Practical Points from a Residency Clinic. Susan Faragher Bannon, MD, FACP Medical Director Department of Internal Medicine WMU School of Medicine

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1 Practical Points from a Residency Clinic Susan Faragher Bannon, MD, FACP Medical Director Department of Internal Medicine WMU School of Medicine

2 Dr. Bannon has no financial relationships or conflicts of interest to disclose familynews.com

3 WMU School of Medicine Clinics

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6 The Way it Was Prior to our policy in 2003 Staffing resident clinic led to many requests to refill narcotics, especially on Friday afternoons

7 Current Policy Pain contract Drug screens MAPS No refills after hours No medical marijuana First visit policy No replacement of lost/stolen prescriptions

8 In Future? Pill counts Pain clinic? Talk with prior provider if transferring

9 Hope Simple procedures can be implemented to improve tracking and monitoring of chronic narcotic patients, improve quality of care, decrease doctor shopping and improve patient safety. Adherence to our policy helped improve the clinic flow by having everyone following the same rules and making both patients and physicians aware of the expectations and consequences.

10 First Visit Policy New patients to the clinic will not receive narcotics prior to: Assessment being done Old records being obtained/phone call Drug screen being ordered/prelim looked at MAPS report reviewed Controlled substance contract signed

11 Assessment Characteristic Low Risk Moderate Risk High Risk Substance Abuse Never Past Current Smoking (nicotine) Never Past Current FH of Addiction None Significant Significant Psychosocial factors No major diagnoses, minor diagnoses treated or stable Past major diagnoses current issues with minor diagnoses Current major diagnoses untreated or unstable Age Older N/A Younger Hx of Sexual Abuse No N/A Yes Controlled prescriptions lost or stolen Abnormal drug screen No N/A Yes Consistently negative Initially positive Appropriate Use of Opioids in Chronic Pain, Jan 1, 2012 p. 7 Consistently positive

12 Objective To improve appropriate prescribing habits and monitor therapy on potentially dangerous and abusive prescription narcotics, an audit was done of a residency clinic before and after the implementation of a new policy. We now have 60 month data on compliance with this policy as well as follow up on 426 patients that have ever been on pain contract.

13 Research question Does having a narcotic prescribing policy in place improve the narcotic prescribing habits in a residency clinic? What is the long term disposition of patients on pain contract?

14 Methods Protocol was approved by MSU/KCMS research committee/irb Study included 426 adults, who received chronic opioids prescriptions from KCMS (WMED) Internal Medicine and Medicine Pediatrics Clinics between March 2007 and August 2012

15 Methods New procedures were implemented requiring all chronic narcotic patients to have: a controlled substance contract random drug screening a Michigan Automated Prescription System (MAPS) profile on the chart prescriptions and refills all written by same provider if at all possible no narcotics without old records

16 Methods Residents and faculty in clinics were educated of the new policy during preclinic sessions and conference time. The EMR was used to task residents of missing information on their patients. and evaluation sessions were used to reinforce requirements. Chart review and comparison was done before and after implementation of the new policy.

17 Electronic Medical Records Allscripts (old EMR)-patient list was kept and exported to Excel ECW (new EMR)-code is added to problem list to identify them, structured data is used to monitor, and also in Excel Reports of narcotics written are also run Pt calls for refills monitored for narcotics and to ensure they are on the list

18 Inclusion & exclusion criteria All patients receiving chronic narcotic prescriptions from KCMS IM and MP clinics Only adults identified No patients excluded

19 Results Study included patients patients were dismissed after they violated the pain contract (27.4%) [35% at U of M study] 35 patients died (8.2%) 41 patients were dismissed from clinic due to no show (9.6%) 80 patients stopped following with our clinic for various reasons (18.8%) 39 patients were weaned off narcotics successfully and still patients in clinic (9.2%) 113 patients (26.5%) are currently receiving opioids prescriptions from our clinic

20 5 Years of Data Patients 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% Violations-dismissed No Show-Dismissal Deceased Attrition Weaned off Narcotics Current Narcotic Pts 0.00% % as of August 2012

21 Results Pain contract was present on 51% initially and increased to 94.5% of patients after the new procedures were in place (p-value < 0.001) MAPS was present on 11% initially and increased to 92% of patients after the new procedures (p-value < 0.001) Random drug testing was present on 16.3% initially and increased to 91% after the intervention (p-value < 0.001)

22 Results Variable Baseline 3 Months After the Policy Pain contract 40 Months After the Policy 60 Months After the Policy 51% 73% 94.5% 96.3% MAPS 11% 73% 92% 95.3% Random drug testing 16.3% 43.2% 91% 89.7%

23 Policy Compliance % Baseline 3 Months 40 Months 60 Months Pain Contract MAPS Drug Screen

24 Results & Benefits Increase in compliance with the policy Identification of resident educational needs to target education and feedback All patients are treated equally Improve patient safety Decrease doctor shopping Improve job satisfaction Improve clinic flow/decrease phone calls

25 Discussion Labor intensive to continually monitor and track the data Could improved EMR sophistication automatically link narcotic prescription to these requirements? Legal issues: termination of care/report? Interpretation of drug screens

26 Contact Information Susan Bannon Phone: Cell: