12 July Barbara Wismer, MD, MPH Tom Waddell Health Center San Francisco Department of Public Health

Transcription

1 12 July 2012 Barbara Wismer, MD, MPH Tom Waddell Health Center San Francisco Department of Public Health

2 It s in the literature It s in the news It s on our minds

3 } HCH Clinicians Network priority } National survey of HCH clinicians in 2010 (n=101) } Results showed clinicians: Lacked resources for optimal pain management Lacked access to non-pharmacologic pain interventions Were uncomfortable prescribing opioids, especially if substance use disorders Found successful pain management gratifying

4 What are your thoughts + feelings about working with patients who have chronic pain?

5 Provide framework + tools for evaluation + management of chronic pain Functional goals Multimodal treatment Universal precautions Provide recommendations for practice adaptations for patients experiencing homelessness

6 } [T]he magnitude of the pain suffered by individuals and the associated costs constitute a crisis for America, both human and economic. [A]pproaching pain at both the individual and the broader population levels will require a transformation in how Americans think and act individually and collectively regarding pain and suffering. [T]his transformation represents a moral and national imperative.

7 } Why do we need a cultural transformation? Mismatch between knowledge + application Focus is on diagnostic tests + medical treatment rather than interdisciplinary, biopsychosocial approaches to address psychological (emotional + cognitive) effects Patients have important role to play (self management) Pain not recognized as a serious disease in itself to be treated directly + worthy or research

8 } Pain is a public health issue Affects ~100 million adults Reduces quality of life Affects different groups disparately Costs $ billion annually Can be addressed by public health interventions More consistent data collection Public education

9 Rates* of opioid pain reliever (OPR) overdose death, OPR treatment admissions, and kilograms of OPR sold --- United States, *Age-adjusted rates per 100,000 population for OPR deaths, crude rates per 10,000 population for OPR abuse treatment admissions, and crude rates per 10,000 population for kilograms of OPR sold. Paulozzi LJ, et al. Overdoses of Prescription Opioid Pain Relievers United States, MMWR (2010):87-92.

10 Definitions/Model Diagnosis/Evaluation Plan/Management Service Delivery Design

11 } An unpleasant sensory + emotional experience associated with actual or potential tissue damage, or described in terms of such damage } International Association for the Study of Pain

12 } Pain that persists beyond normal tissue healing time, which is assumed to be 3 months } For this talk, chronic pain = chronic noncancer pain } International Association for the Study of Pain

13 All impact function in the context of pain/suffering. Biopsychosocial%20Model%20of%20Pain.htm

14 } Pain involves 2-way communication between peripheral + central nervous systems, + involves areas of the brain involved with emotions + thoughts } This impacts functions + behaviors } Pain/suffering exacerbated by impact of pain on function/behaviors, which worsens negative mood, physical inactivity, social isolation Negatively reinforcing } Suggests a variety of treatment modalities may be needed; most successful combination may take time to determine; may require team

15 } Homelessness increases risk of chronic pain, exacerbates suffering, + makes pain management more challenging More frequent injuries + assaults Less optimal + timely treatment Exposure to the elements More frequent behavioral health problems Higher risk of misuse/abuse of opioids Less treatment options

16 Definitions/Model Diagnosis/Evaluation Plan/Management Service Delivery Design

17 } History Ask + listen Pain, function, quality of life Behavioral health Living situation } Physical exam Trauma informed care } Further testing/referral if indicated

18 } Use of standard measures can help track progress, as well as effectiveness of treatment } Examples: numeric/faces pain scales, Brief Pain Inventory (Short Form), PEG (3-item scale)

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21 What number best describes your pain on average in the past week? No pain Pain as bad as you can imagine What number best describes how, during the past week, pain has interfered with your enjoyment of life? Does not interfere Completely interferes What number best describes how, during the past week, pain has interfered with your general activity? Does not Completely interfere interferes Krebs EE, et al. Development and Initial Validation of the PEG, a Three-Item Scale Assessing Pain Intensity and Interference. JGIM 24.6 (2009):733-8.

22 } Important but challenging Pain + addiction frequently co-occur, have overlap in neurophysiology, can have similar effects on all aspects of health, cause/impact each other Both conditions must be managed simultaneously for best chance of success Patients may not be (initially) forthcoming about use or history, for many reasons Reassess frequently, using non-judgmental approach Consider assessment tools, urine drug testing

23 } Pain + mental health disorders frequently cooccur, symptoms can overlap, + outcomes for one can affect the other Anxiety Depression Post-Traumatic Stress Disorder } Psychological factors can influence pain Coping, acceptance, self-efficacy } Pain associated with suicide not related to mental illness

24 } Approach to engaging with people who have history of trauma that recognizes the presence of trauma symptoms + acknowledges role that trauma has played in their lives provides a framework for safety } Examples for physical exam: Explain what comprehensive exam will entail Ask permission to perform exam; explain what you will do before touching patient } National Center for Trauma Informed Care (

25 Definitions/Model Diagnosis/Evaluation Plan/Management Service Delivery Design

26 Focus on function Multimodal approach Opioids Universal precautions Follow up/ Aberrant drug related behaviors

27 } Rationale Generally cannot eliminate pain - at most, 2-3 point decrease on pain scale possible but small decreases in pain can lead to significant improvements in function More (objectively) measurable Respects individual differences More likely to increase quality of life + reduce burden of pain Particularly valuable when using opioids can help determine if addiction present

28 } What do you plan to do with this treatment that you can t do now? } What does pain keep you from doing? } If the answer is Feel better, or Everything consider: Asking about ADLs, sleep, walking/other physical activity, care of family/pets, hobbies, social activities with family/friends } Must be realistic, achievable, meaningful, measurable } Remain flexible

29 You see a 45 year old homeless man in primary care who has low back pain after failed disk surgery complicated by infection. He can t do anything because of the pain. He s couch surfing + spends most of the day inside drinking to ease the pain. His relationships are strained because he s irritable from the pain + from lack of sleep. He s ashamed to visit his family. He can t seem to get out to apply for benefits. He wants something from you to help with his pain. What functional goals might make sense?

30 Improved sleep Getting outside daily Applying for general assistance Reuniting with family

31 Psychological Self care, pacing, relaxation, coping, sleep hygiene Cognitive behavioral therapy Physical Multiple causes/impacts of pain suggest a multimodal approach Physical activity Physical therapy/physiatry, injections, surgery Pharmacological Non-opioids, opioids Complementary/alternative medicine Acupuncture, meditation, yoga, massage Other conditions Mental health Substance use Education, promote self management Self esteem, self efficacy Psychosocial needs Finances, housing, relationships, stress

32 Other conditions Psychological Psychosocial Physical Education Pharmacolog ical

33 } Based on concept that pain influenced not only by underlying pathophysiology but also thoughts, feelings, + behaviors } Can decrease pain, improve function, reduce disability, improve mood, reduce anxiety related to activity, improve relationships } Evidence-based } } Keefe FJ. (1996). Cognitive behavioral therapy for managing pain. The Clinical Psychologist, 49.3 (1996):4-5. Otis JD. Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach. New York: Oxford University Press, 2007.

34 Treatment rationale Thoughts + behaviors affect pain experience Patients play role in controlling pain Coping skills training Relaxation Activity pacing/pleasant activity scheduling Distraction Cognitive restructuring Also includes stress + anger management, sleep hygiene, relapse prevention Application of coping skills

35 } Individual or group } Benefit of groups: More time efficient Allows learning coping skills from one another Illustrates not alone Provides social support

36 } Non-opioids Analgesics Muscle relaxants Anticonvulsants Antidepressants Topicals } Use type of pain (nocioceptive, neuropathic)/ condition as guides } Consider other symptoms/conditions

37 } Make plan for safe storage of medications Locked box Arrangement for storage at clinic or shelter } Adapt prescribing/dispensing as indicated

38 Indications Universal precautions approach Considerations in patients with substance use disorders Follow-up

39 } More severe pain/impaired function/quality of life } Insufficient improvement with other treatments or other treatments contraindicated } Benefits outweigh risks/harms } Opioids are part of good medical care, but must have appropriate structures/processes in place to prescribe them if not, develop contacts to refer elsewhere

40 } Approach Additional structure Ongoing assessment For all patients } Rationale High rates of substance abuse/dependence Increased risk of opioid misuse, abuse, diversion Difficulty predicting/detecting misuse, abuse, diversion } Gourlay et al. Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain Pain Medicine 6(2):

41 Diagnosis with appropriate differential Psychological assessment including risk of addictive disorders Informed consent Treatment agreement Pre/post intervention assessment of pain level/ function

42 Appropriate trial of opioid therapy +/- adjunctive medication Reassessment of pain score/ level of function Regularly assess Four A s Periodically review pain diagnosis/ comorbid conditions, including addictive disorders Document- ation 4A s=analgesia, activity, adverse effects, aberrant behavior (ADBR)

43 } Study of a subset of indigent patients with HIV } Patients who were on chronic opioids + their PC providers (PCPs) surveyed } Purpose: accuracy of PCP estimation of opioid misuse + illicit substance use } Vijayaraghavan M, et al. Primary Care Providers Judgments of Opioid Analgesic Misuse in a Community-Based Cohort of HIV-Infected Indigent Adults. JGIM 26.4 (2010):412-8.

44 } Results: Misuse 20% patients reported misuse PCPs estimated 50% of patients misused No concordance (kappa score 0.09, p=0.10) Illicit substance use 43% of patients reports illicit substance use PCPs estimated 50% of patients used illicit substances Concordance (kappa score 0.37, p<0.001)

45 } Results: PCPs more like to think younger patients (AOR 0.89 (95%CI )), African American patients (AOR 2.53 (95%CI )), + patients who used illicit substances (AOR 3.33 (95%CI ) had misused opioids Per patients, younger + African American patients not more likely to report misuse of opioids; those who used illicit substances were (AOR 3.01 (95%CI ))

46 } Conclusions: No concordance between patient report of opioid misuse + PCP estimate of patient misuse PCPs more likely to overestimate misuse in younger + African American patients } Use Universal Precautions!

47 } Managing addiction risk in patients with substance use disorders on opioids Risk of relapse increased, especially if past opioid addiction Universal precautions approach Consider urine drug testing More frequent visits Smaller supply of medication Inclusion of family/friends/others Increased support/adherence Collateral information

48 } When starting opioids: Minimize euphoric effects of opioids Avoid prescribing supratherapeutic doses Use slow-onset opioids Use forms less easily convertible to be injected, smoked, snorted Titrate rapidly to avoid prolonged dose finding } While on opioids: For minor relapse: increase support (SA counseling, short dispensing intervals, frequent urine drug testing treatment programs) For active addiction: discontinue/taper opioids For opioid addiction: refer to methadone maintenance therapy Consider buprenorphine off label, but legal for chronic pain + opioid addiction

49 4A s Analgesia (pain control) Activities of daily living (function) Adverse events (side effects) Aberrant drug related behavior

50 } Aberrant drug-related behavior Behavior outside the treatment agreement Examples: Request for early refill Missed appointment Report of lost/stolen medications Disruptive/violent behavior Appearing intoxicated or high, or with withdrawal symptoms Stealing/forging prescriptions Selling medications

51 } Aberrant drug-related behavior Take a uniform approach Use a non-judgmental harm reduction (motivational interviewing) approach Assess functional status

52 Determine a differential diagnosis Worsening of physical condition Additional acute pain syndrome Worsening of mental illness or substance abuse Misuse of opioids Pseudo-addiction Diversion Conditions of homelessness Not clear Address based on etiology/ severity of issue Increase in opioid dose Increase in structure (more frequent prescribing/dispensing, safe storage space) Intensification of mental health/ substance use treatment (including residential treatment) Additional information: urine drug testing, pill counts, Prescription Monitoring Program Discontinuation of opioids Further consultation (e.g., peer, team, or specialist review)

53 } Urine drug testing Can be an additional tool during initial + ongoing assessment for substance use disorders Can be used to monitor treatment adherence, as well as non-prescribed opioid use, to help reduce diversion/misuse/abuse by patients on opioids Pills counts + Prescription Monitoring Program data additional options

54 } Urine drug testing Be clear about rationale for use + what response to results will be Explain to patient Expectation of regulatory agencies of monitoring of adherence + substance use Focus on risks/benefits of opioids, patient safety Understand patients may have negative associations Know characteristics of test + how to interpret Do not forego monitoring of function

55 } Randomized trial of patients with chronic back/neck pain on opioids who had increased risk for or actual prescription opioid misuse } Question: Does an intervention of individual + group substance misuse counseling, selfreport compliance checklists, + regular urine drug testing improve compliance? } Jamison RN. Substance misuse treatment for high-risk chronic pain patients on opioid therapy: A randomized trial. Pain (2010):

56 } Intervention: cognitive behavioral training program for prevention of substance misuse Knowledge + training for substance misuse awareness + recovery Enhancing + maintaining motivation to abstain from illicit substance use Coping with urges to misuse medication Problem solving related to substance misuse Lifestyle balance 1 or more group sessions Monthly individual motivational counseling sessions Substance misuse education worksheets Monthly opioid compliance checklist Monthly urine drug tests

57 } Results: After 6 months, 26% of intervention patients (vs 74% of control patients) had positive scores on DMI DMI (drug misuse index) based on patient self report (prescription drug use questionnaire), physician report (addiction behaviors checklist), + urine drug test

58 } Conclusion: A brief cognitive behavioral/ motivational intervention can decrease misuse among high risk patients on opioids for chronic back/neck pain

59 Definitions/Model Diagnosis/Evaluation Plan/Management Service Delivery Design

60 Teams Groups Policies/Procedures Other

61 } Multiple causes/impacts of pain suggest a multimodal approach Teams provide the scope of perspectives + skills needed } Chronic pain management is time-consuming + stressful Teams also increase resources + support } Team members: Primary care provider, nurse, social worker, case manager, addiction specialist, psychiatrist/psychologist Pharmacist, physical therapist, pain specialist Providers from other agencies (mental health clinics, methadone treatment programs, residential/day treatment programs)

62 } Interactive education } Self management goal setting } Medication refills/form completion } Other treatments (CBT, physical therapy) } Other benefits (decreased isolation, peer support, empowerment decreased staff burnout) } May improve ability to address needs of challenging patients } Can couple with individual encounter with medical provider } Can allow more patients to benefit from services

63 } Can systematize practice, provide support, protect therapeutic relationship, improve management of challenging patients, establish monitoring/tracking/review mechanisms } Based on practice guidelines, universal precautions

64 } Self care } Clinic safety safety plan/training } Opportunities for discussion Peer to peer / Multidisciplinary / Case conferencing Differences in practice styles / Difficult cases } Opportunities for ongoing education + skill building Functional goals, multimodal treatment Difficult conversations (substance use, addressing aberrant behavior, discontinuing opioids)

65 Provide framework + tools for evaluation + management of chronic pain Functional goals Multimodal treatment Universal precautions Provide recommendations for practice adaptations for patients experiencing homelessness

66 } Wismer B, et al. Adapting Your Practice: Recommendations for the Care of Homeless Adults with Chronic Non-Malignant Pain. Nashville: HCH Clinicians Network, National HCH Council, Inc, } Chou R, et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. Journal of Pain 10.2 (2009):

67 } SAMHSA. Managing Chronic Pain in Adults With or in Recovery from Substance Use Disorders. TIP Series 54. HHS Publication No. (SMA) Rockville, MD: SAMHSA, } Fishman SM. Responsible Opioid Prescribing: A Physician s Guide. Washington, DC: Waterford Life Sciences, 2007.

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69 } SOAPP-R (Screener + Opioid Assessment for Patients with Pain Revised) } ORT (Opioid Risk Tool) } Somewhat effective in identifying those at higher risk for aberrant behaviors (behaviors outside the treatment plan)

70 } ORT (Opioid Risk Tool) } Different scores (0-5) for different items, female/male respondents Family history substance abuse Personal history substance abuse Age History preadolescent sexual abuse Psychological disease } Low risk (0-3 total); moderate (4-7); high (>=8) (predicts future ADRB)

71 } COMM (Current Opioid Misuse Measure) } Predicts current ADRB } 18 questions about past 30 days Thinking, function Treatment elsewhere Suicidality, anger Misuse (taking others meds, med use)

72 } Yellow Flag Committee Multidisciplinary group that meets monthly to review hard cases of patients on opioids, or patients on high dose opioids Any staff can suggest patient for review Any staff member can attend Provider + team present patient Provider, team, + committee generate recommendations for care Recommendations placed in patient record

73 } Yellow Flag Committee results so far Provides opportunity for provider review Provider/promotes team dialogue around hard cases Provides support for provider + team Recommendations often followed Hopefully will promote more consistency in care