PRESCRIPTION DRUG ABUSE MEDICAL TASK FORCE February 2018: Summarizing the January 12, 2018 Meeting Discussion. WWW.SANDIEGOSAFEPRESCRIBING.ORG In This Issue MBC Letters AREN’T the Death Diaries Letters……..……..….……...1 MBC Letter………………….….……...2 CAFP Response to MBC Letters.3 San Diego Proposal to MBC.……3 Accelerator Program………..…....4 CDPH Opioid Safety Project Update………………….………………..4 DEA Update…….…………………..…4 Benzos as the New Opioids….…5 Benzo Tapering…………………..…6 Health Plan Formularies…………7 WWW.SANDIEGORXABUSETASKFORCE.ORG San Diego Medical Examiner Letters are NOT Associated with the Medical Board of California Letters Dr. Roneet Lev heard from many San Diego physicians who received an inquiry from the Medical Board of California. The MBC requested medical records to complete an investigation about a prescription death. This inquiry came at the same time that the San Diego Union Tribune ran an article about Dr. Lev's research on prescription related deaths and prescriptions found in CURES, also called the San Diego Death Diaries. Dr. Lev clarified that letters from the San Diego Medical Examiner's office had no association with letters from the MBC. The “Death Diaries” refers to the project where 2013 prescription-related deaths from the Medical Examiners dataset were examined against the CURES dataset. This data showed that 713 providers prescribed to 186 people that died. Only 16.5% of people who died, were "compliant", in that they died of the same medication that was prescribed, did not have alcohol or illicit drugs at time of death, and were not doctor shopping. The 713 providers most likely had no idea that their patient died. MAT and ED’s………………………..7 In the News……………………………7 Next Meeting: April 13, 2018 at noon San Diego County Medical Society, 5575 Ruffin Road, San Diego. “Round Two” of the Death Diaries looked at 2015 deaths. Dr. Jason Doctor from USC was awarded a grant from the California Health Care Foundation to study the effects of sending a letter to providers about a patient death and their subsequent prescribing patterns. An informational, gentle letter was sent by the San Diego County Medical Examiner's office to 400 clinicians found on CURES reports for patients who died. The letter directed the providers to the SanDiegoSafePrescribing.com web site that listed specific educational tips. The control arm of the study was 400 clinicians who did not receive a letter. The results showed that clinicians who received the letter reduced their morphine equivalents in prescribing as well as decreased new start chronic prescriptions. 1 Medical Board of California Letter Several physicians at the task force reported that they received letters from the MBC investigating a death and requesting medical records. Did the patient's family contact the MBC? Not likely that so many families got together all at once. The San Diego Medical Examiner confirmed that they did not provide information to MBC. The letters were about deaths from 2012 and 2013 - that's a while back. Kaiser related that the letters were not just in San Diego. Local DEA was not involved. This led to a further investigation to find out what these letters were about. Dr. Lev reached out to Dr. Kelly Pfeiffer at California Health Care Foundation, Ted Mazer, president of CMA, Dev Gnanadev, president of MBC, and Kim Kirchmeyer, Executive Director of MBC. The task force members expressed much concern about the MBC letters, which result in medical legal fees and cause providers not to want to prescribe any pain medications at all. Dr. Lev watched the July 27, 2017, 1 hour and 18-minute enforcement committee meeting of the MBC. The highlights were:  The California Department of Public Health (CDPH) provided the MBC death certificates from 2012-2013 of people who died of an opioid overdose as certified by a physician pathologist. Counties without a certified pathologist to confirm cause of death were excluded.  We also believe that the MBC letter disproportionately target San Diego physicians because our county is one of the few across California that have a physician medical examiner rather than a law enforcement coroner.  The MBC received 2,692 deaths that met their criteria; of those, 2256 (83.8%) had a CURES report.  522 (23%) physicians might have been overprescribing, according to preliminary investigation by 5 experts.  The MBC is now investigating these physicians for possible overprescribing and not following the standard of care. The local MBC offices will be conducting these investigations.  Attempts were made to contact family members of decedents regarding the investigations. Dr. Lev spoke to Kim Kirchmeyer who confirmed the MBC project of sending letters, and that a new batch of letters are scheduled to be sent. The letters were sent as an official investigation that could lead to sanctions. The MBC is using their November 2014 guidelines and 80 morphine equivalents as a concern for high morphine equivalents. 2 CAFP RESPONSE TO MBC INVESTIGATIONS Our coalition includes leaders with the California Academy of Family Physicians, CAFP. In collaboration with the information obtained from our task force, CAFP sent a communication to members on responding to such letters. The advice is to retain an attorney and inform yourself about MBC investigations.  Information on a typical MBC Investigation Process: o https://aws.predictiveresponse.net/fwd.ht m?redirect=http://www.mbc.ca.gov/Enfor cement/enforcement_process.pdf&org=7 94&lvl=100&ite=1974&lea=489882&ctr=0 &par=1&trk=a0S0a000005doi1EAA  Newsletters from MBC on what you should do in the event of a complaint and investigation o https://aws.predictiveresponse.net/fwd.ht m?redirect=http://www.mbc.ca.gov/Publi cations/Newsletters/newsletter_2014_11. pdf&org=794&lvl=100&ite=1974&lea=489 882&ctr=0&par=1&trk=a0S0a000005doi1E AA o https://aws.predictiveresponse.net/fwd.ht m?redirect=http://www.mbc.ca.gov/Publi cations/Newsletters/newsletter_2015_01. pdf&org=794&lvl=100&ite=1974&lea=489 882&ctr=0&par=1&trk=a0S0a000005doi1E AA 3 San Diego Task Force Proposal to MBC Dr. Lev solicited members of the task force and submitted a proposal to the MBC for an improved methodology by the MBC. We have extensive study in prescription deaths in San Diego, 10% of California's population. The proposal includes: 1. The MBC or designee would send an educational, not investigatory letter to 100% of providers identified in CURES reports for all prescription related deaths. 2. A more focused standard of investigation is needed. 3. Investigations should take account the standard of care at the time of death. The CDC guidelines were published in 2016. Time is required for education and dissemination. CURES 2.0 was available July 1, 2015, and not widely adopted until 2016. In 2016, the MBC’s web site still posted SCOPE Pain education that promoted high dose methadone and did not discuss high dose treatment. California Opioid Safety Network Accelerator Program Our San Diego coalition is one of 22 coalitions, representing 31 counties across California who were accepted into the new Accelerator Program. The program grants the opportunity to engage AmeriCorps VISTA members (Volunteers in Service to America) who assist coalitions in their activities. Congratulations to Sarah Salven, a MPH student will be serving us in this new position. California Department of Public Health Project Angela Goldberg and Sarah Salven gave an update on the grant project. The naloxone distribution project will provide pre-written naloxone prescriptions using Dr. Lev's medical license to pharmacies. The goal is to have a standing order for naloxone for any patient who is receiving more than 50 morphine equivalents a day or opioid/benzodiazepine combination. Members reviewed a draft letter to pharmacies, a patient handout and sample prescription. Good feedback was received, and the team will modify the letter/handout. The group also looked at an excel file listing MAT programs. Members suggested the file could be useful as an online tool at the www.sandiegosafeprescribing.org site. But a much simpler and briefer handout would be useful as a printed handout. DEA Update Agent Bob Harkins reported that the San Diego DEA field office has hired a physician with a medicinal chemistry degree as a subject matter expert to be used in expanded prevention activities. She will develop education materials to use with students. Members discussed the need to track medicinal sources compared to illicit or cartel sources for opioids. Synthetics are becoming increasingly a drug of choice. Bob will remain as the line of communication for leads and anonymous tips. He leads a team of 15 investigators who look at diversion and prescription fraud cases. He’s been working in Chula Vista with the local police and small pharmacies to teach how to respond to suspicious scripts. The team has received 200 leads since April. All leads enter a grid and are investigated as appropriate. If you have concerns about prescription fraud, theft, doctor shopping, pill mills, or other DEA concern, please email agent Harkins: Robert.J.Harkins@usdoj.gov He welcomes leads or questions from members. 4 Benzodiazepines Are Becoming the New Opioids with Rising Deaths (Graphs and information from U.S. Department of Veterans Affairs Academic Detailing Service) There is widely disseminated information about opioid safety and tapering. There is less information about benzodiazepines. Pharmacist Maggie Mendes shared materials and information about how the VA manages the benzodiazepine taper process. This is part of a list of VA academic detailing projects. Links the VA resources will be added to the San Diego Safe Prescribing web site. Benzodiazepine Role in Treatment There is a role for benzodiazepines for seizures, panic attacks, severe anxiety, alcohol withdrawal and benzodiazepine withdrawal. There is no evidence of benefit from chronic benzodiazepine use in anxiety or insomnia. For most cases of severe anxiety, benzodiazepines should be limited to 4 - 6 weeks. For insomnia, tolerance develops quickly and is associated with rebound insomnia with discontinuation. It is recommended for short term and intermittent use (< 5 nights per week). Benzodiazepines should be avoided with:        PTSD Chronic Respiratory Disease (COPD, Sleep Apnea) With CNS Depressants (e.g. opioids) Substance Use Disorder (alcohol, opioids, etc.) Traumatic Brain Injury Dementia Elderly 5 Benzodiazepine Tapering from the VA’s Perspective The VA has a published Summary of Strategies to Discontinue Benzodiazepines. 1. Determine Benefit vs Harm 2. Employ Strategies to Help with Long Term Discontinuation. Recommendation to taper, Educational intervention, psychotherapy intervention 3. Slow Taper Over 6 months. Approximately 10-25% every 4 weeks with use of a benzo taper calculator Use Vistaril, gabapentin, and anti-epileptics Warm Line advice for addiction Communication with Clinician Colleagues A pain physician has noticed that her patients are receiving medications from other prescriber despite a signed medication agreement with her. An ED physician notices a patient requesting medications while having a regular physician at a different facility. A patient has an adverse reaction to a medication that was prescribed by a different physician. These are examples where clinician-to-clinician communication is helpful and important. It is much better for us to talk to each other than get letters from the Medical Examiner's office or the Medical Board. It is an investment in time to reach out to a physician you do not know and may not be in your system, but it is well worth it. CURES provide a method of communication, but it is only helpful when a physician logs into their computer. Several of the task force members have tried this method with little success. A phone call is the gold standard communication method and is often received with appreciation. NALOXONE DISTRIBUTION The San Diego County Public Health Department was awarded a grant from the California Department of Public Health (CDPH) to distribute 6,622 doses of naloxone. Dr. Sayone Thihalolipavan, deputy public health officer, is managing the distribution. The dosages will go to groups who have expressed interest in participating: law enforcement, schools, substance use disorder treatment providers, and federally qualified health clinics. Organizations who receive the free medication are required to provide documentation on the distribution. 6 Health Plan Formularies: Turning off at the Tap alcohol abuse, pregnancy, liver failure, and acute intoxication. Patients need to be in withdrawal, monitored for effect, and referred to a clinic for continued treatment. Roneet Lev described the engagement of local health plans in safe prescribing. By taking off Soma (Carisoprodol) off the formulary for new start prescriptions at Community Health Group, they experience a dramatic decrease in the number of Soma prescription after one year. The decline was more than expected by just "turning off the tap" to new prescription. That is because even chronic users who had a gap in prescribing where then identified as a "new start" and not continued on regular scripts. The power of formulary changes has been palpable at the Medical Examiner's office. There has been a campaign to remove Soma from the formulary at several health plans - Indian Health, VA, Kaiser, and others. With this effort the number of Soma related deaths in San Diego has declined significantly. We can do the same with Xanax and high dose opioids. The VA and several health plans already have Xanax off formulary. Dr. Loretta Stenzel did grand rounds at Tri-City on the MAT services available at Vista Community Clinic and has reached out to their emergency department. Dr. Lev will work with Family Health Centers and Scripps Mercy. IN THE NEWS  CDC's National Center for Health Statistics released data and statistics on drug overdose deaths in the United States from 1999-2016. 63,632 drug related deaths, 21% higher than in 2015. https://www.cdc.gov/nchs/data/databriefs/db294.pdf  Death Diaries front page of San Diego Union Tribune featuring research by Dr. Lev http://www.sandiegouniontribune.com/opinion/commentary/ sd-utbg-opioid-crisis-drugs-20171122-story.html  Medication Assisted Treatment and ED’s Scromiting is the new name for Cannabis Hyperemesis syndrome Scromiting is Dr. Lev's favorite word because she publicized this made-up word during a media interview that went viral. The word can be traced to Scripps Mercy hospital and a local NBC story. You will now find Scromiting on Google, images, YouTube, and Twitter. The Hub and Spoke model is implemented in San Diego with Fashion Valley Clinic and several community clinics. The emergency departments are interesting in referring to these clinics. There is a state and national movement to start MAT treatment in the ED with a warm hand off of the patient to the clinic. Dr. Lev received her X waiver, but notes that the 8-hour educational program is geared towards primary care and has many cautionary conditions against using buprenorphine such as methadone use, benzodiazepine use,  The Pulse San Diego. Scott Silverman and Roneet Lev chat with Cindy Matalucchi http://www.thepulsesd.com/live/  Free safe disposal from Walmart for opioids and unused medication https://www.usatoday.com/story/money/2018/01/17/walmar t-takes-opioid-crisis-offering-free-solution-safely-disposeunused-meds/1039548001/ 7  CHIP Public Policy Committee Community Conversation  Illicit Fentanyl reaches San Diego http://www.sandiegouniontribune.com/news/publicsafety/sd-me-fentanyl-crisis-20171006-story.html The San Diego Prescription Drug Abuse Task Force did a presentation on The Opioid Epidemic and Solutions for San Diego. This featured Dr. Sayone Thihalolipavan, deputy public health officer; Cindy Cipriani, US Attorney Office; Linda Bridgeman-Smith, Behavioral Health Services; and Dr. Katie Hirst, psychiatrist. Kaiser Health Plan in San Diego One San Diego The One San Diego vision for safe prescribing practicing, promotes a unified approach to prescribing, whether you are an emergency physician, primary care, pain specialist, surgeon, dentist, psychiatrist, pharmacist, or health plan. has removed the "Unabomber" from their satisfaction scores. The "Unabomber" is the patient who given all zeros from all the questions - 0 -0 - 0 - 0 - 0. These surveys are removed from all the statistics. One of the medical groups in San Diego who prides itself for hiring physicians with good scores, has remove MTF MEETING SCHEDULE SAN DIEGO COUNTY MEDICAL SOCIETY AT 5575 RUFFIN ROAD CONTACT INFORMATION Meeting Quarterly on Second Fridays at 12 noon RONEET LEV, MD, CHAIR: RONEET@COX.NET April 13, 2018; July 13, 2018; HTTP://WWW.SANDIEGOSAFEPRESCRIBING.ORG ANGELA GOLDBERG, PDATF FACILITATOR: ANGELAGOLDBERG@SBCGLOBAL.NET October 19, 2018 8