The  411  on  a  Successful  Rx  Weaning  Program  

Third  Party  Payer  Track  April  23,  2014  

Moderator: Mark Pew, Senior Vice President PRIUM (www.prium.net), Duluth, GA Medical intervention on clinically complex claims

Panelists: Kathryn S. Bronstein, PhD, RN, Vice President, Medical Affairs Ameritox, Inc. (www.ameritox.com), Baltimore, MD Medication monitoring solutions

Krista D. Jordan, PhD, ABPP, Program Director RestoreFX (www.restorefx.com), Austin, TX Interdisciplinary functional restoration clinic

Kathryn S. Bronstein wishes to disclose that she is an employee of Ameritox, Inc.

Krista D. Jordan has no financial relationships with proprietary entities that produce health care goods and services.

1.  Describe the pharmacological and medical process of opioid discontinuation

2.  Evaluate the psychosocial issues and coping skills that impact weaning and recovery

3.  Analyze criteria of successful pain management and functional restoration programs

2011 study on opioid discontinuance trends •  Almost 30,000 patients (primarily private health plans)

prescribed opioids continuously for at least 90 days during a 6-month period

•  Approximately 66% were still on opioids after 5 years •  Attributing factors were:

•  Intermittent prior opioid exposure •  Daily opioid dose > 120mg MED •  Possible opioid misuse

Source: Martin BC, et al. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med. 2011 Dec; 26(12): 1450-1457, http://www.ncbi.nlm.nih.gov/pubmed/21751058

•  Opioid dosage > 120mg MED per day •  Acetaminophen dosage > 4000mg per day •  NSAID dosage > 3200mg per day

•  Opioids used > 2 contiguous months after injury or surgery •  Muscle relaxants used > 2 contiguous months •  NSAIDs used > 6 contiguous months •  Benzodiazepines used > 4 contiguous weeks

•  No exit strategy by the prescriber

•  Topical analgesics •  Anti-narcoleptic drugs •  Hormonal supplements •  Spinal Cord Stimulator and topical / oral analgesics •  Drug regimen that has automatic refills

•  More than one prescribing physician •  No opioid treatment agreement •  No urine drug monitoring •  No liver / kidney toxicity tests where applicable •  Prescriber not utilizing the state’s PDMP

•  Insomnia

•  Lethargy

•  Atrophy

•  Depression

•  Sexual dysfunction

•  Constipation

•  Addiction

PAIN  

zolpidem

modafinil

carisoprodol

duloxetine

sildenafil

stool softener

buprenorphine

Opioid

All  of  this  makes  the  pain  harder  to  

iden2fy  and  treat  

Fentanyl?

Per the AMA Guides March/April 2011 Newsletter, “21 of 23 patients in the study reported a significant decrease in pain

after detoxification”

Iatrogenesis – “inadvertent and preventable induction of disease or complications by the medical treatment or

procedures of a physician or surgeon” -- Merriam-Webster

Over 526,000 patients currently being treated for chronic pain

Urine Drug Monitoring   35.9% prescribed drug not found or lab results warranting

review   32.3% contained a drug not prescribed by the clinician   11.1% contained one or more illicit drugs

  Of 105,000 samples with an illicit drug found:   78% THC   19% Cocaine   3% Heroin

Bohnert A, Valenstein M, Bair M, et al. JAMA 2011;305(13):1315-1321.

1. Krenzischek DA et al. J Perianesth Nurs. 2008;23(Suppl 1):S28-S42. 2. Lordon SP. Curr Pain Headache Rep. 2002;6(3):202-206. 3. Townsend CO et al. J Clin Psychol. 2006;62(11):1433-1443. 4. Patel G et al. Med Clin N Am. 2007;91(1):141-167. 5. Freedman MK et al. Arch Phys Med Rehabil. 2008;89(3 suppl 1):S56-S60. 6. Stanos SP et al. Anesthesiol Clin. 2007;25(4):721-759.

Pharmacotherapy1 Interventional Approaches2

Psychological Support3

Complementary and Alternative Medicine4

Physical Medicine and Rehabilitation6

Lifestyle Change5

Medical component of weaning

1.  Determine venue, in- or out-patient

2.  Decide if a specialist is required

3.  Assess co-morbidities and complicating factors

4.  Manage the withdrawal symptoms

5.  Define success

Pharmacological component of weaning

1.  Determine clinical appropriateness for each drug

2.  Separate pain management from disease management drugs

3.  Assess drug cocktail for interactions

4.  Create a taper strategy   Sequence of discontinuance, by classification   Add drugs to take away drugs?

5.  Monitor the process (UDM 101)

Psychological component of weaning

1.  Evaluate psychological and/or physical dependence, anxiety and/or depression, family and other interpersonal factors that may be maintaining dependency

2.  Explain risks and potential benefits of long-term use of opiates

Psychological component of weaning

3.  Motivate the patient to make a life change   Stages of Change Model   CBT 101

4.  Identify how patient will manage pain with less/no dosage   Recovery Lifestyle   Coping skills   Function

Profile of a successful functional restoration program

  Is there an inter-disciplinary approach (vs. single discipline or multidisciplinary)?

  Do they offer complementary treatments (e.g. yoga, Pilates)?

  Do they have in-patient access for significant addiction/health issues?

  Are patients assessed and sometimes denied entry?

Profile of a successful functional restoration program

  Are treatment plans customized per patient?

  Is progress objectively measured regularly?

  If inadequate progress are adjustments made?

  Are patients followed for at least one year post-discharge?

  Do patients have access to booster sessions? If so, are they charged for these?

Flor, H, Fydrich, T, Turk, DC. Efficacy of multidisciplinary pain treatment program centers: a meta-analytic review. Pain. 1992; 49:221-230.

•  Shows that compared to no treatment or single-discipline treatment, functional restoration was superior in achieving return to work and healthcare utilization

Turk, DC. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clinical Journal of Pain. 2002; 18;355-365.

•  Shows functional restoration yields reductions in pain, increased return to work, reduced medication usage, decreased healthcare utilization, closure of disability claims

Woman enters program for knee pain related to OTJ injury. Physically and psychologically dependent on opiates to manage pain. Marriage is strained to the point of collapse.

During the program her husband and children attend weekly family therapy group, the patient is able to discontinue narcotics.

Patient returns a year later at the urging of her husband secondary to obtaining a prescription for Vicodin for a back strain.

Patient and family resume family groups, patient attends additional group therapy and yoga classes, within 3 weeks is able to feel confident about managing without narcotics (and patient never did take the Vicodin prescribed).

At one year follow up after this incident she is still opiate free.

  26 of 41 (63%) patients were on opiates at intake   7 of 41 (17%) were still taking opiates upon discharge

  Decrease of 73%

  100% of patients interviewed for one-year follow-up were functional and/or working   16 of 48 (33%) program completers