1

Rx for Drug-Seeking Patients in the EDThe Monterey County Prescribe Safe Initiative

2

AIM:

Be the Catalyst for Change in your Community

OBJECTIVES:

•Why change is important•How we made change in Monterey County•How to pitch the story in your community•Provide practical tools and resources to get started

3

Tools and Resourceswww.chomp.org/for-healthcare-professionals/prescribe-safe

4

•Opiate use in the U.S.

▫80% of the world’s prescription opiate supply

▫99% of the world’s hydrocodone supply

▫From 1997 to 2007, the milligram per person use of prescription opioids in the U.S. increased from 74 milligrams to 369 milligrams, an increase of 402% (enough to supply every American adult with 5mg of hydrocodone every 4 hours for a month)

Scope of the Problem

5

•7 Million Americans use prescription drugs recreationally annually (2.3% of the U.S. population)

•50 Million Americans have used recreationally at least once during their lifetime (16.1% of the U.S. population)

Scope of the Problem

6

Scope of the Problem• Increased adverse medication events related to

prescription drug misuse▫Estimated > 700,000 ED visits per year related to

prescription drug misuse alone

•Approximately 10% of all patients on chronic opiates account for 40% of all overdoses▫Usually on high daily doses▫Getting drugs from multiple prescribers

7

Scope of the Problem

• Death from opiate overdoses have increased 300% since the 1990s

• We lose more years of productive life in the US to prescription drug overdose than motor vehicle accidents

• Prescription drug related deaths exceed motor vehicle-related deaths in 29 states and Monterey County

• Prescription drug related deaths now outnumber those from heroin and cocaine combined

8

Scope of the Problem

•Gateway: Nearly 1/3 of people aged 12 and over who used drugs for the first time in 2009 began by using a prescription medications non-medically

9

Street Value

www.streetrx.com

10

11

12

•Selling drugs for consideration (sex, addicted physicians)

•Medicine cabinet parties•Prescription fraud• Insurance fraud•MRI forgery black market

DIVERSION

13

14

An Experiment

15

An Experiment (circ. 2005)

• Frequent Users of the ED Group (FUG)• The Team:

▫ ED physicians ▫ ED nurse▫ Administration ▫ Addictionology ▫ Hospitalist ▫ Pain management physician▫ Psychiatrist▫ Behavioral health nurse▫ Social worker

16

EDRVP

Emergency Department Recurrent Visitors Program

2013

17

EDRVP Purpose

•Adequately meet the needs and improve the overall care of patients recurrently seeking care in the ED for chronic medical problems, including, but certainly not limited to, opiate or benzodiazepine addiction 

18

Change Concept•Apply care management concepts:

▫Identify and engage recurrent visitors▫Remove barriers to more appropriate care

Barriers to self-management Establish PCP or referral to more appropriate specialist Address socioeconomic barriers to care and refer to

community resources Engage payer in the process

•Apply evidence-based and safe standards of care

19

Criteria • Frequency

▫≥ 4 visits in 1 month▫≥ 6 visits in 3 months▫≥ 12 visits in 12 months

• Using the ED as a PCP office for non-emergencies▫Chronic condition management▫Repeat imaging and laboratory▫Medication refills

• Seeking pain medication refills and/or + CURES test• Abusive or out of control behavior• Provider or outside referral

▫Pharmacy▫ Insurance company

20

Care Management Process•Screen all referrals using criteria•Review (prior 6 month chart review)

▫Utilization patterns▫Visit reason▫Diagnostics▫PCP▫Medications refills

•Engage patient, family, providers, insurance

21

Care Management Process•Draft Plan of Care (POC)•Advisory Council review of POC (monthly meeting)•Communication with Patient

▫Letter to patient and providers▫POC uploaded in electronic medical record (green dot)

22

Tracking Board “Green Dot” Alert

23

Advisory Council

•ED Physician•Urgent Care Physician/Addictionologist•ED Director•CHI ED Transition Care Manager and Referral

Coordinator•Social Worker•Clinical Specialist Behavioral Health Services•Hospitalist Coordinator•CCAH Care Management Supervisor

24

Health Information Technology Enablers

•High utilizer reports•Electronic referral process•Auto-population of POC

25

Monterey County Prescribe Safe Initiative

• Launched in February 2014•Modeled after the San Diego Collaborative•Aim: Develop a broad-based coalition representing

those interested in dealing with the epidemic of prescription drug abuse in Monterey County

26

County-Wide Engagement

27

Monterey County Prescribe Safe Initiative Strategic Objectives

•Establish county-wide ED Pain Medication Prescribing Guidelines

•Develop resource tools to support ED efforts•Community physician education• “CURES Party”

28

29

30

31

32

33

CURES Report

34

CHOMPResults

35

2006 2007 2008 2009 2010 2011 2012 2013 20140

20

40

60

80

100

Enrollees into Program

36

37

38

39

Resources•FUG:

▫Periodic Committee meeting▫0.2 FTE Assistant Director of ED▫Annual Cost: $50,000

•EDRVP▫Advisory Council meeting▫0.5 FTE TCM▫Annual Cost: $75,000

40

Future•More of the same for the CHOMP EDRVP

•County-wide EDRVP Program

•Engage local pharmacies

•Engage local health plans

41

Take Home Messages•A national epidemic with local implications (including

your community)•Exhaust the behavior – push in the same direction

▫Use CURES▫Countywide medical community prescribing practices▫Engage the neighborhood

•Do it because it is the right thing to do AND there is a return on investment

•You’re behind – catch up by visiting our website

QUESTIONS?

Thank you

Anthony Chavis, MD831-644-7466Anthony.chavis@chomp.org

Reb Close, MD831-625-4900Reb.close@gmail.com