Nevada Osteopathic Medical Association ......Nevada Osteopathic Medical Association 65th Annual...
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LEGISLATOPLASTY : How Nevada Addressed the Opioid Epidemic through Common Sense Legislative and Medical Solutions Nevada Osteopathic Medical Association 65 th Annual Meeting & Symposium May 2-5, 2018 Las Vegas, NV
Transcript of Nevada Osteopathic Medical Association ......Nevada Osteopathic Medical Association 65th Annual...
LEGISLATOPLASTY :
How Nevada Addressed the Opioid Epidemic through Common Sense
Legislative and Medical Solutions
Nevada Osteopathic Medical Association
65th Annual Meeting & Symposium
May 2-5, 2018Las Vegas, NV
LEGISLATOPLASTY
DR. JOHN DIMURO, DO, MBA• Former Chief Medical Officer,
State of Nevada and co-creator of Nevada AB474• President, DiMuro Pain Management
-Reno & Las Vegas•Board Certified in Anesthesiology &
Pain Medicine
THE CREATION OF NEVADAAB474 AND THE “PRESCRIBE
365” INITIATIVE
Creation of a responsible and rational governmental approach to controlled substance prescribing
Controlled Substance Abuse & Prevention Act
What is AB474?
• A bill presented to the 2017 Nevada State Legislature to combat both illicit and licit substance abuse, misuse and diversion.
• Sponsored by Governor Sandoval• Passed unanimously
TASK
Using State data, determine the problem
1Develop effective, rational strategies to mitigate the abuse, misuse and diversion of controlled substances
2Increase communication amongst State agencies
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Barriers
• Legislators• Lobbyists• Public• Prescriber groups• Time
MUST…Appease ALL stakeholders
The Problem
PRESCRIPTION CONTROLLEDSUBSTANCES FOR PAIN
MisuseAbuseDiversion
Why do we have a problem?
• Increased supply of legal drugs• Increased access to illegal drugs• Dark Web
• Provider over-prescribing• Surgeons• Primary Care• Logistics
• Dental prescriptions• Providers not wanting to prescribe due
to perception• Lack of access to appropriate providers
How could this happen?
• According to State data:1) NO CHECKING OF THE PDMP PRIOR TO
PRESCRIBING!!This is the only mandate in the NRS code!• Not all prescribers are even
registered for the PDMP• All physician prescribers must
be compliant or face punitive measures by the Board
• MD Board issues• What the Board of Pharmacy
knows …
How can this happen?
• According to State data:1) No checking of the PDMP prior to prescribing2) HIGH QUANTITY OF PILLS PRESCRIBED
• “Convenience” for prescribers• Dentist prescriptions• Poor knowledge about alternative
treatments• Poor access to alternative
treatments• Insurance limitations
How can this happen?
• According to State data:
1) No checking of the PDMP prior to prescribing
2) High quantity of pills prescribed
3) HIGH NUMBER OF POLYPHARMACY PRESCRIPTIONS
• sedating and lethal combinations of meds
-opioid + BZD + sleeper
• fear of reprisal from patient
• taking over meds from another provider
How can this happen?
• According to State data:1) No checking of the PDMP prior to prescribing2) High quantity of pills prescribed 3) High numbers of polypharmacy prescriptions4) LACK OF EVIDENCE-BASED DIAGNOSIS
• Can’t just use “back pain” or “chronic pain” as a diagnosis
• No appropriate work-up performed
• Patient refusal to adhere to recommendations/referrals
• logistical constraints
How can this happen?
• According to State data:1) No checking of the PDMP prior to prescribing2) High quantity of pills prescribed 3) High numbers of polypharmacy prescriptions4) Lack of evidence-based diagnosis5) LACK OF PROVIDER FOLLOW-UP
• logistical constraints• inconvenient to provider• inconsistent providers• ignoring warnings from Board
of Pharmacy
How can this happen?
• According to State data:1) No checking of the PDMP prior to prescribing2) High quantity of pills prescribed 3) High numbers of polypharmacy prescriptions4) Lack of evidence-based diagnosis5) Lack of provider follow-up6) LACK OF APPROPRIATE SCREENING BY
PRESCRIBER
• not utilizing valid risk screening tools• no required or regimented body fluid
checks• poor understanding of long-term
effects of chronic use
Who is responsible?
• Prescribers• Patients• Insurers • Pharmaceutical companies• Government payers• Pharmacists
Current State Mandates
• 1) MUST check the PDMP prior to prescribing opioids• ONLY MANDATE!!!
MAJOR POINTS OF NEVADA AB474
• 1) DOES NOT HANDCUFF THE PHYSICIAN
MAJOR POINTS OF NEVADA AB474
• 1) Does not handcuff the physician
• 2) MUST REGISTER WITH THEPDMP
MAJOR POINTS OF NEVADA AB474• 1) Does not handcuff the
physician• 2) Must register with the PDMP• 3) MUST HAVE NORMAL FOLLOW UP
Major Points of Nevada AB474
• 1) Does not handcuff the physician
• 2) Must register with the PDMP
• 3) Must have normal follow up
• 4) EVIDENCE-BASED DIAGNOSISWORK-UP
Major Points of Nevada AB474
• 1) Does not handcuff the physician• 2) Must register with the PDMP• 3) Must have normal follow up • 4) Evidence-based diagnosis work-up• 5) CHANGES IN BOARD OVERSIGHT
Major Points of Nevada AB474• 1) Does not handcuff the
physician• 2) Must register with the PDMP• 3) Must have normal follow up • 4) Evidence-based diagnosis
work-up• 5) Changes in Board oversight• 6) PRESCRIPTION CHANGES
Major Points of Nevada AB474
• 1) Does not handcuff the physician• 2) Must register with the PDMP• 3) Must have normal follow up • 4) Evidence-based diagnosis work-up• 5) Mandatory urine drug screening• 6) Changes in Board oversight• 7) Prescription changes• 8) PRESCRIBE 365
Major Points of Nevada AB474
• 1) Does not handcuff the physician• 2) Must register with the PDMP• 3) Must have normal follow up • 4) Evidence-based diagnosis work-up• 5) Mandatory urine drug screening• 6) Changes in Board oversight• 7) Prescription changes• 8) PRESCRIBE 365• 9) URINE TOX SCREENS?
MAJOR LOSS FOR NEVADA AB474
• Attempt to include at least annual body fluid analysis drug screening for all patients taking controlled substances for pain
INITIAL RX CONSIDERATIONS
1) Have bona fide relationship2) Check PDMP! 3) Initial prescription >15 days4) Complete Informed Consent5) Complete Opioid Risk Tool
>30 DAYS RX CONSIDERATIONS
1) Need prescription medication agreement
>90 DAYS RX CONSIDERATIONS
1) Work-up for evidence-based diagnosis2) PDMP check every 90 days3) Consider specialist referral
Major Points of Nevada AB474
• 1) Does not handcuff the physician
• 2) Must register with the PDMP
• 3) Must have normal follow up
• 4) Evidence-based diagnosis work-up
• 5) Changes in Board oversight
• 6) Prescription changes• 7) Prescribe 365 Initiative• 8) BEHAVIORAL HEALTH RISK
ASSESSMENT
How did we get it done?
How did we get it done so quickly?
CAN WE REALLY DIAGNOSE AND TREAT PAIN WITHOUT PRESCRIPTION DRUGS?
What is my job?
• To obtain an appropriate PAIN diagnosis and then direct the patient to the best treatment option after presenting the patient all viable options.
What is the difference between a “medical” diagnosis and a “pain” diagnosis?
A medical diagnosis is usually a broad,
generalized term that is used to most accurately
reflect an appropriate ICD-10 classification code.
Example: Low back pain
A pain diagnosis is a specific diagnosis made
using a clinical intuition or factual diagnosis.
Example: Internal Disk Disruption vs. L4 Radicular
Pain
How does a physician or non–physician clinician typically arrive at a pain diagnosis?
1) Massage Therapist
2) Acupuncturist
3) Athletic Trainer
4) Physical Therapist
5) Chiropractor
6) General Physician
7) Specialist Physician
HOW DOES A PHYSICIAN OR NON–PHYSICIANCLINICIAN TYPICALLY ARRIVE AT A PAIN DIAGNOSIS?(whether doing it correctly or incorrectly?)
MASSAGE THERAPIST• Will use palpatory feedback and assessment of somatic structures • and assimilate patient history info supporting the diagnosis.• If complaint of low back pain, will usually diagnose “pulled muscle” or some other type of musculoskeletal abnormality.
HOW DOES APROVIDER
TYPICALLY ARRIVEAT A PAIN
DIAGNOSIS?
ACUPUNCTURIST• Patient History• Patient Complaint• Assess for musculoskeletal involvement through physical exam colors, sounds, odors, emotions• If patient complains of low back pain, acupuncture diagnosis would likely assess a problem with a specific meridian, acupuncture point or extraordinary channel
HOW DOES A PROVIDER TYPICALLY ARRIVE AT A PAINDIAGNOSIS?
ATHLETIC TRAINER
• Medical history
• Movement screening
• Anatomical assessment
• If patient complaint of low back pain, diagnosis may be “hip flexor weakness” or “lumbar sprain/strain”
HOW DOES A PROVIDER TYPICALLYARRIVE AT A PAIN DIAGNOSIS?
PHYSICAL THERAPIST• Patient history
• Usually Physician referral
• Movement screening
• Palpatory diagnosis
• If patient complaint of low back pain, diagnosis may be “iliopsoas syndrome”
HOW DOES A PROVIDER TYPICALLYARRIVE AT A PAIN DIAGNOSIS?
CHIROPRACTOR
• Patient history
• Movement screening
• Palpatory diagnosis
• Imaging slides (X-Ray, MRI)
• If patient complaint of low back pain, diagnosis may be “spinal
arthritis” this can allow them to continue to treat using H.V.L.A.
HOW DOES A PROVIDER TYPICALLYARRIVE AT A PAIN DIAGNOSIS?
PRIMARY CARE PROVIDER
• Thorough incident history
• Thorough past medical history including family history, genetic predisposition
• Palpatory diagnosis
• Imaging studies: X-Ray, MRI, CT scan, ultra-sound
• Blood work
• Systemic physical examination-assessing for aneurysm, ecchymosis, induration
• If patient complains of low back pain, a physician may say “urogenital anomaly” or “possible angiosarcoma.”
HOW DOES A PROVIDER TYPICALLYARRIVE AT A PAIN DIAGNOSIS?
INTERVENTIONAL PAIN PHYSICIAN
• Thorough medical history, incident history, mechanism of
injury, family history, surgical history, genetic history, medical
implications
• Review of all prior imaging studies and physician notes
including blood work, imaging studies, etc.
• Thorough physical examination including both a general
and focused exam
• Post-examination consultation and debriefing
HOW DOES A PROVIDER TYPICALLY ARRIVE AT A PAINTREATMENT?
• Debriefing with patient and family
• Render my opinion on current diagnosis
• Discuss treatment options taking into account multiple factors:A) Type of insuranceB) Risk vs. reward of treatmentC) Financial considerationsD) “cure” vs. “band-aid” optionsE) Pertinent medical history
TREAMENT OPTIONS 1) Do nothing!!
TREAMENT OPTIONS
1) Do no harm2) MEDICATIONS• Antibiotics, Sleeping aids, anxiolytics, anti-
depressants
• Anti-inflammatories
• Muscle relaxants
• Opioids, aka “Pain killers”
1) Do Nothing2) Medications
Athletic Trainer
3) Physical Rehabilitation Modalities
Acupuncture PhysicalTherapy
Yoga/Pilates Home ExerciseProgram
Chiropractic
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TREAMENT OPTIONS 4) FURTHER DIAGNOSTIC TESTING
Thin slice C.T. Scan
Flexion/Extension X-Rays
MRI Neurography
MRI Angiography
C.T. Arthrogram
TREAMENT OPTIONS
SPECIALIST REFERRAL
• Endocrinologist• Rheumatologist• GI Specialist
TREATMENT OPTIONS
SURGICAL REFERRAL
• Orthopedic Surgeon• Neurosurgeon• General Surgeon
7) Interventional Pain Physician
1) Do Nothing2) Medications3) Physical Rehabilitation Modalities
5) Specialist Referral6) Surgical Referral7) Diagnostic work-up to prove the diagnosis
4) Further Diagnostic Testing
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Answer : It depends upon what condition/diagnosis we are trying to prove.
1) Disc
2) Joint
3) Nerve
4) Muscle
5) Bone
6) Tendon
7) Ligament
8) Peripheral nerve
9) Organ
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1) DiscHow do we determine if the disc is a source of pain or discomfort?
Is it a clinical diagnosis?
Is it a movement screening diagnosis?
No, it is a scientific diagnosis.
Provocation Discography
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1) Disk
Suspected Pain Generator
DiagnosticProcedure
Discogram
A Discogram is a method of stimulating the disc through pressurization with fluid to see if concordant pain is elicited.
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Discogram
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Discogram - Abnormal Tear
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1) Disc
Suspected Pain Generator
InterventionalDiagnostic
Test
Discogram
2) Joint Joint Injection
Treatment OptionsIf Positive Test
Surgery
TransdiscalBiacuplasty
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Spinal Joint Injection(“Zygapophyseal” or “Facet” Joint)
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1) Disk
Suspected
Pain Generator
Interventional
Diagnostic
Test
Discogram
2) Joint Joint Injection
Treatment Options
If Positive Test
Surgery
Transdiscal Biacuplasty
3) Nerve Selective Nerve
Root Block
Surgery
Radiofrequency Ablation
P.T./Chiro/Trainer
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Selective Nerve Root BlockPerformed for Suspected Pain in a Dermatomal Distribution
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Dangers of Cervical Injection Therapy
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1) Disc
Suspected
Pain Generator
Interventional
Diagnostic
Test
2) Joint
Treatment Options
If Positive Test
3) Nerve Surgery
Epidural Steroid Injection
Phys rehab modalities
Selective Nerve
Root Block
Joint Injection Surgery
R.F.A.
Plus Rehab Modalities
Discogram Surgery
Transdiscal Biacuplasty
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Pain with Abduction and External Rotation during Hip Flexion
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1) Disk
Suspected Pain Generator
InterventionalDiagnostic Test
Discogram
2) Joint Joint Injection
Treatment Optionsif Positive Test
• Surgery• Transdiscal Biacuplasty
3) Nerve Selective Nerve Root Block
• Surgery• R.F.A. • Plus Rehab Modalities• Surgery• Epidural Steroid Injection • Phys rehab modalities
4) Muscle Intramuscular InjectionUnder Fluoroscopy
• Physical Rehab Modalities• Prolotherapy• Botox• Medication
5) Bone Rami communicans block,Imaging studies
• Rami Communicans RF, • Meds, Bracing
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Suspected Pain Generator
InterventionalDiagnostic Test
Treatment Optionsif Positive Test
5) Bone Rami Communicans Block,Imaging studies
• Rami Communicans RF, • Meds, Bracing
6) Tendon Tendon Injection Fluoro Guidance
• Rest, Brace, P.T., • Prolotherapy
7) Ligament Ligamentous injection- Very Hard to Do
• Rest, Prolotherapy• Bracing• Surgery
8) PeripheralNerve
Peripheral Nerve Injection • Surgery• Meds • Desensitization Injections
9) Organ Pain Sympathetic Plexus Block • Surgery• Meds • Nutrition
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Sympathetic Block
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What are the take-home points?
1) Realize that sometimes things are not as simple as they seem.
2) If you can’t prove it, you can’t say it!
3) There really are ways to prove diagnoses.
4) Some people are just broken!
5) Depth of knowledge is not well appreciated.
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LEGISLATOPLASTY :
How Nevada Addressed the Opioid Epidemic through Common Sense Legislative and Medical Solutions
THANK YOU!
Nevada Osteopathic Medical Association
65th Annual Meeting & SymposiumMay 2-5, 2018
Las Vegas, NV
