Rx for Drug-Seeking Patients in the ED

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Rx for Drug-Seeking Patients in the ED

• The Monterey County Prescribe Safe Initiative

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• AIM
• Be the Catalyst for Change in your Community
• OBJECTIVES
• Why change is important
• How we made change in Monterey County
• How to pitch the story in your community
• Provide practical tools and resources to get
  started

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Tools and Resources
www.chomp.org/for-healthcare-professionals/prescri
be-safe
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Scope of the Problem

• Opiate use in the U.S.
• 80 of the worlds prescription opiate supply
• 99 of the worlds hydrocodone supply
• From 1997 to 2007, the milligram per person use
  of prescription opioids in the U.S. increased
  from 74 milligrams to 369 milligrams, an increase
  of 402 (enough to supply every American adult
  with 5mg of hydrocodone every 4 hours for a
  month)

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Scope of the Problem

• 7 Million Americans use prescription drugs
  recreationally annually (2.3 of the U.S.
  population)
• 50 Million Americans have used recreationally at
  least once during their lifetime (16.1 of the
  U.S. population)

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Scope of the Problem

• Increased adverse medication events related to
  prescription drug misuse
• Estimated gt 700,000 ED visits per year related to
  prescription drug misuse alone
• Approximately 10 of all patients on chronic
  opiates account for 40 of all overdoses
• Usually on high daily doses
• Getting drugs from multiple prescribers

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Scope of the Problem

• Death from opiate overdoses have increased 300
  since the 1990s
• We lose more years of productive life in the US
  to prescription drug overdose than motor vehicle
  accidents
• Prescription drug related deaths exceed motor
  vehicle-related deaths in 29 states and Monterey
  County
• Prescription drug related deaths now outnumber
  those from heroin and cocaine combined

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Scope of the Problem

• Gateway Nearly 1/3 of people aged 12 and over
  who used drugs for the first time in 2009 began
  by using a prescription medications non-medically

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Street Value
www.streetrx.com
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DIVERSION

• Selling drugs for consideration (sex, addicted
  physicians)
• Medicine cabinet parties
• Prescription fraud
• Insurance fraud
• MRI forgery black market

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An Experiment
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An Experiment (circ. 2005)

• Frequent Users of the ED Group (FUG)
• The Team
• ED physicians
• ED nurse
• Administration
• Addictionology
• Hospitalist
• Pain management physician
• Psychiatrist
• Behavioral health nurse
• Social worker

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EDRVPEmergency Department Recurrent Visitors
Program2013
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EDRVP Purpose

• Adequately meet the needs and improve the overall
  care of patients recurrently seeking care in the
  ED for chronic medical problems, including, but
  certainly not limited to, opiate or
  benzodiazepine addiction 

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Change Concept

• Apply care management concepts
• Identify and engage recurrent visitors
• Remove barriers to more appropriate care
• Barriers to self-management
• Establish PCP or referral to more appropriate
  specialist
• Address socioeconomic barriers to care and refer
  to community resources
• Engage payer in the process
• Apply evidence-based and safe standards of care

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Criteria

• Frequency
• 4 visits in 1 month
• 6 visits in 3 months
• 12 visits in 12 months
• Using the ED as a PCP office for non-emergencies
• Chronic condition management
• Repeat imaging and laboratory
• Medication refills
• Seeking pain medication refills and/or CURES
  test
• Abusive or out of control behavior
• Provider or outside referral
• Pharmacy
• Insurance company

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Care Management Process

• Screen all referrals using criteria
• Review (prior 6 month chart review)
• Utilization patterns
• Visit reason
• Diagnostics
• PCP
• Medications refills
• Engage patient, family, providers, insurance

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Care Management Process

• Draft Plan of Care (POC)
• Advisory Council review of POC (monthly meeting)
• Communication with Patient
• Letter to patient and providers
• POC uploaded in electronic medical record (green
  dot)

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Tracking Board Green Dot Alert
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Advisory Council

• ED Physician
• Urgent Care Physician/Addictionologist
• ED Director
• CHI ED Transition Care Manager and Referral
  Coordinator
• Social Worker
• Clinical Specialist Behavioral Health Services
• Hospitalist Coordinator
• CCAH Care Management Supervisor

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Health Information Technology Enablers

• High utilizer reports
• Electronic referral process
• Auto-population of POC

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Monterey County Prescribe Safe Initiative

• Launched in February 2014
• Modeled after the San Diego Collaborative
• Aim Develop a broad-based coalition representing
  those interested in dealing with the epidemic of
  prescription drug abuse in Monterey County

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County-Wide Engagement
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Monterey County Prescribe Safe Initiative
Strategic Objectives

• Establish county-wide ED Pain Medication
  Prescribing Guidelines
• Develop resource tools to support ED efforts
• Community physician education
• CURES Party

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CURES Report
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CHOMP

• Results

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Resources

• FUG
• Periodic Committee meeting
• 0.2 FTE Assistant Director of ED
• Annual Cost 50,000
• EDRVP
• Advisory Council meeting
• 0.5 FTE TCM
• Annual Cost 75,000

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Future

• More of the same for the CHOMP EDRVP
• County-wide EDRVP Program
• Engage local pharmacies
• Engage local health plans

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Take Home Messages

• A national epidemic with local implications
  (including your community)
• Exhaust the behavior push in the same direction
• Use CURES
• Countywide medical community prescribing
  practices
• Engage the neighborhood
• Do it because it is the right thing to do AND
  there is a return on investment
• Youre behind catch up by visiting our website

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Questions?
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• Thank you
• Anthony Chavis, MD
• 831-644-7466
• Anthony.chavis_at_chomp.org
• Reb Close, MD
• 831-625-4900
• Reb.close_at_gmail.com