Sept-Oct 2017 Colorado Medicine by Colorado Medical Society

September/October 2017

Volume 114, Number 5

Award-winning publication of the Colorado Medical Society

contents Sept/Oct 2017, Volume 114, Number 5

Cover story The opioid epidemic

is one of the greatest challenges facing health care today and physicians have a role in reducing opioid misuse and abuse in our patients, as do other partners in the pharmaceutical industry, hospital accreditation and other advocacy organizations. Physicians now know more about the effectiveness and consequences of chronic opioid medications, and alternatives for pain management. It’s time to implement new knowledge and strategies for the good of patients. Read more starting on page 8.

Inside CMS

5 President’s Letter 7 Executive Office Update 55 CMS Education Foundation scholarships 57 COPIC Comment 58 Reflections 60 Introspections

Departments 62 65

Medical News Classified Advertising

Colorado Medicine for September/October 2017

Features. . . 12

Letter from Colorado‘s CMO–Larry Wolk, MD, MSPH.

Affecting families–A personal connection to addiction.

A pain story– One patient tells how she tapered off all

Non-opioid pain treatment– Limiting opioids with “rational polypharmacy” can be an important tool.

Thoughtful prescribing– Communication is essential for choosing the most effective treatments for chronic pain.

The “ALTO” approach–Emergency departments are implementing a pain strategy for opioid alternatives.

Specialty focus–Surgery, pedatrics and obstetrics.

Consortium update–Making gains against the epidemic.

Colorado leads in prevention–The AMA recognizes progress in the fight against the opioid epidemic.

Prescription drugs in Colorado–The Prescription Drug Monitoring Program is an important tool for physicians.

Physician health program– CPHP helps physicians

Utilizing risk management–Physicians have obligations to ensure medication safety and responsible prescribing.

Facing scrutiny– CPEP can help physicians understand their vulnerabilities to peer review and regulators.

Controlled substances–Learn practical approaches to avoiding the pitfalls of prescribing opioids.

Multi-pronged approach–Payers implement strategies to address the opioid epidemic.

Who wants a raise?– QPP resources for practices.

State Innovation Model–Practices in the first two SIM cohorts have made great strides.

Final Word–Emergency physician Donald Stader, MD,

opioid medications and reclaimed her life.

overcome addiction and educates on effective prescribing.

gives physicians strategies to address the opioid epidemic. 3

C OLOR A D O M EDICA L S O CI ET Y 7351 Lowry Boulevard, Suite 110 • Denver, Colorado 80230-6902 (720) 859-1001 • (800) 654-5653 • fax (720) 859-7509 • www.cms.org

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF

2017 Officers Katie Lozano, MD, FACR President M. Robert Yakely, MD President-elect Michael Volz, MD

Treasurer

Alfred D. Gilchrist Chief Executive Officer

Board of Directors Kiara Blough, MS Cory Carroll, MD Curtis Hagedorn, MD Mark B. Johnson, MD Richard Lamb, MD David Markenson, MD Gina Martin, MD Patrick Pevoto, MD, RPh, MBA Brandi Ring, MD Charlie Tharp, MD Kim Warner, MD C. Rocky White, MD Kelley D Wear, MD

AMA Delegates A. “Lee” Morgan, MD M. Ray Painter Jr., MD Lynn Parry, MD Brigitta J. Robinson, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Katie Lozano, MD Tamaan Osbourne-Roberts, MD AMA Past President Jeremy Lazarus, MD

Michael Volz, MD Immediate Past President COLORADO MEDICAL SOCIETY STAFF Executive Office Alfred Gilchrist, Chief Executive Officer, Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer, Dean_Holzkamp@cms.org Dianna Fetter, Director, Professional Services, Dianna_Fetter@cms.org Tom Wilson, Manager, Accounting, Tom_Wilson@cms.org

Division of Health Care Financing Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

Division of Communications and Member Benefits Kate Alfano, Communications Coordinator, Kate_Alfano@cms.org Mike Campo, Director, Business Development & Member Benefits, Mike_Campo@cms.org

Division of Government Relations Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Adrienne Abatemarco, Program Manager Adrienne_Abatemarco@cms.org

Division of Health Care Policy Chet Seward, Senior Director, Chet_Seward@cms.org JoAnne Wojak, Director, Continuing Medical Education, JoAnne_Wojak@cms.org

Division of Information Technology/Membership Tim Roberts, Senior Director, Tim_Roberts@cms.org Tim Yanetta, Coordinator, Tim_Yanetta@cms.org

Colorado Medical Society Foundation Colorado Medical Society Education Foundation Mike Campo, Staff Support, Mike_Campo@cms.org

COLORADO MEDICINE (ISSN-0199-7343) is published bimonthly as the official journal of the Colorado Medical Society, 7351 Lowry Boulevard, Suite 110, Denver, CO 80230-6902. Telephone (720) 859-1001 Outside Denver area, call 1-800-654-5653. Periodicals postage paid at Denver, Colo., and at additional mailing offices. POSTMASTER, send address changes to COLORADO MEDICINE, P. O. Box 17550, Denver, CO 80217-0550. Address all correspondence relating to subscriptions, advertising or address changes, manuscripts, organizational and other news items regarding the editorial content to the editorial and business office. Subscriptions are available for $36 per year, paid in advance. COLORADO MEDICINE magazine is the official journal of the Colorado Medical Society, and as such is also authorized to carry general advertising. COLORADO MEDICINE is copyrighted 2006 by the Colorado Medical Society. All material subject to this copyright appearing in COLORADO MEDICINE may be photocopied for the non-commercial purpose of education and scientific advancement. Publication of any advertisement in COLORADO MEDICINE does not imply an endorsement or sponsorship by the Colorado Medical Society of the product or service advertised. Published articles represent the opinions of the authors and do not necessarily reflect the official policy of the Colorado Medical Society unless clearly specified. Alfred D. Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Kate Alfano, Assistant Editor; Chet Seward, Assistant Editor. Printed by Hampden Press, Aurora, Colo.

Inside CMS

president’s letter Katie Lozano, MD, FACR President, Colorado Medical Society

Working together to address opioid epidemic for patients As physicians, we have a moral imperative to our patients to collaborate with our colleagues, medical societies, elected officials and other stakeholders to address the public health crisis caused by opioid misuse and abuse. Part of our action as individual physicians involves committing to continuous provider education on best practices in prescribing for pain management, ways to help our patients who are addicted to pain medications or other substances, and best practices for finding other ways to treat pain. Throughout this special issue of Colorado Medicine – and especially in the cover story on page 8 – we hope you’ll find effective ways to help you consider and reconsider your approach to opioids and pain management for patients, and realize how that will continue to evolve in your practice to help your patients. Active partnership between CMS, all component societies of CMS, and the state specialty societies is critical to develop a medical consensus on solutions that will help guide public policy discussions on the opioid epidemic toward patient-centered, real-world applications. Read more about how CMS has been fully committed to addressing this epidemic over the past four and a half years in the Executive Office Update on page 7. I would be remiss if I didn’t mention a tremendous asset we have in our state: the Colorado Consortium for Prescription Drug Abuse Prevention, a statewide voluntary collaborative organization that brings together our best and brightest to maximize our efforts on this issue. Read more about the consortium on page 34. We are also fortunate to have the leadership of the executive branch and Gen-

eral Assembly. Gov. John Hickenlooper, Lt. Gov. Donna Lynne and key legislators – through an interim workgroup established by the 2017 General Assembly – are developing the next generation of initiatives intended to curb, prevent and treat opioid abuse. The workgroup is bipartisan and includes five members from each chamber plus liaisons from other interested groups. I appointed Don Stader, MD, an emergency room physician who is nationally known for his expertise on this issue, to serve as the CMS liaison to the interim workgroup. Stader and I testified before the committee at its second meeting on Aug. 1, 2017. Read his goals for the workgroup on page 66. To prepare for the interim study, Lt. Gov. Lynne, on behalf of Gov. Hickenlooper, has been holding preliminary conversations with stakeholders to gather thoughts and strategies on the expanding set of policy options and best practices

being developed in Colorado and other states. Joining me at the CMS meeting with Lt. Gov. Lynne was John Hughes, MD, chair of the CMS Special Committee on Prescription Drug Abuse; CMS President-elect Robert Yakely, MD; CMS Immediate Past President Michael Volz, MD; Susan Koontz, JD, CMS general counsel and director of government relations; and CMS CEO Alfred Gilchrist. It was a friendly, candid meeting and we brought our patient-centered focus to the discussion. The lieutenant governor emphasized the executive branch’s vested interest to achieve greater progress on the opioid crisis before the end of Gov. Hickenlooper’s gubernatorial term in 2018. CMS applauds the efforts in Colorado to curb, prevent and treat opioid abuse and we continue to pledge our full support and cooperation to this collaborative effort. n

Thank you to the members of the advisory group for the special September/October Colorado Medicine on the opioid epidemic The Colorado Medical Society thanks the outstanding committee of experts who helped shape the content of this issue of Colorado Medicine by determining the focus of the package of articles, contributing or reviewing content, and sharing resources and best practices. Elizabeth S. Grace, MD Jason Hoppe, DO John S. Hughes, MD Alan Lembitz, MD

Colorado Medicine for September/October 2017

Katie Lozano, MD, FACR Rick May, MD Kathryn L. Mueller, MD Wilson Pace, MD Jean K. Rex, MD Donald Stader, MD Robert Valuck, PhD, RPh Walter B. Vernon, MD Michael Volz, MD Bruce Waring, MD Steven L. Wright, MD M. Robert Yakely, MD

PDMP Checks: Fast, Easy & on Your Phone Your Opioid Prescribing Game Changer Introducing OpiSafe PocketPDMP

Check one patient or multiple patients simultaneously

UP TO

Available FREE for your iPhone

10x

FASTER

than Coloradoâ&#x20AC;&#x2122;s PDMP website

Automatically interprets even the most complex PDMP reports

Learn more at opisafe.com/pocket

The Colorado Medical Society strongly supports all physicians checking the PDMP for every patient.

Colorado Medicine for September/October 2017

Inside CMS

executive office update Alfred Gilchrist, CEO Colorado Medical Society

Moving the needle on opioid and other narcotic addiction epidemic When the March-April 2013 cover story of Colorado Medicine outlined the emergent opioid abuse and misuse crisis, Colorado ranked 12th nationally in the self reported non-medical use of opioids, and first responders and emergency departments were confronting growing waves of overdose patients. Caregivers were at different stages of struggling with the moral, clinical and economic consequences of the crisis. CMS joined Gov. Hickenlooper’s call from the beginning to combine forces on what he called the “winnable battle” to reduce the escalating trend of opioid abuse and its often tragic consequences. Since then a dedicated group of your colleagues, frontline experts appointed by the board of directors, have been diligently working to address the crisis by focusing on professional education and development, bringing local and national expertise to the governor’s Colorado Consortium for Prescription Drug Abuse Prevention, and supporting public policy initiatives. Other physician-led organizations have stepped up since 2013 when the governor brought stakeholders together. Our friends and strategic partners at COPIC have aggressively increased their prescribing awareness seminars and have confirmed over 2,000 of their insured physicians have taken these courses since 2013. The University of Colorado School of Public Health launched a twohour online course to retrain health care professionals on the current guidelines for management of chronic, non-cancer pain, in conjunction with the state’s Division of Workers’ Compensation under the leadership of Kathryn Mueller, MD. The training is required for all members

of Pinnacol Assurance’s network of providers, and is incorporated into the division’s Level II accreditation course for workers’ compensation providers in the state. To date, more than 2,200 physicians have completed the training. Notably, of those completing the course, 91 percent said that they would use the information to change the way they manage patients with chronic, non-cancer pain. The Colorado Physician Education Program, or CPEP, offers two intensive educational seminars on safe prescribing for managing chronic pain. CPEP has assessed and educated over 400 physicians since the winnable battle began in 2013. Component and specialty medical societies have stepped up by promoting safe prescribing courses and other educational material and forums. There wasn’t time to perform a full accounting of what all health care organizations in Colorado are doing, but as Dr. Lesley Brooks’ cover story and other articles in this issue confirm, physician-led organizations have intensified their educational efforts since the governor announced his winnable battle in 2013. Physicians know that addiction is a mean, almost intractable condition. Because of the combined and coordinated efforts of many starting in 2013, Colorado is experiencing a reduction in the volume of opioid prescriptions. Perversely, to the extent the supply of prescription opioids have shrunk, the severely addicted have tragically moved to street narcotics, most notably black tar heroin and Fentanyl, with more lethal consequences. As Colorado ACEP warns, people who are addicted to prescription opioids are 40 times more likely to be addicted to heroin.

Colorado Medicine for September/October 2017

This is an issue of common cause, a public health threat that has helped our political leaders in both parties to close ranks and work together to reverse a crisis that is systematically hurting or killing, nearly every day, our fellow Coloradans. We are fully engaged with the leadership of the executive and legislative branches of our state government and a broad range of stakeholders. A bipartisan, interim House-Senate study committee has been appointed. Many of the proposals under consideration come from other state experiences and are under careful scrutiny by our frontline experts to determine their adaptability to Colorado and the real world of health care delivery. We understand that some strategies that have worked in other states that are under consideration in Colorado will be met with a healthy dose of skepticism. We won’t get trapped in the policy weeds and argue away your hard-earned standing as a profession dedicated to reversing the crisis. We will advocate appropriate exceptions and two-to-four-year sunset triggers on some of the proposals to ensure that future general assemblies and stakeholders have the ability to assess the effectiveness of legislation enacted in 2018. The opioid crisis urges us to take some policy risks. It is literally a life-or-death choice that we are attacking with elected officials and other stakeholders. Your board of directors has already determined that CMS will remain steadfastly committed to this substantial movement of caregivers and advocates to aggressively develop and support strategies that will move the needle of opioid and other narcotic addiction. n

What Colorado physicians need to know Lesley Brooks, MD

Cover Story The opioid epidemic is one of the greatest challenges facing health care today and physicians have a role in reducing opioid misuse and abuse in our patients. Unfortunately physicians can feel like they are cast in an unfair spotlight with this issue. Tom Frieden, MD, MPH, former director of the U.S. Centers for Disease Control and Prevention, was correct when he said this is a doctor-driven epidemic. No one else prescribes these medications but physicians, dentists, veterinarians and other licensed health care professionals. With that said, others contribute to this epidemic, including our partners in the pharmaceutical industry, hospital accreditation and other advocacy organizations. And perhaps most important, a lack of robust science about the effectiveness and consequences of chronic opioid medications – science that has evolved significantly since the early 1990s – has played a significant role. We now know that these medications can be and are addictive, no matter the patient population, and that these medications can be and are life threatening if taken inappropriately. Policymakers and health care experts understand many of the challenges we face as physicians in our current health care environment. They know that it can be challenging to treat someone with multiple chronic medical conditions that can cause discomfort; that it can be challenging to distinguish between the person with opioid use disorder and the person whose pain may not be well controlled; and that it can be challenging to know when the person who has been taking their legallyobtained opioids safely for months has transitioned to misusing them. Through my practice at Sunrise Community Health, which serves both Larimer and Weld counties, my team of providers delivers full-scope family medicine, including Medication-Assisted Treatment (MAT) for opioid dependence. The latter, including treatment for pregnant women, is conducted through a strong partnership with North Range Behavioral Health and SummitStone Health Partners. The real-world knowledge

gained through our experience inside this collaborative model can be instructive for practices throughout our region to protect our patients and increase our quality of care for those suffering from chronic pain or opioid addiction. Starting with the basics on opioids, it is important for physicians to understand that our patients do have legitimate and organic chronic pain conditions. They can and do develop opioid use disorder on the medications that we give them, even those who have a well-documented source for their discomfort and even those who have a history of using their medications safely. Sometimes patients present with descriptions of chronic pain that are difficult to attribute to a physical source, and that can sometimes be associated with psychiatric or behavioral disorders. It is critical to complete a good assessment to determine the appropriate treatment modality. Some types of pain are not likely to improve and may worsen with chronic opioid therapy, such as abdominal pain, headaches and neurologic pain. Physicians have made some progress in addressing this epidemic. The latest figures from the American Medical Association show that the total number of retail-filled prescriptions for all opioid analgesics in Colorado decreased 13.3 percent between 2013 and 2016, from 3.7 million in 2013 to 3.2 million in 2016. And use of the Prescription Drug Monitoring Program (PDMP) in Colorado nearly tripled from 680,000 searches in 2014 to 1.5 million in 2016. However, there is still a huge educational gap for making better prescribing decisions. Safe opioid prescribing is about understanding how to assess the person with chronic pain, including past medical history, past treatments for pain, what worked best to improve their function and what didn’t, imaging, other chronic conditions – both physical and mental, physical examination findings, and more. Safe opioid prescribing is also about making as specific a diagnosis as you are able based on the data you obtain, understanding what medications are available for the condition you feel you are treating and are appropriate for

Colorado Medicine for September/October 2017

different types of pain, and then helping your patient select the safest regimen for their specific circumstances. This may mean that opioids are not an option or that the opioids they request and the Valium they are already taking are incompatible and you cannot support that regimen. I urge all physicians to obtain the training needed to help strengthen your communication skills.

“Our patients do have legitimate and organic chronic pain conditions. They can and do develop opioid use disorder on the medications that we give them, even those who have a welldocumented source for their discomfort and even those who have a history of using their medications safely.” In addition, I strongly encourage you to obtain a DATA 2000 waiver that allows you to prescribe buprenorphine (ex. suboxone) to treat opioid use disorder if and/ or when it begins. It can also be helpful for some chronic pain indications. Actionable steps It is important to establish the parameters within which you will prescribe opioid medications to your patients and the circumstances under which you will no longer be able to prescribe them. We refer to this as a medication agreement. In the past, it has been referred to as a pain contract. I prefer the term “agreement” because it implies a mutual understanding. Again I emphasize communication skills because I don’t like the idea that there are terms under which my patient

Cover story (cont.) will violate their contract and thus be discharged from my practice. Sunrise doesn’t use that language with our patients. We prefer the idea that there are parameters within which we will continue with the regimen that we have agreed upon and outside of which the terms of our agreement must change. For example, if a patient is going to use methamphetamine while taking the oxycodone that I have prescribed, I am going to insist that he or she see our behavioral health therapist for substance use assessment and attend our weekly group visits (see next page) while working to stop the methamphetamine. If not, we must treat the chronic pain with something other than an opioid. Our therapeutic patient-provider relationship is never at risk because of misuse. If anything, it is an opportunity to enhance it, to understand better the conditions with which our patients struggle. I encourage providers to understand the policies of their local emergency departments and how they will handle patient

requests for pain medicines. It’s also a good idea to let them know how your practice is handling opioid prescribing and how they can refer patients back to your practice.

need to understand the criteria for opioid use disorder and how to apply it.

It is important to seek out training so that we can recognize opioid use disorder in the outpatient setting. (See DSMV-Substance Use Disorder Diagnosis.) I emphasize this because the presentation often differs from what one might find in a traditional substance use treatment setting. Unless we are working in the substance use field, physicians are likely unaccustomed to addressing this issue in our offices.

Finally, I cannot emphasize enough the importance of checking the Colorado Prescription Drug Monitoring Program (PDMP). Registration as a user of the PDMP is mandatory in Colorado, though use of this critical tool is not currently mandated. This is one very important way to understand if, where and what type of controlled substances your patients may be receiving outside of your practice. It is an important, objective tool to use in initiating conversation with our patients around their use of opioids and other controlled substances.

With someone who is using heroin or other illicit substances, that conversation is clear, though not easy. But for someone who is obtaining the means of their addiction legally from you for what you and they believe to be a legitimate condition, the conversation that a physician needs to have when their use has become problematic is nuanced and often calls upon new skills from us. We

The Colorado Consortium for Prescription Drug Abuse Prevention is a tremendous repository for state-specific information on this epidemic. They currently have a link to a two-hour physician CME course, “The Opioid Crisis: Guidelines and Tools for Chronic Pain Management,” in the resources tab of the top-bar navigation on their website, corxconsortium.org. The North Colorado Health Alliance and the consortium have collaborated on the Colorado Opioid Epidemic Symposium, a series of provider education events offering CME and COPIC points. The symposium offers full-day, half-day and evening events for providers to obtain the skills highlighted in this article. The most recent evolution of the symposium is “Moving From What to How: Safe Opioid Prescribing for Chronic Pain,” a 3.0-hour evening CME program focused on educating providers and other members of the multi-disciplinary team. Providers and practices can request training by contacting Whit Oyler at whit.oyler@ucdenver.edu or Deirdre Pearson at dpearson.alliance@nocoha. org. n Lesley Brooks, MD, serves as the chief medical officer for Sunrise Community Health, is the assistant medical director for the North Colorado Health Alliance, and co-chair of the Provider Education Work Group for the Colorado Consortium for Prescription Drug Abuse Prevention.

10 TUCC Symposium Ad Color_081517_OL.indd 1

Colorado Medicine for September/October 2017 8/15/17 1:27 PM

Cover Story

Sunrise Community Health institutes comprehensive opioid oversight and buprenorphine treatment program Sunrise Community Health is a federally qualified health center serving more than 38,000 individuals in Weld and Larimer Counties through robust partnerships with many local agencies, including North Range Behavioral Health and SummitStone Health Partners. Sunrise was an early responder to the nationwide epidemic of prescription drug abuse, especially with regard to opioids. Our medical team noted that there were some patients who were misusing their opioid prescriptions and that our providers needed support to prescribe opioids safely. In direct response to aberrancies in patient behavior and widely varying provider prescribing behaviors, Sunrise established the Opiate Oversight Committee (OOC) in 2008. The purpose was to establish and maintain best practices for opioid prescribing among providers, provide comprehensive review of patients receiving ongoing opioid prescribing, and provide recommendations to providers to improve safe prescribing. Sunrise supported this effort by freeing three physicians to participate in the OOC, hiring an OOC case manager and developing the relevant reporting. Sunrise also incorporated the embedded behavioral health team members supplied by our NRBH and STS partners. The committee of physicians, case management, behavioral health and pharmacy personnel meets weekly to review all patients receiving ongoing prescriptions for opioid pain medications and those who are identified with high-risk behaviors. As part of the review process, a written document is generated with the assessment and recommendations for the provider. The committee deliberately chose to provide recommendations to providers rather than to establish separate work flows to engage directly with patients. Sunrise felt strongly that it was best to educate providers as a result of the review process and leave the patient-provider relationship intact, thus honoring our philosophy that chronic pain is part of the primary care relationship and should be managed within that structure unless specialty care is required. A few years after establishing the review process, Sunrise recognized that while provider communication and education had improved, there were some patients who were not receptive to these efforts and continued to exhibit unsafe behaviors. Consequently, frequent outbursts were taking place in the pharmacy and during office visits with patients who did not understand changes in their medication regimen or were confused by new policies. Clearly, Sunrise was not effectively communicating these changes. As a result, the OOC evolved to include twice-weekly group visits for patients who needed a higher level of care. New patients who had been terminated by their previous provider for aberrancies in managing their opioid medications were coming to the Sunrise community, and it was imperative that a therapeutic relationship be maintained even in the face of potentially aberrant behaviors. Firing patients is always a last resort.

Colorado Medicine for September/October 2017

The group visit is designed as a higher level of care for patients who exhibited unsafe behaviors with these controlled substances. The visit, which involves a Sunrise OOC provider and a behavioral health consultant, allows clinicians to respond to high-risk behaviors and enhances the practiceâ&#x20AC;&#x2122;s ability to monitor these patients more closely. Hour-long group visits involve regular, mandatory urine drug screens, shared teaching around concepts such as safe medication storage, skills for coping with chronic pain, the role of psychiatric and other chronic medical conditions in chronic pain, and alternatives to opioid medications for pain. Patients are asked to attend weekly group visits for four consecutive weeks. If the unsafe behavior can be corrected after engagement in group visits, the patient is returned to routine monthly follow-up with their PCP. If the unsafe behavior continues despite this higher level of care, the patient is told that controlled substance prescribing must be discontinued, but that Sunrise can continue to be their medical home and is willing to continue to treat their chronic pain condition(s) with nonopioid medications. Any specialty services from this point forward are made with a specific request for intervention rather than management of additional opioids. Patients can be reevaluated for reinitiation of opioid medications. Through this enhanced mechanism for safety, Sunrise has also established training for safe opioid prescribing for all new providers during provider orientation. Providers have appreciated OOC involvement in patient care and the enhanced education that has been delivered through systematic review of patients. Patients have also expressed increased satisfaction with the management of their opioid prescriptions and the teaching around safety and skills-building delivered through the group visits. Sunrise began prescribing buprenorphine for opioid use disorder around the same time the OOC was established. The same collaborative programming with North Range and SummitStone is used to initiate and manage patients with opioid addiction, a truly unique practice model. With differing payment structures, practice models, documentation systems and billing practices, there are myriad reasons that partnering between community health centers and community mental health centers should not work. Strong leadership and creative programming have diminished the impact that these challenges might otherwise have, and the shared programming brings primary care and behavioral/mental health together in service to the most vulnerable populations, enabling this critical service to be offered in a more comprehensive manner than either could individually.

Features

A letter from Coloradoâ&#x20AC;&#x2122;s CMO Larry Wolk, MD, MSPH

Larry Wolk, MD, MSPH, addresses Colorado physicians about opioid abuse public health emergency Opioid abuse is one of the most significant health threats facing far too many Coloradans and our health care system. As physicians, we understand firsthand the significance of our role in helping to address what many have now classified as a public health emergency. Whether prescriptive or illicit, opioid abuse almost always begins with diversion of prescriptive opiates. Many may point fingers at physicians and prescribers but more importantly, I believe that we are a significant part of the solution. For those who joined in the early initiatives launched by the governor in 2013, our efforts have changed opioid prescribing and how pain is managed. There are fewer prescriptions and fewer prescriptive drugs available for diversion. There are more medication disposal and takeback sites, taking more opiates and other

harmful drugs off the streets. And with the broader availability and use of naloxone, we have fewer deaths directly related to opiate overdose. But there is much more to be done. As we continue to work to reduce the availability of opioids for nonmedical use, the danger has shifted to street drugs like black tar heroin and adulterated, illegally imported fentanyl. It is a moral and economic burden that compels the expertise and creative collaboration of the medical community, our state officials and our allies among other health care professionals and organizations. The governor, my state agency colleagues and I will continue to work closely with you and your experts on the next generation of strategies, taking full advantage of the important role you play in addressing this crisis. We will need your sustained

effort, whether innovating through our own consortium or as we import successful models and interventions from across the country to adapt to Colorado. I look forward to our continued partnership and thank you in advance for your commitment to making a difference in the health and lives of the people of Colorado. Our work together is certain to get us closer to truly becoming the healthiest state! In good health, Larry Wolk, MD, MSPH Executive Director and Chief Medical Officer, Colorado Department of Public Health and Environment n

Colorado Medicine for September/October 2017

Features

Affecting families John Frank, The Denver Post

For one Colorado lawmaker, Colorado's drug abuse problem is personal

Colorado lawmaker Brittany Pettersen opens up about her family’s history of drug abuse in the hope that it helps others Editor’s note: This article was originally published in The Denver Post on April 30, 2017. It has been reprinted with permission. Brittany Pettersen earlier this month arrived home from a town hall meeting with voters to find her mother outside slumped in a chair. “I thought she was dead,” said Pettersen, a state lawmaker. She rushed to the hospital thinking once again her mother overdosed on heroin. Only weeks earlier, her mother had suggested she didn’t have long to live.

This session, she led a push to add $6 million to substance abuse disorder programs, create an addiction research center and establish an interim committee to study the issue. “My mom might not ever be better,” Pettersen said, only to pause as she’s overcome by the words. “But,” she continues, “I think that there’s people out there that desperately want help who do have the potential to live fulfilling lives again.”

This time was a scare, the doctors said. But days later, recounting the story at a coffee shop near the Capitol, Pettersen was still shaken.

Numbers coming down Colorado once ranked among the nation’s leaders in prescription drug abuse but now fits in the middle of the pack after recent efforts targeting overdose deaths tied to opioid painkillers.

“One of the most devastating things to watch is somebody that you love slowly kill themselves,” the 35-year-old said. “And there’s nothing you can do except try to be there to support them in a path toward recovery.”

In 2016, prescription opioid-related deaths reached their lowest level in six years – a trend state officials credit to public-awareness campaigns, better prescription monitoring and the availability of naloxone to help reverse overdoses.

Pettersen, a three-term Lakewood Democrat now running for Congress, once shied away from talking about her mother, suppressed like so many others by the stigma surrounding drug abuse.

“We’ve made some important early progress and I think we are … among the top handful of states in terms of having a very organized concerned state-level response,” said Robert Valuck, who coordinates the Colorado Consortium on prescription drug abuse. “The bad news is, we still have a long way to go.”

Now, as the nation’s opioid and heroin problem emerges from the shadows, she is becoming a strong advocate at the statehouse – even as she struggles to help her mother.

show, and officials suspect the prescription opioid crackdown is a contributing factor. Nearly 80 percent of heroin users previously abused prescription opioids, according to the National Institute on Drug Abuse.

“What happens when you take an addict’s drug away is they are going to find another way to meet their needs. It just puts them at risk for heroin abuse. It’s cheap. It’s easily accessible.” - Rep. Brittany Pettersen, Colorado House District 32 “She was never the same” The intersection of opioid abuse and heroin is “where my story becomes relevant to what’s going on with Colorado,” Pettersen said. Her family lived a middle-class life in Jefferson County, and her mother, Stacy, worked as a hairdresser. Then, after the death of Stacy’s best friend, she began

Heroin deaths in Colorado increased by 23 percent in 2016, the latest state figures

Colorado Medicine for September/October 2017

Affecting families (cont.) abusing pain pills. Brittany Pettersen was 6 years old. “I remember after that day, she was never the same,” Pettersen said. “She has had a ton of trauma and a really difficult life, and I think it was just the thing that made her snap. And 29 years later, she still hasn’t come back.”

in the state legislature didn’t know until this year about her personal connection to the effects of substance abuse.

tential cost savings to offset the state’s share, which is estimated at $10 million to $20 million.

In her first term, when she sponsored a “Good Samaritan” bill to give immunity to people who administer naloxone to a person experiencing an overdose, Pettersen only mentioned a “family member” struggled with addiction.

“Being told, ‘I’m sorry, there are not any options out there’ – I think that was an even more hopeless feeling than being a kid,” she said.

Her mother abused pain pills and alcohol and then pills again. Like so many others, she said, her mother was overprescribed opioids until being cut off.

She didn’t talk about her mother. She kept a distance to protect herself.

“What happens when you take an addict’s drug away is they are going to find another way to meet their needs,” Pettersen said. “It just puts them at risk for heroin abuse. It’s cheap. It’s easily accessible.”

Her relationship began to change a year ago, after her mother overdosed on heroin. Pettersen was presenting a bill in a committee when she received a text message from one of her brothers that her mother was unconscious in the hospital.

Her mother fears “nothing more than withdrawal,” she added. “She fears it more than death.” One of the bills Pettersen introduced this year would allow pharmacists to only dispense partial prescriptions for opioids to act as a backstop on overprescribing. She also wants the state to send notification letters to doctors who prescribe more opioids than their peers. She drafted another bill to ask voters to impose a cent-per-milligram tax on the distribution of opioids to generate $34 million for substance-abuse treatment. “We don’t have enough money to meet the needs as a state, and the pharmaceutical companies also need to play a role in helping people recover,” she said. Given what she has seen with her mother, Pettersen is so averse to pills, she avoids taking Tylenol. Even after a series of car crashes over the past 10 years, she declines pain medication. Instead, once every four months or so, she undergoes an operation to sever the nerves in her neck to block the pain impulses. A change in relationship Most of Brittany Pettersen’s colleagues

Once recovered, Pettersen’s mother asked for help – and meant it. The plea opened a door for Pettersen to let her mother back into her life. Pettersen on Thursday told her mother’s story to a House committee as she presented a bill designed to increase drug abuse treatment options. “The most difficult part of my childhood was realizing that I couldn’t do anything to save my mom,” she told her colleagues. “It didn’t matter if I cleaned the house, it didn’t matter if I hid her pills, if I hid her keys – she had to be willing to want to get help. And so I had to accept that at a young age and distance myself, and hope that one day my mom would want to come around again.” But when Pettersen tried to help this time, she realized that treatment options were limited. Her mother receives Medicaid coverage, but the government program would only cover four days of detox treatment – not the residential treatment she needed. The federal program makes residential treatment an optional benefit for states, but Colorado does not offer the coverage. Another bill from Pettersen would study the feasibility and explore po-

Making the personal political Wisconsin Rep. John Nygren knows what it’s like to step forward and put a face on the issue of drug abuse. The Republican lawmaker’s daughter Cassie overdosed and did prison time for heroin possession. He initially didn’t talk about it. “At one point in time, it was embarrassing – that we must have screwed up in some way to have this happen in our family, that it was some kind of moral failing on Cassie’s part,” he said. But as the obituaries from overdose deaths mounted in his small town near the border with Michigan’s upper peninsula, Nygren spoke out. Now he counts the substance-abuse programs put in place in the past three years as one of his party’s top achievements. What made the difference, he said, is simple: “We were able to humanize it.” The human side is what Lisa Raville sees every day as the director of Denver’s Harm Reduction Action Center, a public health clinic that treats injection drug users at a facility across the street from the Capitol. Raville says awareness and education are the keys to addressing what she labels an “overdose epidemic” in Colorado. What helps change minds, she said, is people such as Pettersen telling their stories. “There is some confusion about who a drug user is,” she said. “It can be anyone. If it hasn’t affected their family, it can feel very ‘other.’ But if it affects their family, it’s very personal … and the personal is always political.” n

Colorado Medicine for September/October 2017

THE STRENGTH TO HEAL

and a loan repayment program that gives me the freedom to focus on patients. What if you could focus more on caring for patients and less on repaying your medical school loans? As a Reservist on the U.S. Army health care team, you can. By continuing to practice in your community and serving when needed, you can earn up to $250,000 toward the repayment of your medical school loans. Whether your Reserve experience on the U.S. Army health care team takes place in a hospital close to home, at an Army medical center or on a humanitarian mission, youâ&#x20AC;&#x2122;ll encounter learning experiences and leadership opportunities that will further your career and enrich your life.

To learn more about the U.S. Army health care team, contact the Aurora Medical Recruiting Center at 303-873-0491 or visit healthcare.goarmy.com/ib81

Colorado Medicine for September/October 2017

Features

One patient’s pain story Terri L. Schreiber

Reclaiming life after opioid dependence My entry into opioids began innocently enough. I sought medical attention for facet joint damage, a fractured spine and three torn discs weeks before starting a PhD program. The injury happened during labor and delivery when pain was considered a fifth vital sign. Opioid prescriptions were plentiful and I was a model pain patient with no history of taking opioids except following dental procedures and a minor back injury. I took the

“My entry into opioids began innocently enough. ... Little did I know that the initial prescriptions would lead to 10 years of increasing opioid tolerance and opioidinduced hyperalgesia, disability, gaining 50 pounds, hopelessness and withdrawal from PhD studies.” medication as prescribed and adhered to doctor requirements that I use one pharmacy and never fill a prescription early. Little did I know that the initial prescriptions would lead to 10 years of increasing opioid tolerance and opioid-induced hyperalgesia, disability, gaining 50 pounds, hopelessness and withdrawal from PhD studies. The good news is that this article is possible because I tapered off all opioid medications and reclaimed my life. This is intended to be a cautionary tale as to 16

why daily opioids are not always a longterm solution to chronic pain. My pain management story began after obtaining an MRI to determine if a lumbar fusion was warranted. For years, massage and chiropractic care were sufficient to treat a preexisting whiplash injury from a car accident. Benzodiazepines to manage chronic insomnia kept the neck pain manageable. Despite evidence of spine disease, the surgeon gave me sage advice. There was a 30 percent probability that lumbar fusion would eliminate my pain and not create additional problems. The odds were not inspiring so I opted out of the potential surgery and was referred to a physiatrist who oversaw my care for the next eight years. From the earliest days working with the physiatrist, I was naïve about how dependent on the opioids I would become. Initially, they felt like a panacea. I had answers to why I felt so much daily pain and could finally explain the loss of 40 pounds within weeks of delivering my daughter. Further, I thought the medicine would tide me over as we explored a range of viable treatment options. I believed I was doing everything right. What I did not fully appreciate was the longer I took the medicine, the less connected I would become to my body’s signals. Nor did I understand that my acuity and memory were slowly eroding. I tried to trace how my treatment plan became harmful. From the outset, the medications were intended to be an interim solution until the benefits of radiofrequency ablation could be realized. Time passed and I went forward with the procedure, but did not enjoy the intended benefits. Instead, pain levels

increased. From that day forward, my response to almost all procedures was atypical. In addition, and unexpectedly, by taking the medication as prescribed, I became more susceptible to the risk of opioid dependence. By being compliant, I had a seemingly limitless supply of opioids or what I came to believe is “heroin in a pill.” Medication refills continued uninterrupted for 10 years. Yes, interspersed with the prescriptions were efforts to reduce pain. I had a discogram to diagnose the location of my pain and periodic spine injections. I also investigated the viability of a neurostimulator implant. My allergic response to nickel and other materials ruled this out. Medication alternatives were limited. So, it seemed reasonable that I was advised to treat my pain and daily medications as analogous to a diabetic needing insulin. For years, I believed this was my best choice and could not see the hole I was digging. And then a miracle happened. Two events set me on a path to finding a long-term solution. The first was that my treating doctor closed his practice without warning. In the weeks following the closure, by attempting to stop taking the medicine without medical oversight, I learned I was dependent. Then, months into tapering, I had a minor slip and fall. My pain was out of control. I could barely walk. I could not read and my memory was shot. So, I made a choice to taper off all medicine and became emboldened to understand the cause of my immobility. I was terrified. Sure, the MRIs showed multiple spine diseases: bone spurs up and down my spine, degenerative disc disease, facet joint problems, spondylolistheses and stenosis. Surprisingly, the data no longer held the power to overwhelm.

Colorado Medicine for September/October 2017

Features Instead, I started to read literature, recalled my 1993 treatment options following my whiplash injury, and reconsidered any and all non-opioid treatments. Antiinflammatory foods, chiropractic adjustments, embracing a sugar free and gluten free diet, hypnosis, massage, meditation, neurokinetic therapy, physical therapy, Pilates and spine injections all became treatment modalities to explore. I took drastic measures. I withdrew from my PhD program with the goal of reclaiming my health. After six months of physical therapy, I could walk without a limp. Ice, heat and peppermint oil replaced diclofenac patches and a TENS unit. The new diet, hypnosis, meditation, naproxen and Tylenol made it possible to significantly reduce my pain levels. Today, I am no longer dependent on anything. I still keep a small amount of pain pills and muscle relaxants for extreme pain, but take them rarely and with caution. There are days when I am bedridden and need an occasional spine injection, but my cognitive function has been restored. One can attain quality of life after opioids and two spine injuries. Learning to live with tolerable pain and minimal medication not only allows full use of oneâ&#x20AC;&#x2122;s brain, but provides an opportunity for medical providers to identify the true cause of pain and not a hyperexaggerated response. What remains essential is for the patient to take an active role in treatment. The system is designed to find quick solutions and mine was not. Yes, opioids were effective for acute pain, but in my case, to maximize quality of life, chronic pain required a more holistic treatment plan. It is hard work finding more permanent lifestyle solutions, but whoever said the goal should be a pain-free life? When I lost the capacity to understand my bodyâ&#x20AC;&#x2122;s response to injury, I lost much more. I lost the ability to live, affirming the comment I once heard that if you cannot feel pain, you cannot feel anything else either. n

Owned and operated by the Colorado Medical Society and backed by a 50-year history of physician ownership, MTC is uniquely focused on the needs of its clients. Serving medical professionals is all we do. MTC's management team has over 50 years of experience in medical answering services. Our operators are professional, friendly and expertly trained to handle any client situation. We offer a full range of customizable services to ensure your patients enjoy personal, timely communication while you stay on top of your busy schedule. MTC proudly received the prestigious 2009 Award of Excellence for the fourth year from ATSI (Association of TeleServices, Intl.), a service-quality award based on test calls placed over a six-month period. MTC is a member of the Denver/Boulder Bettter Business Bureau, ATSI and Telescan Users Network (TUNe). MTC particpates in the Colorado Medical Society's Disaster Preparedness Program by contacting volunteer providers in the event of a large scale disaster. In addition we collaborate with CMS every six month in testing the response time of the volunteer providers.

Terri L. Schreiber is a community volunteer for the Colorado Consortium for Prescription Drug Abuse and a parent coordinator for Drug Prevention at the Challenge School in Cherry Creek School District.

Colorado Medicine for September/October 2017

Timeline of action steps to address the opioid epidemic in Colorado

Colorado stakeholders have been working to address the epidemics of prescription drug misuse and abuse for three decades, with activities ramping up in recent years.

1986

• Colorado Prescription Drug Abuse Task Force is established

2011

• Data shows that Colorado ranks second among all states for self-reported nonmedical use of prescription drugs among youth and young adults; more than 255,000 Coloradans misuse prescription drugs, and deaths involving the use of opioids nearly quadruple between 2000 and 2011

January 2013

• CMS Board of Directors designates the opioid crisis a high priority, commits full support to the governor in his effort to lead the fight, and refers the issue to the workers’ compensation committee and 10 special advisors to lead the CMS effort

April 2013

• Hickenlooper convenes Colorado in-state policy academy

September 2013

• CMS House of Delegates approves the policy “Public Health and Safety Challenges of Treating Chronic Pain: The Medical Perspective” and establishes the CMS Committee on Prescription Drug Abuse • The Colorado Consortium for Prescription Drug Abuse Prevention is established

2007

• Colorado Prescription Drug Monitoring Program (PDMP) is enacted and begins operation

October 2012

• National Governors Association sponsors policy academy on reducing prescription drug abuse

March 2013

• Colorado Gov. John Hickenlooper convenes Colorado roundtables on reducing prescription drug abuse • CMS publishes Colorado Medicine dedicated to the prescription drug abuse issue: “Where does it hurt? Curbing abuse and preserving patient care”

May 2013

• Stakeholders meet to review and finalize the Colorado Plan to Reduce Prescription Drug Abuse

January 2014

• Committee on Prescription Drug Abuse holds first meeting • The CMS board approves committee members of the CMS Committee on Prescription Drug Abuse and commits full support and cooperation to the consortium

May 2014

• Colorado General Assembly passes HB 14-1207, “Household Medication Take-back Program,” creating a permanent infrastructure to collect and dispose of unused household medications • General Assembly passes HB14-1283, “Modify Prescription Drug Monitoring Program,” updating the PDMP to bring it up to national best practice standards demonstrated to decrease doctor-shopping and reduce prescription drug abuse

November 2016

• At the request of CMS President Katie Lozano, MD, FACR, the CMS board designates the opioid crisis as one of the top three issues of her presidential year

May 2017

• Opioid and Other Substance Use Disorders Interim Study Committee is established to study prevention, intervention, harm reduction, treatment and recovery support strategies for opioid and other substance use disorders in Colorado

August 2017

• The Committee on Prescription Drug Abuse meets to consider new policies and examine and re-consider some current policies

• Interim committee holds second meeting; CMS President Katie Lozano, MD, FACR; CMS liaison Don Stader, MD; and Shannon Jantz, MD, testify before the committee • Interim committee holds second and third meetings

February 2015

• Take Meds Seriously public awareness campaign launches

July 2016

• President Barack Obama signs into law the Comprehensive Addiction and Recovery Act (CARA), S. 524 and H.R. 953, bipartisan legislation that opens new funding streams in the fight against prescription drug abuse

February 2017

• The Committee on Prescription Drug Abuse meets with Kyle Brown, PhD, senior health policy advisor to Gov. Hickenlooper, and Larry Wolk, MD, MSPH, to identify and recommend mechanisms to accelerate current efforts to combat the opioid crisis

July 2017

• Interim committee holds first meeting • CMS board adopts new policy, “155.990 Opioid Prescribing and Treatment Guidelines for Emergency Departments” on emergency department opioid prescribing and treatment guidelines

Colorado Medicine for September/October 2017

Features

Non-opioid pain treatment Jonathan Clapp, MD, Board Certified, Physical Medicine and Rehabilitation, and American Board of Pain Medicine, Physician Pain Consultants, LLC

Using “rational polypharmacy” to control pain with opioid alternatives Preliminary data indicate that drug overdose deaths increased 19 percent from 2015 to 2016 despite increased regulatory control and awareness surrounding the opioid epidemic in the United States. The need for improved education is paramount in limiting potentially dangerous opioids while providing adequate pain relief for the millions of people who struggle to meet vocational and family responsibilities because of their pain. Per population, the rate of drug overdose deaths are almost 2.5 times higher than that of our neighbors to the north in Canada. A contributor is almost surely the difference in hours of standardized pain training in medical schools between the U.S. and Canada (9 hours vs. 19.5 hours on average). The purpose of this article is to outline the utility and importance of non-opioid pain management, otherwise known as “rational polypharmacy.” Getting the right diagnosis A correct diagnosis is paramount in any medical condition before one can determine treatment. Accepting a diagnosis from another provider can be misleading and not in the patient’s best interest. An appropriate and detailed history, physical exam and review of any old records, including diagnostic tests or imaging, is paramount on the first visit. Characteristics of pain are also useful in determining the type of pain, which are treated very differently. Nociceptive pain is involved in inflammation, post-surgical, post-physical trauma, etc. It is typically any of the following: sharp, stabbing, dull, achy, etc. Neuropathic pain is typically burning in nature and can have a pins and needles component with shoot-

ing and can be in a nerve root, peripheral nerve or (in the case of peripheral neuropathy) a stocking-glove distribution. Central pain is more elusive and can involve large parts of the body. The muscle pains in fibromyalgia are an example, but can be burning, dull and achy as well. The mantra for treating biomechanical pain is: If you have a structural or mechanical problem, it needs to be addressed structurally or mechanically. This is often a life-long commitment. For example, for low back pain, focus on muscle groups affecting spine that provide better mechanical support (multifidi, transversus abdominis), abdomen, pelvis, thighs, etc. Focus on proper alignment and distribution of forces across the back, such as limb length discrepancies, flat feet, scoliosis and poor posture. In the last few years, literature has been able to quantify the impact of depression, anxiety and PTSD on pain. For example, a patient with depression or anxiety is two to five times more likely to be on chronic opioids at six months than a patient without, despite the same orthopedic surgical procedure. Catastrophizing (defined as an irrational fear of post-op pain and/or disability) is seven times more powerful than any other predictor in predicting the transition from acute to chronic pain, or being on opioids six months after a procedure. The importance of psychology and perception are huge factors that need to be addressed to best treat pain. Opioid alternatives The most accepted psychological mo-

Colorado Medicine for September/October 2017

dality for treating pain is cognitive behavior modification (CBT) that teaches self-coping statements and problem-solving cognitions in attempts to alter one’s perception of their chronic disease. This can include strategies of imaginative inattention, imaginative transformation of pain, focused attention and somatization in a dissociation manner. The “operant” approach of CBT reinforces good behavior and ignores adverse pain behavior. Exercises should be done at a level to avoid “punishment” for activity, reinforce the positive and reward the patient for achieving goals. Biofeedback teaches muscle relaxation and self-regulation of pain. Other treatments include imagery, hypnosis, meditation and diaphragmatic breathing. Literature shows positive effects in chronic low back pain, fibromyalgia, headache and temporomandibular disorders. Regarding pharmacology, there is strong evidence supporting the use of non-opioids for pain and some have been quantified as to how many morphine equivalents each can reduce over 24 hours. For example: 1000 mg of IV acetaminophen every four hours results in 6-9 mg less morphine consumption in 24 hours. Ibuprofen 400 mg daily, celecoxib 200400mg daily and diclofenac 30-60mg per day all resulted in 10.2 mg less morphine consumption. Gabapentin 300-1,200 mg per day also decreased 24-hour morphine consumption by 13-32 mg in 24 hrs. Pregabalin had a dose dependent reduction in morphine (i.e. less than 300 mg/d and greater than 300 mg/d equaled 8.8 mg and 13.4 mg less morphine in 24 hours, respectively.

Features b. “Rational polypharmacy” is considered better treatment for patients suffering with pain than one or two opioids alone. c. Nociceptive pain is characterized by burning, electric, pins and needles, and shooting pains. d. A structural or mechanical problem should be managed with injections or medications only.

Supplements can also be relatively safe and effective. The NIH has developed a website that is updated frequently and is a great resource: (https://nccih.nih. gov/health/herbsataglance.htm). For example, s-adenosylmethionine (SAMe) is shown to be as effective as celecoxib in knee osteoarthritis after two months of treatment and as effective as tricyclic antidepressants in treatment of depression. Omega-3 supplementation at 2.7g per day of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) improves pain in rheumatoid arthritis, osteoarthritis and irritable bowel syndrome after three months (recommend at least twice a day dosing). Turmeric, bromelain and ginger up to 4 grams/ day in divided doses are also shown to be effective. And for neuropathic pain, alpha-lipoic acid up to 600mg/day in divided doses has shown benefits in (diabetic) peripheral neuropathy.

3. Based on current literature, which of the following is NOT considered an appropriate treatment for chronic pain? a. Cognitive behavioral modification b. Opioid treatment greater than 500mg morphine equivalents per day c. Omega-3 supplementation d. Treating with optimal function being the primary goal

The challenges remain for us to limit opioids while still treating pain and maximizing function for our patients with pain. Advances need to be made in standardized medical education and development of new non-opioid pain medications. It is important to use what we already have and understand how these can benefit our patients. n Study questions: 1. The average time spent on pain education in U.S. medical schools is: a. 3 hours b. 6-9 hours c. 20 hours d. 30 hours 2. Which of the following is TRUE? a. Accepting a diagnosis from a specialist should be accepted even if the patient is not getting better. 20

4. Which of the following has NOT been shown to decrease total daily opioid consumption? a. Gabapentin b. Acetaminophen c. Celecoxib d. Tapentadol 5. TRUE or FALSE: A patient with depression or anxiety is two to five times more likely to be on chronic opioids at six months than a patient without, despite the same orthopedic surgical procedure. Sources • Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med 2003; 349:1943-1953. • Bruera E, Macmillan K, Hanson K, et al. The cognitive effects of the administration of narcotic analgesics in patients with cancer pain. Pain 1989; 39:13-16 • Chabal C, et al. Narcotics for chronic pain. Yes or no? A useless dichotomy. APS Journal 1992; 1(4):276-281. • Ciccone DS, Just N, Bandilla EB, et al. Psychological correlates of opioid use in patients with chronic nonmalignant pain: a preliminary test of the downhill spiral hypothesis. J Pain Symptom Manage 2000; 20:180-192.

• Clinical Guideline Subcommittee on Low Back Pain; American Osteopathic Association. American Osteopathic Association guidelines for osteopathic manipulative treatment (OMT) for patients with low back pain. J Am Osteopath Assoc. 2010 Nov;110(11):653-66. • Colorado Dept. of Regulatory Agencies. Open Letter to the General Public on the Quad-Regulator Joint Policy for Prescribing and Dispensing Opioids. October 15, 2014. • Goldberg RJ, Katz A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. J. Pain 129 (2007) 210-223 • h t t p s : / / w w w . n y t i m e s . c o m / interactive/2017/06/05/upshot/opioidepidemic-drug-overdose-deaths-arerising-faster-than-ever.html?mcubz=0 • Mezei, L. et al. Pain Education in North American Medical Schools. The Journal of Pain. Vol. 12, Issue 12. Dec, 2011. Pgs 1199-1208 • National Institute of Health. National Center for Complementary and Alternative Health. https:// nccih.nih.gov • Najm WI, et al. BMC Musculoskelet Disord. 2004 Feb 26; 5:6) (Role of Sadenosyl-L-methionine in the treatment of depression: a review of the evidence 1, 2, 3, 4 American Journal of Clinical Nutrition, Vol. 76, No. 5, 1158S-1161S, November 2002© 2002). • Stambaugh JE. Pharmacokinetics and mechanisms of action of analgesics in clinical pain. J Clin Pharmacol 1981; 21:S295-S298. • U.S. Department of Health and Human Services. Acute pain management: operative or medical procedures and trauma. Clinical Practice Guidelines Feb 1992. • Williams GW. Identifying appropriate patients for NSAIDS. CMEZone. com Sept. 2007. • Zacny JP. A review of the effects of opioids on psychomotor and cognitive functioning in humans. Exp Clin Psychopharmacol 1995; 3:432-466.

ANSWERS: 1. B 2. B 3. B 4. D 5. True

Nutrition also plays a role in pain management. Vitamins D, B12, B6 and essential fatty acid deficiencies can cause pain. Excess Omega-6 fatty acids without appropriate balance with Omega-3 fatty acids results in inflammatory mediators that are more reactive. Pro-inflammatory foods include foods high in Omega-6 fatty acids, such as red meat, vegetable oil, dairy and tomatoes to name a few.

Colorado Medicine for September/October 2017

Features Harm reduction philosophy reduces negative consequences of drug use Don Stader, MD

Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. The approach is predicated on respecting patients and their choices, removing stigma, and discussing with patients ways that they can keep safe and reduce risk if they choose to continue using drugs. Harm reduction aims to prevent the spread of infection, including HIV/ AIDS, hepatitis B and C, sepsis, soft tissue infections and endocarditis; reduce the risk of overdose and other drug-related fatalities; and decrease the negative effects drug use may have on individuals and communities. Initially developed in response to the US AIDS epidemic, the harm reduction philosophy has been used in recent years for the treatment of people who inject drugs; however, its principles are broadly applicable to most patients who abuse drugs. Injection drug use is intertwined with the growing opioid epidemic; roughly 75 percent of injection heroin addictions originate with prescription opioids. Significant risks are associated with this behavior, as injection drug use accounts for between 12 percent and 26 percent of new HIV diagnoses and the majority of new hepatitis C infections. Rates of Hepatitis C in Colorado have increased by 80 percent from 2011 to 2015, demonstrating the need for medical providers to take a more proactive approach. For many clinicians, that may involve introducing harm reduction techniques into their practice. Four ways to implement harm reduction in your practice: 1. Judge not: Patients who abuse

opioids should be managed without judgment; addiction is a medical condition and not a moral failing. Caregivers should endeavor to meet patients â&#x20AC;&#x153;where they are,â&#x20AC;? infusing empathy and understanding into the patient/medical provider relationship. A patient who believes that their doctor is judging them is unlikely to be open to counseling. 2. Know how to inject drugs safely: Clinicians should be well-versed in the safe injection of heroin and other intravenous drugs, and understand the practical steps for minimizing the dangers of overdose, infection and other complications. When treating patients with complications of IV drug use, injection habits should be discussed in detail, unsafe practices should be identified and instruction should be given about safe practices. A good video introduction to safe injection can be found at: www.youtube.com/ watch?v=Miv8i-slK2w and more in-depth counseling advice can be found in the Colorado ACEP Opioid Guidelines available online at www. coacep.org. 3. Refer patients who inject drugs to syringe access programs: Local syringe access programs can be life changing. These facilities provide sterile injection materials and support services such as counseling, HIV/hepatitis testing and referrals to recovery centers. They are great public health partners, and medical practices should encourage their use for appropriate patients. 4. Embrace naloxone: High-risk patients such as those who are being treated for an overdose, are on high doses of daily prescription opioids, abuse prescription opioids or inject drugs should be provided naloxone. A best practice is to provide naloxone prior to discharge for high-risk patients. In Colorado,

Colorado Medicine for September/October 2017

Naloxone is available via a standing order at most Colorado pharmacies. However, providing a prescription to a patient or their family member can be a powerful motivator for a patient to follow through and fill their prescription. 2017 Colorado Syringe Access Locations 1. Harm Reduction Action Center 231 E. Colfax Ave. Denver, CO 80203 303-572-7800 2. Denver Colorado AIDS Project 2480 W 26th Ave., Ste. B-26 Denver, CO 80211 303-837-0166 3. Jefferson County Public Health Clinic 645 Parfet St. Lakewood, CO 80215 303-271-5700 4. Access Point Pueblo (available Fridays only) 505 West 8th St. Pueblo, CO 81003 719-621-1105 5. Aurora Syringe Access Services 1475 Lima St. Aurora, CO 80010 (Only available Wednesdays 1-3:30 pm.) 6. The Works 3450 Broadway Boulder, CO 80304 (303) 413-7533 7. Northern Colorado AIDS Project 400 Remington, Ste. 100 Fort Collins, CO 80524 (970) 484-4469 8. Rocky Mountain Morpheus Project 414 Taos St., #B Georgetown, CO 80444 720-401-6569 (Syringe services not currently offered at this site.) 9. West Colorado AIDS Project 805 Main St. Grand Junction, CO 81501 (970) 243-2437

Features

Thoughtful prescribing Kathryn Mueller, MD, MPH, FACOEM

Using the most effective treatments for chronic pain According to the Institute of Medicine, chronic pain affects an estimated 100 million American adults – more than the total affected by heart disease, cancer and diabetes combined. Thus a patient presenting with chronic pain is a common occurrence for many physicians, especially in primary care settings. Opioids are the most powerful analgesics, and their use in acute pain and moderate-to-severe cancer pain is well accepted. However, their use in chronic pain is controversial due to limited effectiveness and documented rates of overdose and death. A study on chronic nonspecific low-back pain offers strong evidence that the short and intermediate term reduction in pain intensity of opioids, compared with placebo, falls short of a clinically important level of effectiveness1. In fact, opioids may not be the most effective medication for many chronic pain patients, and understanding this can change physicians’ prescribing patterns and shape their conversations with patients. In chronic pain situations, the physician faces the challenge of establishing a care plan that addresses the many available treatment combinations and the individual patient’s specific goals for improvement. When considering pain management options, active therapy is an essential component. Regular exercise, especially outdoors, is shown to decrease both depression and chronic pain. Most chronic pain patients suffer from some level of anxiety or depression, and sleep deprivation. It is important to identify these issues during the initial assessment and address them as part of the treatment plan. Cognitive behavior 22

therapy is effective for depression and anxiety as well as sleep disorders. The physician can then look to other options such as mindfulness, acupuncture or yoga, all of which have some evidence supporting their use – depending on the interest of the patient2. Helping the patient choose appropriate physical and cognitive activities is important for recovery. It is essential that the patient and provider understand the type of pain the patient is experiencing and how the pain affects his or her daily activities. The goal is to get the patient active again and participating in his or her life. Some patients with chronic pain avoid exercise and physical activity because they are concerned about the pain it initially causes. The physician may wish to provide some examples of how pain can lead to successful physical performance. For example: “If you wanted to learn to ski, what would you do? You would get up and practice. Then what would happen? Your muscles would hurt but that would show you that you are making progress toward your goal, and eventually, as you become more successful, the pain would decrease. Perhaps you are having pain in your back and there are some agerelated changes to your back on X-ray. Some people with those changes have pain and others do not. It is likely that when you increase the muscle strengthen in the areas supporting your spine, your back pain will decrease. However, to do that you will naturally have some pain in your muscles as you strengthen them.” If the physician adds medication to the

management plan, neuropathic pain much first be ruled out as opioids are less effective. If the pain is primarily non-neuropathic pain and other nonopioid medications and treatment have been ineffective, a physician may decide to try opioids. An opioid trial should be set up like any other drug trial. The initial conversation is extremely important to avoid problems later. Be up front and honest. • Explain that opioids do not work for many people and that use of opioids leads to side effects such as constipation, sexual dysfunction and sleep apnea. Most studies show that only around 50 percent of patients tolerate opioid side effects and receive an acceptable level of pain relief. As long as the patient demonstrates objective functional benefits, such as ability to work, assist their family and/or participate in recreational activities, you will continue to prescribe medication and work to decrease the side effects of the opioid. • Explain that there are precautions against driving and that the patient cannot work in a job that requires driving during initiation of the trial or while escalating doses. The patient should also not use opioids if he or she works in a safety-sensitive job such as operating a forklift or roofing. • Establish reasonable expectations, telling the patient that if the opioid does not work to improve function, he or she will be gradually tapered from the opioid as in any other medication trial. The end point is not total absence of pain but rather returning to function in life. If he or she isn’t getting more out of life and is sleeping excessively or not exercis-

Colorado Medicine for September/October 2017

Features ing, that is not an outcome you can prescribe for and it will be time to switch. • Explain that your job as a physician is not to manage the opioid; the goal is to make the patient healthier. Opioids are a small factor in this equation and do not work for all patients in this situation. • There is no magic pill; a combination of therapies is needed to address chronic pain. Most patients will cooperate with the treatment plan if they haven’t been introduced to opioids before, aren’t specifically seeking them and have a guided discussion with the doctor as outlined above. When confronted with a “problem patient” who may be opposed to trying other options or reluctant to stop an opioid that isn’t working, the physician can continue to focus on their job to make the patient healthier. Thus evidence that the opioid isn’t beneficial will require a change of course. These patients may be inherently harder to

...there is a fatal overdose in Colorado every 9 hours and 24 minutes?

manage, especially if their initial introduction to opioids was managed poorly.

without the use of opioids. All of these are acceptable treatment patterns.

Continue to work to change the patient’s mindset, explaining that the problem is that chronic pain is preventing him or her from enjoying the things the physician and patient identified together as the patient’s chosen goals. This is the problem they will solve together.

The main goal is promoting shared decision-making and helping patients identify their goals. They should have verbalized actionable items to which they are attached and that can be used as treatment goals. To stay home and to not have pain are not realistic treatment goals! n

There are a variety of reasons a physician might taper a patient off of an opioid and start over, especially in cases where a patient has become less functional than would be expected for the injury involved. If you plan to taper the opioid, explain that you want to get the right plan in place and figure out what’s best for the patient. Many people who cease taking an opioid never go back because they feel much better off of opioids. Once the patient is off of opioids and compliant with the other elements of chronic pain treatment, the physician must decide if he or she is willing to put the patient back on the same or a different opioid or if the other elements of treatment are sufficiently successful

Source: http://stoptheclockcolorado.org.

...that nearly half of all opioid overdose deaths in the United States involve a prescription opioid? Source: CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov.

References 1. Abdel Shaheed, C., Maher, C. G., Williams, K. A., Day, R., & McLachlan, A. J. (2016). Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med, 176(7), 958-968. doi:10.1001/ jamainternmed.2016.1251 2. Draft Chronic Pain guidelines: www. colorado.gov/pacific/sites/default/ files/2017_Chronic_Pain_exhibit_9. pdf

...there has been a 183% increase in drug overdose deaths involving both prescription opioids and benzodiazepines?

Source: http://www.sciencedirect.com/ science/article/pii/S0749379715001634

WHAT CAN YOU DO AS A PROVIDER?

• Talk with your patients about alternatives to opioids. • Talk with your patients about safe use, safe storage and safe disposal. More than half (55%) of people who abuse prescription opioids get them free from family or friends (i.e., unlocked medications). • Use extreme caution when co-prescribing opioids and benzodiazepines. • Consider writing a prescription for naloxone with your opioid prescription.

Colorado Medicine for September/October 2017

Features

The “ALTO” approach Rachael W. Duncan, PharmD, BCPS, BCCCP

Incorporating opioid-sparing options into various treatment pathways Using non-opioids to address pain management is a novel strategy called Alternatives to Opioids (ALTO). The first Colorado ALTO programs were implemented under the direction of the Colorado Hospital Association and Colorado ACEP in eight emergency departments throughout the state in spring of 2017, the first multi-center effort of its kind. ALTO recommends using opioids infrequently, primarily as second-line treatments, and only after effective non-opioid alternatives have been trialed. Such programs are not exclusive to the ED setting. Many of the concepts are applicable to inpatient practice, as well as in the community for outpatient providers (see table 1: Opioid Alternatives at Discharge). Through education and partnerships within the community, an ALTO-based multidisciplinary approach can transform pain management practice in Colorado. Treatment goals • Utilize non-opiate approaches as the first-line therapy • Utilize opioids as a second-line treatment • Opioids can be given as rescue medication • Discuss realistic pain management goals with patients • Discuss addiction potential and side effects with those using opioids The ALTO program utilizes the CERTA concept: channels, enzymes, receptors, targeted, analgesia. The CERTA concept optimizes the following medication classes in place of opioids: Cox-1, 2, 3 inhibitors, NMDA receptor antagonists, 24

sodium channel blockers, nitrous oxide, inflammatory cytokine inhibitors and GABA agonists/modulators. Specific agents include NSAIDs and acetaminophen, ketamine, lidocaine, nitrous oxide, corticosteroids, benzodiazepines and gabapentin. The protocol targets multiple pain receptors, making use of non-opioid medications, trigger-point injections, nitrous oxide, and ultrasound-guided nerve blocks to tailor a patient’s pain management needs and substantially decrease opioid use. Examples of this approach include: • Treating renal colic with intravenous lidocaine; • Managing acute lower-back pain with a combination of oral non-opioids and topical pain medications with directed trigger-point injections; • Treating extremity fractures with ultrasound-guided nerve blocks; and • Using an algorithm to manage acute headache/migraine pain with a variety of non-opioid medications. Only if patients’ pain is not adequately managed using ALTO techniques are opioids used as a rescue medication. Alternative medications Ketamine Ketamine has been used extensively in the emergency department for procedural sedation and rapid-sequence intubation. Recent research has demonstrated that a low (subdissociative) dose (0.1-0.3 mg/ kg IV) is safe and effective for pain management. Due to the relatively short-lived analgesic effects of ketamine, the initial bolus can be followed by an infusion of 9-30 mg/hour for sustained effect.

Lidocaine Lidocaine is an ideal agent for treating visceral and central pain, and also may be useful when narcotics are inefficient or lead to undesirable side effects. Intravenous or topical (5 percent transdermal patch) doses are effective for controlling renal colic and neuropathic pain associated with conditions such as diabetic neuropathy, postoperative or postherpetic pain, headaches, and neurological malignancies. Topical lidocaine also is an appropriate treatment for low back pain and can be prescribed as the 5 percent patch OR found over the counter as the 4 percent patch. Side effects of the drug are minimal when used sparingly. Trigger-point injections A focal area of spasm and inflammation (e.g., trapezius, rhomboid, low back) can be associated with chronic myofascial pain syndrome. Palpation of the trigger point should fully reproduce pain, which may be referred to other areas (e.g., nodule or taut band of spasm). Dry needling will cause a disruption of the spastic feedback loop by interrupting abnormal activity in the sensory and motor nerve endings and muscle fibers. Using local anesthetics such as bupivacaine or lidocaine for this procedure often resolves pain and decreases soreness. Indications for this approach include a palpable, taut band or nodule, reproducible pain with palpitation, or a chronic painful condition. Trigger point injection has also been found to be a successful treatment strategy for migraines. Nitrous oxide Nitrous oxide is a tasteless, colorless gas

Colorado Medicine for September/October 2017

Features

Table 1: Opioid alternatives at discharge Headache12: For acute attacks: • Sumatriptan 100 mg • Acetaminophen/Aspirin/Caffeine (Excedrin Migraine) • Acetaminophen 1000 mg every 6 hours • DHE 2 mg nasal spray • Naproxen 500-550 mg twice daily • Metoclopramide 10 mg every 6 hours • Ibuprofen 600 mg PO every 6 hours

Uncomplicated neck pain5: • Acetaminophen 1000 mg every 6 hours • Ibuprofen 600 mg every 6 hours • Cyclobenzaprine 5 mg every 8 hours • Physical therapy • Lidocaine 5% patch Q12 hours

Uncomplicated back pain6,7: • Acetaminophen 1000 mg every 6 hours • Ibuprofen 600 mg every 6 hours • Lidocaine 5% patch Q12 hours For prevention: • Diclofenac 1.3% patch TD twice • Propranolol 40 mg BID daily • Divalproex DR 250 mg twice daily • Diclofenac 1% gel 4 g four times OR ER 500 mg daily daily PRN Cyclobenzaprine 5 mg • Topiramate 25 mg at bedtime PO three times daily • Magnesium supplementation 600 • Heat mg daily • Physical therapy • Exercise program Sore throat: • Ibuprofen 600 mg every 6 hours Simple sprains: • Acetaminophen 1000 mg every 6 • Immobilization hours • Ice • Dexamethasone 10 mg once • Ibuprofen 600 mg every 6 hours • Viscous lidocaine • Acetaminophen 1000 mg every 6 hours Fibromyalgia3,4: • Diclofenac 1.3% patch TD twice • Cardiovascular exercise daily • Strength training • Diclofenac 1% gel 4g four times • Massage therapy daily PRN (need more)8 • Amitriptyline 10 mg at bedtime • Cyclobenzaprine 10 mg every 8 Contusions9: hours • Compression • Pregabalin 75 mg twice daily • Ice • Ibuprofen 600 mg every 6 hours 1. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache. 2015 Jan;55(1):3-20. 2. Matchar DB et. al. Evidence-Based Guidelines for Migraine Headaches in the Primary Care Setting: Pharmacological Management of Acute Attacks. American Academy of Neurology. 3. Chinn S, Caldwell W, Gritsenko K. Fibromyalgia pathogenesis and treatment options update. Curr Pain Headache Rep. 2016; 20-25. 4. Goldenberg DL, Burckhardt C, Crof-

ford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17;292(19):2388-95. 5. Schnitzer, TJ. Update on guidelines for the treatment of chronic musculoskeletal pain. 25 (Suppl 1), Clin Rheumatol. 2006;25 Suppl 1:S22-9 6. McIntosh G, Hall H. Low back pain (acute). Clin Evid (Online). 2011;05:1102. 7. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3). 8. Derry S, Moore RA, Gaskell H, McIntyre M, Wiffen PJ. Topical NSAIDs for acute musculoskeletal pain in adults. Co-

Colorado Medicine for September/October 2017

• Acetaminophen 1000 mg every 6 hours • Lidoderm 5% patch Non-traumatic tooth pain10: • Ibuprofen 600 mg every 6 hours AND • Acetaminophen 1000 mg every 6 hours • (clove oil, other topical anesthetics?) Osteoarthritis11: • Diclofenac 50 mg every 8 hours • Naproxen 500 mg twice daily • Celecoxib 200 mg daily • Diclofenac 1.3% patch TD twice daily • Diclofenac 1% gel 4 g four times daily PRN • (topical NSAIDs, capsaicin?) Undifferentiated abdominal pain: • Dicyclomine 20 mg every 6 hours • Ibuprofen 600 mg every 6 hours • Acetaminophen 1000 mg every 6 hours • Metoclopramide 10 mg every 6 hours • Prochlorperazine 10 mg every 6 hours Neuropathic pain: • Gabapentin 300mg at bedtime • Amitriptyline 25 mg at bedtime • Pregabalin 75 mg twice daily chrane Database Syst Rev. 2015. 9. Jones P, Dalziel SR, Lamdin R, MilesChan JL, Frampton C. Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury. Cochrane Database Syst Rev. 2015 Jul 1. 10. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions. JADA. 2013; 898-908. 11. da Costa, Bruno R et al. Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network metaanalysis The Lancet. 2016. 2093-2105.

ALTO approach (cont.) administered in combination with oxygen via mask or nasal hood at a maximum concentration of 70 percent. Featuring a rapid onset and elimination (<60 sec), the agent contains both analgesic and anxiolytic properties. It typically is used in combination with a local anesthetic or other pain medications. Pulse oximetry is the only patient monitoring required. There are no NPO requirements, patients can drive after administration and no IV line is needed. There is solid evidence to support its role in the management of pediatric pain and sedation, prehospital pain relief, colonoscopy, and bronchoscopy. Indications for the use of nitrous oxide include laceration repair, incision and drainage, wound care, foreign body removal, central venous access, peripheral venous access, fecal disimpaction, and as an adjunct for dislocations and splinting. Haloperidol Haloperidol is a â&#x20AC;&#x153;typicalâ&#x20AC;? or first-generation antipsychotic agent. It can be administered intravenously, intramuscularly and orally and often is used for the treatment of psychiatric emergencies.

The drug also can be used in low doses as an adjunct treatment for pain and nausea. At doses of 2.5 to 5 mg, haloperidol is effective for the management of abdominal pain and migraine-associated headaches. All medical providers should be familiar with the ALTO approach by learning new skills such as trigger-point injections and the appropriate administration of medications such as ketamine, haloperidol, lidocaine (IV and topical), gabapentin and NSAIDs. While not all treatment options can be utilized in the outpatient setting (i.e. lidocaine IV and ketamine IV), many of these strategies can still be used (i.e. trigger-point injection for back pain, nitrous oxide for a painful procedure, oral and topical options described). 1. For musculoskeletal pain, consider a multimodal treatment approach using acetaminophen, NSAIDs, steroids, topical medications and low-dose ketamine. Trigger-point injections also can be considered. 2. For headache and migraine, consider a multimodal treatment approach that

includes the administration of antiemetics, valproic acid, steroids and triptans. Strongly consider administering a cervical or trapezius triggerpoint injection. 3. For pain with a neuropathic component, consider gabapentin. 4. For pain with a tension component, consider a muscle relaxant. 5. For pain caused by renal colic, consider an NSAID, lidocaine infusion and DDAVP nasal spray. 6. For chronic abdominal pain, consider low doses of haloperidol, dicyclomine, diphenhydramine and lidocaine infusion. 7. For extremity fracture or joint dislocation, consider the immediate use of nitrous oxide and low-dose ketamine while setting up for ultrasound-guided regional anesthesia. 8. For arthritic or tendinitis pain, consider an intra-articular steroid/anesthetic injection. See table 2: Pain Pathways by Indication (opposite page) for specific pathways and medication doses for each indication. n

Colorado Medicine for September/October 2017

Features

Table 2: Pain pathways by indication

Colorado Medicine for September/October 2017

Features

Specialty focus: Surgery Saurabh Saluja, MD, MPP, Don Selzer, MD, FACS, John G. Meara, MD, DMD, MBA, FACS, Kathleen Heneghan, PhD, RN, PN-C and John M. Daly, MD, FACS, FRCSI(Hon)

Individual strategies for surgeons to combat the opioid epidemic Editor’s note: This is an excerpt of the article, “The opioid epidemic: What can surgeons do about it?” originally published in the American College of Surgeons Bulletin, July 2017, Volume 102, Issue 7, Pg. 1317. It has been reprinted with permission. The opioid epidemic – and particularly the role of prescription drugs – is a nationwide crisis3 and surgeons can play a role in curtailing it. First, we must be aware of the existing resources to help curb opioid overuse. Current mechanisms for monitoring, counseling and treating patients across the continuum of care can help minimize risk to our patients and our communities. Preoperative management The surgeon’s role in addressing the opioid epidemic starts during the preoperative period by setting patient expectations and assessing the potential risk for opioid misuse or addiction.8 A candid preoperative discussion with patients about the pain they can expect as a result of their procedure can help set expectations postoperatively, specifically the fact that the patient will not immediately (or perhaps ever) reach zero on the pain scale. This discussion should include information about the potential benefits of non-opioid analgesics. Additionally, this preoperative conversation is an opportunity to discuss the adverse systemic effects of opioids as well as the fact that opioids are unsuitable for treating all types of pain. Beyond these conversations, surgeons should also check prescription drug monitoring programs (PDMPs) as part of their routine preoperative practice. 28

These statewide registries collect information on the distribution of controlled substances and can help health care professionals determine an individual patient’s pattern of prescription drug use. PDMPs are used to track opioid prescriptions in some manner in all states except for Missouri. More than 30 states require prescribers to check the PDMP if certain conditions are met, although these conditions vary by state.9 These databases, in conjunction with risk screening tools such as the Brief Risk Inventory, will allow surgeons to better identify patients at high risk for opioid abuse and tailor their prescribing behavior accordingly.10 A review of the CDC Guidelines for Prescribing Opioids on Chronic Pain – United States 2016 provides a good resource to identify high-risk populations and those with the highest risk of abuse and mortality.11 Inpatient management The immediate postoperative period is a critical time when the patient’s need for analgesia is greatest and a pattern of the provider’s prescribing behavior is established. For a patient in the hospital, continued management of expectations regarding pain is important. Establishing realistic expectations involves a multidisciplinary approach with physician providers (surgeons, anesthesiologists, residents and physician delegates) and allied health care providers (pharmacists, registered nurses and social workers) playing an important role in this process. Although the assessment of pain as a “fifth vital sign” has gained widespread

use, it must not be blindly used to determine whether and how much of an opioid should be prescribed.12 A patient with a high pain scale may benefit from a discussion with the nurse and surgeon about the nature of postoperative pain and the associated expectations and management. Additionally, surgeons are using multimodal therapies to manage pain, including applying local analgesics directly into the surgical site and maximizing the use of oral nonopioid analgesics such as nonsteroidal antiinflammatory drugs and acetaminophen. In addition, use of epidural analgesia and long-acting nerve blocks are important tools for postoperative management. Ultimately, consultation with an inpatient pain management team may be warranted. Guidelines on the Management of Postoperative Pain developed by the American Pain Society and endorsed by numerous societies can help in this decision-making.13 Outpatient management Upon discharge, patients assume management of their opioid use. In this setting, surgeon-prescribers can control the total amount but not the frequency of drug administration. To help control use, surgeons must be judicious in the amount of opioids they prescribe and avoid prescribing additional doses or refills “just in case” the patient feels they need more intense or extended drug therapy. Whereas pain is subjective and can vary substantially from individual to individual, the use of specialty or procedure-specific guidelines can help inform surgeons, physician extenders

Colorado Medicine for September/October 2017

Features and residents regarding what constitutes appropriate prescribing behavior. For patients requiring more opioid pain relief than expected, in-person consultation allows for objective assessment of the patient, consideration of alternative explanations for the pain, and reevaluation of the PDMP before represcribing opioids. Some states have established legal limits on the amount of opioids that can be prescribed, which would supersede any hospital-based guidelines. In 2016, states began limiting the length of opioid prescriptions. Connecticut, Maine, Massachusetts, New York and Rhode Island passed laws limiting initial prescriptions to seven days. Vermont passed a law that requires the state health department to set an opioid prescribing limit through the regulatory process in consultation with the Vermont Medical Society.9 Whenever patients administer their own opioids in an unmonitored setting, patients and their caregivers must be educated on safe administration and disposal. The Centers for Disease Control and Prevention and the U.S. Surgeon General have released opioid prescribing guidelines to turn the tide on addiction. While the guidelines are

designed for treatment of chronic pain, and surgeons more commonly treat acute pain, several points are noteworthy. Specifically, surgeons must consider the effects of polypharmacy on their patients and continue to work with the American College of Surgeons to identify best practices for patients already managing opioid addictions and those receiving methadone, as well as patients on high-risk medications such as benzodiazepines. For patients who suffer from chronic pain and who may be receiving particularly high doses of opioids (greater than 50 morphine milligrams equivalents daily or approximately 10 tablets of 5 mg hydrocodone daily), the U.S. Surgeon General recommends offering a Naloxone prescription for accidental overdose.14 n References 3. Centers for Disease Control and Prevention. Drug overdose death data. Available at: www.cdc.gov/ dr ugoverdose/data/statedeaths. html. Accessed May 18, 2017. 8. Kaafarni HMA, Weil E, Wakeman S, Ring D. The opioid epidemic and new legislation in Massachusetts: Time for a culture change in surgery? Ann Surg. 2016;265(4):731-733. 9. Liepert AE, Ackerman TL. 2016 state legislative year in review and

a look ahead. Bull Am Coll Surg. 2016;101(12):35-39. 10. Jones T, Moore T, Levy JL et al. A comparison of various risk screening methods in predicting discharge from opioid treatment. Clin J Pain. 2012;28(2):93-100. 11. Centers for Disease Control and Prevention. Guidelines for Prescribing Opioids on Chronic Pain– United States 2016. Available at: www.cdc.gov/mmwr/volumes/65/ rr/rr6501e1.htm. Accessed May 29, 2017. 12. Hanks S. The law of unintended consequences: When pain management leads to medication errors. Pharmacy and Therapeutics. 2008;33(7):420-425. 13. Chou R, Gordon DB, de LeonCasasola OA, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, executive committee, and administrative council. J Pain. 17(2):131-157. 14. Murthy VH. Ending the opioid epidemic–A call to action. N Engl J Med 2016;375(35):2413-2415.

Colorado Medical Political Action Committee Call 720-858-6327, 800-654-5653, ext. 6327, or email susan_koontz@cms.org Colorado Medicine for September/October 2017

Features

Specialty focus: Pediatrics Jean K. Rex, MD

The opioid epidemic and the newborn patient While the current opioid epidemic has had a devastating effect on the adult population, an increasing number of children have also become victims, especially infants. Recent studies have found that 14-28 percent of pregnant women filled a prescription for an opioid medication during their pregnancy1,2. The effect of ongoing opioid use can be hazardous to the pregnant mother and fetus, with complications including increased incidence of preterm birth, low birth weight and neonatal abstinence syndrome1. Neonatal abstinence syndrome (NAS) is a constellation of symptoms found in the newborn who was exposed to opioids in utero. It was first described by Hippocrates in the 5th century B.C., but became more clearly defined in the medical literature in the 1970s3. Since the advent of the current opioid epidemic the rates of NAS have soared, increasing five-fold from 2000 to 20124,5. By 2012 the rate of NAS was 5.8/1000 live births, and accounted for over $1.5 billion in hospital charges annually5. While more recent data is not yet reported, the rates in the past five years have likely continued to grow. Providers who care for newborns should pay close attention to the mother’s obstetrical chart for documentation of antenatal opioid use so that at-risk infants can be closely monitored for signs of NAS (see table). Symptoms of opioid withdrawal may not be apparent at birth, but usually emerge in the first four to five days of life, often necessitating a prolonged period of monitoring in the hospital after birth. Mothers who combined opioids with 30

sedative medications or those on highdose methadone during pregnancy may have infants with delayed onset of symptoms taking up to two weeks before the withdrawal symptoms become apparent3. There is a higher risk of NAS symptoms if the mother also had a concomitant history of tobacco or selective serotonin reuptake inhibitor use during pregnancy. Short-acting opioid preparations and longer cumulative opioid exposure are also related to increased incidence of NAS2. Infants noted to be at risk for NAS should be monitored closely using a scoring system such as the modified Finnegan system, which includes recommendations for supportive care of the infant and possible medical intervention for infants with more severe symptoms of withdrawal. In-hospital management of these infants includes maternal urine toxicology screen, infant urine and meconium, or cord blood toxicology screens to help confirm the diagnosis. Case Management consultants are vital in their roles of counseling families about the risks of opioid use to the whole family, providing resources to families affected by opioid use, and involving child protective services if needed, if there is a positive drug screen or the infant has symptoms of NAS. For infants who show signs of NAS, there are several non-pharmacologic strategies to help relieve symptoms. Infants should be swaddled, kept in a dimly-lit and quiet room with minimal stimulation. In recent years many newborn nursery units have begun the practice of infants rooming-in with

Table: Symptoms associated with Neonatal Abstinence Syndrome Central nervous system: • Excessive crying • High-pitched cry • Sleep disturbance • Hyperactive Moro reflex • Tremors • Increased muscle tone • Excoriation • Myoclonic jerks • Seizures Metabolic/ vasomotor/ respiratory systems: • Sweating • Hyperthermia • Yawning • Mottling • Nasal stuffiness • Sneezing • Nasal flaring • Elevated respiratory rate Gastrointestinal system: • Excessive sucking • Poor feeding • Vomiting • Diarrhea • Poor weight gain their mothers as much as possible. One study showed that parental presence at the bedside of infants with NAS symptoms led to significantly decreased NAS scores and shorter opioid treatment duration for those with more severe NAS scores6. Breastfeeding should be promoted for

Colorado Medicine for September/October 2017

Features all infants with NAS, unless otherwise contraindicated in the mother, such as in the case of maternal HIV infection. In fact breastfeeding can help decrease NAS symptoms in infants and decrease the need for pharmacologic treatment of NAS7. Even mothers who are undergoing treatment for opioid addiction, such as those on long-term methadone, can breastfeed their babies, as the low levels of methadone transmitted across the breastmilk may help alleviate withdrawal symptoms.

ioral or attention problems, cognitive deficits and sleep disturbances9. The risk of hospital readmission is higher in infants treated for NAS, as are the chances of child abuse and neglect1. It is hoped that through a concerted public health effort to reduce the prevalence of opioids in our population, as well as the efforts of individual health care providers, we will soon see the numbers affected by opioid addiction decrease in the tiniest members of our communities. n

Infants with moderate to severe NAS scores may benefit from pharmacologic treatment to decrease the symptoms of withdrawal by providing a slow wean from the medication. Infants are typically treated with oral morphine or methadone, but some studies are emerging that suggest buprenorphine, often used in addicted pregnant women, may be efficacious for infants as well8. For infants with refractory symptoms, phenobarbitol or clonidine can be added to improve the effects of medication and shorten treatment duration. Infants on pharmacologic treatment should continue to be followed for symptoms of NAS once stable on treatment and while medications are weaned.

References: 1. Pryor JR, Maalouf FI, Krans EE, et al. The opioid epidemic and neonatal abstinence syndrome in the USA: a review of the continuum of care. Arch Dis Child Fetal Neonatal Ed 2017; 102: F183-F187. 2. Patrick SW, Dudley J, Martin PR, et al. Prescription opioid epidemic and infant outcomes. Pediatrics 2015; 135 (5): 842-850. 3. McNett W. Chapter 56: Neonatal abstinence syndrome. In: Zaoutis LB, Chiang VW, eds. Comprehensive Pediatric Hospital Medicine. Philadelphia: Mosby; 2007: 286-290.

An infant can usually be discharged home once he or she is off medications without evidence of moderate to severe NAS symptoms for 48 hours, has achieved good oral intake of breastmilk or formula, has shown good weight gain, has been cleared by social services, and close follow up has been arranged. Occasionally infants are sent home to continue a medication wean with close supervision by the pediatric provider. The mean length of stay in the hospital for an infant on pharmacologic treatment is 23 days, a significant increase in hospitalization length and costs compared to the typical infant discharged between one and four days after birth5. The long-term prognosis for infants treated for NAS has not been studied extensively. Even with successful treatment mild symptoms may continue for up to four months3. Long-term effects include possible vision, motor, behav-

4. Corr TE, Hollenbeak CS. The economic burden of neonatal abstinence syndrome in the United States. Addiction 2017; 112 (9):15901599. 5. Patrick SW, Davis MM, Lehman CU, et al. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009-2012. J Perinatol 2015; 35 (8): 650-655. 6. Howard MB, Schiff DM, Penwill N, et al. Impact of parental presence at infantsâ&#x20AC;&#x2122; bedside on neonatal abstinence syndrome. Hosp Pediatr 2017; 7 (2): 63-69. 7. Welle-Strand GK, Skurtveit S, Jansson LM, et al. Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr 2013; 102 (11):1060-1066. 8. Kraft WK, Adeniyi-Jones SC, Chervoneva I, et al. Buprenorphine for the treatment of the neonatal abstinence syndrome. N Engl J Med 2017; 376: 2341-2348. 9. Maguire DJ, Taylor S, Armstrong K, et al. Long-term outcomes of infants with neonatal abstinence syndrome. Neonatal Netw 2016: 35 (5): 277-286.

All friends of medicine are eligible to participate. Email susan_koontz@cms.org or call 720-858-6327 or 800-654-5653, ext. 6327

Colorado Medicine for September/October 2017

www.cms.org/advocacy/sdc

Features

Specialty focus: Obstetrics Kaylin Klie, MD, MA

Lesley Brooks, MD

Opioid use in pregnancy: High risk and high reward In parallel with the national opioid epidemic, opioid use in pregnancy has increased dramatically in the last decade. Pregnant women with substance use are an important population in which to emphasize screening, brief intervention and referral for further assessment and treatment. Pregnancy provides an important opportunity to identify and offer treatment to women who are typically highly motivated for help. Here are some basic recommendations to help improve our identification and assistance provided to pregnant women with substance use. Screening In alignment with statements from the American College of Obstetricians and Gynecologists and the American Society of Addiction Medicine, universal screening for substance use in pregnancy is recommended as part of comprehensive prenatal care. SBIRT (screening, brief intervention and referral to treatment) is an evidenced-based in-office modality to assess for substance use1. Screening must be universal, as opposed to screening based only on factors (scant prenatal care, poverty, etc.), as this type of stereotyped screening can lead to missed opportunities as well as perpetuation of stigma. As substance use disorders are known to be distributed across all racial, ethnic and socioeconomic groups, so must our screening be made available to all pregnant women2. There are several validated screening tools for use in pregnancy, including the 4Ps, CRAFFT (ages <26), etc. Diagnosis Opioid use disorder is a pattern of opioid use that is characterized by cravings, impulsive use and continued use despite harm or consequence. While tolerance 32

and dependence are expected physiological adaptations to repeated opioid exposure, and certainly are typically present in women with opioid use disorders, they may also be found in women without opioid use disorder as well. For this reason, a diagnosis should also depend upon DSM-V specific criteria as above, as well as opioid interference in roles: social problems or inability to fulfill obligations at work, home or school. Many women with opioid use disorder describe using opioids as a “full-time job,” as the shortacting nature of most opioids of abuse require frequent dosing throughout the day, as well as activities necessary to raise adequate funds to ensure a continuous supply to prevent withdrawal. Chronic pain Not all opioids utilized in pregnancy are illicit. As the overall amount of opioids prescribed for pain in the United States has increased, so has opioid prescribing increased for pregnant women. In 2007, 22.8 percent of women enrolled in Medicaid across 46 states filled an opioid prescription during pregnancy3. Similar to recommendations for the treatment of chronic pain in non-pregnant people, providers who care for pregnant women with chronic pain are encouraged to discuss goals with the patient, including risks and benefits of continuing chronic opioid therapy in pregnancy. Some women elect to reduce or discontinue opioids for chronic pain in pregnancy due to risk for neonatal abstinence syndrome and concern about safety in breastfeeding. For some women, the functional benefit of continuing chronic opioid therapy must be considered. Whether the decision is made to continue chronic opioid therapy, strategies to increase alternative pain therapies should be implemented:

exercise, physical therapy and nonopioid pharmacotherapies. Treatment If a woman is screened and there is concern of clear evidence for opioid use disorder, a referral to treatment should not be delayed and should be independent of a woman’s decision to continue the pregnancy. Addiction treatment specialists can then assist a woman in making treatment decisions that are right for her, and meet her level of severity of disease. Medication-assisted treatment with methadone or buprenorphine is considered standard of care4. For patients who live in areas with limited or no access to specialty addiction care, referral should be made to a qualified provider who can address the substance use issues. A local data-waived physician may have these qualifications. Physicians engaged in the care of obstetric patients are strongly encouraged to obtain a DATA 2000 waiver and partner with their local community mental health centers to deliver the mental health services so critical to this population. Detoxification alone has been demonstrated to result in unacceptably high rates of relapse, overdose and death when compared to MAT5-6. Naltrexone has not been studied enough at this time for use in pregnancy. Providers should also provide naloxone overdose reversal kits to pregnant women; although severe precipitated withdrawal could contribute to fetal distress, naloxone should never be withheld in the event of maternal overdose, and should be used to potentially save the woman’s life. A note about CPS Colorado is a state where reporting to Child Protective Services (CPS) for substance use during pregnancy is not man-

Colorado Medicine for September/October 2017

Features datory for a person with no other children in the home. Mandatory reporting is required when the pregnant person has other children in the home whose safety may be compromised because of ongoing drug use. Likewise, a positive urine drug screen at the time of delivery in the hospital will likely trigger a duty to report by the hospital staff. Notably, the pregnant person who is compliant with treatment and is otherwise stable does not require reporting. CRS 13-25136 protects pregnant persons from being criminally penalized by the results of drug and alcohol screenings obtained during prenatal care, though this may not protect them if they are involved in abuse/neglect proceedings. It goes without saying that many pregnant persons may be concerned about the potential for communication with and involvement by government entities that could result in separation from their children. The physician’s role here is clear, with supportive documentation where possible and early and direct communication as needed. When reporting is required, the CPS team would benefit from understanding the level of substance use, willingness to engage in treatment and compliance with the current treatment regimen. If a woman is already involved with CPS, communicating her engagement in treatment to her case manager may be of value to the patient and to the CPS team. Labor and delivery The labor and delivery team will benefit from awareness of the patient’s involvement in treatment. She will receive the best care possible when all team members are aware of her treatment plan. Communication with anesthesia and the labor and delivery team in developing the plan of care for pain management is critical. While maintenance on buprenorphine or methadone during labor and delivery is reasonable, the plan for pain management needs to be individualized7. Setting clear expectations and providing reassurance that your patient’s pain will be managed appropriately with proactive planning is of great importance to her. A meeting with the anesthesiologist prior to delivery would be ideal.

Breastfeeding Methadone and buprenorphine are both safe in breastfeeding. Women who have no other contraindication to breastfeeding, such as HIV positive or ongoing substance use, should be supported and encouraged to breastfeed. Even though methadone and buprenorphine may cause Neonatal Abstinence Symptoms in the newborn, NAS is an expected, temporary and treatable condition that at this time does not appear to have any longer-term effects on the child’s future growth and development. The possibility of NAS occurring is not a reason to avoid providing medication-assisted treatment to pregnant and mothering women. Conclusion As our understanding of opioid dependence and its attendant treatment evolves, so must the care of vulnerable populations who present with this diagnosis. We now know that opioid replacement therapy in pregnancy is safe and can be highly effective in fostering maternal recovery, healthy parenting and re-establishing the family unit. n References: 1. Wright TE, et al. The role of screening, brief intervention, and referral to treatment in the perinatal period. American Journal of Obstetrics and Gynecology. 2016; 11: 539-547.

2. American College of Obstetricians and Gynecologists. Opioid Use and Opioid Use Disorder in Pregnancy. ACOG Committee Opinion no. 711. Obstet Gynecol 2017; 130:e81-94. 3. Desai RJ, Hernandez-Diaz S, Bateman BT, Huybrechts KF. Increase in prescription opiid use during pregnancy among Medicaid-enrolled women. Obstet gynecol 2014;123:997-1002. 4. Center for Substance Abuse Treatment. Medication-assisted treatment for opioid addiction during pregnancy. In: Medication addicted treatment for opioid addiction in opioid treatment programs. Treatment Improvement Protocol (TIP) Series, No. 43. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005. P211-24. 5. Jones HE, Terplan M, Meyer M. Medically assisted withdrawal (detoxification): Considering the mother-infant dyad. J Addic med 2017; 11:90-2. 6. Saia KA, Schiff D, Wachman EM, Mehta P, Vilkins A, Sia M, et al. Caring for pregnant women with opioid use disorder in the USA: Expanding and improving treatment. Curr Obstet Gynecol rep 2016;5:257-63. 7. Jones HE, et al. Treatment of Opioid Dependent Pregnant Women: Clinical and Research Issues. J Subst Abuse Treat 2008;35:245–59

Now scheduling Regional Forums across the state! Colorado Medical Society leaders are ready to travel to your community for a homegrown meeting open to all physicians. CMS will work with you or your component society to plan and execute the event. Email president@cms.org or call 720-858-6321

Colorado Medicine for September/October 2017

Features

Consortium update Robert Valuck, PhD, RPh, FNAP

Colo. Consortium for Prescription Drug Abuse Prevention celebrates early successes, looks to increase impact The Colorado Consortium for Prescription Drug Abuse Prevention was created in the fall of 2013 to establish a coordinated, statewide response to the major public health problem of prescription drug abuse. The mission of the consortium is to reduce the abuse and misuse of prescription drugs in Colorado through development, coordination and implementation of policies and programs. Work on this issue began 30 years prior through the Colorado Prescription Drug Abuse Task Force, and it was this group that was responsible for advocating for the establishment of the Colorado Prescription Drug Monitoring Program (PDMP) in 2005. Efforts to reduce prescription drug abuse increased dramatically in 2012 when Colorado Gov. John Hickenlooper chaired a task force on reducing prescription drug abuse through the National Governors Association. NGA resources enabled stakeholders to pursue statewide strategic planning on prescription drug abuse. Completed in May 2013, the Colorado Plan to Reduce Prescription Drug Abuse was handed to the Colorado Prescription Drug Task Force for implementation and the task force was renamed the Colorado Consortium for Prescription Drug Abuse Prevention. Since its founding, the consortium has served as a backbone for the effort, providing infrastructure and support to link the many agencies, organizations, health professions associations and societies, task forces and programs that were addressing the 34

prescription drug abuse problem but were doing so in relative isolation and without the benefit of an organized, coordinated approach. What began with 150 individuals has now expanded to 450 people with vast professional and lived experience. The consortium is housed administratively in the Skaggs School of Pharmacy and Pharmaceutical Sciences at the University of Colorado Anschutz Medical Campus. This year the General Assembly passed Senate Bill 17193 to establish a center for research into substance use disorder prevention, treatment and recovery support strategies at the University of Colorado Anschutz Medical Campus. The bill appropriates $1 million to establish or expand programs for research, innovative treatments for substance use disorders, expand partnerships and collaboration throughout the state and nation, and seek federal and private resources to further research activities. The consortium includes experts from the Anschutz Medical Campus health professional schools and colleges, and leaders from key agencies and organizations in Colorado that comprise work groups responsible for implementing the major initiatives outlined in the strategic plan. The original five initiatives were health care provider education, public awareness, safe disposal, PDMP improvements, and research/data sharing. Four more groups were added as needs arose: improving access and referrals to treatment, increasing awareness of and

access to naloxone, advocating for affected friends and family, and heroin response. Each work group is co-chaired by two experts from state agencies, community organizations or the university. The Colorado Medical Society has been an active participant and strong supporter in the consortium since the beginning and CMS-member physicians and staff are present on each work group. Through the collective work of consortium partners we have experienced several major, early successes. Take Med Seriously is a statewide marketing campaign and public outreach effort, which includes the website TakeMedsSeriously.org. The campaign educates consumers on safe use, safe storage and safe disposal, and provides physician practices and pharmacies with customizable handouts and other durable materials. Sister program TakeMedsBack.org provides resources related to safe disposal. Colorado is the only state in the country that funds permanent takeback locations. The program is run through the Colorado Department of Public Health and Environment and the consortium is working to establish a drop box in every county of the state by the end of the year; currently 42 counties out of 64 are represented, with 80 boxes in the 42 counties. Another success has come through provider education. More than 2,000 prescribers have taken online courses

Colorado Medicine for September/October 2017

Features developed, promoted and offered in partnership with the University of Colorado, including “The Opioid Crisis: Guidelines and Tools for Chronic Pain Management,” and several hundred have taken in-person courses offered by expert faculty who travel across the state to educate their peers. Finally, naloxone access has increased dramatically due to the work of the consortium. Currently more than 400 pharmacies and more than 125 police and sheriff’s departments have naloxone that did not have it one year ago. And thanks to a standing order written by Larry Wolk, MD, MSPH, CDPHE executive director and chief medical officer, any Colorado citizen can walk into one of more than 430 pharmacies around the state and fill a prescription to access naloxone.

the workgroups say we should do and the workgroups are comprised of interested stakeholders from across the state. We’re working on a collective vision by bringing experts to the table in an open, collaborative, transparent process. We believe the best solutions are formed this way and we are excited to continue this important work. We have much more to do. We are redoubling our efforts and increasing our staff to support the work, and we look forward to continued collaboration with CMS and all of our partners. Together we will turn the tide on this problem, and make Colorado the healthiest state in the nation. n

AMA task force: Take six actions to help reverse the opioid epidemic 1. Register and use state prescription drug monitoring programs 2. Enhance education and training 3. Support comprehensive treatment for pain and substance use disorders 4. Help end stigma 5. Co-prescribe naloxone to patients at risk of overdose 6. Encourage safe storage and disposal of opioids and all medications

CMS .ORG ORG CMS CMS CMS.ORG ORG Colorado Medical Society

Every success of the consortium can be attributed to the work of our partners. The consortium only does what

Read more on www.end-opioidepidemic.org.

Lead the way HONE YOUR SKILLS WITH THE COLORADO MEDICAL SOCIETY PHYSICIAN LEADERSHIP SKILLS SERIES

As changes in Colorado health care accelerate, is more important have well-trained and active physician As changes in Colorado health care accelerate, it is moreitimportant Don’tthan missever thistoopportunity! leaders guiding the way. That is why the Colorado Medical Society is launching the Leadership Series than ever to have well-trained and active physician leaders guiding When was the last timePhysician you did something for Skills your professional and (PLSS) in January 2017. The series will feature eight innovative programs over the year aimed at deepening your the way. Thanks to a generous grant from the Physicians Foundation, personal well being? Now is the time to follow throughawareon the comness, developing crucial skillstoand equipping you with the toolsmitment and experience lead tomorrow’s health care to exthe Colorado Medical Society is proud present the Physician Leaderto yourselfyou andneed your to profession. Continue your journey in Colorado. ship Skills Series (PLSS) to help enhance physician leadership capacity cellence by developing and enhancing your leadership potential. Join in Colorado and provide current and emerging physician leaders with with like-minded colleagues in a dynamic and interactive series where the knowledge and skills they need to serve their patients, their pracleadership meets medicine. tice, their profession and their community. Programs are currently scheduled BLENDED CUTTING-EDGE MAKING THE in September and Registration is FREE and EXCLUSIVE to CMS memberPROGRAMMING physicians, resiNovember. Find more information at www.cms.org/events/ LEARNING MOST OF YOUR PLSSfor curriculum dents APPROACH and medical students. All programs will beThe eligible CME leadership-skills. PRECIOUS TIME was developed based PLSS uses short skills credit.This series will focus

Program Benefits

upon physician feedback and on knowledge and skills-based recognized gaps in physician development using dynamic There programming are three moreby programs remaining in the business, Physician management Leaderand leadership experts in the ship Skills Series. Each innovative program is aimed at deepening yourareas include skills. Key topic field who have years of experience teamwork, conflict awareness, developing crucial skillsEach and equipping you with thenegotiation, tools working with physicians. programyou canneed accommodate up to health management, and experience to lead tomorrow’s care in Colorado.facilitating meetings, persuasion, public speaking and best 100 physicians and participants can practices in board service. cycle in and out of programs based on interest and past experience.

Colorado Medicine for September/October 2017

sessions and experiential learning to provide a robust program with a manageable time commitment. The programs will be held at convenient times, like Saturday mornings in person around the state or weeknights via video conference, to minimize disruptions in your practice.

Colorado Medicine for September/October 2017

Features

Colorado leads opioid prevention Patrice A. Harris, MD, MA, AMA Opioid Task Force Chair

And it’s time to take the next step Physicians should be proud reading this issue of Colorado Medicine because it highlights the dedicated steps clinicians are performing daily to reverse Colorado’s opioid epidemic. This information, coming from state legislators, practicing physicians, leaders in harm reduction and other policy advocates, represents the forward momentum that is essential for Colorado’s long-term health. It also provides a backdrop as to why the state is seeing progress on several fronts. Physicians and other health care professionals used the Colorado state prescription drug monitoring program (PDMP) more than 1.5 million times in 2016 (a 122-percent increase from 2014), decreased opioid prescriptions by nearly half a million since 2013, and instituted one of the most wide-ranging naloxone access and Good Samaritan laws in the country. The AMA has commended the work of the Colorado Consortium for Prescription Drug Abuse Prevention, which is among the nation’s finest group of stakeholders working together to end harms from opioid-related misuse. As a public health physician, I know firsthand that working across disciplines throughout the community is the most effective way to achieve positive change. I am proud to say that these state-level efforts are also being seen across the country – with national PDMP use up 121 percent since 2014 to more than 136 million queries; and national opioid prescribing decreasing by nearly 17 percent since 2012. In addition, over the past two years, more than 100,000 physicians have taken continuing medical education and training courses related to opioid prescribing, pain

management, substance use disorders treatment and related topics. Every state now has a naloxone access law, and physicians are co-prescribing the life-saving opioid reversal drug more than ever before. To further encourage physicians to make use of PDMPs, to make available meaningful state- and specialty-specific education, and to become trained to provide in-office buprenorphine to patients, the AMA has launched a new opioid microsite (www. end-opioid-epidemic.org) that includes key resources specifically for Colorado physicians (www.end-opioid-epidemic. org/colorado). These are signs of progress, but we all know that this progress is tempered by the reality of opioid-related overdose and death. The AMA will continue to pursue implementation of the recommendations of our Opioid Task Force, but you will also see a renewed emphasis in three key areas that must occur to end this epidemic. First, we need to increase access to specialists in addiction medicine and pain. This will require policymakers and the health care community working together to increase the number of trained specialists. As provider network rules are enforced, advocates and policymakers need to consider alternative access plans that allow for timely access to care, especially in rural or isolated communities that are common in Colorado. That might mean that patients are able to see providers outside their network without being penalized, and that we consider additional, innovative ways to provide care for patients. When patients seek help for an opioid use disorder – or need comprehensive

Colorado Medicine for September/October 2017

care for chronic pain – care delayed often means continued harm, and in some cases, could mean the difference between life and death. This is critically important as more patients now are

“Physicians and other health care professionals used the Colorado state prescription drug monitoring program (PDMP) more than 1.5 million times in 2016 (a 122-percent increase from 2014), decreased opioid prescriptions by nearly half a million since 2013, and instituted one of the most wide-ranging naloxone access and Good Samaritan laws in the country.” dying from heroin and illicit fentanyl than from overdoses due to prescription opioids. Second, we need to remove administrative barriers that stand in the way of care. For example, health insurers should remove prior authorization requirements for medication assisted treatment (MAT) as well as address other similar barriers to non-opioid and

Colo. leads way (cont.) non-pharmacologic pain care. The evidence is unequivocal that MAT is effective and saves lives, and several national insurers have already taken steps to remove prior authorization barriers. All of Colorado’s insurers should follow suit. Finally, patients need access to MAT, as well as alternatives for pain management. As the nation seeks to change the paradigm for treating pain and encourages physicians to recommend all appropriate pain management modalities to patients, insurance plans need to cover those treatments. It is also critical that advocates seek enforcement of parity laws and other requirements concerning coverage of mental and behavioral health care. Stakeholders should consider the impact of benefit designs and patient cost-sharing on the affordability of treatments. Here in Colorado, employers need to recognize that patients may require time away from work to participate in therapeutic modalities so opioid analgesics are not the only affordable option. These three steps – improving access and availability to treatment for substance use disorders and pain; removing prior authorization for MAT; and increasing coverage for non-opioid pain therapies – are areas where physicians, policymakers and stakeholders can work together. The authors of the articles in this issue are leaders in reversing the opioid epidemic. The AMA stands ready to work with them – and all physicians in Colorado – to help get it done. n

www.cms.org/central-line

Colorado Medicine for September/October 2017

Features

Prescription drugs in Colorado Maria Butler, Katie Olson, Allison Rosenthal, Andres Guerrero and Lindsey Kato, CDPHE Prescription Drug Overdose Prevention Unit

Using the Prescription Drug Monitoring Program Nationally and in Colorado, opioid use disorders have emerged as a significant public health concern. Colorado’s prescription opioid related overdoses have quadrupled since 2000. Nearly 224,000 Coloradans misuse prescription drugs each year. For a majority of the past 15 years, Colorado’s drug overdose rate has been significantly higher than the national rate and opioid related overdoses represent a large portion of those deaths. To combat this epidemic, Colorado legislators passed a bill in 2014 that aligned Colorado’s Prescription Drug Monitoring Program (PDMP) with best practice strategies, such as: mandating registration for prescribers and pharmacies, daily reporting of controlled substances dispensed by pharmacies, allowing prescribers to delegate access to PDMP records and giving Colorado Department of Public Health and Environment access to PDMP data to provide population-level results. The Colorado PDMP is a secure database that collects information on schedule 2-5 controlled substance prescriptions dispensed by Colorado pharmacies. They are categorized into five classes: opioids, benzodiazepines, stimulants, sedatives and muscle relaxants. From 2014 through 2016, opioid prescriptions in Colorado represented a majority of prescriptions dispensed, and benzodiazepines represented about a quarter of all prescriptions. In 2016, the number of opioid prescriptions per recipient ranged from one to 184 (median=1.0; mean=3.8), and the number of opioid prescriptions per patient increased with age.

tices and patient behaviors that are associated with increased risk of overdose. According to the U.S. Centers for Disease Control and Prevention (CDC), potential risk factors for prescription drug misuse include high-dose prescribing, multiple provider episodes, long duration opioids, and overlapping opioid and benzodiazepine prescriptions. Understanding these risk factors and using the PDMP to assess them may help providers better assist their patients in pain management while protecting their health and safety. Risk factors for prescription drug misuse Patients receiving high dosage prescriptions Morphine is considered the standard measure for managing pain and is used as a reference for calculating opioid prescription doses. In 2014, the Colorado Quad-Regulator Boards of Dental, Medical, Nursing and Pharmacy suggested limiting dosages to less than 120 mg morphine equivalents (MME) per day to reduce negative outcomes, and in 2016, the CDC’s prescribing guidelines recommended opioid dosages not exceed 90 MME per day. Although there is variability regarding safe dosage thresholds, assessing dosage can help identify problematic prescribing practices and patients who may be at risk for substance use disorders. Multiple provider episodes (MPEs) The use of multiple prescribers and pharmacies is associated with highrisk, drug-related behaviors and adverse events. The number of prescribers and pharmacies a patient visits is often used

The information captured in the PDMP is useful in monitoring prescribing pracColorado Medicine for September/October 2017

Resources Violence and Injury Prevention Network: vipreventionnetworkco. com/p/prescription-drugoverdose.html Colorado Consortium for Prescription Drug Abuse Prevention: www.corxconsortium.org Colorado Prescribing Guidelines: www.colorado.gov/pacific/ dora/Medical_News CDC Prescribing Guidelines: http://dx.doi.org/10.15585/ mmwr.rr6501e1 Take Meds Seriously: http://takemedsseriously.org Rise Above Colorado: www.riseaboveco.org Colorado Department of Public Health and Environment Violence and Injury Prevention-Mental Health Promotion Branch Prescription Drug Overdose Prevention Unit: www.colorado.gov/cdphe/ pdo-prevention Email: cdphe_PDOinfo@ state.co.us

PDMP (cont.) as a proxy measure for “doctor shopping.” The CDC defines MPE as receiving opioid prescriptions from five or more prescribers and pharmacies in a six-month period. Patients prescribed long-acting/extended release (LA/ER) opioids who were opioid-naïve Opioid naïve patients may be more vulnerable to adverse effects of LA/ER opioids such as respiratory depression and overdose. For this metric, opioid naïve refers to patients who did not fill an opioid prescription in the previous 60 days. Time-scheduled opioids are associated with greater total average daily dosages and increased risk for long term use. Patients with overlapping prescriptions Both benzodiazepines and opioids are central nervous system depressants that can compromise the respiratory system. Benzodiazepines enhance the effects of opioids, so concurrent use

can increase the risk of adverse events. This indicator measures the duration of overlapping prescriptions. Longer duration of overlapping prescriptions may raise concerns of potential drug interactions and resulting side effects. In the wake of the opioid overdose epidemic, the PDMP has been identified as a promising practice to address prescription drug misuse and associated adverse health outcomes. However, safe prescribing of opioids should take a balanced approach and help preserve access to medications for the management of care and patient expectations while also decreasing the misuse and diversion of controlled substances. Use of the PDMP demonstrates Colorado’s efforts to improve the health of Coloradans through coordinated state and local efforts. For additional resources, including local data, please reference the following websites or contact the Prescription Drug Overdose Prevention Unit. n

Latest statistics for overdose deaths in Colorado Overdoses from prescription opioids in Colorado fell by about 9 percent in 2016, compared with 2015, from 329 deaths to 300, according to final numbers from the state. But heroin deaths rose sharply – more than 42 percent – from 160 deaths in 2015 to 228 deaths in 2016. That is an even bigger increase than what preliminary numbers showed five months ago. State health officials said the two trends could be the result of a crackdown on opioid prescribing in Colorado coupled with people who are addicted to the painkillers switching to heroin. For all of 2016, the death rate specifically from prescription opioid overdoses in Colorado was 5.3 out of 100,000 population, the lowest it has been since 2010. The death rate from heroin overdoses, though, was 4.1 per 100,000, substantially higher than it has been in any year in over a decade. In 1999, for instance, the heroin overdose death rate in Colorado was 0.9 deaths per 100,000 population.

Source: www.thecannabist. co/2017/08/08/drug-overdosedeaths-2016/85560/

Colorado Medicine for September/October 2017

Features

Physician health program Heidi Letko, LPC and Doris C. Gundersen MD

Addressing the opioid epidemic Much is known about the origins of the United States’ current opioid problem, with pharmaceutical companies and physician overprescribing widely to blame. It is important to remember that the pharmaceutical industry downplayed the risk for addiction with drugs such as Oxycontin, and the fifth vital sign was adopted in the 1990s, making pain treatment a priority for all patients. In 2000 the Joint Commission published a book citing studies suggesting that addiction was not a significant issue in patients prescribed opioids for pain control and that doctors’ concerns about addiction potential were inaccurate and exaggerated. (Note: The book was sponsored by Purdue Pharma). What has evolved in the last decade or more demonstrates that the concerns raised by physicians were indeed legitimate. Media coverage of the current opioid epidemic is at an all-time high with drug overdose now the leading cause of death for those under age 50 and opioids driving the crisis. In 2015, of the over 52,000 drug overdose deaths, 33,000 were related to prescription opiates or heroin. That number has continued to rise in both 2016 and 2017. In response to this crisis, pharmaceutical companies have begun to reformulate their drugs so as to make them less prone to abuse. State-legislated prescription drug monitoring programs were created and efforts were made to increase physician awareness with a new emphasis placed on alternative methods for the management of chronic pain, while restricting the use of narcotic analgesics for post-surgical and terminal pain. The Center for Disease Control’s recently disseminated guidelines for

treating chronic pain will be helpful in stemming the tide of over prescribing narcotic analgesics. The Colorado Physician Health Program (CPHP) has been addressing the crisis from two angles; helping the addicted physician and ensuring that those physicians who may be overprescribing are provided the education needed to responsibly treat their patients’ pain. CPHP has been evaluating, monitoring and advocating for physician health for more than 30 years. CPHP evaluates, on average, 300 new clients each year and actively monitors approximately 500 physicians and physician assistants at any one time. Of those 500 clients, 10-15% are monitored for substance use disorders, with 26% of those being monitored for opiate abuse. When CPHP identifies an active substance use disorder, recommendations for treatment include intensive outpatient or residential programs at facilities that specialize in treating physicians. Following successful completion of primary treatment, a physician’s aftercare typically includes 12 Step meetings, specialized physician support and treatment groups, individual treatment, and ongoing tissue testing so that relapses can be discovered early. Anesthesiologists and emergency medicine physicians are known to be at higher risk of opioid addiction (versus alcohol or other drugs) due to ready access to their drug of choice. Following treatment, returning to practice poses unique challenges for these recovering physicians. Opioid users have the highest rates of relapse and proximity

Colorado Medicine for September/October 2017

to their drug of choice places these physicians at significant risk. Additionally, the short half-life of certain opioids, such as fentanyl and sufentanil, can make urine drug screen testing alone inadequate. Therefore, physicians recovering from opioid use disorders also submit to quarterly hair or nail testing as these tests have a significantly longer, (three-month) window of detection.

“The Colorado Physician Health Program (CPHP) has been addressing the crisis from two angles; helping the addicted physician and ensuring that those physicians who may be overprescribing are provided the education needed to responsibly treat their patients’ pain.” Additionally, most of these specialists are prescribed the opioid antagonist naltrexone which can prevent death if a relapse occurs. With these provisions in place, physicians in recovery can practice medicine safely. Regardless of drug of choice, the recovering physician is monitored for approximately five years with an overall success rate of greater than 80 percent

CPHP (cont.) (successful program completion as well as continued ability to practice medicine). [Am J Addict 2012;21:327-334]. Recovery rates for the general population are considerably less favorable. Physicians in Colorado have the benefit of Safe Haven which allows physicians who are known to CPHP, and who are without legal history or adverse actions related to their health issue, to keep their health information private when applying or reapplying for licensure. This provision encourages individuals to proactively seek and receive the healthcare they need while receiving enough oversight from CPHP that the Colorado Medical Board (CMB) can be confident that the public is safe in the absence of knowing the monitored physicianâ&#x20AC;&#x2122;s personal health history. As a result of the opioid crisis, CPHP has also seen an increase in the number of physicians mandatorily referred for evaluation due to excessive prescribing. CPHP evaluates these physicians to rule out any health related problem. CPHP also makes recommendations for prescribing classes and other educational resources and guidelines. We conduct research, provide presentations about physicians who develop substance use disorders and also consult with workplaces contending with an ill or impaired physician. You can learn more about our program at www.cphp.org. n

Plug in to your reinvented medical society! Log on today to choose Interest Areas, submit policy proposals, and more. www.cms.org/central-line 42

Colorado Medicine for September/October 2017

Features

Utalizing risk management Steven Wright, MD

REMS is not a four-letter word In 2007 the FDA Amendments Act authorized the FDA to develop legally enforceable Risk Evaluation and Mitigation Strategies (REMS) for pharmaceutical companies to ensure safe medication use. Physicians, in turn, face certain downstream obligations when it comes to medication safety and responsible prescribing, especially when it comes to opioids. When the treatment of pain generators is unresponsive for more than three to six months, the chronic pain diagnosis is used to reflect the inability to heal; this occurs daily and indefinitely for 25 million Americans. The opium poppy has been known to provide analgesia for thousands of years and has received overamped accolades by many like Sir William Osler calling it “God’s own medicine.” Evidence of long-term efficacy, while generally considered insufficient, can be seen in clinical practice. However, the past injunctive to regard pain as a vital sign – misconstrued to demand opioids – paired with a disregard of addiction became a substrate for the current crisis.

problems / sexual trauma. Current use of addiction-prone substances is determined with drug testing, the online prescription drug monitoring program database (PDMP), and patient report (SBIRT: Screening Brief Intervention and Referral to Treatment) corroborated by family, friends and medical records. For those reporting substance use, secondary screeners can help determine problematic use of alcohol (Alcohol Use Disorders Identification Test, or AUDIT), cannabis (CUDIT), and other drugs (DUDIT). Risk for future opioid-related aberrancies can be addressed with imperfect screeners, such as the Screener and Opioid Assessment

for Patients with Pain (SOAPP), which has the best validation. Medical judgement takes all this into account to determine risk stratification, which assigns a level of controlled substance risk: low, intermediate or high. This estimate will, in turn, help determine the frequency and type of monitoring. If the risk is high, controlled substance use should proceed cautiously – if at all. If the decision is made to proceed with opioid therapy, risk mitigation is per-

What, then, are clinicians to do if opioids are to be considered at all? Risk management is a stepwise process that can reduce the likelihood of negative outcomes, and includes: 1. Risk Screening 2. Risk Stratification 3. Risk Mitigation 4. Risk Monitoring 5. Aberrancy Management Initial risk screening begins with identifying major risk factors: a personal and family history of substance use disorder, and a personal history of psychiatric Colorado Medicine for September/October 2017

Risk management (cont.) formed to minimize future risks by following these steps: 1. Goal setting for function and analgesia 2. Regular opioid sparing trials 3. Informed consent: risks, benefits, alternatives, use 4. Lowest opioid dose necessary, tracked by Morphine Equivalent Dose calculation 5. Abuse deterrent formulation considerations (debated) 6. Medication security (storage, disposal) instructions 7. Naloxone prescription with overdose rescue instructions 8. Controlled Substance Agreement outlining expected/prohibited behavior, monitoring permissions, and potential responses to aberrancies If the decision is made to prescribe opioids, then this should be done on a trial basis only and ongoing safe use should be addressed through risk monitoring, which includes: 1. Behavioral aberrancy surveillance through patient report and observation – the Clinical Opioid Misuse Measure is useful 2. Online PDMP review 3. Definitive drug testing 4. Pill counts 5. Screening with overnight oximetry for nocturnal hypoxia 6. QTc interval on the EKG if methadone is prescribed If opioid-related aberrancies are identified, then aberrancy management responses include: 1. Adherence coaching 2. Specialty referral: pain management, addiction, psychiatry 3. Opioid discontinuation 4. Discharge from the practice as a last resort Einstein once said, “Keep things as simple as possible…but not simpler.” This risk management model is trimmed to limit complexity without losing the best practice elements. Keep it simple by seeing patients monthly (rarely more often) to address the “5 A’s”: analgesia, adverse events, 44

activities of daily living (function), affect (mod) and aberrancies. Keep it simple by understanding and running interference on your own tendency to over- or undertrust, to over- or under-prescribe. Our obligation, though, is not so simple; overdose deaths rose 15 percent in each of the last two years for which we have data (2014, 2015). Disheartening, as there has been so much effort to reverse this trend. On the other hand, since in up to 80 to 95

percent of overdose fatalities there were indicators of addiction prior to death, thoughtful risk management – REMS – if widely employed, might play an important part in identifying those with Opioid Use Disorder, moving them off standard opioids, and assisting them into a recovery process, ultimately saving lives. Not too bad for a four-letter word. REMS: Don’t let patients head to the pharmacy without it. n

Identifying risky prescribing patterns and safe prescribing patterns Elizabeth S. Grace, MD, FAAFP, CPEP medical director RISKY prescribing behaviors Trust that every patient is being totally forthcoming about diagnosis, previous evaluation and prior treatment. Decide that it is not worth assessing risk of addiction until concerns arise.

Assume that the patient’s prior provider established an appropriate diagnosis and treatment plan. Skip checking the Prescription Drug Monitoring Database (PDMP) until concerns arise. Skip doing drug testing because you don’t want patients to think that you don’t trust them. Prescribe controlled substances to self or family. Prescribe escalating doses of opioids because the patient in not improving.

Fail to be vigilant for signs of diversion.

Sign prescriptions for (or give computer authentication to) your nurse to do refills while you are on vacation.

SAFE prescribing behaviors Trust, but verify. Obtain and review old records.

Routinely assess risk of addiction before initiating – even for shortterm prescriptions, which could potentially be enough to trigger an addiction in remission. As for any other condition, assess for legitimate treatment indications before adopting a prior clinician’s treatment plan. This is your patient now and it is your treatment plan. Routinely check the PDMP before prescribing. Establish office protocols for testing all patients receiving chronic opioids, with frequency based on risk. You and your family have established medical providers to address prescribing needs. Reconsider the diagnosis and/or treatment plan. Failure to respond to a reasonable trial of opioids may be reason to lower or discontinue an opioid. Do urine drug testing (ideally randomly) to identify inconsistencies and respond appropriately. Consider pill counts, if warranted. Get coverage during your time away.

Colorado Medicine for September/October 2017

Features

Facing scrutiny Elizabeth S. Grace, MD, FAAFP, CPEP Medical Director

Peer review and regulators “I got a letter in the mail from the board – I was totally shocked. A patient’s mother filed a complaint saying that I got her son addicted to opioids, and the board requested several charts.” These are the words of a physician, recently referred to the Center for Personalized Education for Physicians (CPEP) after being sanctioned by their licensure board for prescribing inappropriately. (Details altered to protect identity.) CPEP is a Colorado-based not-for-profit that has been helping physicians since 1990 through educational needs assessments, targeted remedial education, reentry programs and continuing medical education seminars. While the majority of our programs are open to all physicians, most assessment-program participants are referred by licensure boards and, currently, approximately one-third of our assessmentprogram referrals are for physicians who have had concerns raised about controlled substance prescribing. Most of the referred physicians are aware of the current concerns about opioid prescribing and the opioid epidemic, but they do not believe that their prescribing habits are any different from their colleagues, and are surprised by the board’s inquiry. Others admit that they may have been uncomfortable with some of their prescribing but felt that they were doing the best they could for their patients with the resources available. Legislation in Colorado prohibits the medical board from reviewing the Prescription Drug Monitoring Program

(PDMP) to identify the state’s highest prescribers; board inquiries are prompted by specific triggers – such as NPDB reports or complaints filed with the board, as in this physician’s case. Once an investigation has been initiated, if adequate cause exists, the board can subpoena a clinician’s PDMP record and identify the patients of highest concern.

approach is not being used) is not evident from the record. Other things that might attract the attention of someone reviewing a medical record would include: prescribing opioids for vague or ill-defined purposes and prescribing for conditions for which opioids are not generally recommended, such as migraine or fibromyalgia.

“It seems that they were interested in patients who were on higher morphine equivalent doses and those on combinations of benzodiazepines and opioids.”

“When they looked at my records, they were concerned about my electronic medical record documentation. They couldn’t understand why I was increasing doses of certain patients and they couldn’t tell how I was responding to abnormal results. More precisely, to them it looked like I wasn’t doing anything when patients had ‘unexpected’ urine drug test results.”

Prescribing guidelines published in the recent past do not agree on what thresholds of dosing should prompt higher levels of screening and caution, but they all acknowledge the increased mortality risk for patients on higher overall doses of opioids; therefore it is not surprising that these patients get a lot of attention. For example, in Colorado the Policy for Prescribing and Dispensing Opioids from 2014 states that morphine milligram equivalents (MMEs) over 120 are “more likely dangerous” and warrant additional precautions including consideration of referral. More recently the CDC guidelines recommend careful reassessment at doses over 50 MME and avoidance of doses over 90 MME. In addition, since the FDA’s “black box” warning about and the CDC recommendation against co-prescribing of opioids and benzodiazepines, licensing boards and other overseeing entities will raise concerns about clinicians who have a significant number of patients on both agents, especially if the rationale for doing so (and why an alternative

Colorado Medicine for September/October 2017

While this is not a problem unique to electronic medical records, our observation at CPEP is that the EMR format may make it more difficult for clinicians to document their clinical rationale – which is so important when anyone else is reviewing a record, be it the licensing board or a physician consulting on a patient’s case. Furthermore, it is more variable in how, where and whether a clinician documents things that occur outside of an office visit in an EMR – for example, documentation of a phone call with a patient to discuss a urine drug test result delivered to the physician in paper format one or two days after the patient has been seen. In a paper record, there are few options; in an EMR there may be several op-

Scrutiny (cont.) tions and they may not be easy to find (or print out in response to a records request).

Case study: Swedish Medical Center is reducing opioid use in the emergency department

“I was working at the Quick-Fix Clinic back then. It is an absolutely toxic work environment. I can’t take good care of patients in a 10-minute visit. On top of all that, the clinic’s top opioid prescriber retired and I inherited all of his pain patients. I should have left months before I did.”

Reducing our reliance on opioids is more than simply saying “stop.” Providing alternatives to providers is essential. At Swedish Medical Center, our emergency department has implemented a set of opioidalternative pathways to give providers the tools to treat pain effectively but also expose fewer patients to the potentially harmful effects of opioids.

There are “environmental” influences that impact our ability to do a good job as clinicians. These range from practice environments that might pressure us to see many patients, patient satisfaction scores that subliminally influence physicians to want to make their patients leave the office happy, isolated practices in which clinicians lose sight of the evolution of good practice, or personal and financial stressors that distract us from our work. Clinicians will benefit from developing an awareness of personal vulnerabilities and when they may be impacting practice. Physicians generally have good instincts and if your gut feeling is that a practice is not a good fit for you, the best way to keep out of the sights of the licensing board and to protect your license (and your patients) may be to pay attention to that little voice inside your head. n

Erik Verzemnieks, MD

Many conditions have more effective analgesic options than opioids, making implementation common sense. Intravenous lidocaine combined ketorolac is an effective way to control the pain of renal colic. Musculoskeletal pain, including back pain, can be treated with ketamine, lidocaine patches, and trigger point injections. In headaches, opioids can be detrimental, and there are many effective options ranging from simple high-flow oxygen to haloperidol and valproic acid. Though there is an emphasis on opioid alternatives, opioids do have a continued role in pain control in the emergency department. But with multiple alternatives now available to our providers, we are

beginning to see many fewer indications where opioids are first-line or even required. Now we are not alone in this endeavor. Several other emergency departments and hospitals throughout the state have joined in a pilot study to assess the effectiveness of these alternative pathways. These include Boulder Community Health and BCH Community Medical Center Emergency Room, Gunnison Valley Health, Medical Center of the Rockies, UCHealth-Greeley Emergency and Surgery Center, Poudre Valley Hospital, UCHealth Emergency Room-Harmony, Sedgwick County Health Center, Sky Ridge Medical Center and Yampa Valley Medical Center. It will be exciting to see the results of these interventions as we all work to fight the opioid epidemic and provide better care to our patients throughout Colorado. For those interested in learning more about these pathways, they are outlined in the most recent Colorado ACEP 2017 Opioid Prescribing and Treatment Guidelines. Find the guidelines online www.coacep.org.

Join Now!

Colorado Medical Political Action Committee Call 720-858-6327, 800-654-5653, ext. 6327, or email susan_koontz@cms.org 46

Colorado Medicine for September/October 2017

Features

Controlled substances Elizabeth S. Grace, MD, FAAFP, CPEP Medical Director

A practical approach to avoiding the pitfalls of prescribing Providing care that incorporates best practices and current clinical guidelines and appropriately documenting that care will achieve the dual goals of providing safe care for your patients and protecting yourself. Here are some practical tips to help you stay on course. Note: While these tips are primarily directed at primary care physicians and other non-pain management physicians, for the most part they represent generally good approaches to care that transcend specialty. • Independently and objectively evaluate all patients, including patients who present with established diagnoses and treatment plans. Don’t presume that the previous physician conducted a thorough evaluation and formulated a thoughtful treatment plan. Review old records. • Assess for risk of abuse before prescribing and periodically thereafter. Several risk tools are available, such as the Opioid Risk Tool (ORT), Screener and Opioid Assessment for Patients with Pain (SOAPP®-R), and Current Opioid Misuse Measure (COMM). • Establish measurable functional treatment goals for chronic pain patients (e.g., to be able to walk for 15 minutes three days a week) and educate patients that pain is not likely to be completely eliminated by any treatment, including opioid therapy. • Know your state (DORA QuadRegulator Joint Policy for Prescribing and Dispensing Opioids) and national (CDC Guideline for Prescribing Opioids for Chronic Pain) guidelines. See links below. • Obtain a urine drug test before prescribing and at least annually, as recommended in the CDC guidelines. Most providers will test more fre-

•

quently, commensurate with the patient’s level or risk. Random testing is typically more effective in identifying aberrancies. Document/include results in the chart. These should be actual results, not just your interpretation. CDC guidelines also recommend that you check the prescription Drug Monitoring Program before prescribing and at least every three months thereafter. Consider checking the PDMP even before prescribing acute, short term opioids - particularly if it is for a new patient. Utilize controlled substance agreements to educate patients about risks and establish expectations for both parties. Having an agreement in place can make it easier for you to respond to aberrant behaviors because the patient has had fair warning of potential consequences. At follow-up visits, update the history and conduct physical exams at appropriate frequency. It is easy to convince oneself that an exam is not necessary for a stable patient, but periodic exam is warranted to justify ongoing treatment. At each follow-up visit, document the 5 As: Activity – progress toward patient-specific functional goals; Analgesia – is the medication helping?; Adverse effects – side effects of opioids such as sedation, constipation, etc.; Aberrant behaviors – requests for early refills, unexpected urine drug testing results, etc.; and Affect – mood changes, presence of depression or anxiety. Do not post-date prescriptions. This is prohibited by the DEA. You may issue multiple prescriptions totaling a 90-day supply for schedule II substances by writing separate prescriptions, with the date they are written, with a

Colorado Medicine for September/October 2017

•

note on each prescription indicating the earliest date that the particular prescription can be filled (e.g., “Do not fill before June 15, 2017” on one prescription; “Do not fill before July 15, 2017” on the next, etc.) Update the medication list. In certain EMRs, failing to renew a medication does not automatically remove the medication from the medication list. Then, if you begin prescribing a different medication or a different dose, it may appear from the medication list that the patient is on multiple opioid medications. Become familiar with addiction treatment resources in your area. Patients who are drug-seeking because they have an addiction have a disease – substance use disorder – and they need treatment. They may not take you up on your offer the first time, but they may at a subsequent visit. Avoid concurrent prescribing of benzodiazepines and opioids. Benzodiazepine withdrawal can be dangerous, and tapering can be tricky. If appropriate, refer to an addictionologist or psychiatrist for help. Avoid morphine milligram equivalents (MMEs) that are considered high, based on current guidelines. Get help from consultants, including pain management specialists, addictionologists, or psychiatrists. Patient medical comorbidities, such as obstructive sleep apnea, can increase risk of adverse events from opioids. Consider medical comorbidities when formulating treatment plans. If you do prescribe higher dose opioids, or to patients at higher risk due to other factors, mitigate risk by:

Pitfalls (cont.) o Assessing for adverse effects, for example with sleep studies or nocturnal pulse oximetry, periodically and when increasing dosing. o Prescribe naloxone in case of overdose. o Document carefully. Document your clinical rationale for using dosing that is considered high so that someone reading the chart will understand your decisions, and document that you have discussed the increased risks with the patient. • If you decide to taper a patient’s opioid dosing, establish and agree upon a clear, documented tapering plan. • Use the PDMP to provide an overview of your own prescribing. Do a query of all your controlled substances for a one-month period. Are you prescribing high doses to more patients than you realized? Are you co-prescribing benzodiazepines and opioids more often than you recalled? • Do not prescribe controlled substances to yourself or family members. The Colorado Medical Practice TUCC_COMedicine_Ad_081517_OL.pdf Act defines prescribing, distributing

CMY

or giving a controlled substance to a family member or to oneself except on an emergency basis as unprofessional conduct and grounds for discipline. • Know your own vulnerabilities. Be self-aware if saying “no” to a demanding patient is difficult for you. Get help building these skills. • If a patient’s family member calls to talk to you, take the call and inform the family member that you can listen, but you cannot respond or discuss any patient without their permission. You are not breaching patient confidentiality if you listen to the concerns of the family member, and it may give you some insight and help you take care of the patient. For example, “Doctor, I want you to know that my son is addicted to the medications you are prescribing and he is getting them from at least three other physicians.”

Do you want to learn more? CPEP offers the following CME courses. • 8/15/17 Prescribing Controlled Drugs: Criti1:25 PM cal Issues and Common Pitfalls: A

three-day CME course based on curriculum developed at Vanderbilt University, this is an intensive, skill building course designed to increase skills in safe prescribing, identification of substance abuse, and how to say “no” to a patient asking for controlled substances when it is in the best interests of the patient. Approved for 22.75 AMA PRA Category 1 credit. www. cpepdoc.org/cpep-courses/prescribingcontrolled-drugs/#toggle-id-7. • Basics of Chronic Pain Management: Essentials for the Non-Pain Management Specialist: This is a one-day CME course covering the pathophysiology of chronic pain, non-pharmacologic treatment, interventional pain management, and both opioid and non-opioid medications used in the treatment of chronic pain. Approved for 8 AMA PRA Category 1 credit. www.cpepdoc.org/cpep-courses/basicsof-chronic-pain-management. Additional resources • DORA Quad-Regulator Joint Policy for Prescribing and Dispensing Opioids: http://www.ucdenver.edu/ academics/colleges/PublicHealth/ research/centers/CHWE/Documents/ DOR A%20Opioid%20Policy%20 Revised%2010.15.14.pdf. • CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016: https://www.cdc.gov/media/ modules/dpk/2016/dpk-pod/rr6501e 1er-ebook.pdf. • Pain Treatment Guidelines, Oregon Pain Guidance Group: http:// www.oregonpainguidance.org/app/ content/uploads/2016/05/OPG_Guidelines_2016.pdf • Sample controlled substance agreement: https://www.drugabuse.gov/ sites/default/files/files/SamplePatient AgreementForms.pdf. • DEA Prescriber’s Manual: https://www. deadiversion.usdoj.gov/pubs/manuals/ pract/pract_manual012508.pdf. • Brief about benzodiazepine tapering: https://www.va.gov/PAINMANAGEMENT/docs/OSI_6_Toolkit_Taper_ Benzodiazepines_Clinicians.pdf. • Brief about tapering opioids: https:// w w w.c dc.gov/d r ugoverdo se/p d f/ clinical_pocket_guide_tapering-a.pdf. n

Colorado Medicine for September/October 2017

Features

Multi-pronged approach Chet Seward, Senior Director, CMS Division of Health Care Policy

Payers respond to the opioid epidemic As this special issue of Colorado Medicine demonstrates, a collaborative effort is needed to address the opioid epidemic. One front is health insurers, who are deploying their own strategies with network physicians and beneficiaries. CMS encourages physician members to explore resources, programs and potential partners in the payer realm. CMS reached out to the medical directors of major health insurance plans in Colorado. Below are their responses. Elizabeth Kraft, MD, CMO, Anthem Anthem has adopted a multi-pronged approach to combat the devastating national opioid abuse epidemic which centers on 1) addressing opioid prescribing practices with educational seminars and pharmaceutical management; and 2) early identification and treatment support. Anthem has already reduced opioid use in Colorado by 15 percent and covered up to a 150 percent increase in admissions in residential treatment, inpatient and partial hospital programs for opiate use disorders. Locally, Anthem has robust prevention and treatment programs in place, including: • Increased access to and support from behavioral health services as part of medication assisted therapy for opioid addiction; • Robust education efforts within Anthem’s Enhanced Primary Health Care (EPHC), including streaming videos on treatment for pain and opioid overuse; • Aligning with the March 2016 CDC guidelines for opioids for chronic

pain, which includes removing any prior authorization for MAT drugs and limiting prescriptions for shortacting opioids to seven days; and • Creating the Pharmacy Home program that assigns members with concerning patterns of number of prescribers and scripts for opioid to one pharmacy and/or provider, which has reduced hospital and ER admissions. Mark Laitos, MD, CMO, Cigna Cigna has made significant progress toward reaching its goal to reduce opioid use among its customers, with the help of health care providers. Within the last 12 months, Cigna customers’ use of prescribed opioids has declined nearly 12 percent – about halfway to achieving the company’s goal of 25 percent reduction by 2019 – which would return to 2006 levels, before the drug crisis. While Cigna has adopted a multipronged response to the epidemic that includes multiple stakeholder groups, the key to this initial progress has been Cigna's work with doctors, especially those that participate in its Cigna Collaborative Care arrangements. Cigna assists doctors in preventing, recognizing and treating opioid misuse by: • Analyzing integrated claims data across pharmacy and medical benefits to detect opioid use patterns that suggest possible misuse by individuals, and then notifying their health care providers. This helps identify individuals with substance use disorders more quickly so they can get the help they need. • Alerting doctors when their opioid prescribing patterns are not consis-

Colorado Medicine for September/October 2017

tent with the Centers for Disease Control and Prevention’s (CDC) guidelines that include opioid selection, dosage and duration. • Establishing a database of opioid quality improvement initiatives for doctors that can help them determine next steps for improving patient care, including referrals into chronic pain management or substance use disorder treatment programs. Cigna is also implementing additional customer safety measures in support of the CDC guidelines. Effective July 1, most new prescriptions for a long-acting opioid that are not being used as part of treatment for cancer or sickle cell disease, or for hospice care, will be subject to prior authorization, and most new prescriptions for a short-acting opioid will be subject to quantity limits. Finding a long-term solution means modernizing the approach to prevention, treatment and communication regarding substance use disorders. Cigna is committed to working together to identify the right solutions. Kevin R. Fitzgerald, MD, CMO, Rocky Mountain Health Plans Health plans and physicians need to collaborate to tackle this important issue together, so that we have access to data and some leverage with our members to change behavior. Rocky Mountain Health Plans has been working with community physicians, other prescribers, pharmacies, and patients for a number of years. We share policy and procedures that practices that prescribe opioids should consider putting in place

Payers (cont.) for offices, along with other resources like opioid contracts. We also have a Drug Safety Program specifically designed around schedule 2 medications that has been in place for a number of years. That program will identify patients (health plan members) with aberrant opioid prescription patterns (i.e., multiple narcotic prescriptions in a month, filling those prescriptions at a number of different pharmacies, etc.) and linking the patient to one prescriber (who agrees to be their sole source for prescriptions of opioids) and one pharmacy (for filling those prescriptions) or they are not paid for by our health plan. We also look for patterns of ER usage that might identify doctor shopping and through our care management department link those patients with one primary care physician. We will also address with the patient their behaviors and refer them to addiction counseling and other services as necessary. RMHP partnered with the community

and our local health information exchange (QHN) to develop the system where providers can place the opioid contract they have with a patient for other providers to see (like the ER and referral specialist). Judy Zerzan, MD, MPH, CMO/ Client and Clinical Care Office Director, Colorado Department of Health Care Policy and Financing Our pain management resources and opioid use webpage can be accessed at: colorado.gov/hcpf/pain-managementresources-and-opioid-use. It contains a collection of provider resources, including links to the department’s prescription opioid policies, what is covered by Health First Colorado (Colorado Medicaid) to treat pain or other behavioral health conditions (pharmaceutical and non-pharmaceutical), information about the state of Colorado’s Prescription Drug Monitoring Program, and professional publications and peer-reviewed literature about opioid use and its associated risks.

Colorado Medical Society is pleased to announce Carr Healthcare Realty as our newest Member Benefit Partner.

The goal of this new treatment-naïve opioid policy is twofold. First, to reduce the number of Medicaid members who might develop an addiction to opioids when it could be prevented. Second, to reduce the amount of excess opioid pills in the community. The department wants to ensure members have appropriate medication to treat their pain, without excessive doses that are not needed. All the steps that we can take within reasonable parameters are important and should be taken. Progress to date has been encouraging. n

Encourage a colleague to join the Colorado Medical Society and your local medical society today!

Visit www.cms.org to learn more about the benefits of becoming a member.

Carr Healthcare Realty is the nation’s leading provider of commercial real estate services for healthcare tenants and buyers. Thousands of healthcare practices trust us each year to achieve the most favorable terms on their lease and purchase negotiations; including New Offices, Lease Renewals, Expansions, Relocations and during Practice Acquisitions. Visit: CarrHR.com

In a continued effort to address the growing opioid epidemic in Colorado, the Department of Health Care Policy and Financing continues to tighten its policy on prescribing and dispensing opioid pain medications to Health First Colorado (Colorado’s Medicaid program) members.

For more information, call Tim at 720-858-6306 or email tim_yanetta@cms.org

Colorado Medicine for September/October 2017

Features

Who wants a raise? Allyson Gottsman

The Colorado QPP Coalition can help you get a “raise” from Medicare – and other payers, too Practices are encouraged to take advantage of abundant Colorado resources to get a “raise” in Medicare rates through the Quality Payment Program (QPP). There is no need to accept a decrease in your Medicare Part B fees by sitting on the sidelines. The pay cut is not that hard to avoid and there is help to figure out the QPP. Colorado practices of all sizes and specialties have multiple opportunities to get support from local Colorado experts – at no cost to the practices. Approximately 20 organizations (and growing) have joined forces to support Colorado practices through the complex options available in this first year of the QPP. See the next page for a list of current organizations in the Colorado Quality Payment Coalition. It’s very simple to avoid a penalty – just submit one measure. It’s that easy, it’s not too late to get started and there is help to figure out what to submit and how. Your action, or lack of action, in 2017 will impact your rate of Medicare reimbursements for all Medicare Part B fees for all of 2019. It is the goal of the Coalition members for no Colorado practice to get a penalty. But why settle for staying even? Why not get help to benefit from a positive adjustment in your Medicare Part B payments for 2019? This year Medicare is allowing you to “Pick Your Pace” regarding your QPP participation, including minimal effort to stay neutral, some effort and proficiency to get a modest increase, and good effort with good measures and activities to get up to a 4 percent increase for all

of 2019. The rate of increase will grow from there, up to a potential 9 percent increase, if you continue to improve your scores, relative to your peers across the country. The Coalition provides multiple levels of support – all at no cost. They range from material to review for the “do-ityourself-ers” to onsite practice facilitation and clinical HIT advisor support. For the independent high-functioning practice, there are websites, videos and podcasts – see the sidebar for some that the CO QPP Coalition has vetted for you – and there are many more than listed here. You can join monthly webinars hosted by Colorado QPP Coalition members or subscribe to the Coalition’s “Fast Facts in Five Minutes,” a monthly e-mail to explain parts of QPP in small bites, for tips and tools to stay current with how QPP is evolving. For those who want help understanding the program and getting guidance on reporting, Telligen (for larger practices with 16 or more clinicians) and the Texas Medical Foundation Health Quality Institute (for smaller practices with 15 or fewer clinicians) have staff, resources and tools. For Telligen, contact Courtnay Ryan at Courtnay. Ryan@area-d.hcqis.org. For TMF, contact 1-844-317-7609 or QPP-SURS@ tmf.org. If your aspirations are higher than avoiding a penalty and you would like help improving your MIPS score to get a positive adjustment, there is help for

Colorado Medicine for September/October 2017

that, too. The Transforming Clinical Practice Initiative (TCPi) is available to practices of all specialties of all sizes. TCPi practice support is offered through multiple Colorado organizations, but practices need to register at http://www.practiceinnovationco. org/tcpi/get-engaged/ before Sept. 20, 2017. In addition to TCPi, any program that works with practices to improve competency in quality improvement, team-based care, care coordination across medical neighborhoods, population management, and a host of other content will be a step toward not only the short-term goal of succeeding in the QPP but also, and more importantly, preparing your practice for future value-based compensation programs by commercial carriers. Go to http://catalog.practiceinnovationco. org to pursue an electronic catalog of options for practice-level support available to practices across Colorado by more than 20 different organizations. If you have questions about which support option is best for you, contact the organization that suits you best to get guidance. Find a list on the Colorado QPP Coalition webpage, www. cms.org/coqpp/coaching.

See QPP resources from the Colorado QPP Coalition on the next page 51

QPP (cont.)

QPP resources QPP website: qpp.cms.gov Colorado QPP Coalition website: www.cms.org/coqpp Questions and support for QPP reporting: • Practices with 15 or fewer clinicians: Texas Medical Foundation Health Quality Institute - 1-844-317-7609 or QPP-SURS@tmf.org • Practices with 16 or more clinicians: Telligen – Courtnay Ryan, Courtnay.Ryan@area-d. hcqis.org • Coffee talk by Telligen – Second Thursday of the month, 10 a.m.: https:// telligenqinqio.com/qppcoffee-talks • CO QPP Coalition – Third Tuesday at noon: https:// ucdenver.zoom.us/webinar/ register/044cb914c32bb73 9d746f627e8486654; watch for registration information from CMS or one of the other Coalition members. Support for QPP navigation and reporting AND improving your MIPS score: • Transforming Clinical Practice Initiative Practice facilitation and Clinical HIT Advisors: www.practiceinnovationco. org/tcpi On demand QPP electronic modules: Videos, slide presentations and podcasts: • American Medical Association: www.ama-assn. org/qpp-reporting • Federal CMS: https://qpp.cms. gov/about/resource-library Catalog of program offerings to build competencies needed for the future: http://catalog. practiceinnovationco.org n

CMS Corporate Supporters and Member Benefit Partners While CMS analyzes the quality and viability of our member benefit partners and their offerings, we do not guarantee any product or service will be right for you. Before you make a purchase, we recommend you perform your own due diligence.

AUTOMOBILE PURCHASE/ LEASE US Fleet Associates 303-753-0440 or visit usfacorp.com * CMS Member Benefit Partner FINANCIAL SERVICES COPIC Financial Service Group 720-858-6280 or visit copicfsg.com * CMS Member Benefit Partner

PRACTICE VIABILITY, (CONT. Carr Healthcare Realty 303-817-6654 or visit carrhr.com Dynamic Physician Billing Solutions 303-913-0508 or visit dynamicphysicianbilling.com Eide Bailly 303-770-5700 or eidebailly.com/healthcare

LendKey – Student Loan Refinancing 888-549-9050 or visit LKrefi.com/co-med * CMS Member Benefit Partner

First Healthcare ComplianceTM 888-54-FIRST or visit 1sthcc.com *CMS Member Benefit Partner

INSURANCE PROGRAMS COPIC Insurance Company 720-858-6000 or visit callcopic.com *CMS Member Benefit Partner

HealthTeamWorks 866-401-2092 or visit healthteamworks.com *CMS Member Benefit Partner

UnitedHealthcare 877-842-3210 or visit UnitedhealthcareOnline.com

Medical Telecommunications 866-345-0251, 303-761-6594 or visit medteleco.com * CMS Member Benefit Partner

MEDICAL PRACTICE SUPPLIES AND RESOURCES Colorado Drug Card 720-539-1424 or visit coloradodrugcard.com *CMS Member Benefit Partner

The Legacy Group at Re/MAX Professionals 720-440-9095 or visit legacygroupestates.com/physicians

MedjetAssist 1-800-527-7478, referring to Colorado Medical Society, or visit medjet.com/cms *CMS Member Benefit Partner University of Colorado Hospital/CeDAR 877-999-0538 or visit CeDARColorado.org PRACTICE VIABILITY ALN Medical Management 866-611-5132 or visit alnmm.com

TransFirst 800-613-0148 or visit transfirstassociation.com/cms *CMS Member Benefit Partner Transcription Outsourcing 720-287-3710 or visit transcriptionoutsourcing.net TSI 800-873-8005 or visit web.transworldsystems.com/npeters * CMS Member Benefit Partner

Colorado Medicine for September/October 2017

Features

State Innovation Model Heather Grimshaw, Communications Manager, SIM

Mapping the way to better health care in Colorado Every practice in Colorado can benefit from the investments made by the Colorado State Innovation Model (SIM), which will work with 400 primary care practice sites and four community mental health centers during its four-year time frame.

Map: Regional distribution of SIM resources

The application for the third and last cohort will be released this winter, but every health care provider in the state can benefit from infrastructure and resources funded by SIM, which is funded by the Centers for Medicare and Medicaid Services, to help integrate behavioral and physical health in primary care settings and to test alternative payment models. The initiative has made strides in its first year and a half. Customized practice facilitation and clinical health information technology advisors are working with practices across Colorado to improve process efficiency and effectiveness and to help quality improvement teams collect, report and use practice data in actionable ways so providers can deliver the type of integrated – or whole-person care – that improves health outcomes and reduces cost. It requires an investment of time, energy and practice resources that resonate with clinicians, who value the type of support that enables them to deliver the type of care that patients need. “You recognize that you can do a better job taking care of your patients if you are able to incorporate mental health into your practice,” says Glenn Madrid, MD, a family physician with Primary Care Partners in Grand Junction that is part of SIM cohort 1. “For me it’s been

Local public health agencies 1. El Paso County Public Health 2. Mesa County Health Department 3. Northeast Colorado Health Department 4. Ouray County Public Health 5. Pueblo City-County Health Department 6. TriCounty Health Department 7. San Juan Basin Health Department 8. Rio Grande County Public Health Agency

personally rejuvenating. It’s rewarding to be able to do a better job taking care of the whole individual.” Providers recognize that integrated care is the best way to improve health outcomes and lower costs, and initial data collected by Milliman, an actuarial firm that is charting return-on-investment (ROI) for SIM, shows correlated cost savings and cost avoidance for SIM practice sites in their first six months of the program. The SIM team will release more data on this ROI in coming months.

Colorado Medicine for September/October 2017

SIM cohort 1 practice sites Community mental health center Behavioral health transformation collaborative Regional health connector Sources: U.S. Census Bureau 2015 Cartographic Boundary Shapefiles and the Colorado State Innovation Model (SIM)

Expanding the SIM circle In addition to helping practice sites integrate behavioral and physical health in sustainable ways, the SIM initiative has invested in a new health workforce of 21 regional health connectors, who are located across the state and help practices identify and tap into community resources that benefit patients. See the regional distribution of SIM resources across Colorado in the regional map above.

SIM (cont.) The initiative has also funded the work of eight local public health agencies (LPHAs) and two behavioral health transformation collaboratives (BHTCs). Resources provided by LPHAs, BHTCs and RHCs, which are working to address mental health stigma and to improve access and connect providers with community health resources, are available to all providers in the state. Learn more about these resources, which include “Let’s Talk Colorado,” a stigma-reduction campaign – and ways your practice can benefit from them – during short SIM podcasts (http://bit. ly/2pK3FWK) with LPHA and RHC representatives. While many practices assign different team members to research community resources, “RHCs are fully-funded to do that work,” explained Ashlie Brown, SIM extension service director at the Colorado Health Institute. Get a few examples of the meaningful work that RHCs are doing across the state (http:// bit.ly/2g53OSo), such as identifying resources for LGBTQ youth as well as patients with childhood obesity that save care teams time and provide patients and families with help and support. Practical work The 94 practices in SIM cohort 1, which

Map: SIM practices, cohorts 1 and 2

started their practice transformation work in 2016, will be joined by approximately 150 practices accepted for cohort 2 that start their work in September. The second cohort includes a diverse group that is made up of private solo or group practices (about 38 percent) and runs the gamut from school-based health centers and rural health clinics to hospital- or health-system-owned fa-

Support the CMS Foundation with your tax-deductible donation

The Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization in 1997. We strive to administer and financially manage programs that improve access to health care and health services to improve the health of Coloradans. The CMSF Board of Trustees is committed to the success of these programs and excited about the possibilities they present for improving health care services in Colorado. We need your help to meet our goals.

Consider giving a tax-deductible donation of $25, $50 or more to help CMSF continue its mission.

cilities that will follow a streamlined set of practice transformation milestones and will report on a set of clinical quality measures that were aligned with other initiatives to reduce provider burnout (link in resources). The application for SIM cohort 3, the last cohort in this federally funded initiative, will be released this winter. Sign up for the SIM newsletter (link below) to get more information about how SIM practices are integrating care, updated data from the first two cohorts and the release date for the SIM cohort 3 application. n Resources: • SIM website: www.colorado.gov/ healthinnovation • SIM aligns clinical quality measures: http://bit.ly/2v5zg9E • RHCs: www.colorado.gov/pacific/ healthinnovation/rhcs-and-you • SIM podcast series with RHCs, LPHAs, Let’s Talk Colorado representatives and more: http://bit. ly/2pK3FWK • Let’s Talk Colorado: http://letstalkco.org

Questions? Call 720-858-6310. 54

Colorado Medicine for September/October 2017

Inside CMS

CMS foundation helping students Michael J. Campo, PhD, support staff Colorado Medical Society Education Foundation

CMS Education Foundation 2016-2017 scholarship recipients Congratulations to first-year students from the University of Colorado School of Medicine – Casey Dolen, Alec Kerins and Taylor Wand – who were awarded scholarships from the Colorado Medical Society Education Foundation (CMS EF). Brandie Lawrence, a first-year student from Rocky Vista University, was also awarded a scholarship. Each received $5,000. CMS EF, a 501(c)(3) private foundation, renders financial support to select firstyear medical students based on criteria such as the student’s financial status, academic achievement and desire to practice in rural or underserved areas upon graduation. Beyond scholarships, CMS EF supports education programs such as the Colorado State Science and Engineering Fair and the education program at the CMS annual meeting. “The CMS EF Board is thankful for the generous support and financial contribution from CMS members who make our education scholarships possible,” said CMS EF Board Chair Jerry Appelbaum, MD, FACP. The scholarship recipients are as follows. Casey Dolen is an incoming freshman at the University of Colorado School of Medicine. His motivation to pursue medicine comes from a decade of experience as both a paramedic in Colorado Springs and overseas in Afghanistan, where he provided medical support to civilians. Most recently, he has worked as a community paramedic with the Colorado Springs Fire Department Community and Public Health

Division. Casey graduated summa cum laude with a B.S. in Healthcare Science from the University of Colorado in Colorado Springs. His career interests include family medicine, emergency medicine and public health, and he hopes to practice in Colorado after graduation. Alec Kerins grew up in Helena, Mont., and spent the past eight years advocating for educational equity as a teacher, school leader and district administrator in urban school districts across the West. After graduating from Lewis & Clark College, Alec joined Teach for America and taught high school science in one of the nation’s most underperforming school districts. Driven by the inequities he experienced in the classroom, Alec is transitioning to medicine to feed his love for science, health care and community. In his free time, Alec enjoys trail running, camping, skiing and experiencing small, rural communities around Colorado. As a first-year medical student, Alec is eager to combine his rural roots with his experience in urban communities to help ensure all Coloradans have access to the resources necessary to thrive. Brandie Lawrence was born and raised in the Rio Grande Valley of south Texas. She attended the South Texas High School for Health Professions “Med-High” in Mercedes, Texas. She was awarded a Bachelor of Science degree in Psychology from the University of Texas Rio Grande Valley and a Master of Science degree from the

Colorado Medicine for September/October 2017

American College of Healthcare Science based in Portland, Ore. Brandie recently completed additional prerequisite courses and research on pain dynamics at the University of Colorado-Denver. Brandie has a long history of community service, including positions with Boy Scouts of America, HealthSET and the USAF Key Spouse program. Brandie matriculated into medical school at Rocky Vista University in July of 2017. She is passionate about a future in rural family practice and pain management therapy. She spends her free time cuddling with her Great Danes and enjoying the great outdoors. Taylor Wand grew up in Boulder, Colo., and has lived in the state for most of his life. Being raised here, he was constantly in the mountains, exploring the wilderness and natural world around him. These experiences fostered a strong appreciation and wonder for the plants, animals and humans that make up life on our planet. He attended Fort Lewis College in Durango, Colo., and it was here that he discovered his passion for science and understanding the natural world through this lens. This interest led him to the National Institutes of Health in Bethesda, Md., where for the past three years he conducted immunology research as a fellow. Surrounded by outstanding physicians and researchers, his interest in medicine flourished and after many experiences in the clinic and laboratory, he knew he wanted to pursue a career in medicine. He has always found great meaning in serving those in need and is very grateful to now have the opportunity to begin his medical education. n 55

Colorado Medicine for September/October 2017

Inside CMS

Ted J. Clarke, MD Chairman & CEO COPIC Insurance Company

Guidelines and resources to address opioid prescribing The issue of opioid dependence and addiction has been pushed to the forefront of health care in recent years and presents an ongoing challenge for medical providers. In response, we have seen guidance strategies released by public agencies that provide useful risk management advice and medical tools that can assist them to better understand the issue and make informed decisions. Centers for Disease Control and Prevention guidance Published in March 2016, the “CDC Guideline for Prescribing Opioids for Chronic Pain” report is directed at primary care physicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care and end-of-life care. In particular, the following are some key points noted in the report that are relevant to opioid prescribers: 1. Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain, and clinicians should consider opioid therapy only if benefits for pain and function outweigh risks. 2. When starting opioid therapy, clinicians should prescribe immediate-release opioids instead of extended-release/longacting opioids. 3. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed. 4. Clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. Another useful CDC resource is the “Calculating Total Daily Dose of Opioids For Safer Dosage” guide available online. Colorado Medical Board policy In October 2014, Colorado’s “quad boards” of medicine, dentistry, nursing and pharmacy adopted the Joint Policy for Prescribing and Dispensing Opioids. The policy recommends additional safeguards be put in place when prescribing and dispensing exceeds the following evidence-based thresholds that have been associated with adverse outcomes: • 90 days in duration, • 120 MME (note that the CDC now places this at ≥90 MME), or • Certain formulations such as transdermal or long-acting preparations. Colorado Medicine for September/October 2017

The policy also describes the following recommendations prior to the consideration of initiating opioid therapy. Recall that documenting the prescriber’s considerations of all these elements is critical in the defense of a subsequent medical board or medical liability action. 1. Diagnose – Prescribers should establish a diagnosis through history, physician exam and/or laboratory, imaging and/or other studies in the setting of a genuine provider-patient relationship. 2. Assess risk – The policy discusses an expectation of the assessment of risks associated with adverse outcomes such as patient or family history of alcohol or substance use disorder, patient medication history (especially concurrent benzodiazepines), mental health conditions and history, abuse history (physical, emotional or sexual), and concurrent health conditions increasing the risk of adverse outcomes (COPD, CHF, sleep apnea, elderly, hepatic or renal insufficiency). 3. Assess pain – The assessment should not only be about nature, intensity and location, but should also include an assessment of its impact on physical and psychological function. 4. Review the Colorado Prescription Drug Monitoring Program. Additional resources available through COPIC The Opioid Crisis Part I – The Pain That Won’t Go Away: This seminar examines the scope of the opioid problem and uses the guidance of the CDC, FDA, medical boards and other best practices to describe practical approaches to practice more safely with opioids. The Opioid Crisis Part II – Strategies for Reducing the Burden: In response to the opioid epidemic and the role of health care professionals in it, this seminar reviews the reasoning and criteria for opioid dose reduction and discontinuation while teaching techniques to encourage patient buy-in with a focus on overcoming fear and resistance. SCOPE of Pain (FDA REMS-Compliant): This online educational program will help you safely and competently use opioids, if appropriate, to manage your patients with chronic pain. Key areas covered include assessing for opioid misuse risk; counseling patients about opioid safety, risks and benefits; monitoring patients prescribed opioids for benefit and harm; and safe discontinuation of opioids. Interested in hosting a COPIC seminar at your practice? Contact Carmenlita Byrd at cbyrd@copic.com or (800) 421-1834, ext. 6131. Register for seminars and access online programs at www. callcopic.com/education. n 57

Inside CMS

Reflective writing is an important component of the CU School of Medicine curriculum. Beginning in the first semester, medical students write essays, stories or poetry that reflect what they have seen, heard and felt. Reflections is edited by Steven Lowenstein, MD, MPH, and Tess Jones, PhD. It is dedicated to the memory of Henry Claman, MD, Distinguished Professor of the University of Colorado, founder of the Arts and Humanities in Healthcare Program, and original co-editor of this column.

Julia Newman University of Colorado School of Medicine

Julia Newman is a Colorado native and a fourth-year medical student at the University of Colorado School of Medicine. Julia has a passion for service and has spent much of her time outside of school working at the DAWN clinic, a student-run free clinic, and cooking for her family and friends. She also is interested in policy and animal behavior, which happen to overlap more than she would like to admit. Julia is looking forward to providing care for urban underserved patients throughout her career.

Enough The first two years of medical school are spent methodically learning about physiology, pathology and treatments. If your patient has a COPD exacerbation give them oxygen, antibiotics and steroids. If they have diabetes? Metformin and maybe insulin. If they have depression? A selective serotonin reuptake inhibitor is a good place to start. Then when the first line treatment doesn’t work, we turn to the second or third option we learned about. I started third year with this understanding of treatments and an unbridled enthusiasm. Who wouldn’t be excited? I was about to start healing people by applying all the knowledge I had learned from my first two years. I was not 58

naïve enough to think that I would solve all my patients’ problems or even cure them. However, I was going to improve people’s lives with science! What better place to start than at the VA doing inpatient psychiatry? One of my patients had treatment-resistant depression and was admitted for electroconvulsive therapy (ECT). Prior to admission “John” had tried practically every medication available for depression yet continued to have persistent suicidal ideation. To self-medicate he turned to substance abuse, likely only making matters worse. But now he was trying ECT, a treatment that is scientifically proven to treat people like John. Two to three times a week for his final three weeks of treatment I helped administer his ECT and checked in with him every day to monitor his progress. One morning, six weeks in to his treatment, he said to me, “I think I feel happy.” He had been depressed for so long without reprieve that he had forgotten what happiness felt like. From then on, he continued to improve. John was so pleased with how well his treatment went he tried to talk everyone else on the ward into getting ECT. We talked about his excitement to go home and his hopeful outlook for his future. He still had severe anxiety about his depression returning and his other issues, including brittle diabetes and addiction. However, before treatment he admitted those issues would have thrown him into a depressed state and now he could see how to work through his problems. Of course, he was also going to have a lot of help. John was moving into a home that would support his recovery and help him avoid substances, and we had multiple family meetings to help him inform them of his situation and the care he needed. I also helped him research volunteer Colorado Medicine for September/October 2017

Inside CMS opportunities at the animal shelter because his dream was to train dogs. On my last day, he was just a day from discharge and he seemed ready to go. It was clear that we had made a difference in John’s life. Medicine and the support of the medical system had done its job and made John happy. Three months later, I ran into a resident who had rotated at the VA with me and asked her how John had done. There was a long pause. She told me that three weeks after discharge he had died by suicide by leaving the car on in the garage. Initially I was surprised, disappointed and sad. Likely the surprise comes from how we are taught during our first two years. We learn about all these treatments, yet there isn’t much discussion about what happens when none of them work. We talk about suicide, but not usually in the context of people failing treatment. We think of people who “gave up” or were “failed by the system.” But John tried everything. The medical community

tried everything. Yet, it was not enough. Sometimes there are people we cannot fix. I started out knowing that we can’t solve every problem. I never thought there was a magic pill. However, at the start of my third year, I was not as acutely aware that we as doctors, or future doctors, have so many limits. What I now understand is that a career in medicine is not about making everything perfect for our patients or curing every ailment. Being a doctor is about using our knowledge to do our best to improve some part of our patient’s life, even if only temporarily. For John, we made him happy for a little while and that is the best we could do. n

Colorado Medicine for September/October 2017

CMS .ORG ORG CMS CMS CMS.ORG ORG Colorado Medical Society

Serving the Continuing Medical Education needs of Colorado physicians Your bridge to quality improvement in health care

Accredited CME is education that matters to patient care. For more information contact the Colorado Medical Society CME office at 720-858-6309

Departments Inside CMS

Critical reflective writing holds a prominent place in the Medical Humanities curriculum at Rocky Vista University, College of Osteopathic Medicine. Beginning in the first semester of Medical Ethics, students engage in critical reflection to explore their own assumptions and biases and how their values impact their practice. This submission is selected and edited by Christopher Unrein, DO, Professor of Internal Medicine; Nicole Michels, PhD, chair of the Department of Medical Humanities; and Alexis Horst, MA, Writing Center Instructor.

David Baldwin Rocky Vista University College of Osteopathic Medicine David Phillip Baldwin, OMS II, grew up in Littleton, Colo., and attended the University of Colorado Denver where he earned a Bachelor of Science in Biology. After obtaining his degree, he worked in the Department of Immunology at National Jewish Health and the University of Colorado Anschutz. He then worked in the department of Neurology at CU Anschutz until he began his DO degree at Rocky Vista University. David is thankful to all of the physicians who have served as examples and willing teachers throughout his training to be a physician.

Pain management in the ED Each patient who comes to the Emergency Department is subjected to many different questions. It starts with “What brings you here?” and expands from there. During my experience in the ED, it appeared to be relatively easy for the physician to localize pain or explain certain phenomena and help patients through the difficulty that brought them to the ED. This is all under the assumption of patient honesty; but what happens to a physician’s perception when they repeatedly see patients suffering from substance abuse? What about patients looking for a dose of their favorite painkiller, because it turns out that they are “allergic” to everything else? How does a physician maintain a state of compassion while still being on the lookout for those whose sickness is a drug addiction and whose problem extends beyond the reach of the ED? My first few experiences with drug-seeking behavior were 60

nothing spectacular. The encounter usually started with a description of pain that occurred doing something routine at home, which resulted in a fall. Then, since the patient was clearly in pain, they requested pain medication. Following a physical exam, the physician runs the patient’s name through the Colorado Prescription Drug Monitoring Program database. It is from here that the drama can play out. I remember the first time a patient was not allowed access to pain medications. She told us she had not received any prescription pain medication for a long period of time, that she was only taking Advil for pain, but that the pain could no longer be managed. When her refill history suggested that this was not true, alternatives were presented. Unwillingly, she took the non-opioid and non-narcotic options presented to her as well as contact information for a physician who could help her with her long-term pain. The physician did his best to give resources to the patient and help her on a path away from substance dependence. This is difficult given the brief window of access available to a physician in the ED. After multiple encounters like this, I began to see a pattern, and I noted my frustration and curiosity regarding what decisions were made by physicians and patients that led to patients’ compromised well-being and autonomy. I felt this frustration again when a patient came to the ED for a prescription refill for lower back pain. This patient’s story raised a red flag for drug-seeking behavior. I suspect the attending physician thought this as well, but he withheld judgment until he could gain further information and make the most informed decision possible. He started with the patient interview and physical examination. He took no shortcuts, and made sure that her complaint of back pain appeared valid on initial examination. He then checked the prescription database to see when she had last refilled her medication. At her last doctor visit, the previous physician had givColorado Medicine for September/October 2017

Inside CMS en her 30 pills of a strong narcotic. I worried that this much pain medication could severely alter her life by triggering a dependency. The physician I was with expressed dissatisfaction with this prescription; he wanted to help her manage her pain and get her back to a place where prescription pain management would no longer be necessary. He wrote a prescription that would last for one week and described her likely source of pain. He also encouraged her to see a primary care physician for another refill if necessary but, more importantly, suggested she receive therapy to completely resolve her pain. She was given contact information of physicians who would take her Medicaid coverage and a description of what she should tell them from her ED visit. This experience challenged me; I found myself assuming this young woman was a part of the pattern of drug-seeking behavior. I became aware of my own bias, and it made me think that encounters like that can

shape a patient’s attitude toward the medical profession for his or her entire life. Did the doctor listen to the patient, partner with him or her, and empower his or her autonomy? Or did the doctor merely hear the patient’s complaints and write the prescription, or punt the patient to someone else who would? The judicious use of knowledge along with respecting our patient’s autonomy and empowering her welfare were inverted between her doctor’s visits. The first doctor gave her the medication she needed but no follow-up. When she came to visit with us, however, she was given the medication she needed, follow-up, and a long-term plan for getting back to health. I have grown to keep my mind more balanced and less prone to negative, and potentially wrong, assumptions, while watching for patients who suffer from substance abuse. Maintaining this balance will take a lot of learning and watching the exceptional performance of experienced physicians. n

Colorado Medicine for September/October 2017

Encourage a colleague to join the Colorado Medical Society and your local medical society today! Visit www.cms.org to learn more about the benefits of becoming a member. For more information, call Tim at 720-858-6306 or email tim_yanetta@cms.org

Departments

medical news CMS Past President Tamaan Osbourne-Roberts, MD, joins CIVHC as chief medical officer ficer (CMO). In his role on the executive leadership team, Osbourne-Roberts will help advance CIVHC’s mission by engaging and supporting physicians and other providers working to improve health care and lower costs.

Tamaan Osbourne-Roberts, MD CMS Past President Tamaan OsbourneRoberts, MD, has joined the Center for Improving Value in Health Care (CIVHC) as their new chief medical of-

Osbourne-Roberts has an extensive background in patient care paired with local and national work focused on driving health care system transformation. He started his career as a family medicine resident at the University of Colorado where he was part of the inaugural class of the Future of Family Medicine/ P4 national demonstration curriculum, a program designed to prepare physician leaders with exceptional clinical, managerial and practice transformation skills. Passionate about serving Colorado’s underserved, Osbourne-Roberts spent several years providing care in rural communities, and now practices at Salud

Family Health Centers where he serves primarily Spanish-speaking, low-income residents. Through his consulting work, he offers physician leadership services, health care diversity facilitation and helps providers prepare for the future through practice transformation focused on quality and outcomes. “Joining CIVHC’s team enables me to make a greater impact on the lives of both providers and patients by sharing what I’ve learned throughout my career on ways to advance the system,” Osbourne-Roberts said. “I’m thrilled to be a part of an organization that shares my core values and is in a position to support lasting change.” Osbourne-Roberts replaces Jay Want, MD, who recently joined the Peterson Center on Healthcare as their new executive director. n

New opioid-related reports focus on mortality data, women, cancer and hospitalizations As the opioid epidemic continues to grow, new reports continue to underscore the gravity of the epidemic and highlight specific concerns related to women’s health, disparities in income and increases in opioid-related hospitalizations. The new studies include the following. Opioid mortality has been undercounted. An August 2017 study from the American Journal of Preventive Medicine, “Geographic Variation in Opioid and Heroin Involved Drug Poisoning Mortality Rates” by Christopher J. Ruhm, PhD, found that reports from death certificates frequently did not include a specific drug, but that when corrected, opioid-related deaths were 24 percent greater in 2014 and those for heroin were 22 percent greater. 62

Women’s overdose and death rate are growing faster than men’s. A July 2017 report from the U.S. Department of Health and Human Services Office on Women’s Health, “Opioid Use, Misuse, and Overdose in Women,” found that “between 1999 and 2015, the rate of deaths from prescription opioid overdoses increased 471 percent among women, compared to an increase of 218 percent among men.” In addition, the report found that “heroin deaths among women increased at more than twice the rate than among men” and that there was an 850 percent increase in synthetic opioidrelated deaths in women between 1999 and 2015. Opioid-related hospitalizations. The Agency for Healthcare Research and

Quality issued an interactive report, “Trends in Opioid-Related Hospitalizations,” that provides a state-by-state look at opioid-related hospital care, including hospitalization trends between 2009 and 2014 and hospitalizations in 2014 broken down by patient age, sex, geographic area and income. Between 2005 and 2014, opioid-related inpatient stays in Colorado increased 36 percent. Women experienced a higher hospitalization rate than men in 2014, at 206 per 100,000 people, and patients age 65 and older had the highest hospitalization rate, at 354 per 100,000 people. Small metropolitan areas had the highest hospitalization rate geographically, 347 per 100,000 people, and the lowest-income people had the highest hospitalization rate, 272 per 100,000 people. n

Colorado Medicine for September/October 2017

Departments

Miles away from help: CHI examines MAT in Colorado Medication-assisted treatment, or MAT, is a proven way to fight the epidemic of opioid addiction and overdose deaths. The medication manages the symptoms of withdrawal and helps reduce cravings while counseling and other recovery support services address the psychological symptoms.

medical news Physician leaders meet with U.S. Sen. Bennet and Gov. Hickenlooper to discuss health care reform

A May 2017 study by the Colorado Health Institute examined the state of MAT in Colorado and showed that the need for treatment is great. Overdose death rates for all drugs increased in every region of Colorado between 2002 and 2014, and the state reported 472 opioid-related overdose deaths in 2015 – up from 108 deaths in 1999. Abuse or dependence on prescription opioids has begun to level off in recent years, but heroin is stoking the opioid epidemic. Rates of dependence on heroin increased five-fold between 2003 and 2014 in Colorado. Hospitalization rates due to heroin increased by 41 percent, and the rate of emergency room visits more than doubled from 2011 to 2014. An annual average of 22,000 Coloradans reported abuse or dependence on opioids, while only 4,000 – or about one of five – received treatment annually at a specialty facility between 2011 and 2014. CHI’s analysis revealed that 31 of the state’s 64 counties do not have a location that provides MAT. An additional 15 counties have just one location. This means that 540,000 Coloradans, about one of 10 residents, live in places with little or no access to medication-assisted treatment. Ten of the 31 counties with no treatment locations had drug overdose death rates above the state rate in 2014.

Representatives from the Colorado Medical Society joined U.S. Sen. Michael Bennet and Colorado Gov. John Hickenlooper for a small-group roundtable discussion on June 16 to discuss the American Health Care Act and discuss ideas to improve the health care system. In attendance were CMS President-elect M. Robert Yakely, MD, Past President Tamaan Osbourne-Roberts, MD, and Pueblo County Medical Society President Henrique Fernandez, MD. The event was held at the Pueblo Community Health Center. n

Read the full report at www.colorado healthinstitute.org. n Colorado Medicine for September/October 2017

Colorado Medicine for September/October 2017

Departments

classified advertising Publication of any advertisement in Colorado Medicine is not an endorsement by the Colorado Medical Society of the product or service. Colorado Medicine magazine is the official journal of the Colorado Medical Society and is authorized to carry general advertising.

â&#x17E;¤ PROPERTIES

Support the Colorado Medical Society Foundation The Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization in 1997. We strive to administer and financially manage programs that improve access to health care and health services to improve the health of Coloradans. Consider giving a taxdeductible donation of $25, $50 or more to help CMSF continue its mission. Questions? Call 720-858-6310.

NEUROLOGY PRACTICE FOR SALE - DENVER, CO: Southeastern suburban. Revenue $3.7 million. Long established, high patient satisfaction, providing these services: Neurological Consultations, EMG, EEG, aEEG, Infusion Therapy including medical Botox injections. Independent appraisal available. Two PAs provide most services; MD works only three days/week. Photos available. Offered at only $470,000. Contact info@ MedicalPracticesUSA.com. 800-5766935. www.MedicalPracticesUSA.com

â&#x17E;¤ PROFESSIONAL OPPORTUNITIES SEEKING OB/GYN IN GLENWOOD SPRINGS, CO: Fulltime, will consider part-time with shared call; call 1:3; salary with bonus; private practice; full benefits, including free lift tickets for Aspen resorts. Requirements: 4-5 years post-residency experience, active CO license, board certified. Email CV to kris@womens-carepc.com.

LOOKING FOR WORK: Experienced board-certified pediatrician looking for work along the Front Range area. Strong background in outpatient peds and child/adolescent psych. PALS, BLS, NRP, and stable certified. Call or text Dr. Murray Caplan at 720-495-8443 or email adddoc660@gmail.com. EXPERIENCED PHYSIATRIST LOOKING FOR PRACTICE OPPORTUNITY: Board-certified in Physical Medicine and Rehabilitation and specializing in musculoskeletal and neuromuscular medicine and EMG/ Nerve Conduction Studies. Additional skills include peripheral joint and trigger point injections, spine medicine and sports injuries. Can work flexible hours and willing to travel along Front Range. CO license. Email Dr. Richard Gordon at richmg@comcast.net.

Serving the Continuing Medical Education needs of Colorado physicians Your bridge to quality improvement in health care Accredited CME is education that matters to patient care. For more information contact the Colorado Medical Society CME office at 720-858-6309 Colorado Medicine for September/October 2017

Features

the final word Donald Stader, MD

The opioid epidemic: Let’s keep working On Aug. 10, the opioid epidemic was declared a national emergency – a designation befitting a crisis that has ensnared and destroyed many American lives. The statistics are truly staggering. Overdose has become the leading killer of Americans under the age of 50. Analysts predict that more than 60,000 patients will die of overdoses in 2017; the majority of these deaths will be attributed to opioids. An estimated 12.5 million Americans admit to abusing opioids, and more than 2 million report being dependent on them. Last year alone, the opioid epidemic cost the United States an estimated $78.5 billion. In addition, communicable diseases such as HIV and hepatitis C are experiencing a commensurate boom; the incidence of new infections for the latter have tripled since 2010. Despite the known risks of these dangerous narcotics, more than one-third of Americans received an opioid prescription in 2015. Colorado can take pride in the fact that it is a low opioid-prescribing state. Although our population continues to grow, the number of opioid prescriptions has fallen by 13.3 percent over the past three years and prescription opioid overdoses have declined by 6 percent in the past year (although overdoses from heroin continue to increase). Despite the shortcomings of the Prescription Drug Monitoring Program (PDMP), physician utilization of the system has increased by 122 percent since 2014. While these trends are encouraging, they are just a beginning. If we are to reverse decades of liberal opioid prescribing practices and address the neglected needs of the masses who struggle with addiction and drug misuse, we must do more. Although there is much debate about 66

the multitude of factors that created the opioid epidemic – from the influence of pharmaceutical companies, to patient satisfaction scores, to misguided regulations, to the disproven and disastrous concept of pain as a vital sign – we must also accept that clinicians played a central role in creating the largest public health crisis of our time. We overprescribed. We underestimated risk. We harmed many of those we intended to heal. While our actions may have been rooted in good intentions, the results have been disastrous. In acknowledging our errors, we can begin to reform our practices and reverse these grim statistics with resolve, purpose and innovation. Your own medical practice is the best place to start. Ask yourself if you are doing everything you can to address this epidemic. Have you reduced your opioid usage? Do you communicate with your patients about the dangers of opioids when prescribed? Do you treat addiction as a medical disease, not as a moral failing? Have you integrated harm reduction into your practice? Are you an expert in multimodal pain control strategies and alternatives to opioids (ALTOs)? Have you considered what role you can play in treating patients with addiction through medically assisted treatment or partnership with appropriate practices? If any of these questions give you pause, we invite you to explore the resources available through the Colorado Medical Society, the American Medical Association, the Colorado Consortium for Prescription Drug Abuse Prevention, the American College of Emergency Physicians, and many of our other national and regional partners. All you have to do is ask – CMS is here for you.

Across our state efforts are underway to address the opioid epidemic. As this article goes to press, the Opioid and Other Substance Use Disorders Interim Study Committee, a cohort of 10 Colorado legislators, is finalizing several new prospective state policies and laws addressing opioids and substance abuse. CMS has collaborated closely with these lawmakers to ensure that potential legislation addresses the crisis both adequately and safely. Colorado is also home to one of the largest opioid safety pilot studies in the nation; clinicians in emergency departments across the state are utilizing alternatives to opioids as first-line agents for pain control, and are evaluating their role in reducing opioid usage. Opisafe, a new medical app, holds great promise for making access to the PDMP less onerous for clinicians. Finally, the Colorado Consortium continues to bring together stakeholders, CMS among them, to address the opioid crisis through medical and community-based initiatives. We encourage you to join the movement by attending the organization’s annual meeting on Oct. 19 (www.corxconsortium.org). The Colorado Medical Society stands with the families and patients afflicted with opioid addiction and misuse. We honor our colleagues who compassionately and dutifully care for the citizens of our great state. We realize the enormity of the task that lies before us as we confront the opioid crisis; it is incumbent upon physicians to lead the charge. CMS thanks you for your service and promises to be a resource and a partner to you. Together, we can begin the process of curing the state and our nation of this deadly epidemic. n

Colorado Medicine for September/October 2017