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Department of Health and Vanderbilt University Chronic Pain Symposia
Mitchell Mutter, M.D.Medical Director for Special Projects
Disclosure Information
I have no financial relationships to disclose
I will not discuss off label use and/or investigational use in my presentation
Effectiveness of pain meds (from Cochrane reviews) (References 17,18,19,20)
Two 5 mg Percocet
pills
Ibuprofen 200mg
Ibuprofen 400 mg
Oxycodone 15 mg
Tylenol #3 (2)
Ibu 200 + acet 500
0
10
20
30
40
50
60
70
Percent of people getting 50% pain relief(1/NNT)
Overall Utilization of Pharmaceuticals by State
Rank StateRx per Capita Rank State
Rx per Capita
1 West Virginia 19.9 27 Delaware 12.42 Kentucky 18.7 28 South Dakota 12.13 Rhode Island 18.3 29 Illinois 11.94 Tennessee 17.1 30 Virginia 11.85 District of Columbia 17.1 31 Florida 11.66 Louisiana 16.9 32 Wisconsin 11.47 Alabama 16.7 33 New Jersey 11.48 Mississippi 16.5 34 New Hampshire 11.39 Arkansas 16.4 35 Texas 11.210 South Carolina 14.5 36 Maryland 11.111 Ohio 14.4 37 Vermont 11.012 New York 14.4 38 Minnesota 10.813 Pennsylvania 14.3 39 Arizona 10.614 Nebraska 14.3 40 Nevada 10.515 Massachusetts 14.0 41 Oregon 10.316 Missouri 13.9 42 New Mexico 10.317 Iowa 13.9 43 Idaho 10.118 North Carolina 13.7 44 Utah 10.119 Kansas 13.7 45 Montana 10.020 Michigan 13.5 46 Washington 9.921 Indiana 13.3 47 Hawaii 9.622 Maine 13.2 48 Wyoming 9.423 North Dakota 13.2 49 California 8.824 Connecticut 13.1 50 Colorado 8.625 Oklahoma 13.0 51 Alaska 7.026 Georgia 12.8 52 Puerto Rico N/A
A State Comparison: Annual Prescriptions per Capita 2014All Products
All states = 12.4 annual prescriptions per capita
Growth in Utilization of Pharmaceuticals by State
Rank State%
Change Rank State%
Change1 Rhode Island 7.0% 27 District of Columbia 2.7%2 Kentucky 6.8% 28 South Carolina 2.6%3 West Virginia 6.6% 29 California 2.4%4 Arkansas 5.8% 30 Delaware 2.3%5 Nevada 5.7% 31 Nebraska 2.3%6 New Mexico 5.5% 32 North Carolina 2.2%7 Alaska 4.6% 33 Illinois 2.2%8 Arizona 4.5% 34 Kansas 2.1%9 New York 4.4% 35 Louisiana 2.0%10 Washington 4.2% 36 Georgia 2.0%11 Texas 3.6% 37 Pennsylvania 1.8%12 Maryland 3.6% 38 South Dakota 1.8%13 Oregon 3.6% 39 Minnesota 1.8%14 Connecticut 3.5% 40 North Dakota 1.7%15 Mississippi 3.4% 41 Hawaii 1.7%16 Michigan 3.3% 42 New Hampshire 1.6%17 Wyoming 3.3% 43 Tennessee 1.6%18 Florida 3.2% 44 Montana 1.2%19 Missouri 3.1% 45 Virginia 0.7%20 Idaho 3.1% 46 Maine 0.7%21 Colorado 3.0% 47 Indiana 0.6%22 Ohio 2.9% 48 Vermont 0.4%23 Utah 2.8% 49 Wisconsin 0.3%24 Massachusetts 2.8% 50 Oklahoma -1.3%25 New Jersey 2.8% 51 Alabama -1.6%26 Iowa 2.8% 52 Puerto Rico N/A
Percent Change in Filled Prescriptions, 2014 vs 2013All Products
All states = 2.8% annual percentage of change
C-II Controlled Substance Utilization by State
Rank StateRx per Capita Rank State
Rx per Capita
1 Alabama 1.4 27 District of Columbia 0.82 Tennessee 1.3 28 Massachusetts 0.83 Louisiana 1.2 29 Virginia 0.84 West Virginia 1.2 30 Iowa 0.85 Mississippi 1.2 31 Nebraska 0.86 Kentucky 1.2 32 Montana 0.87 Arkansas 1.2 33 Vermont 0.88 South Carolina 1.1 34 Washington 0.89 Oklahoma 1.1 35 Connecticut 0.810 Michigan 1.0 36 Arizona 0.711 Indiana 1.0 37 Maryland 0.712 North Carolina 1.0 38 Wyoming 0.713 Delaware 1.0 39 North Dakota 0.714 Kansas 1.0 40 Colorado 0.715 Ohio 1.0 41 South Dakota 0.716 Rhode Island 0.9 42 Illinois 0.717 Maine 0.9 43 New Mexico 0.718 Missouri 0.9 44 Florida 0.719 Utah 0.9 45 Minnesota 0.720 Oregon 0.9 46 Texas 0.721 Georgia 0.9 47 Alaska 0.622 Pennsylvania 0.9 48 New Jersey 0.623 New Hampshire 0.9 49 New York 0.624 Idaho 0.8 50 California 0.525 Nevada 0.8 51 Hawaii 0.526 Wisconsin 0.8 52 Puerto Rico N/A
A State Comparison: Annual Prescriptions per Capita 2014CII Products
All states = 0.8 annual prescriptions per capita
2013 USA total CII prescriptions = 257,450,331; TN total = 8,954,9732014 USA total CII prescriptions = 249,953,231; TN total = 8,668,742
C-II Controlled Substance Growth by State
Rank State%
Change Rank State%
Change1 South Dakota 3.7% 27 South Carolina -1.5%2 North Dakota 1.5% 28 Florida -1.5%3 Vermont 1.4% 29 Alaska -1.7%4 Nebraska 0.2% 30 North Carolina -1.7%5 Arkansas 0.0% 31 West Virginia -1.8%6 Utah -0.1% 32 Pennsylvania -2.0%7 Wyoming -0.2% 33 Oregon -2.1%8 Washington -0.2% 34 Missouri -2.1%9 Idaho -0.2% 35 Mississippi -2.2%10 Iowa -0.3% 36 Illinois -2.2%11 Minnesota -0.3% 37 Hawaii -2.8%12 Delaware -0.3% 38 Ohio -2.9%13 New Mexico -0.4% 39 Montana -3.0%14 Connecticut -0.5% 40 Louisiana -3.0%15 Maryland -0.8% 41 New York -3.2%16 Nevada -0.8% 42 Tennessee -3.2%17 Massachusetts -1.0% 43 Georgia -3.5%18 District of Columbia -1.0% 44 Maine -3.6%19 Wisconsin -1.0% 45 Virginia -3.7%20 Arizona -1.1% 46 California -3.7%21 New Hampshire -1.1% 47 Rhode Island -4.8%22 Colorado -1.2% 48 Alabama -6.8%23 Kansas -1.2% 49 Indiana -8.2%24 New Jersey -1.3% 50 Texas -8.4%25 Michigan -1.4% 51 Oklahoma -9.7%26 Kentucky -1.5% 52 Puerto Rico N/A
Percent Change in Filled Prescriptions, 2014 vs 2013CII Products
All states = -2.9% annual percentage of change
Opioid Utilization by State
Rank StateRx per Capita Rank State
Rx per Capita
1 Alabama 1.32 27 Montana 0.762 West Virginia 1.29 28 Arizona 0.763 Tennessee 1.27 29 Wisconsin 0.744 Arkansas 1.19 30 Washington 0.735 Mississippi 1.14 31 Virginia 0.736 Louisiana 1.13 32 Iowa 0.737 Kentucky 1.12 33 New Hampshire 0.718 Oklahoma 1.10 34 Maryland 0.719 Michigan 1.04 35 Wyoming 0.7010 South Carolina 1.00 36 South Dakota 0.6911 Indiana 0.96 37 Colorado 0.6912 North Carolina 0.94 38 New Mexico 0.6913 Ohio 0.93 39 Connecticut 0.6914 Missouri 0.93 40 Florida 0.6915 Kansas 0.93 41 North Dakota 0.6916 Nevada 0.88 42 Texas 0.6817 Delaware 0.88 43 Vermont 0.6618 Pennsylvania 0.86 44 Massachusetts 0.6619 Oregon 0.86 45 Illinois 0.6620 Idaho 0.84 46 Alaska 0.6221 Georgia 0.83 47 Minnesota 0.6022 District of Columbia 0.81 48 New Jersey 0.5723 Maine 0.80 49 California 0.5424 Utah 0.80 50 New York 0.5325 Nebraska 0.79 51 Hawaii 0.4926 Rhode Island 0.78 52 Puerto Rico N/A
A State Comparison: Annual Prescriptions per Capita 2014Opioid Products
All states = 0.77 annual prescriptions per capita
Growth in Opioid Utilization by State
Rank State%
Change Rank State%
Change1 South Dakota 2.5% 27 Utah -2.4%2 Arkansas 1.3% 28 Wisconsin -2.4%3 Nevada 1.3% 29 Minnesota -2.4%4 New Mexico 1.0% 30 North Carolina -2.6%5 Arizona -0.2% 31 Pennsylvania -2.6%6 Vermont -0.6% 32 Missouri -2.7%7 Washington -0.8% 33 Kansas -2.7%8 Idaho -0.9% 34 Montana -2.8%9 Delaware -1.1% 35 Mississippi -3.0%10 Maryland -1.1% 36 Hawaii -3.2%11 Colorado -1.1% 37 Illinois -3.2%12 Iowa -1.2% 38 Texas -3.3%13 West Virginia -1.3% 39 Massachusetts -3.3%14 South Carolina -1.4% 40 Tennessee -3.4%15 Connecticut -1.4% 41 New Hampshire -3.5%16 New Jersey -1.5% 42 Georgia -3.9%17 Michigan -1.6% 43 Maine -4.1%18 Florida -1.6% 44 Ohio -4.1%19 Nebraska -1.8% 45 Louisiana -4.5%20 District of Columbia -1.9% 46 New York -4.6%21 North Dakota -1.9% 47 Virginia -4.7%22 Oregon -1.9% 48 Rhode Island -5.6%23 Kentucky -1.9% 49 Alabama -6.2%24 Wyoming -2.0% 50 Indiana -8.9%25 Alaska -2.3% 51 Oklahoma -9.1%26 California -2.3% 52 Puerto Rico N/A
Percent Change in Filled Prescriptions, 2014 vs 2013Opioid Products
All states = -2.9% annual percentage of change
Drug Overdose Death, 2014
2011 2012 2013 2014950
1000
1050
1100
1150
1200
1250
1300
10621094
1166
1263
Total Numbers
Source: TN Department of Health
Drug Overdose Death, 2014
2011 2012 2013 201415
15.5
16
16.5
17
17.5
18
18.5
19
19.5
16.6 16.6
17.9
19.3
Rate per 100,000
Source: TN Department of Health
Neonatal Abstinence Syndrome (NAS)
Controlled Substance Monitoring Database
Prescription Safety Act 2012A. Mandatory Sign-up
• Pharmacy and PrescribersB. Query Database C. Pharmacies filledD. Data – 7 days to near real time E. Method of Payment
Number of Registrants in CSMD, 2010 - 2014
Year Registrants
Change (%)
2010 13,182 -
2011 15,323 16.2
2012 22,192 44.8
2013 34,802 56.8
2014 38,871 11.72015 (as of July 31)
41,650 9.8
Registrants in the CSMDby Role (as of July 31, 2015)
Practitioner 18,080
Practitioner Extenders 5,260
Residents/VA 2,746
Advance Practice Nurse
5,743
Physician Assistant 1,335
D.Ph. 7,306
D.Ph. Extenders 1,115
Number of DEA Registrants in Tennessee (as of July 31, 2015)
ProfessionNumber of DEA in
TN
Pharmacy 1,784
Hospital / Clinic 245
Practitioner 24,584
APN 7,522
Optometrist 919
PA 1,613
All other 487
TOTAL 37,154
Public Chapter 898
All APN’s and PA’s MUST add supervising physicians in their accounts for each practice location and must have their supervising physicians log into their accounts to approve them to complete the process, otherwise, those without supervising physicians will not be able to pull patient requests after June 15, 2015.
Advanced Nurse Practitioners Across the State
Total APNs in StateTotal APNs in State (with prescribing
authority)APNs with a TN DEA
Number APNs registered in CSMD APNs registered in
CSMD with Active supervisor (s)
0
2,000
4,000
6,000
8,000
10,000
12,000 11289
9842
7522
5743
3984
Data as of 7/31/2015Sources: TN License and Regularly System, Drug Enforcement Agency, Controlled Substance Monitoring Database
Supervisor will log into CSMD. As soon as they enter correct username and password this screen appears directing them they have delegates waiting for approval. Click the box to go to “My Account” screen.
Once the Supervisor clicks “My Account” this screen opens. The supervisor will see any approved delegates and any delegates awaiting approval. As you can see this one is awaiting approval.
Once the Supervisor clicks “Approve” You can see the successful message at the top. Also when you look at the delegate area the Supervisor now has the ability to “Revoke” this user if the Supervisor no longer supervises this delegate.
APN or PA will now be notified of the approval and when they log into the CSMD their “My Account” show “Active” for the Supervisor (s). The APN or PA have the option to “Delete” this supervisor.
Ratio of Number of Prescription to Number of Request in CSMD, 2010-2015*
2010 2011 2012 2013 2014 2015
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
13.8 : 1
12.2 : 1
9.9 : 1
4.2 : 13.7 : 1 2.8:1
Rati
o (
Nu
mb
er
of
Pre
scri
pti
on
: N
um
ber
of
Req
uest)
Prescription Safety Act of 2012 be-came PC 880
Prescribers / dispensers re-quirement to be registered in CSMD by 1/1/13
Mandatory CSMD check before prescribing opioid / benzodiazepine after 4/1/13
* VA prescriptions and requests were included.
Year
Law Enforcement Request
2012 2013 20140
500
1,000
1,500
2,000
2,500
3,000
Number of Requests from Law Enforcement in CSMD, 2012-2014
Year
Nu
mb
er
of
Pati
en
t R
eq
uests
Number of Prescriptions of Controlled Substances Dispensed and Reported to CSMD, 2010-2014
2010 2011 2012 2013 201415,500,000
16,000,000
16,500,000
17,000,000
17,500,000
18,000,000
18,500,000
19,000,000
Year
Nu
mb
er
of
Pre
scri
pti
on
s
Number of Prescriptions of Controlled Substances Reported to CSMD by Class, 2010-2014
2010 2011 2012 2013 20140
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
Opioid
Benzo-di-azepinesMuscle Relaxant
Other
Year
Num
ber
of P
resc
ript
ions
2010-2014 Morphine Milligram Equivalents Reported to CSMD *
*Note: Morphine Milligram Equivalents (MME) were converted based on CDC MME conversion tables . Above numbers were derived from CSMD data downloaded on January 5, 2015. 2014 data are subject to change due to database updating. VA pharmacies were excluded from above analysis.
Cumulative Morphine Milligram Equivalent for 1st and 2nd quarter of each year, 2010-2015*
2010 2011 2012 2013 2014 20150
500,000,000
1,000,000,000
1,500,000,000
2,000,000,000
2,500,000,000
3,000,000,000
3,500,000,000
4,000,000,000
4,500,000,000
5,000,000,000 4,229,839,695
4,685,289,2274,886,576,526 4,894,084,587 4,784,927,865 4,489,046,327
Note: data used in this analysis were downloaded on July 3, 2015; VA pharmacies were excluded from the analysis. MME was derived based on CDC tables.
Comparison of Overall Prescriptions, Number of Opioid Prescriptions and MME Dispensed/Reported to CSMD, 2010-2014
2010 2011 2012 2013 20140
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
12,000,000
14,000,000
16,000,000
18,000,000
20,000,000
8,200,000,000
8,400,000,000
8,600,000,000
8,800,000,000
9,000,000,000
9,200,000,000
9,400,000,000
9,600,000,000
9,800,000,000
10,000,000,000
Overall Prescriptions of Controlled SubstancesPrescription of OpioidMorphine Milligram Equivalent
Year
Num
ber
of P
resc
ript
ions
Am
ount
of M
orph
ine
Mil
ligr
am E
quiv
alen
t
Number of Methadone Products and Morphine Milligram Equivalents (MME) Dispensed/Reported to CSMD, 2010-2014
2010 2011 2012 2013 20140
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
0
50,000,000
100,000,000
150,000,000
200,000,000
250,000,000
300,000,000
350,000,000
400,000,000
Prescriptions of MethadoneMME of Methadone
YearNu
mb
er
of
Pre
scri
pti
on
s o
f M
eth
ad
on
e
Am
ou
nt
of
Morp
hin
e M
illig
ram
Eq
uiv
a-
len
ts
More PDMP Queries, Fewer High Utilization Patients
Result of Survey on Doctor Shopping
Strongly agree 61.6%
Agree 23.9%
Neutral 9.3%
Disagree 2.8%Strongly disagree 2.4%
The CSMD is useful for decreasing the incidence of doctor shopping.
Number of Doctor Shopper Identified in CSMD by Quarter, 2010-2014*
Year1st
Quarter2nd
Quarter 3rd Quarter 4th Quarter TotalChange
(%)
2010 1,695 2,005 2,127 1,830 7,657 -
2011 1,950 2,413 2,515 2,352 9,230 20.5
2012 2,246 2,218 2,261 1,940 8,665 -6.1
2013 1,785 1,533 1,533 1,335 6,186 -28.6
2014 1,374 1,404 1,278 1,307 5,363 -13.3
*Doctor and pharmacy shopper was defined as a person who got his/her prescriptions from 5 or more different DEA prescribers and filled the prescriptions at 5 or more different DEA pharmacies within 3 months.
*If patients in CSMD had same date of birth and same result of soundex first name and last name, we took the patients as same person. Data used for above analysis were downloaded on Jan. 5, 2015. Data are subject to change due to database updating and the other reasons. VA pharmacies were excluded from the analysis. Doctor and pharmacy shopper was defined as a person who got his/her prescriptions from 5 or more different DEA prescribers and filled the prescriptions at 5 or more different DEA pharmacies within 3 months.
2010-2014 Number of “Doctor and Pharmacy Shoppers" in CSMD *
Annual Top 50 Prescribers
Public Chapter 396 Registered letter Significant control substances Number of patients Morphine Equivalents prescribed Department may withhold information if
active case in BIV or OGC Prescriber must respond with an
explanation justifying the amounts of control substance prescribe within 15 business days.
Top 50 Prescribers Identified in 2015(based on data from Jan – Dec 2014 using CDC MME Conversion Tables)
Morphine Milligram Equivalents Dispensed by Top 50 Prescribers in 2013, 2014, and 2015*
2013 2014 20150
200,000,000
400,000,000
600,000,000
800,000,000
1,000,000,000
1,200,000,000
1,400,000,000
1,600,000,000
Year
Mor
phin
e M
illig
ram
Equ
ival
ents
12% decrease
8% decrease
* Note: Time periods of prescriptions fill used for identification of top 50 were as below: 2013: from 4/1/2012 to 3/31/2013 ; 2014: 4/1/2013 to 3/31/2014 2015: 1/1/2014 to 12/31/2014
Top 50 Prescribers Identified in 2015(based on data from Jan – Dec 2014)
66%
10%
2%
22%
APNPADOMD
Small County Prescribers Identified in 2015(based on data from Jan – Dec 2014)
Top 10 prescribers in small counties Small defined as <50,000 people Total MMEs for Small Counties: 122,671,152
Why do you check the CSMD before prescribing?
Mandatory check
New patient Other ED Visit Planned surgery
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%67.3%
52.0%
35.3%
13.4%
4.6%
Reason of checking CSMD
How has checking the CSMD changed the way you practice medicine?
No change 37.5%
Less likely to pre-scribe controlled
substances 41.4%
More likely to prescribe con-
trolled sub-stances 0.7%
Other 20.5%
Public Chapter 475
Effective July 1, 2016New requirements for pain clinic
Medical Director must be a physician and pain specialist
Pain Specialists are board certified by ABMS, ABPM, ABIPP, or AOA
Expected Outcomes
Tennessee Pain Clinics per County
Public Chapter 623 “Naloxone”
Licensed Healthcare Practitioner Patient, family member, friend of patient at
risk for overdose death Naloxone Education will be available on the
Department of Health website on July 1, 2014
Instruction how to administer http://www.tn.gov/health/topic/information-for-naloxone
2015 Legislative Updates
PDMP reporting window reduced to daily by 2016
Immunity to those who prescribe or administer naloxone to patients
January 1, 2015: Prohibit dispensing of opioids and benzodiazepines directly from any clinic
Prescription Safety Act of 2012 set to sunset June 30, 2016
Public Chapter 475 will take effect
Chronic Pain Guidelines
Chronic Pain Guidelines Expert Panel
Public Chapter 430
Chronic Pain Guidelines written by January 1, 2014
All prescribers with DEA 2 hours CME every 2 years
Prescribe 30 days at a time Schedule II-IV
By January 1, 2014 the commissioner shall develop recommended treatment guidelines for prescribing opioids, benzodiazepines, barbiturates, and carisoprodol. That can be used in the state as guide for caring for patients.
Process Began on January 28, 2013
Selected the Panel of Experts
Selected the Steering Committee
First Meeting Steering Committee Meeting July 1, 2013
Chronic Pain Guidelines Steering Committee:
Worker’s CompensationAbbie Hudgens
Office of General CounselAndrea Huddleston, J.D.
Controlled Substance Monitoring Database
Andrew Holt, D.Ph.
Department of HealthBruce Behringer, MPHDavid Reagan, M.D.Larry Arnold, M.D.
Mitchell Mutter, M.D.
Department of TennCareVaughn Frigon, M.D.
Board of Medical ExaminerMichael Baron, M.D.
TN Department of Mental Health
Rodney Bragg, M.A., M.Div.
Tennessee Medical FoundationRoland Gray, M.D.
Special Thanks To:Ben E. Simpson, J.D.
Tracy BacchusDebora Sanford
Chronic Pain Guidelines Panel Members:
Autry Parker, M.D.Brett Snodgrass, APNC. Allen Musil, M.D.Carla Saunders, APNCharles McBride, M.D.James Choo, M.D.Jason Carter, D.Ph.Jeffrey Hazlewood, M.D.Jim Montag, PA-CJohn Culclasure, M.D.Katie Liveoak, D.Ph.
Michael O'Neil, D.Ph.Paul Dassow, M.D.Raymond McIntire,
D.Ph.Rett Blake, M.D.Stephen Loyd, M.D.Ted Jones, Ph.D.Thomas Cable, M.D.Tracy Jackson, M.D.W. Clay Jackson, M.D.William Turney, M.DJohn Standridge, M.D.T. Scott Baker, M.D.
Chapters in the Chronic Pain Guidelines
Introduction - Before initiating chronic opioid therapy (over 90 days)
Screening (including TN risk model), non-opioid therapies, referral to MH, others
Informed consent Women's special considerations
Initiating chronic opioid therapy - Standard therapy, combination therapy Special considerations
Methadone/suboxone UDS - qualitative & quantitative CSMD Documentation in decision making
Follow up of therapy - UDS - qualitative & quantitative CSMD ED visits for OD What constitutes a failure of standard therapy? Referral to pain specialist Taper / discontinuation of opioids Documentation of decision making
Chronic Pain Guidelines Appendices
Pain Medicine Specialist Risk Assessment Tools Pregnant women Use of Opioids in Worker's Compensation Medical
Claims Tapering protocol Sample Informed consent Sample Patient Agreement Controlled Substance Monitoring Database Medication Assisted Treatment Program Morphine equivalents dose Psychological Assessment Tools Prescription Drug Disposal Safety Net Definitions Table of Frequently Prescribed Pain Medications Urine Drug Testing Special Consideration: Women of Child Bearing Age
Section I: Prior to Initiating Opioid Therapy
Non Opioid Treatment if Possible All Newly Pregnant Women Should Complete evaluation: History and
Physical Testing documented in medical record
prior Chronic Pain shall not be treated via
telemedicine Co-Morbid Mental Conditions There shall be the establishment of
a current diagnosis that justifies a need for opioid therapy
Section I: Prior to Initiating Opioid Therapy (cont.)
Risk for Abuse Validated Risk Tools CSMD UDT Goals for Treatment Treatment plan for opioid and non-opioid
treatment Increase function, not to eliminate pain Documentation in medical record
Section II: Initiating Opioids
Maximum four doses of short-acting opioids per day
Non pain medicine specialist should not prescribe methadone
Prescribers shall not prescribe buprenorphine in oral or sublingual for chronic pain
Avoid benzodiazepines Document reasons for deviation from
guidelines in record
Section II: Initiating Opioids (cont.)
Therapeutic trial Lowest possible dose Opioid Naïve Informed Consent Treatment Agreement female patient Continually monitor for abuse, misuse, or
diversions CSMD and UDT
Section II: Initiating Opioids (cont.)
Women’s Health Birth Control Plans Informed Consent Ask regarding pregnancy each visit Before starting opioids – in women shall
have pregnancy test
Section III: Treatment with Opioids
Single provider and pharmacy Opioids used at lowest effective dose
5 A’s Analgesia Activities Adverse side effects Aberrant Affect
Section III: Treatment with Opioids (cont.)
Ongoing Therapy Greater than 120 MEDD (Morphine
Equivalent Dose) should refer to Pain Specialists
Greater than 120 MEDD shall refer UDT twice/year Continual assessment via 5A’s UDT, CSMD Emergency Physician, Primary Provider
Communication Discontinue when risk greater than benefits
ABPM
Recognizes boards in the following certification as qualified to sit for Board Exam
Anesthesia Psychiatry Neurology Neurosurgery Physical Medicine and Rehabilitation
50 hours CME in Pain Medicine past two (2) years
Substantial, recent and comprehensive clinical practice experience
Pain Specialist
Board of Medical Specialties (ABMS) primary physician certification organization in US
ABMS certifies pain medicine fellowship programs in Anesthesia, Physical Medicine and Neurology
American Board of Pain Medicine (ABPM) is not ABMS and does not oversee fellowship training programs.
ABPM offers practice – related examinations to qualified candidates. Diplomates of ABPM have certification in Pain Medicine
AOA Certification ABIPP
Pain Specialist (cont.)
Patients requiring less than 120 MEDDa. Must have valid license by respective
board and DEAb. CME pertinent to pain management
directed by regulatory boardc. Recommend (do not require) 3 year
residency and be ABMS eligible or certified
Pain Specialist (cont.)
Patients requiring > 120 MEDDa. 11 times more likely to have adverse event
such as overdose deathb. Consultation with pain specialists
1. Pain Specialists up to 7/1/2016 shall have unencumbered license with no prior actions unless an exception is approved by the respective board
2. Two year experience3. Minimum 25 CME hours in pain
management every 12 months 4. Pain consultants after 7/1/2016 shall
have ABPM diplomate status or ABMS Boards
CDC Chronic Pain Prescribing Guidelines
Evaluate Tennessee against CDC recommendations
Morphine Milligram Equivalent (MME) at which risk of Overdose significantly increases
Long vs. Short Acting opioid treatment options– Relative efficacy?– Relative safety?
Websites:
Prescription for Success http://tn.gov/mental/prescriptionforsuccess/
Email address for public comments [email protected]
Pain Clinic Websitehttp://www.tn.gov/health/topic/PM-board
Pain Clinic Guidelines http://
www.tn.gov/assets/entities/health/attachments/ChronicPainGuidelines.pdf
2015 Legislative Reporthttp://
www.tn.gov/assets/entities/health/attachments/CSMD_AnnualReport_2015.pdf
Websites:
NSC white papers:Evidence on the efficacy of pain medications: nsc.org/painmedevidence
The Psychological and Physical Side Effects of Pain Medications: safety.nsc.org/sideeffects
Prescription Pain Medications: A fatal cure for injured workers: http://www.nsc.org/RxDrugOverdoseDocuments/Rx-Fatal-Cure-For-Injured-Workers.pdf
Questions and Contact Information:
Mitchell Mutter, MDMedical Director for Special Projects
Tennessee Department of [email protected]
615-532-3541
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