Third-Party Payer: The 411 On a Successful Rx Weaning Program - Dr. Katheryn Bronstein and Dr. Krista Jordan

1. The
411
on
a
Successful
Rx
Weaning
Program
Third
Party
Payer
Track
April
23,
2014

2. Moderator: Mark Pew, Senior Vice President
PRIUM (www.prium.net), Duluth, GA
Medical intervention on clinically complex claims
Panelists: Kathryn S. Bronstein, PhD, RN, Vice President, Medical Affairs
Ameritox, Inc. (www.ameritox.com), Baltimore, MD
Medication monitoring solutions
Krista D. Jordan, PhD, ABPP, Program Director
RestoreFX (www.restorefx.com), Austin, TX
Interdisciplinary functional restoration clinic

3. Kathryn S. Bronstein wishes to disclose that she is an employee of
Ameritox, Inc.
Krista D. Jordan has no financial relationships with proprietary entities
that produce health care goods and services.

4. 1. Describe the pharmacological and medical process of
opioid discontinuation
2. Evaluate the psychosocial issues and coping skills that
impact weaning and recovery
3. Analyze criteria of successful pain management and
functional restoration programs

5. 2011 study on opioid discontinuance trends
• Almost 30,000 patients (primarily private health plans)
prescribed opioids continuously for at least 90 days
during a 6-month period
• Approximately 66% were still on opioids after 5 years
• Attributing factors were:
• Intermittent prior opioid exposure
• Daily opioid dose > 120mg MED
• Possible opioid misuse
Source: Martin BC, et al. Long-term chronic opioid therapy discontinuation rates from
the TROUP study. J Gen Intern Med. 2011 Dec; 26(12): 1450-1457, http://
www.ncbi.nlm.nih.gov/pubmed/21751058

6. • Opioid dosage > 120mg MED per day
• Acetaminophen dosage > 4000mg per day
• NSAID dosage > 3200mg per day
• Opioids used > 2 contiguous months after injury or surgery
• Muscle relaxants used > 2 contiguous months
• NSAIDs used > 6 contiguous months
• Benzodiazepines used > 4 contiguous weeks
• No exit strategy by the prescriber

7. • Topical analgesics
• Anti-narcoleptic drugs
• Hormonal supplements
• Spinal Cord Stimulator and topical / oral analgesics
• Drug regimen that has automatic refills
• More than one prescribing physician
• No opioid treatment agreement
• No urine drug monitoring
• No liver / kidney toxicity tests where applicable
• Prescriber not utilizing the state’s PDMP

8. • Insomnia
• Lethargy
• Atrophy
• Depression
• Sexual dysfunction
• Constipation
• Addiction
PAIN
zolpidem
modafinil
carisoprodol
duloxetine
sildenafil
stool softener
buprenorphine
Opioid
All
of
this
makes
the
pain
harder
to
iden2fy
and
treat
Fentanyl?

9. Per the AMA Guides March/April 2011 Newsletter, “21 of 23
patients in the study reported a significant decrease in pain
after detoxification”
Iatrogenesis – “inadvertent and preventable induction of
disease or complications by the medical treatment or
procedures of a physician or surgeon” -- Merriam-Webster

10. Over 526,000 patients currently being treated for chronic pain
Urine Drug Monitoring
 35.9% prescribed drug not found or lab results warranting
review
 32.3% contained a drug not prescribed by the clinician
 11.1% contained one or more illicit drugs
 Of 105,000 samples with an illicit drug found:
 78% THC
 19% Cocaine
 3% Heroin

11. Bohnert A, Valenstein M, Bair M, et al. JAMA 2011;305(13):1315-1321.

12. 1. Krenzischek DA et al. J Perianesth Nurs. 2008;23(Suppl 1):S28-S42. 2. Lordon SP. Curr Pain Headache
Rep. 2002;6(3):202-206. 3. Townsend CO et al. J Clin Psychol. 2006;62(11):1433-1443. 4. Patel G et al. Med
Clin N Am. 2007;91(1):141-167. 5. Freedman MK et al. Arch Phys Med Rehabil. 2008;89(3 suppl 1):S56-S60.
6. Stanos SP et al. Anesthesiol Clin. 2007;25(4):721-759.
Pharmacotherapy1 Interventional
Approaches2
Psychological
Support3
Complementary
and Alternative
Medicine4
Physical
Medicine and
Rehabilitation6
Lifestyle
Change5

13. Medical component of weaning
1. Determine venue, in- or out-patient
2. Decide if a specialist is required
3. Assess co-morbidities and complicating factors
4. Manage the withdrawal symptoms
5. Define success

14. Pharmacological component of weaning
1. Determine clinical appropriateness for each drug
2. Separate pain management from disease management drugs
3. Assess drug cocktail for interactions
4. Create a taper strategy
 Sequence of discontinuance, by classification
 Add drugs to take away drugs?
5. Monitor the process (UDM 101)

15. Psychological component of weaning
1. Evaluate psychological and/or physical dependence, anxiety
and/or depression, family and other interpersonal factors
that may be maintaining dependency
2. Explain risks and potential benefits of long-term use of
opiates

16. Psychological component of weaning
3. Motivate the patient to make a life change
 Stages of Change Model
 CBT 101
4. Identify how patient will manage pain with less/no dosage
 Recovery Lifestyle
 Coping skills
 Function

17. Profile of a successful functional restoration program
 Is there an inter-disciplinary approach (vs. single discipline
or multidisciplinary)?
 Do they offer complementary treatments (e.g. yoga, Pilates)?
 Do they have in-patient access for significant addiction/
health issues?
 Are patients assessed and sometimes denied entry?

18. Profile of a successful functional restoration program
 Are treatment plans customized per patient?
 Is progress objectively measured regularly?
 If inadequate progress are adjustments made?
 Are patients followed for at least one year post-discharge?
 Do patients have access to booster sessions? If so, are they
charged for these?

19. Flor, H, Fydrich, T, Turk, DC. Efficacy of multidisciplinary pain
treatment program centers: a meta-analytic review. Pain. 1992;
49:221-230.
• Shows that compared to no treatment or single-discipline
treatment, functional restoration was superior in achieving
return to work and healthcare utilization
Turk, DC. Clinical effectiveness and cost-effectiveness of
treatments for patients with chronic pain. Clinical Journal of Pain.
2002; 18;355-365.
• Shows functional restoration yields reductions in pain,
increased return to work, reduced medication usage,
decreased healthcare utilization, closure of disability claims

20. Woman enters program for knee pain related to OTJ injury. Physically and
psychologically dependent on opiates to manage pain. Marriage is strained to the
point of collapse.
During the program her husband and children attend weekly family therapy
group, the patient is able to discontinue narcotics.
Patient returns a year later at the urging of her husband secondary to obtaining a
prescription for Vicodin for a back strain.
Patient and family resume family groups, patient attends additional group
therapy and yoga classes, within 3 weeks is able to feel confident about
managing without narcotics (and patient never did take the Vicodin prescribed).
At one year follow up after this incident she is still opiate free.

21.  26 of 41 (63%) patients were on opiates at intake
 7 of 41 (17%) were still taking opiates upon discharge
 Decrease of 73%
 100% of patients interviewed for one-year follow-up were
functional and/or working
 16 of 48 (33%) program completers