Teaming Up for Safer Pain Management: Strategies for Effective Collaboration
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1 Teaming Up for Safer Pain Management: Strategies for Effective Collaboration Noah Nesin, MD, FAAFP, Vice President of Medical Affairs, Penobscot Community Health Care Felicity Homsted, PharmD, DPLA, Chief Pharmacy Officer, Penobscot Community Health Care
2 Target Audience: Pharmacists ACPE#: L04-P Activity Type: Knowledge-based
3 Teaming Up for Safer Pain Management: Strategies for Effective Collaboration Noah Nesin, MD, FAAFP, Vice President of Medical Affairs, Penobscot Community Health Care Felicity Homsted, PharmD, DPLA, Chief Pharmacy Officer, Penobscot Community Health Care
4 Disclosures: The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Noah Nesin: No relationships to disclose Felicity Homsted: No relationships to disclose The data presented is from a single health system
5 Session Objectives Identify mechanisms for collaboration between pharmacists and prescribers to minimize opioid misuse, while ensuring that patients with legitimate needs have access to opioids. Describe effective communication strategies between pharmacists and prescribers to optimize care and minimize patient risk. Describe policies around PDMP use and other mechanisms being used to manage risk and diversion and support appropriate medication use.
6 1. Assessment Question 1. Which of the following is not an example of how pharmacists and prescribers can collaborate to minimize opioid misuse. A. Develop interdisciplinary teams to review challenging cases B. Create community prescribing and monitoring guidelines C. Establish formal communication process between community pharmacist and prescribers to address prescribing concerns D. Construct a punitive based process for giving providers feedback
7 2. Assessment Question 2. Which of the following is not an effective way for pharmacists to improve communication to ensure safe prescribing practices and address community needs. A. Provide evidence base education to prescribers B. Counsel that state laws are the reason for opioid tapers C. Establish relationships with key prescriber stakeholders and leadership D. Reinforce safe-prescribing messaging in pharmacy
8 3. Assessment Question 3. Which of the follow is not optimal in mitigating diversion and supporting appropriate medication use. A. Reviewing prescription monitoring program data B. Utilization of urine drug screens C. Performing scheduled pill counts D. Requiring patient contracts for chronic opioids
9 Overview Established in 1998 Federally Qualified Health Center Patients: 65,000+ patients in 2017 Majority lower incomes Thousands uninsured Four integrated pharmacies, 1 rural dispensary, and 3 pharmacy residency programs 150,000 prescriptions dispensed annually
10 PCHC Integration Model
11 Primary Care Pharmacy Services Diabetes management Anticoagulation management Comprehensive medication management Chronic care management Hepatitis C management Controlled substance stewardship
12 Interdisciplinary Committee Structure Controlled Substance Stewardship (CSS) Committee Chief medical officer, chief psychiatrist, pharmacists, prescribers, social workers, & care managers Provider-patient agreements Policies with oversight Proactive case reviews Homsted F, Magee C, Nesin N. Population health management in a small health system: Impact of controlled substance stewardship in a patient-centered medical home. Am J Health-Syst Pharm. 2017;74: M8
13 Slide 12 M8 quality assurance/improvement reports? Magee,Chelsea, 3/15/2016
14 Impact Analysis: First 90 Days Retrospective chart review: 93 cases involving opioids reviewed in a 90-day period Dose reductions suggested in 78 cases At three-month follow-up, 76% of dose reductions implemented 32% of patients had the prescription eliminated completely Gernant SA, Bastien R, Lai A, et al. Development evaluation of a multidisciplinary controlled substances committee within a patient-centered medical home. JAPhA. 2015;55(6):
15 Annual Compliance Monitoring to Support Appropriate Use Informed consent & patient provider agreement Urine drug screens (UDS) - Prior to prescribing & random Pill Counts Also as needed at points of concern, random Prescription Drug Monitoring Program (PDMP) review - Prior to prescribing & scheduled by prescriber Opportunities for pharmacists to support
16 Informed Consent and Provider/Patient Agreement Provider reviews informed consent and patient/provider agreement with patient, ensuing patient understands all aspects Patient and Provider both sign, placed in medical record, copy for patient Designates single filling pharmacy Opportunity: Pharmacists support in drafting
17 Informed Consent: Opioids for Chronic Pain Goal is Improved 35% of people No proven function, not may develop benefit for total pain relief addiction chronic pain Higher risk of injury, falls, car accidents, breathing problems, heart disease, accidental overdose & death Bangor Area Controlled Substance Work Group. Controlled substance clinical documents resource informed consent for opioids for chronic pain Boscarino JA, Rukstalis MR, Hoffman SN, et al. (2011) Prevalence of Prescription Opioid-Use Disorder Among Chronic Pain Patients: Comparison of the DSM-5 vs. DSM-4 Diagnostic Criteria, Journal of Addictive Diseases. 2011;30(3):
18 Partnership Approaches to Ensure Legitimate Access to Opioids Begin with evidence based medicine Collaborate to develop consistent practices Identify strategies for managing inappropriate practices and utilize them Continuously educate Wiedemer NL, Harden PS, Arndt IO, Gallagher RM. The opioid renewal clinic: a primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Med. 2007;8(7):
19 Where is the evidence? Trauma informed care Eye movement desensitization & reprocessing (EMDR) Cognitive behavioral therapy (CBT) Antidepressants Anticonvulsants Physical therapy Support groups Weight loss Acupuncture Massage Chiropractic CDC guideline for prescribing opioids for chronic pain - United States, MMWR Recomm Rep. 2016; 65(RR-1): 1-49.
20 Communication Methods to Optimize Care and Minimize Patient Risk Consistent process evaluation and improvement Reinforce deprescribing messaging Increase consumer awareness Have difficult conversations
21 Non-Reassuring Behaviors Requests for early refills Lost or stolen medications Inability to reach for pill counts or UDS Failure to make scheduled appointments Reports of suspected diversion
22 PCHC Experience: Provider impact Practice security New addiction focus Awareness of suffering
23 Pill Counts % 90.00% 80.00% 70.00% Data from PCHC Clinical Tracking Scorecard. Goal 80.00% 67.14% 65.78% 60.00% 50.00% 40.00% 30.00% 20.00% 35.97% 31.28% 10.00% 0.00% Oct-13 Nov-13 Apr-14 Jun-14 Sep-14 Dec-15 Mar-15 Jun-15 Oct-15 Mar-16 May-16 Oct-16 Dec-16 Mar-17 May-17 Jun-17 Oct-17 Opportunity: Perform pill counts
24 Collaboration Strategies to Support Safe & Effective Pain Management Start small Build a team Develop a process Maximize interdisciplinary expertise Expect challenges and adapt
25 Patients On Chronic Opioid Prescriptions % Reduction Overall Homsted F, Magee C, Nesin N. Population health management in a small health system: Impact of controlled substance stewardship in a patient-centered medical home. Am J Health-Syst Pharm. 2017;74:
26 Community Pharmacy Based Intervention 1010 patients, 1062 prescriptions review Addressed only >100 MMEs* daily Study sample (n) = 84 patients *100 MMEs selected in accordance with Maine law
27 Community Pharmacy Based Intervention Informed providers of patients exceeding dose limits Distributed provider and patient education handouts Provided pharmacists patient lists & intervention forms Interventions included recommending tapering for those prescriptions greater than 100MME and not having medical exceptions stated in the law.
28 Community Pharmacist Intervention Taper Results Change in Opioid Prescribing at 6 months Tapering 18% No change 14% Discontinued 11% Tapered < 100 MMEs 57% MMEs Average MMEs Daily Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Nair, S. Evaluating the impact of the new opioid dose limits mandated by the state of Maine on provider specific treatment plans for pain management. ASHP Poster Presentation
29 Conclusion Community pharmacist have an important role to play in safer pain management Evidence-based practices should be used to inform collaboration with prescribers to prevent diversion and promote better pain control Strong pharmacist-prescriber communication channels are key to improving medication safety in pain management
30 1. Assessment Question 1. Which of the following is not an example of how pharmacists and prescribers can collaborate to minimize opioid misuse. A. Develop interdisciplinary teams to review challenging cases B. Create community prescribing and monitoring guidelines C. Establish formal communication process between community pharmacist and prescribers to address prescribing concerns D. Construct a punitive based process for giving providers feedback
31 2. Assessment Question 2. Which of the following is not an effective way for pharmacists to improve communication to ensure safe prescribing practices and address community needs. A. Provide evidence base education to prescribers B. Counsel that state laws are the reason for opioid tapers C. Establish relationships with key prescriber stakeholders and leadership D. Reinforce safe-prescribing messaging in pharmacy
32 3. Assessment Question 3. Which of the follow is not optimal in mitigating diversion and supporting appropriate medication use. A. Reviewing prescription monitoring program data B. Utilization of urine drug screens C. Performing scheduled pill counts D. Requiring patient contracts for chronic opioids
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