 2014 evaluation of impact of state PMPs on opioid dispensing

  Implementation of state PMPs through 2008 had no measurable overall impact on prescription opioids dispensed

  Result likely related to unexamined factors: interstate sharing, frequency of reporting, education about PMP, restrictions on access, integration into health care systems

  J Brady, H Wunsch, C DiMaggio, B Lang, J Giglio, G Li. Prescription Drug Monitoring and Dispensing of Prescription Opioids. Public Health Reports, March-April 2014; vol. 129: 139-147.

● 2012 analysis of Poison Control Center data

  In states with PMPs, rate of increase in opioid misuse/abuse less than in states with no PMP

  Independent of # of patients filling prescriptions

  Reifler L., Droz D, Bailey J, Schnoll S, Fant R, Dart R et al. Do prescription monitoring programs impact state trends in opioid abuse/misuse? Pain Medicine 2012; 3(3):434-42.

REGULATION OF PAIN CLINICS/PAIN MANAGEMENT

Law and Policy

● 9 states with pain clinic regulation acts

● Definition of “pain clinic”

  publicly or privately owned facility

 majority of patients in a specific time frame, usually a month, are prescribed or dispensed certain substances, e.g., opioids

● Ownership eligibility

  Example: Must be physician with unrestricted license

● Certification and training requirements for owners and practitioners at clinic

● Prescribing and dispensing restrictions

● Requirement to access state PMP

● Owners/medical directors have to be on site % of operating hours

● Indiana

  State medical licensing board required to issue rules for prescribing of controlled substances

 December 2013 – emergency rules for use of opioids for chronic pain patients receiving certain dosage amounts

  Requirements:

 Discuss risks/benefits with patient

  Schedule periodic visits

 Check PMP at beginning of treatment and annually

● Alabama

 All physicians providing pain management services must register with the medical board

  Registrants must access state PMP


● Florida – University of Central Florida, Criminal Justice Assistant Professor Jacinta Gau

  “Pill mill” legislation implemented as designed

  Impact of legislation

● Kentucky – University of Kentucky, College of Pharmacy, Institute for Pharmaceutical Outcomes and Policy

 Unintended consequences of pain clinic and other laws

  Recommendations for improvements

PRESCRIBING & DISPENSING GUIDELINES/ PRACTICES

Law and Policy

● Seven commonly recommended prescribing practices for non-cancer or chronic pain

  Required or recommended education on selected topics

  Comprehensive patient exam – physical and substance abuse screening

  Treatment plan

  Informed consent

  Periodic review

 Use of state PMP

  Recommended steps for high risk patients

 Referral to addiction or pain management specialists

  Patient agreements – urine drug testing and lock-in program

  Limitations on number of days’ supply or refills of Schedule II or Schedule III prescriptions

 Maintenance of complete and accurate medical records


● Washington state evidence-based prescribing guidelines

  23% reduction in drug overdose death rate since 2008

 National Safety Council, Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic, 2013.

● Federation of State Medical Boards (FSMB), Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain, July 2013.

GOOD SAMARITAN & NALOXONE ACCESS

Law and Policy

● Good Samaritan – 14 states + D.C.

● Naloxone access – 18 states + D.C.

  Removes civil and criminal liability for prescribers and lay administration

 Allows third party prescription

● The Network for Public Health Law, Legal Intervention to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws, March 2014.

Research - surveys, studies, assessments

● National Association of State Alcohol and Drug Abuse Directors (NASADAD), Overview of State Legislation to Increase Access to Treatment for Opioid Overdose, December 2013.

  Trained bystanders can safely and effectively administer injections like naloxone

  Peers able to administer second dose when needed and prevent victims from additional opioid use

 No evidence that people will increase drug use by removing threat of overdose

SARAH KELSEY ACTING CEO

NAMSDL 1598 Gray Fox Trail

Charlottesville, VA 22901 Phone: 703-836-6100, ext. 119

Email: [email protected] WEBSITE: www.namsdl.org

Overview of State Strategies: The Crisis of Unintended Opiate Overdose Deaths in New Mexico

Joanna Katzman, MD, MSPH Associate Professor, Neurosurgery, University of New Mexico

Director, University of New Mexico Pain Center Project ECHO® Pain

Jennifer Weiss, MBA, BSIT Execu&ve Director, Healing Addic&on In Our Community

 Known as the Land of Enchantment.  Popula&on: 2,085,500.  Biggest City is Albuquerque.  Popula&on: 552,800.  We are NEW Mexico, not Mexico.  Yes, we have running water.  We are home to the largest interna&onal hot air balloon fiesta.  You will be asked “red, green or Christmas” at every Mexican food restaurant you venture into.

Facts About New Mexico

Healing Addic&on in Our Community

 501c3 Non-‐Profit

 Dedicated to educa&on and awareness regarding substance abuse issues.

 40+ volunteer member base comprised of parents and people in recovery.

 Speaking engagements (over 5,000 people), advocacy, grade school and college educa&on programs, legisla&ve support, provide assistance finding treatment resources.

 Opening NM’s 1st Adolescent Transi&onal Living Center.

Rest in Peace!

Grieve not, nor speak of me with tears, but laugh and talk of me as if I were beside you there.!

Drug Overdose Death Rates Leading States, U.S., 2009

Sources: CDC Vital Signs Rates are age-adjusted to the 2000 US Standard Population.

0.0

5.0

10.0

15.0

20.0

25.0

30.0 1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012*

Deaths pe

r 100,000 pe

rson

s

Year

Drug Overdose Death Rates New Mexico and United States, 1990-‐2012

New Mexico

United States

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0

Union Cibola Curry

United States Luna

McKinley Roosevelt

Lea Los Alamos

San Juan Dona Ana Sandoval Chaves Otero

Lincoln Socorro Colfax

New Mexico Valencia

Guadalupe Eddy

Santa Fe Torrance Bernalillo Hidalgo Grant Taos

San Miguel Quay

Catron Sierra Mora

Rio Arriba

Age-‐adjusted Rated per 100,000 persons

Drug Overdose Death Rates by County New Mexico, 2008-‐2012* and U.S., 2010

Senate Bill 159   Added new sec&on to the New Mexico Drug, Devise and Cosme&c Act in

regard to prescrip&on opioids which:

  Required a discussion with pa&ent and provide educa&onal pamphlet on opiate addic&on/risk.

  Required that prac&&oners receive wrilen consent from pa&ents receiving opiates for the first &me indica&ng that they understand the risk.

  Limited those with cancer pain, chronic pain, or those in hospice care to a 30 day supply per Schedule II opioid prescrip&on.

  Limited those with acute pain or cough to a 7 day supply per Schedule II opioid prescrip&on.

  Forbade refills for prescrip&on opioids.

  Mandated use of a Prescrip&on Drug Monitoring Report.

Senate Bill 215 – Passed Senate and House in 2012

  Amended the pain Relief Act in the following ways:

  Provided specific defini&ons of “chronic” and “acute” pain.

  Called on licensing boards to adopt rules, standards, and procedures for the applica&on of the Pain Relief Act.

  Required provider con&nuing educa&on (CEUs) for the treatment of non-‐cancer pain management.

  Established the Prescrip&on Drug Misuse and Overdose Preven&on and Pain Management Advisory Council alached to DOH.

 Mandatory use of the Prescrip&on Drug Monitoring Program (PDMP) by all prescribers.

In 2012….  NM now requires all clinical licensing boards to mandate CME specific to pain and addic&on.

 NM Medical Board and other clinical licensing boards require use of Prescrip&on Monitoring Program (PMP) at least on ini&al use of chronic opioids and every 6 months.

 NM Board of Pharmacy upgrades PMP to share data with other states regionally.

 NM Governor developed the Prescrip&on Drug Misuse and Overdose Preven&on and Pain Management Advisory Council.

Rules and Values: A Coordinated Regulatory and Educational Approach to the Public Health Crises of Chronic Pain and Addiction

•  UNM Health Sciences Center •  Joanna G. Katzman, MD, MSPH

•  Cynthia M. A. Geppert, MD, PhD, MPH

•  George D. Comerci, MD, FACP

•  Sanjeev Arora, MD, FACP

•  Summers Kalishman, PhD

•  Lisa Marr, MD

•  Chris Camarata, MD

•  Daniel Duhigg, DO, MBA

•  Jennifer Dillow, MD

•  Eugene Koshkin, MD

•  Denise E. Taylor, MD

•  Healing Addic[on In Our Community •  Jennifer Weiss, MBA, BSIT

•  Project ECHO® Ins[tute •  Sanjeev Arora, MD, FACP

•  Joanna G. Katzman, MD, MSPH

•  George D. Comerci, MD, FACP

•  Daniel Duhigg, DO, MBA

•  NM Department of Health •  Michael Landen, MD, MPH

•  NM Board of Pharmacy •  Larry Loring, RPH

•  NM Medical Board •  Steven M. Jenkusky, MD, MA, FAPA

•  Presbyterian Health Care Services •  Steven M. Jenkusky, MD, MA, FAPA

•  NM Veterans’ Affairs Health Care System •  Cynthia M. A. Geppert, MD, PhD, MPH

 University of New Mexico Pain Center and Project ECHO Pain Clinical Centers of Excellence -‐ American Pain Society

 UNM Pain Center-‐ the only interdisciplinary Pain Center with integrated addic&on services in New Mexico

 Project ECHO Pain-‐ began in 2009, par&cipants include primary care clinicians from New Mexico and throughout the United States

 ECHO Pain Program replicated by University of Washington (TelePain), UC Davis, Community Health Centers (CHC), the VA (SCAN-‐ECHO), the DoD (Army Pain ECHO), the Indian Health Service (ECHO Pain and Addic&on), and Canada (ECHO Ontario Pain and Addic&on)

University of New Mexico

Family Medicine Internal Medicine Pediatrics Psychiatry Emergency/Urgent Care

Series1 356 150 79 76 72

356

150

79 76 72

0

50

100

150

200

250

300

350

400

Total = 733

Table 1: Most represented UNM Pain Center Course par[cipants by MD and DO specialty

NP PA DDS CNM

Series1 214 113 18 12

214

113

18 12

0

50

100

150

200

250

Total = 357

Table 1: Most represented UNM Pain Center Course par[cipants by profession for non-‐physician clinicians

0

200,000,000

400,000,000

600,000,000

800,000,000

1,000,000,000

1,200,000,000

2008 Jan-‐Jun

2008 Jul-‐Dec

2009 Jan-‐Jun

2009 Jul-‐Dec

2010 Jan-‐Jun

2010 Jul-‐Dec

2011 Jan-‐Jun

2011 Jul-‐Dec

2012 Jan-‐Jun

2012 Jul-‐Dec

2013 Jan-‐Jun

Total MME of Opioids Dispensed

Total MME of Opioids Dispensed

0

200

400

600

800

1,000

1,200

1,400

2008 Jan-‐Jun

2008 Jul-‐Dec

2009 Jan-‐Jun

2009 Jul-‐Dec

2010 Jan-‐Jun

2010 Jul-‐Dec

2011 Jan-‐Jun

2011 Jul-‐Dec

2012 Jan-‐Jun

2012 Jul-‐Dec

2013 Jan-‐Jun

Opioid MME per prescrip[on

Opioid MME per prescrip&on

0.0

5.0

10.0

15.0

20.0

25.0

30.0 1990

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2005

2006

2007

2008

2009

2010

2011

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Deaths pe

r 100,000 pe

rson

s

Year

Drug Overdose Death Rates New Mexico and United States, 1990-‐2012

New Mexico

United States

Drug Overdose Death Rates Leading States, U.S., 2010

Sources: CDC Wonder Rates are age-adjusted to the 2000 US Standard Population.

 The NM Board of Pharmacy has noted a 7% decline in the quan&ty of Schedule II and Schedule III controlled substances dispensed in the first 6 months of 2013.

 Opiate prescrip&ons and benzodiazepines decreased more than 7% sugges&ng safer controlled substance prescribing.

 New Mexico had 35 fewer overdose deaths in 2012 compared to 2011.

 Down from 521 deaths to 486.

In Summary:

 Mandatory PDMP usage

 Doctor Shopping laws  Support for Substance Abuse treatment services through Medicaid expansion

 Prescriber educa&on required  Good Samaritan Laws

 Rescue Drug Laws  ID requirement for controlled substances

 Lock-‐in programs for Medicaid pa&ents

New Mexico Scored 10 out of 10 on New Policy Report

Card of Promising Strategies to Help Curb Prescrip&on Drug Abuse

Lessons Learned:   Iden&fy ALL of your stakeholders and bring them on board

early in the process.

  Iden&fy possible unintended consequences and acknowledge them and alempt to address them.

 Don’t make assump&ons. Address all issues associated with whatever change you are proposing and work with people to find out pros and cons from all perspec&ves.

 Funding…. Ensure you have a plan to address funding issues and incorporate this plan within your strategy.

Next Steps  Increase prescriber knowledge for beler pain management prescribing prac&ces.

 Increase and improve the use of the PDMP.  Establish evidence-‐based drug preven&on programs in the middle and high schools.

 Expand and improve access to evidence-‐based drug addic&on treatment.

 Increase Medically Assisted Treatment and the number of Bupenorphine prescribers.

 Increased Naloxone distribu&on statewide in communi&es, pharmacies (April 2014) and first responders.

www.healingaddic&onnm.org healingaddic&[email protected] P.O. Box 56632 Albuquerque, NM 87187 @HAC_Heal

hlp://hospitals.unm.edu/pain/ hlp://echo.unm.edu

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