Ss HCiINe School of Medi inai Mt S: Interlibrary Loan = § ILLiad TN: Borrower: NCUNCC Lending String: Patron: Crozier, Mary - $6805 Journal Title: Journal of opioid management Volume: 6 Issue: 5 MonthiYear: 2010 Pages: 359-64 Article Author: Crozier M;Mcmilian S:Hudson S;Jones S Article Title: The eastern north carolina opioid prescribers proj Notes:Alternate email address: hsldoedel@ecu.edu Special Instructions:Alternate email address: hsldocdel@ecu.e Imprint: ILL Number: 30170326 ANE Call #: Location: 11/18/2010 8:43:26 AM Charge Maxcost: $11.00 Shipping Address: East Carolina University Laupus Health Sciences Library 2540 Health Sciences Bldg. 600 Moye Blvd Greenville, NC 27858-4354 Fax: E-Mail: yandlej@ecu.edu Phone: 1.252.744-222 ‘System ID: DOC Document Type: Article System Number: 301703265 see -eTeeatteunnaria tess ORIGINAL ARTICLE The Eastern North Carolina Opioid Prescribers Project: A model continuing medical education workshop Mary K. Crozier, EdD; Sherté McMillan, PhD Student; Suzanne Hudson, PhD; Stephanie Jones, MS ARTICLE INFO ABSTRACT Kewords The decision to prescribe opioid medications 1s complex. Physicians often strug ‘Fiat Ble to balance the risks of medication diversion and abuse with the benefits of prescription medication substance abuse ‘sbmance misise Unugseeking patients continving medical education rik reduction ‘opioid risk management Pain management. Nationally, more than 40 percent of primary care pbysi- cians report difficulty in discussing the possibility of prescription medication abuse with patients and more than 90 percent fail 0 desect symptoms of sub- stance abuse. Continuing medical education workshops were developed in Eastern North Carolina to mitigate problems with opioid prescriptions. Attendance at these workshops suggests that prescribers are interested in tmprov- ing opiotd prescribing practices and reducing Patient risk, Presurvey data indi- cate that prescribers are knowledgeable about screening tools and they consider ‘ariel isto Received 19 Mach 2010 Keceived in revised form 4 May 2010; une 2010 Accepted 4 june 210 OF-10,5055/jom 2010.0033, © 2010 our of Opioid Management AlLRighs Reserved ‘OVERVIEW Recent high-profile celebrity deaths have been attributed to overdoses of prescription opiate and painkiller drugs." Although abuse and addiction 10 ‘opioid agents is nota new phenomenon,? these pub- licized tragedies have shed light on the growing problem of drug poisoning deaths that can be seen in individual states.* The new aspect is the extent and growth of opioid overdoses? because they seem to represent an expanded pathway to opioid addic- tion.® There are abundant federal, state, and local data to show that prescription opioid abuse is signif- icantly contributing to criminal activity,” hospitaliza- tion and emergency room visits, substance abuse among teens,® and a 300 percent increase in admis- sions for substance abuse treatment over the last decade.” A study conducted by Hall etal. flustrated that $6 percent of abusers had no registered pre- scription for an opioid and another 20 percent had misrepresented themselves to five or more physi- Gians to receive opivid prescriptions, also known as patient risk factors for misuse. “doctor shopping.” A slight increase int nonmedical use of prescription lopioidl pain relievers was noted between 2002 to 2008 in 18- to 25-year-old subjects, and the 2008 data estimated that 4.7 million Americans used these drugs nonmedically in the past month” Prescriptions filled for opioids increased by 222 per- cent between 1992 and 2002 with the opioid hydro- codone being the most frequently preseribed drug in the United States, accounting for 85.1 million of the three billion prescriptions filled in 2003. Although prescription opioid abuse is a concern nationwide, it is heavily localized in rural, suburban and small urban areas...most notably the Appalachian region of the United States."*P""' in Nomth Carolina, a correla- tion has been found berween counties with high rates of controlled substance prescribing and high rates of death due to accidental poisonings caused by drug overdoses.!S Unintentional overdose by pre- scription [opioid] painkillers is the leading cause of accidental death in North Carolina." Deaths from opioid overdoses in North Carolina have increased faster than the national average.’ In 2008, Carteret Jour of opioid Mangement GS Sepeember/Ociober 2010 359County had the highest rate of controlled substance prescribing in Eastern North Carolina counties and ‘one of the highest throughout the state.) Although there are many risks of opioid use, this article will address opioid prescription. An educa- tional, pilot project was developed to mitigate one or more of the environmental causes of opioid abuse in several Eastern North Carolina counties, which are at increased risk of substance abuse in general and opioid abuse in particular. Spanning 6 months, this project benefited from a number of professional collaborations and used multiple fund: ing sources to offer continuing medical education (CME) workshops for prescribers. The goals of these posiservice, educational workshops were to improve opioid prescribing practices and to detect abuse or addiction in primary care. These goals fol- low the American Medical Association (AMA) and the Office of National Drug Control Policy call for better physician education, physician responsibility Of prescription diversion, and appropriate preserib- ing practices." LITERATURE REVIEW Physicians may feel caught between following the Hippocratic Oath and causing harm by prescrib- ing potentially addictive medications. They have been the target of prescription marketing and subse~ quent opioid educational and intervention efforts. An example is the development of oxycodone in. 1916 as an improved opioid but it was later heavily marketed to address the increased demand for pain management medications in a sustained release dose. Those marketing efforts for oxycodone were successful and sales peaked at $2 billion in 2005." Reports of oxycodone and other opioid abuse prompted the federal government to address phar- maceutical opioids by targeting drug companies, patients who divert opioids, and physicians. In 2002, the Drug Enforcement Administration prose- cuted 410 physicians for recklessly prescribing opioids —an 800 percent increase in physician prose- cutions from 1999. Many physicians and addiction specialists believe that this concerted federal effort has spawned paranoia in primary care physicians, placing patients and physicians in adversarial roles when ireating chronic pain. Dahl? acknowledged highly publicized opioid prescsiption abuse cases that instilled fear in honest prescribers. Nonetheless, physicians and other preseribers play a key role in 360 safer opioid prescribing as most addicts visit a pre- seriber every 6 months and many teens who abuse opioids access medications prescribed for friends or family members.” ‘An additional challenge is the role that pre seribers play in balancing the benefits of opioid pre- scription with the risks of abuse and the protocols of regulatory agencies. More than 40 percent of pri- mary care physicians report difficulty in discussing the possibility of prescription drug abuse with patients and more than 90 percent fail to detect symptoms of substance abuse.” Prescribers who use substance abuse screening, brief intervention, and referral to treatment (SBIRT) through the use of the Alcohol Use Disorders Identification Test, Alcohol ‘Smoking and Substance Involvement Screening Test (ASSIST), CAGE," or Drug Abuse Screening Test screening tools can be highly effective”; especially, if treatment services are available in their community. Thus, it is recommended that before considering an opioid trial, the patient should be assessed for predictors of opioid abuse. These predictors include a history of alcohol or substance abuse and drug-related convictions!® as well as “pseudoaddiction™9" through the use of the several risk assessment screen- ing tools available. Patient risk assessment, screening, and monitor. ing are important prescriber tools. Joranson et al. researched opioid prescription monitoring pro- ‘grams for the treatment of pain that focused on the patient, physician, and the pharmacist. Prescription monitoring programs are intended to track prescrib- ing habits and patient's drug-seeking habits as well as data review and collection, Practicing physicians have benefited from postservice training on opioid use for pain management as measured by improve- ments in knowledge, attitudes, and patient manage- ment of chronic pain Research has been conducted on the effectiv ness of postservice education programs for phy’ cians, Most physicians receive CME, and the over- whelming majority of those physicians changed theie practice as a result of a CME workshop. The Accreditation Council for CME evaluates the outcomes of CME workshops on criteria such as physician competence to physician performance and patient outcomes. The Accreditation Council also suggests follow-up CME workshops for optimal “CAGE {a8 acronym of terms that represent addciton criteria (Cut down, Annoyed, Guilty, Bye-Opens bee Pee Eirceeeece eee Journal of Opioid Management 65 & Seprember/Ocrober 2010 yy — —— — ————————_§|_—transference of knowledge and performance improvement CME workshops are vital for practi- tioners who have not received specialized preser- vice training in emerging issues. Unlike addiction medicine specialists who are trained in the use of opioids and methadone, mast primary care practi- tioners have not received specialized taining, Researchers caution that patients may be at increased risk if prescribers do not receive postservice training in opioid medications, pain management, prescrip- tion monitoring tools, utilization of evidence-based screening tools, and laws pertaining to opioid prescribing.” PRESCRIBER WORKSHOPS A number of small grants were awarded to Lumina Wellness inc. to conduct three pilot work- shops on “Safer Opioid Prescribing” in Eastern North Carolina for CME credit during the fall of 2008 and spring of 2009. The workshops were scheduled via the local AMA chapters and were offered to all physicians, physician's assistance, dentists, and other prescribers. The workshops were built around a 3-hour, national curriculum entitled, Clinical chal- lenge: Prescribing controlled drugs? and were facili- tated by experts from within the state. This curriculum is research based and is applicable to this region and state. Training emphasis was on the following ‘aspects: pain management; the targeted prescription opioids analgesics oxycodone, hydrocodone, and methadone; a review of SBIRT and evidence-based screening tools; and the North Carolina Controlled Substance Reporting System (NCCSRS). Screening tools included the CAGE Adapted to Include Drugs (AID), the Opioid Risk Tool, the Pain Medication Questionnaire, and the Screener and Opioid ‘ssesstent for Patients with Pain, Participants were reminded of the need to choose opioid medication carefully, consider nonpharmacological alternatives, document consistently, recognize aberrant behav- ior, discern legitimate medical concerns from doctot shopping, educate patients, and discontinue pre~ scribing when necessary (Dr. Goli, personal com munication, CME workshop fall 2008), DATA COLLECTION METHODS The Institutional Review Board's approval was given to collect anonymous, self-report pre/post data from prescribers attending the three CME pilot workshops. ‘The workshops were offered in Carteret, Craven, and Dare County. Paper surveys were distributed prior to each workshop and 3 months afterward. The surveys asked the prescribers about the following: academic degree; type of medical practice: use of pain assess- ‘ment and patient risk stratification tools; use of treat- ment agreements, urine drug screens, and other monitoring tools during ongoing opioid treatment; awareness of the NCCSRS; use of referrals; and use of screenings and brief intervention practices, The data were used to deiermine effectiveness and usefulness of these pilot CME workshops. ‘The presurvey was administered after patti were registered, but prior to the start of the work- shop speakers, Of the 73 surveys collected, only 67 were completed and used. Participants included ‘medical doctor (n = 35), doctor of osteopathy (n = 1), podiatry (n = 1), nurse practioner (n = 14), physi- Gian assistant (a = 7), dentist (a = 5) and other non- prescribers (n = 4). The postsurvey was mailed to attendees 3 months after the Workshop with a prepaid stamped enve- lope. Because of insufficient returns, the postsurvey could not be tabulated and will not be included in this article. DATA SUMMARY Approximately one fifth of the registered pre- scribers in each of the aforementioned counties attended a CME workshop. Responses from the presurvey were analyzed to describe prescriber practices and needs. Of note was the consistency within respondents who considered patient risk fac- tors for opioid addiction of misuse; 86 percent indicted that they either always or frequently con- sidered risk factors, There was more variability in responses to most ‘of the presurvey questions (Table 1). For example, 36 percent said that they would frequently perforsn brief interventions when it became evident that a patient was abusing opioids, but 18 percent said that they would never perform a brief intervention Only 15 percent said that they would refer a patient to substance abuse treatment if needed, and 29 per- cent said that they would never refer to treatment. ‘The majority (58 percenD, however, said that they would sometimes refer a patient (0 treatment Respondents indicated that they used different tools such as a pain disability index (25 percent), pain drawings (19 percent), the CAGE-AID (19 percent), | Journal of Opiold Management 85 % September/ October 2010 361Table 1, Professional practice of prescribers as per presurvey ‘Never, | Sometimes, ] Frequendy, | Always, Professional prncice of prescribers inpercent | impercent’ | inpercent’ | in percent Consider rak facorsfrmisuse and oraddicnon(a=6O| 45 106 HB 70 Perform brief interventions when abuse or addiction is Z evident (n = 67) ae 7 pet Refer paints to substance abuse weatnent (a= 68) 292 3a 3A 7 Tiducate patente about afe drug aking song, and os us os oe disposal pacts ( 3 ‘se the North Carolina Controlled Substance System to z verify suspicious (n = 63) 86 206 238 Use opioid wrestmentcontcts wen opioids used on an ongoing basis (n = 54) a He 333 204 ‘Document informed consent about rks and benelis oF 7 opioids (n = 58) ee 276 be ie “Nota category for this queston and the ASSIST (9 percent) either exclusively or simultaneously to assess pain and/or risks. When asked about educating patients on safe opioid tak- ing, storing, and disposal practices, the range of response was from 18 percent (always), 72 percent (Sometimes and frequently), and 10 percent (never). ‘There was also variability in responses when asked about the use of the NCCSRS; 56 percent never used it and 24 percent frequently used it with the largest group of nonusers being medical doctors. The most prevalent reasons given for not screening, interven- ing, or referring patients was lack of information fol- lowed by a lack of time and tools. LUMITATIONS This pilot study describes a new, research-based, opioid prescriber CME workshop conducted in three Eastern North Carolina counties during 2007- 2008. The CME attendees may be a self-selected group and thus may not represent the breadth of prescribers in Eastern North Carolina or the state, CONCLUSIONS This is an unprecedented time regarding opioid prescription and abuse. The recent high-profile deaths and national abuse rates have piqued con- sumer and prescriber attention. Unfortunately, how- ever, there is limited research on opioid prescription practices. This pilot CME attempted to address atti- tudes and knowledge held by practicing Bastern 362 North Carolina physicians on prescribing opioids and to increase safer opioid prescribing practices. It offered training on a sensitive and timely issue by CME accredited providers. It also followed the 2006 National Leadership Conference on Medical Education in Substance Abuse Guidelines and it used multiple conduits to reach providers. As per the presurvey, prescribers requested better real-time access to pain management specialist and addictio- nologists to manage their patients with chronic or long-term pain syndromes. Telemedicine and/or arrangements for prompt, expert telephone consul- tations with addictionologists were well received and needed. ‘This CME will be replicated throughout North Carolina. The main objective is to provide postser- vice training on consistent standards of care, use of the NCCSRS, and documentation protocols that can help to reduce medical and legal exposure. In ad tion, peer coaching will continue to be discreetly offered as needed. RECOMMENDATIONS Although providers need to be mindful of the potential for opioid diversion schemes, Winfield? cautions against fear of prescribing opioids as they can be part of an effective multimodal treatment plan. Thus, if is advised that prescribers regularly assess the “4 As” of pain medicine, which include routine assessment of Analgesia, Activity, Adverse effects, and Aberrant behaviors, It is also suggested Tourn of Opioid Management 6:5 M Seplember/Octaber 2010Tamers Spon Thereny ee} | Tere Conanee Spee tae y J [tn b+ ome a Figure 1. Algorithm for opioid treatment of chronic pain Coptimize therapy). that prescribers have an exit strategy for opioid pre- seribing: “If you don't know how to land, don’t take of” (Dr. Goli, personal communication, CME work- shop fall 2008), ‘The current research suggests that better prescrib- ing practices in opioid treatment for chronic pain could help to reduce prescription opioid abuse because 10-25 percent of patients who became addicted to prescription opioids did not have or acknowledge having a prior substance use disorder.» ‘The simple algorithm shown in Figure 1 can be used for opioid prescription decision making 30 ‘The key components of any effort to change med- ical practice and physician behavior are education, feedback, financial rewards, financial penalties, administrative change, and physician participation.”? Best practices can be achieved via finavicial incentives, ‘emphasis on standards of care, an increased availabi ity of pain management clinics (Dr. MeMillan, per- sonal communication, 2008), collaboration between local and national organizations, and “booster shot” ‘educational programs to physicians.!” ‘ACKNOWLEDGMENTS ‘The autbors thank Dr. Gwen Liman, Dr. James Finch, Dr Veeru Gols, Bill Bronson, Kay Sanford, Dr. Brian Mcwilhian, and Dr. David Ames. Mary K. Crozier, BAD, Assistant Professor, Department of Rehabilitation Studies, East Carolina University, Greenville, North Carolina. Sherré McMillan, PhD Studont, Department of Rebabi. Ihtation Studies, East Carolina University, Greenville, North Carolina. Suzanne Hudson, PhD, Assoctate Professor, Department of Biostatistics, East Carolina University, Greenville, North Carolina. Stephanie ones, MS, Department ofRehabitwaton Studies, ast Carolina Univers, Groontile, Nor Carolina ‘REFERENCES, 1. Balinsky M: Drug overdose killed DJ AM, offcial says, CNN, Available at bapy/Avnow.cnn com/2005SHOWBIZ/Music/09/29/ DIAM autopsy index bimbiref-newssearch. Accessed September 29, 2008. 2. Bryner J: Overdose epidemic: Not just for celebrities, Live Science. Available at burp./Auuo tscionce com/culture/090729- celeb-overdoses.biml. Accessed July 29, 2009. 3, De Quincey T: Confessions ofan English Opium-Fater [1821]. World's Classtes Edition, New York: Oxford University Press, 1998, 4, Paulozzi 1J, Ryan GW: Opioid analgesics and rates of Fatal drug poisoning in the United States, am J Prev Med, 2006; 31(6) 506-511 5. Compton WM, Yolkow ND: Major increases in opioid anal _gesic abuse in the United States: Concems and staxegies. Drug ‘Alcohol Depend. 2006; 81(2): 103-107, 6, Siegal HA, Carlson RG, Kenne DR, et al: Probable relation- ship between opioid abuse and heroin use. Am Fam Physician, 2003; 67(5): 942-945. 7. North Carolina Department of Justice: North Carolina Crime Statistics. Available at_ btp:/Sbi2.sus state.nc.us/erp/public/ Default btn. Accessed October 10, 2009, 4, Substance Abuse and Mental Health Services Administration, COfce of Applied Studies: Results from the 2008 National Survey on Drug Use and Health National Findings, Available at btip// wurw.cas.sambsa.gowNSDUN/2RBNSDUH/2k8 results. cfm? 3. ‘Accessed October 23, 2009, 9, Substance Abuse and Mental Health Services Administration: Emergency room visits climb for misuse of prescription and. ‘over-the-counter drugs. Available at bitp://wrow sambsa.gou! neusroor/advisortes/070313 5921 aspx. Accessed Seplember 23, 2009, 10. Hall AJ, Logan JE, Toblin RL, et al: Pattems of abuse among unintentional pharmaceutical overdose fatalities, Jam Med Assoc. 2008; 300(22): 2513-2620, 11. National Center on Addiction and Substance Abuse at Columbia University: Under the counter: The diversion and abuse of controlled prescription drugs in the US. Available at huip.//uww casacolumbia.ore/absolutenm/ariiclefiles/380- Underte200bes20Counter%20-%20DIversion pd’. Accessed September 25, 2009. 12, Cicero 1J, Dart RC, Inciadi JA, et al: The development of a comprehensive risk-management program for prescription opi- old analgesics: Researched abuse, diversion and addiction- related surveillance (RADARS'), Pat Med. 2007; 82) 157-170, 13, Sanford C: An unrelenting epidemic of deaths from prescrip- tion deugs in North Carolina. Forum (NC Medical Board). 2008; 132): 4-7, 14, North Carolina Department of Health and Human Resources: Health Profile of North Carolinians: 2007 Update. Available at bunp:/howw schs state.nc.us/SCHSpdf/FealtbProfile2007 pdf. “Accessed Ocrober 10, 2009. 15, Sanford C: Deaths from unintentional drug overdoses in "North Carolina, 1997-2001: DHHS investigation info uninten- ‘ional poisoning-related deaths. Available at bnp:/injursfrenc, nedbbs.gov/About/unintentionalpoisoningsReport pdf. Accessed September 7, 2009. Journal of Opioid Management 6:5 # September/October 2010, 36316. North Carolina Mental Health Developmental Disabilities and Substance Abuse Services: Noth Carolina controlled sub- ‘stances reporting system. Available at brip./ww dbbs state. nc.us/MHDDSAS/controlledsubstance/index bim, Accessed September 7, 2009. 17, Madras B: Charge 10 working groups. In National Leadersbip Conference on Medical Education Substance Abuse. Washington, DC: Office of National Drug Control Policy, 2006: 62 18. Cohen SP, Raja SN: The middle way! 4 practical approach to prescribing opioids for cticonic pain, Nat Clin Pract Newrol. 2006, 2(11) 580-581, 19, Dabl JL: Working with regulators to improve the standard of ‘are in pain management: The US. experience, J Pain Sympiom ‘Manage. 2002; 24(2): 136-147 20. Joranson DE, Gilson AM, Dahl JL, etal: Paln management, controlled substances, and state medical board policy: A decade of change. J Pain Symptom Manage 2002; 23(2): 138-147, 21, Mct wan S: Substance abuse screening and brief interven- tion in Primary care. N C’Med . 2009; 70(1): 38-42, 22, Savage SR, Kirsh KL, Passik SD: Challenges in using opioids {o teat pain in persons with substance use disorders. Addict Sct (Clin Pract. 2008; 42): 425, 23. Joranson DE, Cartow GM, Ryan KM, etal. Pain manage- ment and prescription monitoring, J Pain Symptom Sfanage. 2002; 25(3): 231-238. 24, Gilson AM, Maurer MA, Joranson DE: State medical board _members beliefs about pain, addiction, and diversion and abuse: ‘A changing regulatory environment. Pain, 2007; 89): 682-59. 364 25, Wentz DK, Gannon MI, Osteen AM: Continuing medical education. JANA. 1990; 264(7): 836-840. 26. MeKenna M, Richart S, Tyler: Impact of educational inter- ventions on physician performance and patient outcomes CE Meas J Outcomes Meas Continuing Healtbcare Fauc. 2008; 20}: 246, 27. Peppin JF: The use of methadone “as needed," is it justified? J Opiold Manage. 2009; 501): 79. 28, Westley H: Center for substance abuse teeatment substance abuse and mental health services administration: Initiative on prescription drug abuse. In National Zeadersbip Conference on ‘Medical Education tn Substance Abuse. Washington, DC: Office ‘of National Drug Control Policy, 2006: 55-58, 29. Center for Substance Abuse Treatment, Substance Abuse sand Mental Health Services Administration: Clinical Challenge Presenibing Controlled Drugs. Beaufort, NC: Lumina Wellness, Inc. 2008. 30. Office of National Drug Control Policy: Drug policy informa- tion clearinghouse, state of North Carolina: Profiles of drug incica- tors, Avallable at bup,/fuow whitebousedragpelicy gowstatelocal’ ncinc pf Accessed August 21, 2009. 31. Compton WM, Volkow ND: Abuse of prescription drugs and the risk of addiction. Drug Alcobo! Depend. 2006; 83 Suppl. 1): S497 232, Winfield JB: Pain and arthritis. NC Mec), 2007; 68(6) 444-446. 33, Katz N: Teaching appropriate prescribing. In National Teadersbip Conference on Medical Education in Substance ‘Abuse. Washington, DC: Office of National Drug Contsol Policy, 2006: 31-34, Joumal of Opioid Management 65 @ September/Ociober 2010 — EEE — — — — eh