Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Pharmaceutical marketing wikipedia , lookup
National Institute for Health and Care Excellence wikipedia , lookup
Adherence (medicine) wikipedia , lookup
Pharmaceutical industry wikipedia , lookup
Dextropropoxyphene wikipedia , lookup
Prescription costs wikipedia , lookup
Pharmacogenomics wikipedia , lookup
Prescription drug prices in the United States wikipedia , lookup
State Approaches to Improving Opioid Prescribing Dr. Grant Baldwin, CDC Dr. Charissa Fotinos, Washington Medicaid Program Dr. Christopher Pezzullo, MaineCare Dr. Vaughn Frigon, Bureau of TennCare, Tennessee Health Care Finance and Administration Medicaid National Meeting on Prescription Drug Abuse and Overdose February 1, 2016 State Approaches to Improving Opioid Prescribing Medicaid National Meeting CDC PERSPECTIVE Grant Baldwin, PhD, MPH February 1, 2016 National Center for Injury Prevention and Control Division of Unintentional Injury Prevention 145,000 Rx opioid deaths in 10 years. 4x as many deaths In 2013 as 1999. 2002 Rapid Increase in Drug Overdose Death Rates by County SOURCE: NCHS Data Visualization Gallery 2007 Rapid Increase in Drug Overdose Death Rates by County SOURCE: NCHS Data Visualization Gallery 2014 Rapid Increase in Drug Overdose Death Rates by County SOURCE: NCHS Data Visualization Gallery Rise in Rx overdose deaths since 2000 and recent increase in heroin & fentanyl deaths Deaths per 100,000 population 5 Commonly Prescribed Opioids like oxycodone or hydrocodone 4 Heroin 3 Methadone 2 1 Synthetic opioids like fentanyl 0 2000 2002 2004 SOURCE: National Vital Statistics System Mortality File. 2006 2008 2010 2012 2014 For every Rx opioid overdose death in 2011, there were... 12 treatment admissions for opioids 25 emergency department visits for opioids 105 people who abused or were dependent on opioids 659 nonmedical opioid users 0 100 SAMHSA NSDUH, DAWN, TEDS data sets. 200 300 400 500 600 700 Quarter billion opioid prescriptions in 2012 Sharp increases in opioid prescribing coincides with sharp increases in Rx opioid deaths 8 7 6 Opioid Sales (kg per 10k) Rx Opioid Deaths (per 100k) 5 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System. States with more opioid pain reliever sales tend to have more drug overdose deaths Death rate, 2013, National Vital Statistics System. Opioid pain reliever sales rate, 2013, DEA’s Automation of Reports and Consolidated Orders System RX Opioids As Dose Goes Up Risk Goes Up Source: Bohnert, Amy SB, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. Jama 305.13 (2011): 1315-1321. Longer durations and higher doses of opioid treatment are associated with opioid use disorder 140 adjusted OR for opioid use disorder (abuse or dependence) compared with no opioid use 122 120 adusted OR 100 90 or fewer days more than 90 days 80 60 40 29 15 20 3 3 3 0 Low (36 mg or less) Medium (36 to 120 MME) High (120 MME or more) opioid dose Edlund, MJ et al.The role of opioid prescription in incident opioid abuse & dependence among individuals with chronic noncancer pain. Clin J Pain 2014; 30: 557-564. Who is at risk for an overdose? Risk Factors Patients receiving opioids from multiple prescribers and/or pharmacies Patients taking high daily doses of opioids Demographics Men 35-54 year olds Whites American Indians/Alaska Natives Socioeconomics & geography Medicaid Rural Trends in Heroin Use & Health Outcomes 500% Increase in 2014 Fentanyl-Related Deaths in Ohio 225% Percent Increase in Neonatal Abstinence Syndrome live births from 2000 to 2009 Schumacher and Benneyworth, 2012 HHS Secretary’s Opioid Initiative Focus on three priority areas that tackle the opioid crisis and significantly impact those struggling with substance use disorders to help save lives 1 Providing training and educational resources to assist health professionals in making informed prescribing decisions 2 Increasing use of Naloxone 3 Expanding the use of Medication-Assisted Treatment Three Pillars of CDC’s Work Improve data quality and track trends Strengthen state efforts by scaling up effective public health interventions Supply healthcare providers with resources to improve patient safety Prevention for States (PfS) Provides states guidance and resources to prevent prescription drug overdoses by addressing problematic opioid prescribing Builds on the success of the Prevention Boost – Funding Opportunity 16 states funded with average award ranging from $750K to $1M Funding to states with high burden and readiness to act Focus on high impact, data driven activities and give states flexibility to tailor their work Move toward universal PDMP registration and use Make PDMPs easier to use and access Move toward a real-time PDMP Expand and improve proactive reporting Conduct public health surveillance with PDMP Implement or improve opioid prescribing interventions for insurers, health systems, or pharmacy benefit managers. This includes: 1 2 Enhance and Maximize PDMPs Community or Health System Interventions Prior authorization, prescribing rules, academic detailing, CCPs, PRRs, Enhance adoption of opioid prescribing guidelines Prevention for States Program COMPONENTS Rapid Response Projects Allow states to move on quick, flexible projects to respond to changing circumstances on the ground and move fast to capitalize on new prevention opportunities. 4 State Policy Evaluation 3 Build evidence base for policy prevention strategies that work like pain clinic laws and regulations, or naloxone access laws State-based interventions are improving outcomes Opioid Prescribing Guidelines for Chronic Pain Outside of Active Cancer, Palliative, & Endof-life Care PRIMARY CARE Conclusions BURDEN: Overdose deaths from prescription drugs & heroin are at epidemic levels in the U.S. KEY DRIVERS: Understanding the epidemic drivers is critical for effective action. Address prescribing. SCOPE OF SOLUTION: Multifaceted and multisector approach is needed. KNOWN EFFECTIVENSS: Interventions must be evaluated to determine effectiveness and need for state-specific adaptation. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-2326348 E-mail: [email protected] Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Special thanks to Noah Aleshire for his assistance preparing this presentation Strategies to Improve Opioid Prescribing Charissa Fotinos Deputy Chief Medical Officer, Washington Medicaid Program Opioid Related Death in Washington Unintentional Prescription Opioid Overdose Deaths Washington 1995-2014 Unintentional Opioid Overdose Deaths Washington 1995-2014 Source: Washington State Department of Health, Death Certificates Cross Agency Collaboration Collaborative Efforts AMDG Guidelines Division of Behavioral Health & Recovery Health Care Authority Cross-Agency Collaboration Projects Department of Corrections Chronic Pain Rules Prescription Monitoring Program Policy Statewide Plan Medication Assisted Treatment Department of Health Labor & Industry Framework for Washington Statewide Plan Priority Goals GOAL 1: GOAL 2: GOAL 3: Prevent opioid misuse and abuse. Treat opioid dependence. Prevent deaths from overdose. Improve prescribing practices. Expand access to treatment. Distribute naloxone to people who use heroin. Priority Actions GOAL 4: Use data to monitor and evaluate. Optimize and expand data sources. Provider Education: Pain Management • Older policy:2007 – Required state medical, nursing, dental, osteopathic, podiatric boards/commissions to develop rules around management of chronic, non-cancer pain • Repealed permissive pain rules & mandated new rules addressing: 2010 – Opioid dosing criteria – Guidance on when to see pain specialty consultation – Guidance on tracking clinical progress via assessment tools – Guidance on tracking adherent use of opioids Updating Medical Director Guidelines Primary Focus 2010 Guidelines 2015 Guidelines Mostly on chronic, non-cancer pain Expands focus to include opioid use in acute, subacute & perioperative pain phases & in special populations • Recommendations for all pain phases: clinically meaningful improvement in function; dosing threshold; non-opioid options • New section on reducing or discontinuing COAT • New section on recognition & treatment of opioid use disorder • New section on opioid use disorder in special populations: pregnancy, NAS, children, adolescents, older adults, cancer survivors • Expanded sections on tapering & opioid use disorder http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf Main Sections • Initiating, transitioning & maintaining patients on chronic opioid analgesic therapy (COAT) w/ principles on safe prescribing • Optimizing treatment for patients on > 120mg/day MED • Brief sections on getting consultations, aberrant behaviors, tapering, discontinuing COAT Prescription Drug Monitoring Program • Data Sharing with Medicaid – WA State Department of Health is authorized under RCW 70.225 to provide prescription data from PDMP to the Health Care Authority (HCA) for Medicaid recipients – Monthly updates based on matching records to a recipient file that HCA provides • Feeds into Emergency Department Information System • Linkages between EPIC and PMP vendor have been developed Prescription Drug Monitoring Program: What did we look at? • • • • • High (120mg+) MED dose Opiates combined with benzodiazepine &/or muscle relaxants Previous opioid serious sequella event with current prescription Pill volume for chronic, non-cancer pain Clients paying cash – Clients cross reference – ID pharmacies • Results – 1783 cash pay incidents identified – Top 13 pharmacies notified – 88 prescribers received letters of concer – MCOs notified of patients PMP info to assess for PRC Prescription Drug Monitoring Program: Patient Review & Coordination Program Aimed at over-utilizing clients Client & provider education, coordination of care Minimize medically unnecessary services & drug misuse Assist providers in managing PRC clients by providing resource information Targets clients on highest MED and applies authorization as indicated Additional Efforts • Changes to Methadone Access – Has been on the Medicaid Preferred Drug List & did not require prior authorization – As of October 2015, methadone requires prior authorization approved by WA State Pharmacy & Therapeutics Committee • Must have tried and failed 2 other long-acting opioids • Maximum starting dose restrictions – Future removal from Medicaid Preferred Drug List is likely • Emergency Department 7 Best Practices – Feedback reports to ED physicians about initiating opioids • Have seen a decrease Increasing Access to MAT: Changes to Medicaid Guidelines Buprenorphine monotherapy • Covered only for pregnant women who meet DSM-IV criteria for opioid dependence or DSM-V criteria for moderate/severe opioid use disorder Buprenorphine/ Naloxone • Covered for all non-pregnant individuals age 16 or older who meet DSM-IV criteria for opioid dependence or DSMV criteria for moderate/severe opioid use disorder Treatment Facilities • Treatment in a DSHS approved facility is encouraged, but not required for initiating MAT with buprenorphine Overdose Prevention • May 2015, ESHB 1671 Passed – Allows health care practitioners to prescribe, administer, distribute opioid OD reversal medication directly or via a collaborative drug agreement or standing order to anyone who might witness an overdose. Adds to prior legislation. – Liability Protection • Persons possessing & administering these drugs are protected if acting in good faith & with reasonable care • Prescribers protected if issued as part of legitimate medical purpose & as part of usual professional practice – Increasing Access to Help • Persons administering drug must encourage person with OD to seek care • Persons seeking care for someone with OD, person experiencing OD are protected from possession charges Next Steps Regular monitoring of prescribing patterns/overdose events for Medicaid population Regular monitoring of MCO management of patients identified for the Patient Review and Coordination program Establish metrics for tracking progress; deaths, overdose ED visits and hospitalizations Improve use of PMP Improve uptake of the Agency Medical Director Guidelines Incent/develop payment strategies for non-pharmacologic treatments for chronic pain Implement State wide Opioid Response Plan Continue efforts to expand MAT and access to naloxone Slide 40 An Approach to Pain Management A New Utilization Pattern for Opioid Prescribing 2011-2015 Christopher Pezzullo, DO Chief Health Officer, Maine DHHS Agenda • State Overview • MaineCare Pain Management Policy • What’s on the Horizon? Number of drug deaths involving specific drug types*: 2014** 70 More than one in three overdose deaths involved benzodiazepines. 57 43 42 30 24 More than one in four overdose deaths involved heroin/morphine. *Some deaths may be caused by more than one key drug. **2014 results are preliminary ***Deaths caused by known pharmaceutical morphine removed from total. Source: Marci Sorg, Margaret Chase Smith Policy Center at University of Maine, Office of the Chief Medical Examiner Unintentional Injury Deaths in Maine, by type: 2009-2014 250 208 200 In 2014, there were 208 drug related overdose deaths compared to 131 motor vehicle 150 131 100 50 related deaths. 0 2009 2010 2011 2012 2013 2014 Motor vehicle-related injury deaths 159 161 136 164 145 131 Drug-related overdose deaths 179 167 155 163 176 208 Source: Office of the Chief Medical Examiner, Maine Bureau of Highway Safety/Maine Department of Transportation Number of deaths* caused by pharmaceuticals and/or illicit drugs: 2010–2014 From 2011 to 2014, Maine observed a 34% increase in the number of all drug related overdose deaths. 250 200 150 In 2014, most (89%) drug overdose deaths involved pharmaceutical drugs. 100 There was a 340% increase 50 in the number of illicit drug-related overdose 0 deaths was observed from Pharmaceutical 2011 to 2014. *Deaths involving pharmaceuticals and illicit drugs are not mutually exclusive. 2010 2011 2012 2013 2014 160 140 140 105 186 Illicit 17 17 39 47 75 All 167 155 163 176 208 Source: Marci Sorg, Margaret Chase Smith Policy Center at University of Maine, Office of the Chief Medical Examiner Number of overdose EMS responses related to drugs/medications*: 2011–2014 From 2011- 2014, Maine EMS reported a 35% increase in overdoses from drugs/medications. 3,465 3,217 2,947 2,189 *Drugs/medication include illicit drugs and prescription drugs. Data are not broken down further than this category. 2011 2012 2013 Source: Maine Emergency Medical Services 2014 Heroin related death overdoses, Maine vs. Nation: 2002-2013 5.0 Rates/100,000 4.3 Maine 4.0 3.3 Nation 2.7 2.8 3.0 2.4 2.2 2.0 2.1 1.9 1.8 1.5 1.4 1.1 1.0 0.7 0.7 0.6 0.7 0.7 0.8 1.0 1.9 1.0 1.0 0.5 0.7 0.0 Source, National Data: USCDC; Multiple Cause of Death Files from the Source, Maine Data: Maine Department of Health and Human National Vital Statistics System, 2002-2013. Services, Office od Research, Data and Vital Statistics Number of drug deaths* involving specific drug types**: 2010–2014 In 2014, there were 57 deaths involving heroin/morphine; a 530% increase since 2011. 80 60 40 Fentanyl related deaths increased by 377% from 2013 (9) to 2014 (43) *Deaths caused by known pharmaceutical morphine removed from total. **Some deaths may be caused by more than one key drug. 20 0 Methadone Oxycodone Benzodiazepines Heroin/morphine** Cocaine Fentanyl 2010 50 48 57 7 10 10 2011 42 36 41 9 13 14 2012 32 45 33 28 13 10 2013 37 32 63 34 10 9 Source: Marci Sorg, Margaret Chase Smith Policy Center at University of Maine, Office of the Chief Medical Examiner 2014 30 42 70 57 24 43 Number of drug affected baby notifications*: 2005-2014 In 2014, there were a total of 976 reports of drug affected babies and 995 in 2015. 1000 927 779 800 667 From 2005 to 2014, the number of drug affected baby notifications increased by 480%. *This measure reflects the number of infants born in Maine where a healthcare provider reported to OCFS that there was reasonable cause to suspect the baby may be affected by illegal substance abuse or demonstrating withdrawal symptoms resulting from prenatal drug exposure (illicit or prescribed appropriately under a physician’s care for the mother’s substance abuse treatment) or who have fetal alcohol spectrum disorders. 572 600 451 343 400 274 200 165 201 0 Source: Office of Child and Family Services (OCFS), Maine Automated Child Welfare Information System (MACWIS). 976 PMP • • • • Updated every 24 hours Enrollment mandatory MME threshold letters Optional utilization Paulozzi Reports PMP • 885 Opioid Rx per 1000 people in Maine • 21.8 Long acting opioid Rx per 100 people in 2012 (#1 in the nation) Additional Maine facts… • Maine #1 state per capita long acting extended release opioids (USCDC 2102) • 80 million discrete opioid pills rx’d per year Background • In 2011, the Maine State Legislature passed legislation limiting MaineCare coverage of opioid medications to 45 days. • At that time, the Department determined it would be necessary to implement a new opioid prescribing policy, and that would have to have strong support from a broad base of providers and advocates. Department of Health and Human Services 53 Background The stakeholders involved in this process determined that: • To accomplish decreased utilization of opioids, other more effective treatment options for chronic pain would need to be accessible. • Guidelines needed to be enforced for use of opioid medications in the management of acute pain, which is pain that is expected to last less than eight (8) weeks. • Guidelines needed to be established for use of opioids in clinical situations where the literature no longer supports their use( chronic neck pain, chronic back pain, Fibromyalgia Syndrome & headaches). Department of Health and Human Services Background The stakeholders involved in this process determined that: • Exceptions needed to be made for opioid use during end-of-life care, hospice care and hospital inpatient care. • There should be a maximum allowable dose. • There needed to be a shift in treatment goal from painfree to maximum level of function. Department of Health and Human Services From Drug Management to Pain Management Strategies developed based upon type of pain: • Acute (new onset) • Chronic (long term, or poor response to other treatment) • Diagnoses typically proven not to respond to opioid treatment Department of Health and Human Services Pain Categories • Acute Pain is expected to last less than 8 weeks • Chronic Pain is expected to or already has lasted longer than 8 weeks • Non-responsive: Headache, Chronic back pain, Chronic neck pain, Fibromyalgia Department of Health and Human Services Acute Pain • 15 days per 12 month period with no prior authorization • 14 additional days with Prior Authorization (PA) • Face-to-face visit for each Rx within 96 hours of prescription being written • Up to 3 refills after the first 15 days • Surgeons: a one time PA for 60 days Department of Health and Human Services Acute Pain Treatment Plan • Return patient to previous level of function as quickly as possible. • Minimize long-term use of opioids for pain that is expected to resolve in the near-term Department of Health and Human Services Chronic Pain • Patient must try one or more interventions from a treatment plan • Certain conditions no longer qualify a patient for treatment with opioid medications without a second opinion supporting the use of opioid medications • Limit on total daily dose of opioids Department of Health and Human Services Chronic Pain Treatment Goals • Transition from pain-free expectation to improved level of function • Increase access to proven treatment modalities • Minimize use of opioids where no data supports current level of use Department of Health and Human Services Chronic Pain Treatment Options • • • • • Osteopathic Manipulative Treatment Chiropractic Services- 12 per year maintenance program Physical Therapy- 6 visits per year Cognitive Behavioral Therapy Acceptance Commitment Therapy Department of Health and Human Services Dosing Limits Minimum: 30mg or less MME/MSE- exempt from PA process PA Required: 30-300 MSE/MME Maximum: 300mg MME/MSE is maximum allowed dose Department of Health and Human Services Results After First Year Comparing 2012 to 2013: • Nearly 10,000 fewer MaineCare members received a prescription for opioid medications. • 69,227 fewer prescriptions were filled for MaineCare members. • 5,874,109 fewer opioid pills were dispensed to MaineCare members. • 1,108,202 fewer days’ supply were dispensed to MaineCare members. Department of Health and Human Services PMP Opioid Data—State of Maine Statewide Opioid Utilization by All Payer Sources Recipient Count typically Rx Count Dispensed Text Font Times Qty New Roman Days of Supply TOTAL- 2012 at least 20 point81,743,690 335,990 1,224,629 19,456,079 TOTAL - 2013 Try312,870 to have size consistent throughout 1,183,452 77,275,507 18,962,450 TOTAL- 2014 Change 2012 to 2013 Percent Change Change 2013 to 2014 Percent Change Change 2012 to 2014 Percent Change 324,121 1,223,516 80,323,827 20,202,989 23,120 -7% 41,177 -3% 4,468,184 -5% 493,629 -3% 11,251 4% 40,064 3% 3,048,320 4% 1,240,539 7% 11,869 -4% 1,113 0% 1,419,863 -2% (746,910) 4% Department of Health and Human Services MaineCare MaineCare Statewide Opioid Utilization Medicaid- 2012 Medicaid- 2013 Medicaid- 2014 Change 2012 to 20 13 Percent change Change 2013 to 2014 Percent change Change 2012 to 2014 Percent change Recipient Count Rx Count Qty Dispensed Days of Supply 89,559 356,174 22,144,541 5,457,844 74,394 286,947 16,270,432 4,349,642 50,497 218,250 12,236,397 3,389,985 15,165 -17% 69,227 -19% 5,874,109 -27% 1,108,202 -20% 23,897 -32% 68,697 -24% 4,034,034 -25% 959,657 -22% 39,062 -44% 137,924 -39% 9,908,144 -45% 2,067,859 -38% Over the last three years, MaineCare has seen a 36% decrease in opiate prescriptions. This number incorporates those who are no longer eligible for MaineCare. Department of Health and Human Services Commercial Insurance Opioid Utilization by All Commercial Payers Recipient Count Rx Count Qty Dispensed Days of Supply Commercial Insurance- 2012 169,173 608,399 41,581,042 9,745,466 Commercial Insurance- 2013 159,998 574,557 38,424,810 9,162,888 Commercial Insurance- 2014 178,879 658,365 43,856,430 10,791,020 Change 2012 to 2013 Percent Change 9,175 -5% 33,842 -6% 3,156,232 -8% 582,578 -6% 18,881 12% 83,808 15% 5,431,621 14% 1,628,132 18% 9,706 6% 49,966 8% 2,275,388 5% 1,045,554 11% Change 2013 to 2014 Percent Change Change 2012 to 2014 Percent Change Department of Health and Human Services 2012-2014 Comparison Department of Health and Human Services State of Maine Statewide Opioid Utilization by All Payers, Jan-June Recipient Count Rx Count Qty Dispensed Total- 2012 212,354 613,378 41,134,754 9,715,029 Total- 2013 189,569 585,154 38,335,670 9,316,076 Total- 2014 182,640 569,693 36,216,124 9,117,039 Total- 2015 210,757 647,784 44,058,941 11,172,994 Department of Health and Human Services Days of Supply MaineCare MaineCare Statewide Opioid Utilization , Jan-June Recipient Count Rx Count Qty Dispensed Medicaid- 2012 57,463 177,813 11,168,229 2,734,405 Medicaid- 2013 51,927 154,885 8,926,455 2,324,907 Medicaid- 2014 30,345 101,110 5,447,593 1,528,870 Medicaid- 2015 30,032 106,121 6,188,596 1,689,989 Department of Health and Human Services Days of Supply Commercial Insurance Statewide Opioid Utilization by all Commercial Payers, Jan-June Recipient Count Rx Count Qty Dispensed Commercial Insurance- 2012 106,473 307,391 21,307,473 4,961,612 Commercial Insurance- 2013 93,861 268,750 18,039,348 4,267,654 Commercial Insurance- 2014 100,717 292,898 18,903,615 4,640,753 Commercial Insurance- 2015 117,317 350,599 23,987,652 5,943,697 Department of Health and Human Services Days of Supply What’s on the Horizon? • Pain Management Policy Modifications (ie mandatory use for all Rx’ers, tie MME to pain mgmt policy) • Sharing Pain Policy with Private Insurers in Maine • New Threshold letters from PMP • Mandatory use of PMP by MaineCare prescribers • Align pain management policy with new USCDC Opiate Guidelines Christopher Pezzullo, DO Chief Health Officer Maine DHHS [email protected] Department of Health and Human Services State Approaches to Improving Opioid Prescribing Vaughn Frigon Chief Medical Officer, Tennessee Health Care Finance and Administration Bureau, TennCare Questions ?