Location: UMA: 4500 S. 310 E., Suite 500 in the UMA Board Room. Call in Number 1-641-715-3631 and the access code is 620878#

Utah Coalition for Opioid Overdose Prevention (UCOOP) Provider Training and Education Minutes 8/12/16

Agenda Item Discussion Action Items 7:05 – 7:10 a.m.

Welcome & Introductions

7:10 – 7:20 Survey dissemination ideas • Submit survey to UMA Board for review at September meeting. • UMA – The survey will be presented to the Board and, if • Look into other organizations such as appropriate, they will send it out. The next Board the nurse practitioner group, Utah meeting is scheduled for September 8, 2016. UMA has a Medical Education Council, and the list of and list of nurses. Utah Dental Association for • There is a nurse practitioner group that meets regularly. dissemination. Please provide contacts Look into working with them to disseminate the survey and/or suggestions to Meg Balough at as well. [email protected] or Angela Stander • Utah Medical Education Council may be another at [email protected]. effective route. • Please send any other feedback on the • Utah Dental Association may be another effective route. media campaign materials to Angela Stander at [email protected]. Media campaign

• Media campaign materials were presented for review and several people provided some feedback during the meeting.

7:20-7:50 Objectives and Goals for committee 3-5 • Provide feedback on the subgroup goals Please review the ideas below before the meeting. Other ideas and objectives below. are also welcome. Those wishing to propose their ideas will be given 5 minutes to present.

• Goal 1 Comments: o Is there a way to make people accountable? Receipts at drop boxes? o Keep meds under lock and key. Lock boxes should be up to standard for protecting medications. o More education at the level by for pharmacists and picking up prescriptions regarding pharmaceutical drug misuse, abuse, and overdose, as well as safe and proper disposal. o Naloxone education among patients and pharmacists. Also stress prevention. o Naloxone messaging. It’s not a safety net. o Increase awareness and education on mental health issues as they relate to and opioid abuse. Public awareness campaign needs to include these. • Goal 2 Comments: o License renewal process that includes an exam or education on pharmaceutical drug misuse/abuse/overdose (CME). This process needs not to be longer but more beneficial. Dentists need to have an opioid component in their license renewal process. o Increase education on mental health issues with all practitioners. o Bring together the Dental Associations and Nurse associations and create education for them. o Patient autonomy ??? what was said about this? o Objective 2.2 Comments: . Emphasize the mental health component in SBIRT . Work with health systems to get reimbursement for risk assessments – SBRIT and parity for mental health. . Need to educate practitioners about mental health/risk assessments to increase use of mental health/risk assessments in doctor’s offices. o Objective 2.3 Comments: • Increase education and use of CSD by dentists • The CSD needs to be more user friendly and incorporated into EMR systems. • Goal 3 Comments: o Objective 3.1 . Consider changing the wording to focus on the fact that education on the benefits of using the CSD will likely lead to increased use. . The word “require” is used repeatedly in this section. UMA does not agree with the mandating of CSD checks for first time patients, or first time pain medications. o Objective 3.3.1 . Remove since it is already required that prescribers and dispensers register with the CSD. o Consider an objective that focuses on bringing other associations together (dental association, nurse practitioners, APRN, etc.) to educate on the CSD and other problems surrounding opioid abuse. Insurance companies would also benefit from this education. • Consider adding objective specific to education on Suboxone among dentists. Where do docs send patients who have recognized their addiction?

7:50-8:20 Possible legislation 1-2 priorities • Review Rep. Ward’s list of potential See below for proposals and also feedback on these. Come legislation and provide feedback. prepared to discuss these. • Provide Feedback to Trish Henrie on • Methadone clinics – Should be required to check the legislative priorities and new objectives CSD. as outlined below. • Mental health piece. At what level? Acute/chronic? • Length of time Medicaid will pay for Suboxone. Legislation to require funding longer than 3 years. • Rep. Ward - Safer prescribing habits  this is needed in order to make changes in this epidemic. Prior authorization required before Rx prescribed for more than seven days.

8:20 a.m. – Next steps / Next meeting 8:30 a.m.

Provider Training and Patient Education Work Group Chair: Dr. Trish Henrie, PhD Members: Dr. Jen Plumb, MD, MPH; Luz Seone, RN; Anna Fondario, MPH; Trish Henrie, Ph.D., Mark Hiatt, MD. Medical Director, BCBS, Tim Grange, M.D., Jeremy Joyal, M.D., IASIS, Ben Crouch, M.D., Revere Health, Jim Cloyd, Ph.D., Bruce McCallister, M.D. Revere, Ray Ward, M.D. , Representative, Melissa Cheng, M. D., of Utah, Michelle McOmber, UMA, Jay Bishoff, M.D., IHC, Wayne Cannon, M.D., IHC, Sarah Ann Whitbeck, IHC Goal 1: Improve patient education to include recognizing the risks and warning signs of pharmaceutical drug misuse, abuse and overdose, and safe storage and proper disposal of medications. Objective 1.1: Improve patient education related to safe use, storage, and disposal of pharmaceutical medication 1.1.1: Educate patients to use medications only as prescribed 1.1.2: Educate patients about proper storage of medications to include lock boxes and monitoring number of pills 1.1.3: Educate patients about safe and proper disposal to include recommending against flushing pharmaceuticals 1.1.4: Distribute Use Only As Directed materials in offices, clinics, and Emergency Departments 1.1.5: Increase the use of patient responsibility agreements

Goal 2: Develop and promote the adoption of core education and training guidelines on the prevention of pharmaceutical drug misuse/abuse/overdose and related behaviors by all helping professionals, including graduate and continuing education programs. Objective 2.1: Develop trainings related to pharmaceutical drug misuse/abuse/overdose for a wide variety of helping professionals 2.1.1: Consult with different professional groups (prescribers, dispensers, enforcement, judges, social services, prevention and treatment professionals, businesses, educators, parents, clergy, community groups, public and private government agencies) to determine training needs. 2.1.2: Develop adaptable training materials related to pharmaceutical drug abuse prevention, intervention, and treatment. 2.1.3: Expand prescriber education to include more prescribing professions (can use UMA modules as a template). Objective 2.2: Providers screen for substance abuse as part of a standard clinical examination and assessment 2.2.1: Promote the use of SBIRT as a tool to use for risk assessment for substance use disorders. 2.2.2: Include “impact of Rx medications”, including how large doses can be used for diversion and/or abuse 2.2.3: Educate providers on mental health and assessments and recommend the use of Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs to help providers identify and prevent pharmaceutical drug abuse problems in the primary healthcare and pain management settings. 2.2.4: Work with major health systems to coordinate the implementation of risk assessments and reimbursement for use of. 2.2.5: Offer support to health systems in training and/or educational materials. 2.2.6: Develop a referral directory for providers (patients transitioning from short to long term opioid use, showing signs of addiction, or needed chronic pain treatment but who are also at risk for substance abuse). Objective 2.3: Increase use of the Controlled Substance Database by providers/prescribers 2.3.1: Provide education (fact sheets, etc.) about the existence and utilization of the CSD as part of the licensing processes for prescribers and pharmacists. 2.3.2: Overview of policies related to CSD: providers must search new patients, must search patients on first request for opioids, must search patients for all schedule (II)(required legislation). 2.3.3: Information about registration for CSD. Objective 2.4: Improve and increase continuing education for providers 2.4.1: Include training on patient education related to identifying the risks and warning signs of pharmaceutical drug abuse and misuse, proper storage, and disposal of medications, and identify resources available for addiction treatment or recovery services 2.4.2: Revisit and evaluate UMA training modules. 2.4.3: Update and promote the use of the Utah Clinical Guidelines for Prescribing Opioids to include naloxone recommendations, including the clinical support tools. 2.4.4: Offer continuing education credit in substance abuse identification and treatment. 2.4.5: Identify potential speakers bureau for brown bag sessions for the provider/prescriber/helping professional community. 2.4.6: Plan and schedule brown bag sessions for the provider/prescriber/helping professional community. 2.4.7: Plan trainings related to new laws passed in 2014 related to pharmaceutical drugs. Objective 2.5: Improve education and training for pre-health professionals related to substance abuse 2.5.1: Increase educational requirement for those seeking to enter the health and medical field (to include more focus on substance abuse). 2.5.2: Instruction on the safe and appropriate use and prescribing of opioids.

Goal 3: Develop policy related to pharmaceutical drug use/misuse/abuse, through State Agencies, the legislature, and other avenues as possible. Objective 3.1: Increase education of the benefits of usinguse of the CSD 3.1.1: Require registration with CSD upon license renewal for prescribers and dispensers 3.1.2: Require use of the CSD with pharmaceutical of scheduled drugs when appropriate 3.1.3: Require providers to search CSD on first-time patients - Commented [LB1]: All of this wording needs to be changed to 3.1.4: Require providers to search CSD on first requests for pain medications complay with new legislation. Delete Require…. 3.1.5: Research effectiveness and cost-benefit of doctors using the CSD to provide better care and reduce cost to insurers (may result in more insurers incentivizing use of CSD)

Here are my thoughts. Wayne Cannon, M.D.

We met last year with Bill McCarberg MD who was then (and may still be) the president of the American Academy of Pain . He is from Kaiser in California and is a primary care who has led chronic pain management efforts in Kaiser for some time.

He reported that in California they have gone to a requirement for physicians attending a 12 hour mandatory opioid prescribing course to get licensed. Sadly the evaluation of this effort showed that this 12 hour course did not appear to lead to any change in physician (or patient behavior). That does not mean that a course cannot help change things. But mandating courses may not of themselves create change.

A couple of decades ago the state of Utah with community partners launched campaigns to education consumers that antibiotics were being over used. It was very effective. Then and since then discussions with patients in the office about not needing an antibiotic have been well received, and patients often come in stating they don’t want an antibiotic if possible. Of course other forces were involved than just this campaign, but a state supported public awareness campaign can have a significant effect.

Having said that, here are my recommendations for 3 to 5 objectives/priorities, and 1 to 2 suggestions for legislative priorities.

1. Have a public awareness campaign directed at patients and physicians – same media for both – that teaches: (this will both educate the providers as well, plus give them talking points when patients ask for opioids and provide additional support when they are not given) a. Your doctor often will not prescribe an opioid for pain for you as there are other treatment that are usually just as effective, or if one is prescribed it will be for just a couple of pills. (especially after – no more 30 pills for any procedure) The reason for this is that it has been shown that just one prescription for an opioid pain medication is associated with an increased risk of addiction for the person receiving the medicine. Also the gateway drug for heroin addiction is left over opioids in family medicine cabinets, usually taken innocently for mild symptoms by a family member, which can progress to dependence and addiction. When the opioid supply runs out, they turn to heroin which is cheaper, and the person is a heroin addict. The presence of opioids are especially risky for teenagers and young adults.

b. Opioid addiction and heroin addiction are medical conditions not character flaws. Effective treatment is available and can be effective. The longer you delay treatment the more difficult to overcome the addiction. If you or your loved one has an opioid or heroin addiction, seek help quickly – now!!. Don’t delay. You can be helped.

c. Many patients suffer from conditions that cause chronic pain. Taking opioid medications for these conditions is common, but has never been proven to improve function or quality of life. There is research that for many it increases pain and decreases the quality of life. The things that are known to help those with chronic pain are: 1) Having a primary care physician with whom you have a good relationship, 2) attending a class on chronic pain that includes information on chronic pain itself, and how to help it, 3) Use treatments that have been proven to help, such as mindfulness, meditation, appropriate exercise, and appropriate physical therapy. ** There are many amazing things that can be done these days to treat chronic pain conditions and improve the pain. That should all be investigated thoroughly first and evidence based treatments attempted. I don’t think that needs to be emphasized to patients but wanted to acknowledge that these exist – there is definitely a place for appropriate interventions)

2. Continue the public awareness campaign about naloxone – if there are opioids or heroin in your home for more than a few days, you should have naloxone too. You can get naloxone at many community without a prescription from your own physician. You can just walk in and get it. (All Intermountain Community pharmacies (those that are not attached to a ) have collaborative practice agreement that allows naloxone to be dispensed without the patient bringing in a prescription for the naloxone.)

3. Allow the CSD to be integrated into major electronic health records so that information is more readily available and could even be included in decision support programs that can be built into electronic medical records, allowing the EHR to alert the prescriber to a concern, even without them looking it up.

4. SBIRT has mixed reviews based on research studies. But I personally still think it is worth it. We should educate on this, create simple tools to make this easier in ER, Urgent Care, surgery offices, and PCP offices including information on community resources to help follow up.

Legislative priorities 1. Fund this public awareness campaign 2. Fund medication assisted treatment (MAT) programs so that access can indeed be quick and affordable. Include funding for training providers to assist with MAT that might need to include compensation above and beyond what insurance currently pays.

Thanks Wayne

Ray Ward, M.D. So my legislation (which is currently being drafted, and which I expect will get a hearing in interim later this year), will require that health insurers require a prior authorization for fourDifferent prescribing situations that relate to narcotics.

1 Acute prescriptions for narcotics should be 7 days or less. Acute prescriptions for longer than 7 days would require prior authorizations. 2 Starting a new patient on chronic narcotics (which is very difficult to reverse if the patient doesn't get a good response—and which should only be tried after other non-narcotic options have been tried) would require a prior authorization. 3 When a patient who is already on chronic narcotics is increased to a very high dose. (over 90 mg Morphine equivalents per day. That would require a prior auth. And 4 Putting a patient on a combination of benzodiazepines plus narcotics is a dangerous combination, and would also require a prior authorization. A physician could still get any medication at any dose by showing the medical necessity.

Feedback from Tim Grange, M.D. Been thinking about the legislatures idea to require more preauth for opioids. In general, preauths are a great burden and usually limit the best care as they exist to save money. So I'm not excited about paying for yet more staff to do yet more preauths. For example, why do I have to preauth suboxone but not oxycodone 30mg tablets? (Answer: while the first is safer the second is cheaper). Then the problem is: what are the preatuh criteria? Preauths are protocols that an insurance representative (not a provider) works from -- and what is that protocol? Very difficult to define to the point of impractical for pain. The legistlator should define the specifics before introducing any bill and they should be aware of unintended consequences: if the burden is too high, then people who need a treatment won't get it. Case in point: Molina and Medicaid - too much burden for too little reimbursement. Maybe there could be a NET neutral approach: if you add a preauth, you have to eliminate another. For example, I would recommend that suboxone never has to be preauth'd but we should require preauth of oxycodone IR 15mg or 30mg. Or, if you don't want more opioids, then pay for psychology and a fitness coach and dietician. And let's ban the restriction on psychology -> how about no preauth and no restriction of seeing pts in MD's offices by psychologists. Perhaps the preauth should simply be a pain psychology eval. And I'd suggest that insurance companies have to pay for preauths. If they feel they are necessary then that should be compensable as it takes really substantial amounts of time. Perhaps $25 per required preauth is reasonable. Today, I went to an administrative law judge hearing at the Utah Health Department for a patient to allow for continuation of suboxone for a heroin addict who had been on it more than their 3 year limit. Imagine: one section of the Utah Health Department is trying to cut opioid deaths while another is trying to limit the tools we can use to achieve this goal! This represents the extreme negative effect of preauth and "policy" that is enforced to the absurd. I can't afford to do this for very many patients and why is our very own Health Dept fighting our efforts? tim grange, md

Feedback My biggest issue with Rep Ward’s proposal is that it takes away from the Physician or Health Care Provider. As a Physician, it is our job and due diligence to determine appropriate treatment for our patients. So if we want to start prescribing chronic narcotics or add a benzo to the existing opioid prescription, we need to ensure the Patient is an ideal candidate by asking the right questions. The physician should be the one checking for prior history of abuse, psychiatric disorders, and current poly-pharmacy. Currently, Physicians and Health Care Providers are NOT doing enough appropriate screening and risk assessment. That should be our first goal NOT creating more road blocks to care. It is the same thing as checking for kidney disease before we determine what type of blood pressure medication is appropriate for the patient.

This legislation takes away from physicians and makes us dependent on the insurance company for determining care. It also creates a double standard. We do not ask the insurance company if we can start prescribing a “statin” or blood pressure medication on our patients with , which kills a thousand times more people than opioid overdose. In addition, it places the burden on the Insurance company and they do NOT have direct access to the patients. What about people who do not have insurance. Historically they are the people who are most vulnerable to opioid overdose and addiction. At the end of the day- guidelines are just guidelines. They are suggestions. They are NOT the ultimate determination of care. This is why we became doctors because there is an art to medicine. Medicine is NOT just a decision tree to blindly follow.

The Case for Mental Health – we can’t continue to ignore this important issue!!

A growing body of research implies that individuals with common mental health disorders such as depression and anxiety have higher rates of prescription opioid use than those without common mental health disorders. Further, individuals with common mental health disorders are more likely to have substance abuse disorders. Thus, mental health problems, or pain, could lead to both use of prescribed opioids and substance abuse problems. Findings also suggest that clinicians need to maintain a high index of suspicion for mental health disorders in patients who use prescribed opioids, because it is important to detect and appropriately treat mental health disorders and because treatable mental health disorders may partially mediate the relationship between prescribed opioid use and drug problems.

Prevalence of psychopathology in Pain Patients

Mood disorders: 21.7% and up to 57%

Anxiety disorders: 35.1%

. Unrecognized and untreated psychopathology can interfere with successful rehabilitation Roy-Byrne et al. (2008). Anxiety disorders and comorbid medical illness. Focus, VI, 467-485.

Psychopathology exacerbates treatment non-adherence

Depressed patients are up to 3x more likely to be non adherent to medical recommendations made by their physicians than nondepressed patients

DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysisof the effects of anxiety and depression on patient adherence. Arch Intern Med 2000:160; 2101-07.

Mental Health and Pain are Related

“Patients with severe emotional issues are likely to receive high dose, high risk opioid regimen for chronic pain over a long period of time” Catherine Q. Howe, M.D., PhD., assistant professor in at the University of Washington School of Medicine in Seattle.

"When psychiatric services aren't available, patients often end up on opioid therapy because the drugs numb the emotional pain as well as providing temporary relief for physical pain.”

Bankole Johnson, DSc., M.D., chairman of the department of psychiatry at the University of Maryland School of Medicine

One of the main reasons that doctors do not do formalized risk assessments is the lack of reimbursement by insurance companies for the doctor’s time to screen and review the report generated from risk assessments. Code 96103 ( Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI), administered by a computer, with qualified health care professional interpretation and report) and SBRIT codes are the most typical codes being used for electronic risk assessments. These are being reimbursed by most insurance companies in the state except for Select Health, EMI, and PEHP. They bundle these codes.

These codes should also be reimbursed for nurses and PA’s who prescribe opioids.

Proposed Objectives

1. Educate physicians, PA’s and nurses on the SBRIT program and encourage the use of evidenced based risk assessments be used with all patients being prescribed opioids. 2. Work with major health systems to coordinate the implementation and reimbursement of risk assessments. 3. Include in public awareness campaign, information on the importance of risk assessments. Don’t Guess, Assess. 4. Include in public awareness campaign the importance of mental health in dealing with pain. In addition, include other therapies as an alternative to opioids, i.e. mindfulness, visualization, positive psychological strategies. 5. Develop a referral directory for providers (patients transitioning from short to long term opioid use, showing signs of addiction, or needed chronic pain treatment but who are also at risk for substance abuse).

Interesting report on low risk patients and how we have to be careful not to damage them. Report Institute of Medicine June, 2011

“It’s extraordinary how many patients describe themselves as feeling like collateral damage in the war on drugs because of extraordinarily burdensome [requirements to get opioid medications],” she said.

Thernstrom went on to describe cases in which patients who had been on a stable and effective low dose of medication for years were suddenly cut off by their doctors for no apparent reason. She also spoke of cases in which the required monthly doctor visits caused patients to take time off work and travel hours to see a doctor who would prescribe.

“Many pain patients, in fact, are paying the price for a policy not designed for their benefit,” she said, adding that doctors said they prescribed less than they thought was appropriate because of fear that law enforcement was “looking over their shoulder.” In a passage addressing the question of painkiller misuse, the report notes in italics for emphasis that “the majority of people with pain use their prescription drugs properly, are not a source of misuse, and should not be stigmatized or denied access because of the misdeeds or carelessness of others.”

“Ironically, while many people with pain have difficulty obtaining opioid medications, nonmedical users appear to obtain them far too easily,” the report says. This is more of a reason to administer psychological risk assessments and follow the SBRIT program. Low risk patients who use their prescriptions as indicated should not be penalized.