I Don't Understand the Politics of Drug Deaths

Alcohol Kills More People than Opioids 

But It's NOT an Epidemic?

I don't understand the politics of drug deaths... 

Drugs that kill people fast like opioids are an epidemic and a priority for law enforcement. 
Drugs that kill more people, but kill them slowly are not a priority for anyone... 

The article below says 88,000 people a year die from alcohol. I fear another drug may kill more, because gastrointestinal disease is the 3rd leading cause of death in the U.S. and NSAID's are both sold over the counter and handed out like candy by physicians, I'm afraid the death toll from NSAID's may be higher than we think.

The USA Today article says "As opioid overdoses, which kill about 72,000 people a year, grabbed America's attention, the slower moving epidemic of alcohol accelerated, especially in Southern states and the nation's capital. About 88,000 people die each year from alcohol"

Alcohol Kills More People than Opioids

Kingman Harm Reduction Offers FREE Naloxone Here's How Make a Rugged Naloxone Kit

The Sonoran Prevention Works Kingman Harm Reduction office has free Naloxone clean needles and information on what street drugs contain fentanyl.

Kingman Harm Reduction is located at 3505 Western Ave Suite B in the Mohave Mental Health building, the entrance is to the left as you face the front doors of MMH. 

The Naloxone kits provided at Kingman Harm Reduction have two vials of 0.4 mg Naloxone, two syringes with needles attached. These kits are great and anyone who takes prescription opioid pain medications or who abuse ovoid street drugs should have several of these kits around and always carry them with you. 

I have Naloxone at home and carry a kit in the car. I was concerned having a kit rattling around in the glove compartment the vials could break or the bag become torn. 

So I made a rugged Naloxone kit I could throw in the glove compartment, a ladies purse, a backpack, or anything without worrying too much about it getting broken. 

Rugged Naloxone Kit
The Kingman Harm Reduction kit comes with syringes with needles attached. You'll need to replace these and I explain as we go. 

You need to go to your local pharmacy and talk to the pharmacist, get to know them. Explain what you're doing and ask for one of their large prescription bottles, and a couple syringes with separate needles. 

I found that two 3cc syringes and two needles fit in the prescription bottle that's 3.75" without the lid. This makes a small rugged Naloxone kit you can carry about anywhere.

Naloxone from Kingman Harm Reduction 

Syringes and syringes from pharmacy for Naloxone Kit

Rugged Naloxone Kit in 3.75" Prescription Bottle

WARNING 

Naloxone has a SHORT Half-Life The time it's effects last.....

When naloxone is given intravenously, it starts working within two minutes, and when it’s injected into a muscle, it works within five minutes. When Narcan nasal spray is used, it also works within two to five minutes. 

The effects of Narcan last anywhere from half an hour to an hour. For some people, multiple doses are required, because the length of action of opioids is longer than naloxone’s duration of action. 

What is the Naloxone AKA Narcan half-life? Narcan is metabolized in the liver, and studies have shown the half-life in adults to be anywhere from 30 to 81 minutes. 

In infants, the half-life is around 3.1 hours. Again, Narcan and any form of naloxone doesn’t have any effect if there are no opioids present in a person’s body. It doesn’t have the potential for abuse, and all that it does is reverse the effects of opioids including respiratory depression so that the person who has overdosed can resume normal breathing. LINK TO PAGE

Unlike the rumors some physicians are spreading people are NOT abusing naloxone! 

In 12 years working undercover narcotics I have never seen a drug addict spend half the day finding money, the other half looking for heroin, so they can shoot up and get high only to inject themselves with Naloxone.... 

In my experience as an EMT I've seen many pissed off drug addicts when given Naloxone by EMS because they ruined their high. The fact they were about to die doesn't seem to hit them until later....

NEW Pain Crisis in Mohave County, and America Facebook Page

Please Check Out My 

New Pain Crisis in Mohave County, and America Facebook Page

I'll be sharing pain news and information for the pain patient community

https://www.facebook.com/groups/PainCrisisinAmerica/

A Prescriber's Guide to the New Medicare Part D Opioid Overutilizaton Policies for 2019

If you suffer chronic pain and have Medicare Part D Please Read

Below are some comments from a patient advocate in Nevada about changes to Medicare Part D in January 2019.

It contains, from Medicare:  "A Prescriber's Guide" and a notice to insurers about 2019 Formulary-Level POS Safety Edits, which I find to have very important information.

I hope you find this information useful. I am sure most of you know about this already however the CMS newsletter is only a couple weeks old.  At the Alliance for the Treatment of Intractable Pain, we are giving this information out to pain patients across the country.  We are also trying to get the 2019 Call Letter edits suspended for 1 year.

A Prescriber's Guide to the New Medicare Part D Opioid Overutilizaton Policies for 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18016.pdf

Page 3.  90mme is the threshold to ID potential high risk patients. Of significance, it says "This is not a prescribing limit" 

Page 5.  Palliative care is listed as one of the exemptions.

page 6.  The patient, the patient’s representative, or the physician or other prescriber, on the patient’s behalf, has the right to request a coverage determination for a drug(s) subject to the alert, including the right to request an expedited or standard coverage determination in advance of prescribing an opioid

Page 6   How else can a provider prepare for the new 2019 Medicare Part D over-utilization policies? To avoid a prescription being rejected at the pharmacy, prescribes may proactively request a coverage determination in advance of prescribing an opioid prescription  if the prescriber has assessed that the patient will need the full quantity written 

So what does this all mean?  Palliative care "should" be exempt. 

Find out in advance if the Medicare plan will even have a safety edit at 200mme.

A hard edit at 200mme is optional for the insurance companies. Request a coverage 

determination NOW. The patient can do this.  It does not have to be the doctor.

Personally, I already have a PA for 2019.  This "should" exclude me from having

a hard edit for above 200mme.

October 23, 2018 notice to sponsors

Additional Guidance on Contract Year 2019 Formulary Level Opioid POS Safety Edits

Medicare-PartD-Overutilization-Control-HPMS-memos (October 2018) [ZIP, 1MB]                                                                                                                                   

I include the above link as an attachment also.

MME hard edit (optional) 

In 2019, sponsors will continue to have the flexibility to implement hard safety edits at a threshold of 200 MME or more, with or without prescriber/pharmacy counts. We remind sponsors that they may not use MME thresholds as prescribing limits.  They can only function as a threshold to trigger the edit, indicating potentially unsafe opioid use.

I believe this is a significant statement.

If an enrollee or their prescriber requests a coverage determination and the only issue in dispute is the MME, CMS expects the Part D sponsor to approve the request if the prescriber attests that the higher MME is medically necessary, and  not to apply additional requirements such as the execution of a pain management agreement. 

It seems to me this is quite significant.  The provider should be able, for instance, to just fax a copy

of this notice to the sponsor and simply say "I have reviewed the patient's history and attest the higher dose is medically necessary.  End of discussion.

Q5: Which beneficiaries should be excluded from the opioid safety edits? 

A5: Part D sponsors are expected to develop specifications that exclude beneficiaries who are residents of a long-term care facility, in hospice care or receiving palliative or end-of-life care, or being treated for active 

cancer-related pain from all of the opioid safety edits. Sponsors should use all information available to them to reasonably exclude these beneficiaries from triggering the edits at POS in the first place.  

(so should "someone" alert the sponsor in advance

that the patient is excluded because of say,   palliative care?)

Sponsors should also apply specifications to account for known exceptions, 

such as reasonable overlapping dispensing dates for prescription refills or new prescription orders for continuing fills; and high-dose opioid usage previously determined to be medically necessary such as through coverage determinations, prior authorization, case management, or appeal processes.

I've received a PA already through the end of 2019.  Does

this mean I am excluded already?  If everyone gets a PA, will it avoid the edit?  FYI, my "Medicare and You" handbook lists 10 part-D sponsors. 4 of them

DO NOT list fentanyl patch 100mcg requiring a PA.  ALL plans have an asterisk saying,  "Opioid pain meds are subject to additional safety review"

Under question 6 answer:

Pharmacists are not expected to do extra work contacting  prescribers or patients to find exclusions outside of the normal pharmacy workflow. Rather, pharmacists may have existing knowledge or information that a eneficiary is not opioid naïve or meets one of the opioid safety edit exclusions (such as through pharmacy drug claims history, knowledge of the enrollee’s diagnosis and/or the prescriber’s specialty). 

Also, the pharmacist may learn through a care coordination consult with the prescriber that a beneficiary should be excluded. Sponsors should instruct pharmacists on how to communicate to the plan that the enrollee is excluded (e.g., through a transaction response code or by contacting the pharmacy help desk) to override the edit or to avoid the beneficiary or their prescriber from having to request a coverage determination on this particular fill. Plans are expected to accept this information in real-time so the claim can adjudicate.

so...........this implies to me, as my pharmacist already knows me and my history, he should already be checking with the sponsor and getting an override code.  

Also in NV, the prescription is required to have the ICD code on it giving the pharmacist the information needed to get an override code from the sponsor.

Should the patient go to their pharmacist (with the notice?) and say "hey, please go ahead and get the override code now so we don't have to have a hassle in Jan. OK?

Are Part D sponsors permitted to require that specific criteria or requirements be met, such as a referral to a pain specialist, prior to approving a coverage determination request related to an opioid safety edit? 

A7: No. The opioid safety edits are not intended to be a means to apply additional clinical criteria for the use of opioids, such as being managed by a pain specialist, having a signed pain contract, or having a treatment plan in place. In the absence of other submitted and approved utilization management requirements, the sponsor should allow the beneficiary to access his/her 
medications once the prescriber(s) attests that the
identified cumulative MME level or days supply is the intended and medically necessary amount for the beneficiary.  

This appears to me to limit the amount of hassle the sponsor/pharmacy can give the prescriber. This also re-affirms the comment from the other article saying "if MME is the only thing being considered" then the sponsor is suppose to accept the doctor's attestation that a high dose is medically necessary and should be approved.

CMS also expects sponsors to ensure that their staff are trained to appropriately identify and process enrollee requests for a coverage determination.
This includes verbal coverage determination requests made by enrollees, which should not be mis-classified as inquiries or grievances. Plans are not permitted to instruct an enrollee who is requesting a coverage determination that only their prescriber can initiate that request.

In other words, don't let the sponsor bullshit you.  Fax them a copy of this newsletter.  Give a copy to your pharmacist.  Try to get your patients to request a coverage determination NOW.  Enrollment ends Dec. 7th, 2018

Holidays Family Pain & Depression

The holidays are stressful for everyone and especially for those who suffer chronic pain. Sadly pain and depression go hand and hand especially this time of year. 

As the holidays approach it's especially trying for those with medical problems including chronic pain.

Not having the ability to do the things you once could like pickup a grandchild or simple things around the house is frustrating.

If you have the blues, if you feel depressed please talk to someone. What you’re going through is difficult

You can call the National Suicide Prevention Lifeline at 1-800-273-8255..... 

Lifeline provides free and confidential support for people in distress 7 days a week, 24 hours a day, 365 days a year we will be there for you.

So if you need someone to talk to call Lifeline at 1-800-273-8255