Regulating Pain Management: Another Piece of the Puzzle!

Transcription

1 Regulating Pain Management: Another Piece of the Puzzle! Linda Vanni, MSN, RN-BC, ACNS-BC, NP, AP-PMN Nurse Practitioner, Pain Management Professional Pain Education & Consulting LLC Objectives Discuss how the opioid epidemic effects the ability of healthcare providers to treat patient s cancer pain Identify key elements of the Joint Commission s new 2018 Pain Standards Describe new state legislation related to pain management 1

2 What happened? 1996 APS president s speech about the need to have pain assessed with the same zeal as vital signs. Ortho third highest prescribers of opioids, dentists Let s talk about hoarding Management pain = prescribe opioids Things got out of hand 76 Million opioid scripts written in Million opioid scripts written in 2011 The jump from legal to illicit use, number of days per day from opioid overdose (CDC, 2017) Definition of Pain Pain is whatever the experiencing person says it is, existing whenever he or she says it does. - Margo McCaffery, R.N., M.S., FAAN 2

3 Society of Nuclear Medicine & Molecular Imaging: 2015 Annual Meeting Heavy long term use of cannabis is associated with negative changes in parts of the brain, linked to deficits in learning and memory Negative impact on dopaminergic transmission with other drugs, only with different regional profile, blunting of dopamine release This could be linked to the addictive potential & other problems, such as lack of motivation, seen in regular users People often think of cannabis as a lighter, harmless drug. This study shows that it is not and that it has negative consequences. How the Opioid Crisis Affects Cancer Pain Management? CDC and other recommendations exclude the treatment of cancer pain Addictive disease is wide spread during this opioid crisis and can effect the cancer patient receiving opioids, i.e. access to medication, decrease insurance coverage, safe keeping issues May influence oncology team s prescribing patterns 3

4 Opioid Crisis Cont. Education needs to concentrate on patient safety Safe administration practices Difference between tolerance and addiction Education on opioid use for the patient should include family Approximately 10% of the entire population of 325,000,000 in the U.S. has addictive disease of some type (SAMSHA, 2017) gabapentin abuse Ohio Board of Pharmacy now reporting gabapentin on its PDMP Ohio Substance Abuse Monitoring Network issued alert, February 2017 Fifth most prescribed drug in nation (GoodRx) Can enhance euphoria caused by opioids and stave off drug withdrawals Bypasses the blocking effects of medications used for addiction treatment, enabling patients to get high while in recovery (STAT, 2017) 1/5 of those abusing opioids misuse gabapentin (Addiction, 2016) 300 mg pill sells for as little as 0.75 cents on the street 4

5 Misconceptions: Tolerance, Dependence, Addictive Disease Resolving common misconceptions that may prevent adequate pain management Tolerance: larger dose required for the same relief Dependence: withdrawal causes abstinence syndrome Can be avoided when patient complies with established refill schedule Addiction: a state in which an organism engages in a compulsive behavior. Loss of control in limiting intake Behavior is reinforcing (rewarding or pleasurable) National Institute on Drug Abuse Pseudo Addiction: Addiction-like behavior may signal inadequate pain control or intensification, progression of pain Safety Issues Are we dealing with illegal or legal substances? Multi-substances? Opioid naïve? Are we getting accurate information from the patient, i.e. amount, type of issues? Discrimination on our part? Ethical treatment? 5

6 Caring for the patient with Addictive Disease Be a patient advocate, empathy Treating the patient with AD who has cancer pain Treating withdrawal symptoms All about safety Your safety The patient s safety Visitors, substances in room In 2017, significant issues over chronic opioid use remain Stigma Using opioids for chronic pain, these medications are not benign, ER Who will be the writer? Impotence Expense Addiction Diversion 6

7 Updates on Opioids Label changes: addition of NOWS warning, ER/LA clarification of terminology. Fentanyl patches: package changes to minimize risk of accidental exposure, color changes of patch printing to enable improved verification of dosage. FDA, 9/23/2013 Long-term Opioids No Longer Indicated for Moderate Pain, Medscape, 9/10/2013. Tramadol schedule IV as of 8/18/14 Morphine/oxycodone combo not approved by FDA Oxymorphone ER (Opana ER) voluntarily removed from market Research, Standards and Guidelines for Safe Clinical Practice American Pain Society guidelines Numerous guidelines for special populations and conditions Joint Commission pain standards Evidence-based practice 7

8 Hot off the Press New Guidelines and Strategies National Pain Strategy (2016) Institute of Medicine & NIH Guidelines on the Management of Postoperative Pain (2016) American Pain Society CDC Guideline on Opioid Prescribing (2016) CDC & AMA 8

9 Center for Disease Control Has flagged prescription painkiller abuse as a major health threat. Hit hardest, high rates of poverty areas such as Maine and Ohio CDC Recommendations (2016) Discuss risks and benefits Lowest effective dose Establish goals for pain and function Use strategies to mitigate risk Review PDMP data Use urine drug testing Careful of concurrent benzo use with opioids 9

10 News Flashes Doctors Urge CMS, Joint Commission to Rethink Pain Treatment to Help Stem Opioid Epidemic May 5, 2016 By: Elizabeth Eaken Zhani, Media Relations Manager, H&HN, April 15, 2016 Cigna Plans to Cut Opioid Use Among U.S. Customers by 25% By Reuters Staff, May 19, 2016 Medicare Proposes Omitting Pain Management Questions from HCAHPS, HealthLeaders Media News, July 11,

11 CMS New Composite Measure Communication About Pain As of 8/2/17, FY 2018 IPPS Final Rule 1) During this hospital stay, did you have any pain? Yes/No - 2) (If Yes) During this hospital stay, how often did hospital staff talk with you about how much pain you had? Never/Usually/Always - 3) During this hospital stay, how often did hospital staff talk with you about how to treat your pain? Never/Usually/Always ***Questions on all surveys to patients discharged after January 1, 2018, delayed public reporting until October, 2020 reporting period/fy 2021 payment determination Standards Revisions Related to Pain Assessment and Management 11

12 Leadership APPLICABLE TO HOSPITALS Effective January 1, 2018 Standard LD Pain assessment and pain management, including safe opioid prescribing, is identified as an organizational priority for the hospital. Elements of Performance for LD The hospital has a leader or leadership team that is responsible for pain management and safe opioid prescribing and develops and monitors performance improvement activities. (See also PI , EP 19) 2. The hospital provides nonpharmacologic pain treatment modalities. 3. The hospital provides staff and licensed independent practitioners with educational resources and programs to improve pain assessment, pain management, and the safe use of opioid medications based on the identified needs of its patient population. (See also RI , EP 8) 4. The hospital provides information to staff and licensed independent practitioners on available services for consultation and referral of patients with complex pain management needs. 5. The hospital identifies opioid treatment programs that can be used for patient referrals. 6. The hospital facilitates practitioner and pharmacist access to the Prescription Drug Monitoring Program databases. Note: This element of performance is applicable in any state that has a Prescription Drug Monitoring Program database, whether querying is voluntary or is mandated by state regulations for all patients prescribed opioids. 7. Hospital leadership works with its clinical staff to identify and acquire the equipment needed to monitor patients who are at high risk for adverse outcomes from opioid treatment. (See also PC , EP 6) Medical Staff Medical Staff (MS) Standard MS The management and coordination of each patient s care, treatment, and services is the responsibility of a practitioner with appropriate privileges. Standard MS The organized medical staff has a leadership role in organization performance improvement activities to improve quality of care, treatment, and services and patient safety. Element of Performance for MS The medical staff is actively involved in pain assessment, pain management, and safe opioid prescribing through the following: Participating in the establishment of protocols and quality metrics Reviewing performance improvement data 12

13 Provision of Care Standard PC The hospital assesses and manages the patient s pain and minimizes the risks associated with treatment. Elements of Performance for PC The hospital has defined criteria to screen, assess, and reassess pain that are consistent with the patient s age, condition, and ability to understand. 2. The hospital screens patients for pain during emergency department visits and at the time of admission. 3. The hospital treats the patient s pain or refers the patient for treatment. Note: Treatment strategies for pain may include nonpharmacologic, pharmacologic, or a combination of approaches. 4. The hospital develops a pain treatment plan based on evidence-based practices and the patient s clinical condition, past medical history, and pain management goals. 5. The hospital involves patients in the pain management treatment planning process through the following: Developing realistic expectations and measurable goals that are understood by the patient for the degree, duration, and reduction of pain. Discussing the objectives used to evaluate treatment progress (for example, relief of pain and improved physical and psychosocial function) Providing education on pain management, treatment options, and safe use of opioid and non-opioid medications when prescribed (See also RI , EPs 6 8; RI , EP 6) 6. The hospital monitors patients identified as being high risk for adverse outcomes related to opioid treatment. (See also LD , EP 7) 7. The hospital reassesses and responds to the patient s pain through the following: Evaluation and documentation of response(s) to pain intervention(s) (See also RC , EP 7) Progress toward pain management goals including functional ability (for example, ability to take a deep breath, turn in bed, walk with improved pain control) Side effects of treatment Risk factors for adverse events caused by the treatment 8. The hospital educates the patient and family on discharge plans related to pain management including the following: Pain management plan of care Side effects of pain management treatment ADLs, including the home environment, that might exacerbate pain or reduce effectiveness of the pain management plan of care, as well as strategies to address these issues safe use, storage, & disposal of opioids when prescribed Performance Improvement Standard PI The hospital collects data to monitor its performance. Element of Performance for PI The hospital collects data on pain assessment and pain management including types of interventions and effectiveness. Standard PI The hospital compiles and analyzes data. Elements of Performance for PI The hospital analyzes data collected on pain assessment and pain management to identify areas that need change to increase safety and quality for patients. 19. The hospital monitors the use of opioids to determine if they are being used safely (for example, the tracking of adverse events such as respiratory depression, naloxone use, and the duration and dose of opioid prescriptions). (See also LD , EP 1) 13

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15 Causes of Persistent Cancer Pain Chemotherapy induced peripheral neuropathy (CIPN) Radiation-induced pain Hormone therapy-induced arthralgia Graft vs Host Disease (GVHD)-related pain Surgery-related pain Stokowski, L.A. (2011), Medscape 15

16 The Scope of the Issue 66% of 11.7 million people living with a diagnosed cancer in the US at the beginning of 2007, are expected to still be alive at least 5 years after their cancer diagnosis. By the year 2020, it is estimated that there will be 18.1 million survivors at an annual cost of $ billion. As of January 2012, 13.7 million cancer survivors. SEER Stat Fact Sheet, NCI, 1/2012 Mariotto, et al., J.NCI, 2012 NCI, Journal of Cancer Epidemiology 2013 ASCO Clinical Practice Guidelines (2016) Focuses on Chronic Pain in Survivors Judy Paice, ONN, For chronic pain, it s out-served its usefulness as any kind of warning sign, it s indeterminate in terms of how long it may persist for some people, yet it can have significant effects on physical function, psychological functioning, and the individual s social life. Being hyper-aware for groups under-assessed, undertreated, with limited resources 16

17 ASCO Guidelines Continued Usage of non-pharm approaches, such as physical therapy & rehab, integrative therapies, interventional therapies, psychological therapies, neuro-stimulatory therapies. Clinicians should focus on developing a safe, individualized treatment plan for each survivor aimed at improving quality of life and enhancing function Is pain or dependency driving elevated opioid use among long-term cancer survivors? Canadian population-based cohort study, 2017 Hematology News Rates of opioid prescribing were 1.2 times higher than overall among cancer survivors up to 10 yrs. After diagnosis, compared with matched controls, with more than threefold higher rates of opioid prescriptions for survivors of some cancers. 17

18 Elevated Opioid Use in Cancer Survivors Continued Survivorship is complex Survivors of cancer may have higher prevalence of chronic pain Is this elevated rate due to dependency that originated from opioid use earlier in the disease trajectory? PCPs who treat cancer survivors need to critically examine reasons for lingering opioid use Elevated Opioid Use in Cancer Survivors Continued Reassessment is vital; is pain recognized in the survivor more than in the past or is it due to inappropriate long-term prescribing At point of discharge from oncology care, usually 5 year mark of surviving with no residual disease, opioid use should be examined again Were cancer patients inappropriately started on a opioid for non-opioid responsive pain? 18

19 Elevated Opioid Use in Cancer Survivors Continued Very difficult to find multi-disciplinary cancer survivor clinics Patient s may feel, any new pain is cancer pain until proven otherwise, Dr. T.B. Strouse Should be a call to physicians to understand survivorship, with a goal of determining the patient s absolute minimum opioid requirement Survivorship & Patients with Chronic Cancer Chronic care survivors were more likely than curative intent survivors to experience fatigue, cognitive changes, dyspnea, peripheral neuropathy, lymphedema & erectile dysfunction Nearly ½ of chronic care survivors were managed by an oncologist alone & less likely to be co-managed by a PCP Providers generated fewer survivor care plans for chronic care than for curative intent survivors 19

20 Survivorship continued Fewer chronic care survivors rated their experience and satisfaction with the SCP tool as very good or excellent They were also less likely to share the provider summary with their health care team Frick M, Vanchani C, Bach C, et al. (June 27, 2017) Survivorship and the chronic care patient: Patterns in treatment-related effects, follow-up care, and use of survivorship care plans. Cancer. Doi: /cncr Opioid issues Who is responsible? Is the knowledge base there for the PCP or other practitioners to treat survivor pain? Visits to the oncologist are now less frequent Are we talking about the need for surveillance and monitoring? Is this a role for a pain specialist? The volumes will continue to increase 20

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22 Changing Winds How are these changes effecting oncology patients? Are all of years of work to control pain utilizing opioids coming to an end? Will there be limits on how much can be prescribed? Who can have it? Are long term opioids safe to use?? How long is too long? What else can we use to control the pain? Always linking pain management to function 22

23 Antineoplastic & Antiretroviral Agents 23

24 Multimodal Therapy: Clinical Advantages Peripheral Local anesthetics Opioids Anti-inflammatory agents Capsaicin Multimodal therapy provides a way to achieve balanced, safer pain therapy 1 Improved quality of analgesia 2,3 Fewer side effects 2,3 Better functional status 4 Descending SNRIs, TCAs Endogenous systems Central Anticonvulsants Opioids 2 -agonist (clonidine) Acetaminophen Ascending Local anesthetics Anticonvulsants Opioids NMDA antagonists (ketamine) 2 -agonist (clonidine) 1. Gottschalk A, Smith DS. Am Fam Physician. 2001;63: , Tiippana EM, et al. Anesth Analg. 2007;104: Basse L, et al. Brit J Surg. 2002;89: Patient Barriers to Effective Oncology Pain Management Reluctance to report pain Fear of treatment being discontinued Fear of disease progression Concern about being a good patient Fear of addiction Side effects Fear that pain medication will be ineffective or that they will run out 24

25 New State Legislation 25

26 New State Legislation Using the MAPS as a teaching tool! 26

27 The Shifting Paradigm All about multi-modal Scheduled acetaminophen Pain Management always linked to function Opioid-sparing The future of topicals Integrative therapies Anti-abuse opioids being approved by FDA Medical Marihuana Schedule of Controlled Substances Established by the DEA Based on abuse and dependence liability States may have stricter regulations Schedule I (C-I) potential for abuse so high as to be unacceptable LSD, heroin, cocaine, marijuana 27

28 JAMA Psychiatry, 4/26/2017 Illicit cannabis use and use disorders have increased more in states that passed medical marijuana laws than in those that did not, analysis of national survey data Accompanying editorial, NIDA, analysis confirms two earlier reports linking changes in medical marijuana laws to increases in cannabis use and disorders in adults Robust system of education, prevention, and treatment is needed to minimize the negative consequences that might arise if cannabis use continues to increase, NIDA Final Thoughts Cancer Pain Management has drastically changed in recent years All of our cancer patients deserve effective, evidence-based pain management Medical Marihuana Genetic, targeted pain management Adhering to new regulatory guidelines, mandates and laws will enable us to protect our licenses and the patient s safety that we care for Keeping our patients safe is vital 28