Clinical Track: State Initiatives Impacting Physicians and Patients

1. Clinical Track:
State Initiatives Impacting
Physicians and Patients
Presenters:
• Michael Baier, Overdose Prevention Director, MD Department
of Health & Mental Hygiene, Behavioral Health Administration
• Clare Desrosiers, MSW, Executive Director, ME Diversion Alert
• Denzil Hawkinberry II, MD, Physician, Community Care of WV
• Kathy Paxton, MS, Director, WV State Substance Abuse
Services
Moderator: Van Ingram, Executive Director, Office of Drug Control
Policy, Commonwealth of KY

2. Disclosures
Michael Baier; Clare Desrosiers, MSW; Denzil
Hawkinberry, MD; Kathy Paxton, MS; and Van Ingram
have disclosed no relevant, real or apparent personal or
professional financial relationships with proprietary
entities that produce health care goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
– Carla Saunders – Speaker’s bureau: Abbott Nutrition

4. Learning Objectives
1. Outline an emergency preparedness plan to
mitigate unintentional impacts on a
community due to disciplinary action against
prescribers.
2. Inform clinicians of resources for responding
to patients charged with drug-related crimes.
3. Describe an approach proving successful in
engaging and educating physicians in
behavioral health.

5. Maryland’s Controlled Dangerous
Substance (CDS) Emergency
Preparedness Plan
Michael Baier
Overdose Prevention Director
Maryland Department of Health and Mental Hygiene
Behavioral Health Administration

6. Michael Baier has disclosed no relevant, real or
apparent personal or professional financial
relationships with proprietary entities that
produce health care goods and services

7. Background
2011:
• Wicomico County, Maryland’s Eastern Shore
• Mostly rural, medically-underserved region
• Large pain management practice run by
anesthesiologist, interventional & Rx
• Legitimacy of physician’s CDS prescribing
practices questioned for years by local officials &
providers
• Law enforcement investigations underway

9. The Trigger
• Medicaid MCO review finds standard of care
violations related to CDS Rx in all 14 cases
• MCO refers records to state health dept. (DHMH)
• DHMH Chief Medical Officer reviews records &
reaches same findings
• First time ever: DHMH Secretary summarily
suspends physician’s state CDS permit based on
assessment of imminent public health threat
from continued practice

10. The Aftermath
• Est. up to 2000 patients, many receiving CDS Rx
(primarily opioids)
• Office closes & provides no medical record access
• Patients face stigma in community and can’t find new
providers for months or years
• Local health dept., hospital ED & community providers
overwhelmed
• Local police link string of pharmacy robberies to former
patients
• Pharmacies stop stocking opioids; primary care opioid
Rx is chilled
• At least one patient suicide

11. Who are the Patients?
• No PDMP or other comprehensive data source
easily available to DHMH existed in 2011.
• MCO auditor: “His patient population reviewed
was a combination of addicts, doctor shoppers
and patients where opiates were unwarranted.”
• Local police & health authorities: mostly addicted
patients, many young, some likely diverting, also
smaller number of older pain patients referred to
phys. for legitimate reasons

12. Who are the Patients? Ctd.
From a Health Care Alternative Dispute Resolution Office claim:
“I had two herniated and three bulging/slipped discs in my lumbar
spine, as well as bi-lateral carpel tunnel syndrome and bi-lateral
sciatica. Since I was referred to Dr. X, he increased my dosage of
oxycodone (originally prescribed by my primary care physician) from 5
mg twice per day to 15 mg 3 times per day. When I asked Dr. X what
the effects of taking such a strong dose would have on me, he
informed me not to worry, that only ‘1 in 1000 patients prescribed
narcotic pain relievers ever actually become addicted’… I had become
addicted to narcotic pain relievers… due to Dr. X’s malpractice… all
other doctors refused to treat and care for me… I had lost two good
jobs, spent thousands of dollars, leaving my family impoverished, and I
left attending Narcotics Anonymous and Worcester County Addictions
Center Intensive Outpatient Group sessions three days a week for
three hours a day.”

13. Who are the Patients? Ctd.
Local news op-ed:
“I have four bone spurs in my neck, fibromyalgia, RSD, two bone-to-bone knees, four
bulging herniated discs in my lower back, and sciatica that goes down my right leg to
my foot. I'm in so much pain, I have to see a psychiatrist and go to therapy.” “He gave
me his full attention. Unlike other pain management doctors I've seen, he spends a lot
of time with each patient. Other pain management doctors could take lessons from
him. Neither of the doctors I was forced to go to cared about me, my pain and
suffering or spent any time with me.”
Comments on online article about incident:
“It is criminal what these agency's have done to Dr. X’s patients. Consider his case load
of over 2000 patients. Maybe some of those were drug-seeking addicts, but surely not
most. What happens to these people who are in severe, chronic pain? We are not able
to get our medical records because nobody answers the phone, or comes to the door.
You have to have your records before another doctor will see you, and even then, the
earliest appointment I could find is mid-July. Patients were not told of the doctor's
suspension, so many discovered it only when the tried to fill a dated prescription. No
meds, no medical records, no alternate doctor. Lots of pain. Lots. Thanks, Priority
Partners, DHMH, and Maryland Board of Physicians. In stopping a Doctor from
prescribing for a few bad patients, you have effectively kicked the rest of us to the
curb with no help at all. I thought your jobs were to HELP citizens get access to
healthcare???”

14. Who “Owns” this Problem?
State Medical Board: Can order phys. to turn over records & assist
patients but what happens if no compliance? Slow to act and highly
bureaucratic
State Health Dept: No existing infrastructure or resources to support
patients despite use of CDS regulatory authority
Insurance Carriers: Many Medicaid patients, few accepting providers
in medically underserved area
Local Health Dept: Tried to coordinate with local providers but very
limited resources; limited space in SUD Tx programs, including single
regional OTP
Hospitals: No chronic condition mgmt. from ED
Community Providers: Worried about taking on complicated,
potentially disruptive patients and being next target of
regulatory/enforcement action

15. Lessons Learned
#1 Problem practices can grow over years in
plain sight of locals, but regulatory/enforcement
action is slow to identify and address. Need for
state-level process to identify and intervene
with potential problems before crisis develops.
#2 Need for plan with resources to be deployed
when abrupt, large scale cessation of CDS
prescribing occurs in an underserved community

16. #1: CDS Integration Unit
• DHMH “fusion center” for info on investigations related to
CDS Rx & dispensing
• Includes licensing boards, Medicaid, PDMP, CDS registration
authority, medical examiner, inspector general, behavioral
health, AG’s office, etc.
• Member agencies identify CDS-related data sources, “red
flags” and pool information for analysis
• May make recommendations to Secretary for further
investigation, complaint with licensing board, action against
CDS permit, etc.
• Possibility of “intermediate sanctions” tied to CDS permit,
including education, mentoring, monitoring, etc.

17. #2: CDS Emergency Preparedness Plan
• GOAL IS: temporarily deploy resources at local level to
mitigate impact on public health/safety and healthcare
system.
• GOAL IS NOT: replace normal care coordination or
patient referral processes or remove responsibility of
practitioner, insurers, local health dept., etc.
• 2013 MOU b/t DHMH Behavioral Health Admin & Univ.
of Maryland, School of Pharmacy (UMSOP) to develop
plan
• UMSOP team: clinical pharmacists & RN w/ expertise in
pain mgmt. & palliative care

18. Year 1: Plan Development
• Survey other states on model programs
• Conduct practitioner focus groups to aid plan development
• Assemble network of practitioners educated on process and figure
our how to create “rapid response team” to assess patients, provide
appropriate short term Tx/Rx and smooth referrals to community
providers
• Develop educational/clinical support tools for RRT and other
providers for use during event
• Identify responsibilities of players, including UMSOP, DHMH, LHDs,
etc.
• Plan for disseminating info to local stakeholders and coordinating
players

19. Survey of Medical and
Pharmacy Boards
• High response rates
• Many reported experiencing abrupt cessation
of prescribing due to disciplinary action
• Few report any formal or informal plan for
response
• Little evidence of plans that include dedicated
resources to assist patients during event

20. Focus Groups
3 separate groups for pain management & behavioral health
experts, primary care providers and pharmacists
Goals:
• Identify implementation barriers
• Develop clinical criteria for patient triage
• Identify documentation necessary to support patient
referrals
• Develop cost estimate for purchasing practitioner time
• Provide ongoing feedback on plan development &
implementation

21. Notable Focus Group Guidance
• Timely access to medical records is essential:
 Need for patient & pharmacy record-keeping to facilitate referral (med list,
H&P, labs, imaging, consults, etc.)
 PDMP and health info exchange access
 Investigate legal authorities to compel disclosure
• UMSOP team should assist patients with
compiling all available records during event
• Compile current lists of relevant providers by
specialty area (pain, BH, primary care, etc.)
• Could regulators create a prescriber “safe harbor”
in catchment area to reduce fear?

22. Clinical Support Tools
(Still Under Development)
• Criteria for initial triage screening: low risk
(referral to PCP), unknown risk, high risk (likely
SUD & other comorbidities, referral to LHD
behavioral health division)
• Take into account medical condition, CDS
types/combos, SA/LA opioids, therapy
duration, dosage frequency & escalation,
adult/pediatric, has PCP?

23. Year 1: Obstacles
1. Complications of planning for abrupt cessation of ANY
high volume CDS Rx (incl. benzos, bupe), not just OA for
pain mgmt.
2. Inability to identify means to establish RRT:
– Practitioners need liability protection; only state
employees/contractors covered by tort claims act
– State can’t quickly bring on practitioners as
employees/contractors
– UM system depts. unwilling to have practitioners provide Tx
services; outside of employment scope
– Contract with temp services investigated but not practical
3. NEAR CONSTANT NEED TO RESPOND TO LICENSE
SUSPENSIONS

24. Ad Hoc Responses to Date
• Temp suspension of another E. Shore pain mgmt.
physician; agreed to work w/ UMSOP on triage
• West. MD bupe prescriber dropping patients in
anticipation of Board sanction
• Temp suspension of radiologist who began “pill mill” Rx
before retirement
• Temp suspension of So. MD internist/pediatrician, high
volume benzo/stimulant Rx
• License surrender of elderly med. dir. of outpatient MH
clinic with large benzo/bupe patient caseload

25. Key Components of “Plan” in Action

26. Initial Steps
• Licensing board notification (via CDSIU) of
BHA of imminent sanction (weeks notice
possible)
• BHA gathers intel & notifies UMSOP team &
LHDs where patients reside (can’t ID
practitioner until order is public)
• In consult w/ licensing board, BHA attempts to
contact practitioner (or attorney) to explain
project and solicit cooperation

27. Alerting Local Providers
UMSOP customizes template notifications for local
providers about situation with patient instructions,
work w/ LHD to distribute to:
Local hospitals/ED
Urgent care centers
Pharmacies
Other community practices
Local law enforcement & EMS

28. If Practitioner Cooperates…
• UMSOP project coordinator works w/ office
staff to ID high priority patients & document
clinical info
• UMSOP works with “network” providers &
LHD to identify appropriate referral pathways
and conduct follow-up
• Notifications instruct patients to call
practitioners office, who works w/ UMSOP
project coordinator.

29. If Practitioner DOES NOT Cooperate…
• Notifications instruct patients to call LHD main
line or special hotline, LHD POC works w/
UMSOP project coordinator.
• Harder to know whether high-risk patients are
being identified and directed appropriately
• Requires constant monitoring/contact with
community providers, hospitals, pharmacies,
etc. to detect at-risk patients

30. Special Considerations
• “Bridge” providers don’t want to est. long-term
patient/provider relationship; what about patient
abandonment?
• Bupe patients covered by 42 CFR Part 2; practice needs
consent before disclosure of records => refer patients
to LHD BH division for SUD assessment, possibly OTP
• Serious dangers from benzo withdraw => refer to local
Core Service Agency; what is hospital role?
• How can PDMP, HIE be used more effectively to
support rapid response?

31. Next Steps: Year 2-3
• Finalize Plan, including P&P manual, clinical support
tools, notification templates, stakeholder roles, etc.
• Continue building network of trained/educated
providers willing to support rapid response
• Develop & implement plan for provider education
(academic detailing?) on Plan & “overdose prevention”
topics, including:
Use of PDMP & HIE
SBIRT
Buprenorphine
Naloxone
Safe/effective CDS Rx education

32. Project Personnel
Univ. of Maryland, School of Pharmacy
Co-PIs:
Kathryn Walker, PharmD, BCPS, CPE
Mary Lynn McPherson, PharmD, BCPS, CPE
Project Coordinator:
Micke Brown, RN
DHMH Behavioral Health Administration
Kathleen Rebbert-Franklin, LCSW-C, Dep. Dir. of
Population-Based Behavioral Health
Michael Baier, Overdose Prevention Director
Brian Holler, MPH, MOU monitor

33. Michael Baier
Overdose Prevention Director
Maryland Department of Health and Mental Hygiene
Behavioral Health Administration
michael.baier@maryland.gov
410-402-8643

34. State Initiatives Impacting
Physicians and Patients
Maine’s Diversion Alert Program

35. Disclosure Statement
Clare Desrosiers, MSW, has disclosed no
relevant, real or apparent personal or
professional financial relationships with
proprietary entities that produce health care
goods and services.

36. Learning Objective:
Inform clinicians of resources for responding to
patients charged with drug-related crimes.

37. PMP
What is Diversion Alert?

38. Rx abuse in Maine
0
20
40
60
80
100
120
140
160
180
200
2008 2009 2010 2011 2012
Overdose deaths caused by substances
Pharmaceutical Illicit All
Source: Office of the Chief Medical Examiner – Published in 2014 Maine
State Epidemiological Profile

39. Rx abuse in Maine 2
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Drug deaths by drug type: ME ’00-’12
Methadone Oxycodone Benzodiazepines Heroin
*Some deaths were caused by more than one key drug.
Source: Office of the Chief Medical Examiner – Published in 2014 Maine State Epidemiological Profile

40. So, why is the problem so big in Maine?
Rate of kilograms of opioid pain relievers sold in 2010
per 10,000 people
Source: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention 2011.

41. Source of painkiller abused 2008-2011
27%
26%
23%
15%
9%
High risk non-medical opioid users
Own prescription from
prescriber
Free from friend/relative
Bought from
friend/relative
Bought from drug dealer
Other
Source: Jones et al (2014)

42. What is the Diversion Alert Program?
 Monthly emailed/mailed alerts to health care
providers showing individuals arrested for illegal drug
related crimes;
 Online, password protected drug arrest database;
and
 Educational resources to assist in responding to
patients charged with illegal drug related crimes.

44. Who can register to access Diversion Alert data?
Pharmacists
Licensed Maine prescribers (e.g. NPs, MDs, DOs, PAs,
dentists, podiatrists)
Sub-recipients authorized by licensed prescribers or
pharmacists (e.g. medical office managers, social
service providers)
Law enforcement personnel

45. Is it legal to distribute arrest information?
Yes.
Under Maine’s Criminal History Record
Information Act, a criminal justice agency may
disclose to the public criminal history record
information related to an offense for which a
person is currently within the criminal justice
system. This includes recent arrests that are
actively being prosecuted [16 M.R.S. §
612(3)(A)].

46. Arrest, summons, conviction
Arrest: gives notice to an individual that
he/she is being charged with a crime. Person
is detained.
Summons: gives notice to an individual that
he/she is being charged with a crime.
Conviction: formal declaration by a court that
a person has been found to have committed
(is “guilty” of) a crime.

47. Do not wait for a conviction to
respond to a charge
Given the professional and life-threatening risks associated with
continuing a controlled substance prescription to someone who is
addicted or diverting, it is safer to consider the person
"guilty until proven innocent."

48. Resources for responding to patients
charged with drug crimes:
Tip Sheet 1: Responding to patients charged
with prescription or illegal drug related crimes.
Tip Sheet 2: Clinical changes to consider in
response to patients charged with prescription
or illegal drug related crimes
Tip Sheet 3: Effective alternatives to treat
medical conditions for which controlled
substances are commonly prescribed
Tips for Pharmacists

49. 2013-14 Program Evaluation
Quasi-experimental
pre/post study with
comparison groups in
Maine, New Hampshire,
Vermont
Independent evaluator:
ASTOS Evaluation
State
# completed
pre-surveys
# completed
post-surveys
ME
862 202
NH 580 385
VT 369 195
Total 1811 782

50. How DA information is used:

51. Outcome: Awareness of patients
arrested for drug crime

52. Outcome: Increased communication
with other providers
I communicate with health care providers who share a patient’s treatment
with me.
Rating scale 1=never, 2=sometimes, 3=A lot, 4=All the time
Pre-test mean/SD Post-test mean/SD P*
New Hampshire 3.01/.76 3.05/.8 .000*
Vermont 3.03/.35 3.04/.8 .001*
Maine 2.68/.6 3.04/.7 .000*
I communicate with pharmacists who fill prescriptions for my patients.
Rating scale 1=never, 2=sometimes, 3=A lot, 4=All the time
Pre-test mean/SD Post-test mean/SD P*
New Hampshire 2.42/.78 2.53/.04 .000*
Vermont 3.03/.8 2.66/.8 .000*
Maine 2.62/.77 2.75/.76 .000*

53. Outcome:
Increased attentiveness to prescribing

54. Other outcomes:
Compared to VT & NH, ME providers…
Did not discharge patients but continued to
provide health care
Used preventive practices more
– PMP
– Narcotic agreements (contracts)
– Stopped prescribing controlled substances to pt
arrested for drug crime
– Changed prescription for pt arrested for drug
crime

55. Diversion Alert in other states
No other program known in the US
Our goal is to expand to other states

56. Data References:
Centers for Disease Control and Prevention. Policy
Impact: Prescription Painkiller Overdoses. Atlanta, GA:
US Department of Health and Human Services; 2011.
Jones, CM, Paulozzi, LJ, Mack, KA. (2014). Sources of
Prescription Opioid Pain Relievers by Frequency of Past-
Year Nonmedical Use United States, 2008-2011. JAMA
Intern Med. 174(5):802-803.
Maine Office of Substance Abuse and Mental Health
Services. Substance Abuse Trends in Maine: State
Epidemiological Profile 2014. South Portland, ME:
Hornby Zeller Associates, Inc.; 2013.

57. Clare Desrosiers, Executive Director
clare@diversionalert.org
207-521-2408
www.diversionalert.org
Contact information

58. “State Initiatives Impacting
Physicians and Patients”
Engaging Physicians In Behavioral
Health

59. Disclosure Statement
• Denzil Hawkinberry, MD, has disclosed no
relevant, real or apparent personal or
professional financial relationships with
proprietary entities that produce health care
goods and services.
• Kathy Paxton, MS, has disclosed no relevant, real
or apparent personal or professional financial
relationships with proprietary entities that
produce health care goods and services.

60. Barriers to Engagement
The Expectations:
Gatekeeper, Educator And Treatment Provider
The Barriers:
• Lack Of Education & Practical Experience
• General Lack Of Wanting To Confront Their
Patients
• Inability To Obtain Good Referral Resources

61. WV Responds
• Top Down/ Bottom Up Approach
• Legislation (SB437)
– Required CME
– Checking PDMP
– Regulation of Pain Clinics
– Regulation of Opioid Treatment Centers
• Improvements to PDMP System
– Increased Interoperability (9 States)
– Additional Fields & Reports

62. WV Responds
• Comprehensive Physician Education
– Conferences & Summits (Appalachian, Family Practice,
Perinatal)
– Face to Face Learning Sessions (Hospital/University Based)
– Champions that Mentor (Sullivan, Hall, Hawkinberry,
Maxwell, Chaffin)
– Community Coalitions (Physician Engagement Training)
• Integration of Behavioral Health into Primary Care
– Community Health Specialist Pilot
– HRSA/SAMHSA Awards

63. Results
Practicing Physicians Trained
Residents Trained
Patient Education & Physician Oversight
Pain Clinics Closed
Increase in queries
Decrease in dispensing
Decrease in prescription drug use past 3 years

64. Next Steps
• Curriculum Inclusion
• Combination Physician Rotations
• Increase in Mentoring Programs

65. Clinical Track:
State Initiatives Impacting
Physicians and Patients
Presenters:
• Michael Baier, Overdose Prevention Director, MD Department
of Health & Mental Hygiene, Behavioral Health Administration
• Clare Desrosiers, MSW, Executive Director, ME Diversion Alert
• Denzil Hawkinberry II, MD, Physician, Community Care of WV
• Kathy Paxton, MS, Director, WV State Substance Abuse
Services
Moderator: Van Ingram, Executive Director, Office of Drug Control
Policy, Commonwealth of KY