PRESCRIBING OPIATES IN CONTEXT OF OPIATE USE DISORDER

Transcription

1 PRESCRIBING OPIATES IN CONTEXT OF OPIATE USE DISORDER Ken Hopper, MD, MBA Health Strategies and Population Health TCU/UNTHSC School of Medicine The Hopper Group-Fort Worth, Arlington, Dallas

2 MAKING IT REAL A Family Member s Testimonial A Family Member s Charge to Action

3 HOW DID WE GET HERE? Individual Patient Attributes Societal Elements and Expectations Healthcare System Contributions

4 WHAT TURNS PAIN RELIEF INTO A PROBLEM? Pain has strong physical and emotional components. Opiates have potent effects on both, which leads to Risk of physical dependence and withdrawal Risk of addiction or Opioid Use Disorder (OUD) Risk of opioid overdose High MME/day History of MH/SUD problems Combination with other substances that suppress respiratory center brain or cause sedation other opioids, alcohol, benzodiazepines, certain muscle relaxants

5 RISK FACTORS FOR DEVELOPING AN OUD Adverse Childhood Experiences-ACE Mental health problems Duration of treatment

6 THE 5 C S OF ADDICTION Craving Compulsion Loss of Control Continued use despite Consequences Chronicity

7 HAVE YOU EVER HEARD DIRECTLY OR INDIRECTLY? I know I m addicted to opioids, and it s the doctor s fault because they prescribed them. But, I ll sue them if they leave me in pain

8 HOW HAVE SOCIETAL EXPECTATIONS CONTRIBUTED? All suffering is avoidable-a change in philosophy of the role of pain and discomfort in life and change Medical Boards and Legislation: California 2001 formal training with face value expression of pain Patient satisfaction surveys with specific questions about pain control satisfaction (satisfaction equals better pay)

9 HEALTH SYSTEM Behavior Change is time-consuming, requires behavioral skills, is poorly reimbursed Behavior Change requires leverage-family collaboration, lock in programs, other hospital, system, and/or preferably community change Treatment has moralistic interpretations (and, is filled with double standards) Summary: Treatment is not readily accessible when problems are recognized. Payers, communities, health systems, and doctors must come together to braid funding and resources

10 COMPLEXITY & BEHAVIORAL FINANCING Complex problems require complex procedures/inputs Inputs not necessarily transparently priced Inputs result in variable outcomes using variable techniques

11 WHAT DO WE DO? NIH HEAL Program (Helping to End Addiction Long Term) Builds upon research into complex neurologic pathways and pain Integrates behavioral interventions with MAT (medication assisted treatment) for OUD Key elements: Available Naloxone-injection and nasal for acute rescue Buprenorphine and other medication advancements such as Clonidine/Lofexidine (Lucemyra)* Lofexidine less likely to cause severe low blood pressure than clonidine Mind/Body/Cognitive approaches: Changing the goal from no pain to function. Yoga, Mindfulness, Cognitive approaches surrounded with after session support. Simplicity rules in behavior change.

12 PRESCRIPTION MONITORING AND CONTRACTING ELEMENTS TEXAS PMP AWA E texas.pmpaware.net TEXAS PMP AWA E For assistance using this application, please contact Austin, TX 844-4TX-4PMP ( )

13 UNIQUE MODELS TO SPREAD PRECIOUS RESOURCES Center for Advancing Pain Relief

14 INSERTING EXPERTISE: SEE, DO, PRACTICE UC Davis ECHO Pain Management TeleMentoring UC Davis ECHO - Pain Management is a peer-to-peer video conference mentoring program designed to support community-based, primary care clinicians in their mission to provide high quality, safe and effective pain care. The mission of Project ECHO (Extension for Community Health Care Outcomes) is to develop the capacity of primary care clinicians to safely and effectively manage chronic pain within their communities. A multidisciplinary team of specialists support participating primary care clinicians through weekly peer-to-peer video conferences.

15 UC DAVIS SAMPLE TOPICS/CURRICULUM/SUPPORT Introduction to pain and mental health (e.g., outline for the targeted pain medicine interview, affective diagnosis overlay, intersection of pain pharmacology and psychopharmacology, motivational interviewing) Pain management essentials (e.g., overview of pain, pain anatomy and physiology, analgesic pharmacology) Opioids (e.g., responsible opioid use and risk stratification, adherence monitoring risk assessments, contracts, urine drug testing, prescription drug monitoring program, addiction, chronic opioid therapy equianalgesic dosing, opioid tapering methodologies) Back and neck pain (e.g., examining the lumbar and cervical spine, diagnostic decisions in back and neck pain) Headaches and other pain syndromes (e.g., muscle pain, myofascial pain syndrome, fibromyalgia, neuropathic pain) Diagnostic testing

16 RESOURCES Trends in Overdose: Substituting Fentanyl and Heroin when prescriptions go away Not all pain relief seekers are the same

17 REFLECTION AND QUESTIONS