1. Impacting the Opioid Crisis through Improved Prescribing Practices
Virginia Cardiac Services Quality Initiative
SAN 2.0
October 24, 2017
Good afternoon everyone and thank you for joining us on our first webinar focused on impacting the opioid crisis in our nation. I’m Debbie Nadzam, the project director for VCSQI’s SAN 2.0.

2. Today’s Objectives and Agenda
To provide an overview of the national opioid crisis
Jeffrey B. Rich, MD – VCSQI SAN 2.0 and Cleveland Clinic
To describe the national call-to-action through TCPI
Deborah Nadzam, PhD, RN – VCSQI SAN 2.0
To review general considerations when prescribing opioids
Robert Bales, MD – Cleveland Clinic
To review, at a high level, non-pharmacological methods of pain management Jared Skillings, PhD – American Psychological Association SAN 2.0
Open Discussion
Next Steps
Today’s agenda is organized around our objectives for today, as seen here.

3. Questions to Run On (while listening today)
How is my practice currently prescribing opioids?
How can my practice improve opioid prescribing practices?
Can my practice participate in measurement activities requested by the VCSQI SAN 2.0?
What else do I want to hear more about?
On the national webinars sponsored through CMS and TCPI project, we are often given ‘questions to run on’. These are things to think about during the webinar. So we’ve offered a few here for your contemplation.
So let’s get started.

4. Jeffrey B. Rich, M. D. Chief Clinical Advisor- VCSQI SAN 2
Jeffrey B. Rich, M.D. Chief Clinical Advisor- VCSQI SAN 2.0 Chairman of Operations and Strategy for the Cleveland Clinic Miller Family Heart & Vascular Institute
I’m please to introduce Dr. Jeffrey Rich who serves as our chief clinical advisor in the VCSQI SAN 2.0, but was also the individual who secured our grant. He is a former president of the STS, and also served as the director of Medicare services at CMS during the Bush administration. He currently serves as the Chairman of operations and strategy for the Cleveland clinic Miller family Heart and Vascular institute.
Dr. Rich – the floor is yours to set the background for our webinar with a brief overview of the opioid crisis .

5. The National Opioid Crisis

6. Here’s another way of looking at it – these are overdoses every day, some of which are deaths. You are probably aware of your own state’s numbers and even what it happening in your locale.

7. Deaths (a subset of overdoses).

13. Who Do You Know?
So I’ll conclude with asking another question to run on: Who do you know?
Now, I’ll turn this back to Debbie to tell us about the national call for action.
Debbie….

14. Aligns with CMS Administration’s focus on opioid utilization
Campaign designed to focus on the U.S. opioid epidemic and create change
Aligns with CMS Administration’s focus on opioid utilization
A National Call to Action: The TCPI Medication Management Opioid (MMO) Campaign
Thank you Dr. Rich. In June CMS asked all of the organizations contracted as part of the TCPI initiative, to also take on the challenge of addressing the opioid crisis with participating practices. We have been asked to raise awareness and encourage prescribers to review their current practices toward reducing unnecessary use of opioids, minimizing misuse, while still appropriately managing patients’ pain.

15. VCSQI has been providing updates and resources to you through our bi-weekly updates. This webinar is our next step in bringing this issue to our participating practices. We expect to involve you all on an ongoing basis to meet the national call to action, and as importantly to provide you the resources and guidance you seek to help address the crisis.
We will help you think about and make changes, including taking steps that align with PFE, improving health outcomes and transforming your practice.
With nearly 140K clinicians participating in TCPI across all 50 states, we should be able to make a collective impact for change.

16. How are Prescriptions Contributing to the Problem?
Certainly the opioid crisis is bigger than prescribing and explained by many factors. The CDC reports that prescriptions to the person explain just over 17% of reported sources. However, an additional 60% probably started with someone else’s prescription (55% from friend/relative and 4.8% taken from a friend/relative). One might even question if the 11.4% that were purchased from a friend began with a script.
So this is why we must look at prescribing practices. Prescriptions are contributing to availability and access.

17. What’s in the medicine cabinet at home?
To that same point, many teens reporting getting drugs out the medicine cabinets in their own homes.
This speaks to prescribing, as well as educating those we prescribe to about not leaving their medications in easily accessible places. As well as teaching them how to discard unused meds.

18. When you prescribe, what doses and for what duration are you giving to your patients?
So – let’s go to our guest speakers…..

19. Robert Bales, M.D.
Department of Family Medicine, Center for Behavioral Health
Cleveland Clinic
I’m pleased to first introduce Dr. Robert Bales, from the dept of family medicine at Cleveland Clinic. Dr. Bales also serves on the NE Ohio’s task force addressing opioid issues in NE Ohio and the state of Ohio.
Dr. Bales, please go ahead and share with us general issues to consider when prescribing opiates.

20. Prescribing controlled substances
Robert W. Bales, MD, MPH, FAAFP
Family Medicine Cleveland Clinic
Assistant Professor of Family Medicine

21. Controlled Substances Schedule
Schedule I Schedule I drugs, substances, or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse. Schedule I drugs are the most dangerous drugs of all the drug schedules with potentially severe psychological or physical dependence. Some examples of Schedule I drugs are: heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote Schedule II Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, less abuse potential than Schedule I drugs, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. Some examples of Schedule II drugs are: cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), fentanyl, Dexedrine, Adderall, and Ritalin

22. Controlled Substances Schedule
Schedule III
Schedule III drugs, substances, or chemicals are defined as drugs with a moderate to low potential for physical and psychological dependence. Schedule III drugs abuse potential is less than Schedule I and Schedule II drugs but more than Schedule IV. Some examples of Schedule III drugs are:
Products containing less than 90 milligrams of codeine per dosage unit (Tylenol with codeine), ketamine, anabolic steroids, testosterone
Schedule IV
Schedule IV drugs, substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence. Some examples of Schedule IV drugs are:Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, Ambien
Schedule V
Schedule V drugs, substances, or chemicals are defined as drugs with lower potential for abuse than Schedule IV and consist of preparations containing limited quantities of certain narcotics. Schedule V drugs are generally used for antidiarrheal, antitussive, and analgesic purposes. Some examples of Schedule V drugs are: cough preparations with less than 200 milligrams of codeine or per 100 milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, Parepectolin

23. Chronic Medical conditions
Anxiety
ADD/ADHD
Chronic pain
Fibromyalgia
neuropathy
Back pain
Failed back syndrome
Spinal stenosis
Hypogonadism (Low T)

24. Background
There is a role for low dose narcotic therapy for some patients with chronic non-cancer pain.
Long term use of opiates has little evidence that quality of life is improved.
Pain is a frequent complaint seen in primary care office settings
The use of opioids for treating chronic pain has been increasing.1 In 2010, an estimated 20% of patients presenting to physician offices in the United States with pain symptoms or diagnoses were prescribed opioids. (
Gupta, S. and Atcheson, R. Opioid and chronic non-cancer pain . J Anaesthesiol Clin Pharmacol Jan-Mar; 29(1): 6–12. doi:  /

25. Narcotic “Contracts” Never use the word contract
Treatment consent (informed consent)
Follow institutional guidelines

26. Exit Strategy Difficult to achieve Treatment consents can help
“Legacy” patients
Dose tapering
10-30% dose reduction
Removal from treatment
Fraud
Illegal activities
Abusive behavior

27. New Patients Very Common situation Medical records
Prescription monitoring program
Treatment consents
Not contracts
Other modalities

28. Urine Drug Screening Urine Pain Panel Urine Toxicology Panel
Point of Care Testing

29. Urine Drug Screening
UR Toxicology
UR Pain

30. Prescription Monitoring Programs
State Prescription Monitoring Programs
OARRS
Proxy's

31. OARRS

32. Starting Patients Screen for substance use disorders or history
Urine drug testing
Consults
Start low, go slow
Define goals of treatment
Functionality v. pain
End point of treatment
Treatment consent

33. Addiction Stop prescribing What are your local resources SBIRT
Screening, Brief intervention, referral to treatment
Learn to treat addiction

34. Methadone It will bite you “methadone does not have a sense of humor”
Prolongation of QT
Variable hepatic metabolism
Increasing potency with increasing dose

35. Jared Skillings, Ph.D., ABPP
Chief of Psychology
Spectrum Health System
Michigan State University
College of Human Medicine
Thank you Dr. Bales. Next, we’ll hear from Dr. Jared Skillings from Spectrum Health System, where he is chief of psychology, and on the faculty at Michigan state University's College of Human Medicine. Dr. Skillings is a psychologist and experienced in the area of non-pharmacological approaches to pain management, that he is going to speak to us about now.
Dr. Skillings, please go ahead.

36. Wear a white coat in your mind, not just on your back.

37. Non-pharm Opioid Abuse Treatments
Purpose of non-pharm treatments:
Treatment of opioid and other substance use disorder(s)
This can mean: changing behaviors, beliefs, social networks
Treatment of other psychological disorders
Managing pain

38. It is crucial to help patients through the withdrawal from opioids
It is crucial to help patients through the withdrawal from opioids. If you do not…
↑ RELAPSE

39. Non-pharm Opioid Abuse Treatments
Three methods for delivering treatment:
Group therapy
Individual therapy
Community treatment (e.g. Narcotics Anonymous)

40. Non-pharm Opioid Abuse Treatments
Motivational Interviewing
Mindfulness Based Stress Reduction (MBSR)
Cognitive-behavioral therapy

41. Practice Management
Set clear expectations for practice managers/ staff, providers, and patients/family
Develop policies and professional boundaries for your practice of opioid prescription, tapering, withdrawal management, and addiction

42. Back to Debbie at this point to summarize, and open for discussion with guest speakers.
Unmute your phone or use the chat box.

43. Proposed Practice-level Metrics
Opioid therapy follow up: All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record (QPP measure # 408)
Documentation of signed opioid treatment agreement: All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record. (QPP measure # 412)
Evaluation or Interview for Risk of Opioid Misuse: All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP- R) or patient interview documented at least once during Opioid Therapy in the medical record (QPP measure #414)
Debbie to review proposed metrics for use by participating practices. This first slides shows those that would be collected at the practice level, generating practice-level rates. These are all in QPP as MIPS measures. Frequency of collection remains to be determined.

44. Proposed VCSQI-level Metrics (to be collected via survey at baseline and every 6 months)
Percent of VCSQI participating practices using an opioid prescribing protocol
Percent of VCSQI participating practices that conduct an opioid risk assessment prior to prescribing (based on QPP measure)
Percent of participating practices that document a signed opioid treatment agreement with patients (based on QPP measure)
These are measures that would aggregate at the VCSQI SAN-level. These 3 are stated simply as yes/no-based percent – does this practice do this or not. We could also generate actual rates, by aggregating the denominators and numerators for these measures from each practice to calculate a VCSQI patient-rate.

45. Conclusion Slide from CMS Presentation:
So here we have it – there is certainly a crisis, and there are ways that we in the health care community can help to curb it. Thank you again Dr. Rich, Dr. Bales and Dr. Skillings for your guidance today.
And thank all of you for participating. VCSQI will continue to assist with this challenge – seeking your input and questions, and offering whatever support and resources we can.

46. Survey Coming to VCSQI Participants!
VCSQI will be sending a survey to gather more information about our participating practices’ opioid prescribing protocols.
Primary contacts will receive an with a survey link

47. Take the Pledge! Please follow this link and take the pledge now.
Educate ourselves and our team
Ensure persons with opioid use disorder are treated in a respectful and person-centered manner
Leverage and align with existing programs and initiatives, as appropriate, to combat opioid misuse
Identify and report on successes, and best practices and spread within the TCPI community and other partner communities.
Read more about the Campaign to Reduce Opioid Misuse at