1. Jodie Calain, D. O. PG 111 Al Meyer, M.D. Medical Director Terry Gentry, Practice Manager Jennifer Willis R.N. Nurse Manager Coastal Family Medicine, Wilmington NC

2.  Identify how to screen which patients are appropriate for the use of controlled substances, using an evidence-based approach  Describe how to implement a multi- disciplinary monitoring system in practice to ensure the safety of both patients and the community  Ask each other how our practices can sustain and promote quality changes

3.  http://www.youtube.com/watch?v=jCxpro- QSio&feature=youtube_gdata_player http://www.youtube.com/watch?v=jCxpro- QSio&feature=youtube_gdata_player

4.  Who are you and what do you hope to take away from this discussion?  What are some of the reasons you prescribe controlled substances?  What types of problems that you have had with controlled substance prescribing?

5.  How do we know that what we prescribe is being used according to instruction?  Who uses the medications we prescribe?  What can we do to help pain and suffering but promote safety

6. Trends for Opioid Non-medical Use ED Visits – 2004 - 2008 Source: DAWN Estimates, 2009

7. (259%) (105%) (106%) (73%) (123%) (152%) Percentages shown in parentheses represent the percent changes between 2004 and 2008. Source: DAWN 2008

8. Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2007 Totals may not sum to 100% because of rounding http://www.oas.samhsa.gov / Bought/Took from Friend/Relative 14.1% Drug Dealer/ Stranger 4.1% Bought on Internet 0.5% Other 1 4.2% Free from Friend/Relative 6/6% Bought/Took from Friend/Relative 5.9% Drug Dealer/ Stranger 1.8% Other 1 1.8% Source Where Respondent Obtained Source Where Friend/Relative Obtained One Doctor 18.1% More than One Doctor 2.6% Free from Friend/Relative 56.5% More than One Doctor 2.9% Bought on Internet 0.1% One Doctor 81.0%

9.  Divide into 4 problem solving groups  Each Group is a Practice Quality Team  Take 10 minutes, discuss the problem  One spokes person presents a solution

10.  A 75 year old man with severe heart failure and incapacitating spinal stenosis has been managing his back pain with low dose oxycontin 10 mg bid for the last 2 years. His doctor has just graduated and his new PCP a PGY 1 feels uncomfortable refilling his medications at their first visit.

11.  The PGY 1 gives him enough oxycontin for 30 days with no refills and schedules a follow visit with her in 1 month. She has no openings for 6 weeks. The patient calls back at 27 days and notes he will run out of pain meds before his next appointment. A message is sent to the PGY 1 but the office gets no response in the next 48 hours. The patient calls back multiple times, each time becoming more irate.

12.  The preceptor fills the oxycontin and on the next visit the PGY1 sees his patient, listens to his frustrations and wonders how she might avoid similar levels of patient dissatisfaction in the future.

13.  A 42 year old man with back pain has been taking oxycodone for 3 years presents to your office for initial evaluation.  His history is not clear and after a thorough initial evaluation, the resident suspects diversion.

14.  No controlled substances for longer than 1 month  Faculty on hospital duty refilled all controlled substances  When in doubt refills often approved with some ambivalence  For Faculty created a confusing working relationship with colleagues  For Residents little responsibility or education for controlled substances

15.  A Mechanism for Change: Quality Team  Passionate Residents and Faculty  Emphasis is Patient Safety and Customer Satisfaction

16.  DIRE score  Management Pathways  Post dated prescriptions  Behavior clause  Clear understanding of violations  Mechanism for patient weaning and dismissal

17.  Diagnosis 1-3 Poorly vs. Clearly Defined  Intractability 1-3 Few therapies tried vs. Full engagement  Risk 1-3 Psychological, Chemical, Reliability, Social Support  Efficacy 1-3 Not Improved vs. Improved Function  Rate the patient’s score (1-3) for each factor, and add up the total score.  Score 7-13: not a suitable candidateScore 14-21: good candidate

18. ◦ Sensitivity 94%, specificity 87% for predicting patient compliance ◦ Interrater reliability was 94% (in the study, multiple physicians plus a pain specialist all gave similar scores for a specific patient) ◦ On patients that you already know, usually takes <2 minutes to calculate score ◦ Scoring system has been validated and determined to be reliable using a retrospective study

19. 1. Repeated daytime requests for phone refills 2. After hour telephone requests. 3. Failure to make an appointment with the PCP or designee Q 3 mo. 4. A missed appointment for refills. 5. Lost and stolen drugs/prescriptions. 6. Unauthorized change in medication dose. 7. Unauthorized use of prescriptions by other patients. 8. An illegal substance or a unauthorized cs found in the urine..

20.  Violation of contract  Medical management

21.  Improved safety for patients  Registry of patients using controlled substances >3 months.  Clinic efficiency  No controlled substances for chronic use on first visit.  DIRE score prior to each new drug contract.  Weaning protocols for violators of drug contract.  Clear guidelines for patient drug contract violators  Residents required to precept all drug contracts with dire score less than 14.

22.  No controlled substances on first visit to the CFMC – What about acute pain needs  What about patients when risk of diversion is low?  What about patients with low DIRE scores, in pain and few other options?

23.  Quarterly Reports – percentage of patients taking controlled substances with no contract  Dismissal Protocol  Ongoing Revisions always needed  Hostile or Disruptive patients  The Patient Safety Team

24.  What is your practice change mechanism?  What are strategies that have worked for you?  Our Evidence Based Low Hassel CS Policy  It has worked for us and appears to be sustainable  What we did when the old way didn’t work

25.  Doctors Reddick, Calain, Isaacs, Knapp who asked the questions and sought out the best evidence  The Quality Team especially Mr. Gentry and Ms. Willis that guided the team from start to fruition to sustainability  To Dr. Jan Beste who is tireless in her pursuit of quality care for our patients and quality education for our residents

26.  Belgrade MJ, Schamber CD, Lindgren BR. The DIRE score: predicting outcomes of opioid prescribing for chronic pain. J Pain 2006; 7(9): 671-81.  Ives TJ, Chelminskin PR, Hammett-Stabler CA, et al. Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Services Research 2006; 6: 46.  Romanoff ME. If you prescribe controlled substances, you need to read this. Mecklenburg Medicine 2008; October: 19.  Willis DR, Eaton G, Mackie P. A proactive approach to controlled substance refills. Family Practice Management 2010; Nov/Dec: 22-7.  Anonymous author. A shortcoming you need to know about. Medical Economics 2004; May 7: 65-7.  Standridge JB, Adams SM, Zotos AP. Urine drug screening: a valuable office procedure. Am Fam Physician 2010; 81(5): 635-40.  Nicholls L, Bragaw L, Ruetsch C. Opioid dependence treatment and guidelines. JMCP 2010; 16(1b): S14-21.  Cloos JM. Benzodiazepenes and addiction: myths and realities (part 1). Psychiatric Times 2010; July: 26-9.  Cloos JM. Benzodiazepenes and addiction: long-term use and withdrawal (part 2). Psychiatric Times 2010; August: 34-5.