MANAGING PAIN WHILE MINIMIZING RISK OF SUBSTANCE USE DISORDER OUTLINE. EPIDEMIC / CRISIS The Epidemic / Crisis Around Opioid Prescription Use

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1 MANAGING PAIN WHILE MINIMIZING RISK OF SUBSTANCE USE DISORDER Barbara St. Marie, PhD, ANP, GNP, ACHPN Associate Faculty College of Nursing University of Iowa, Iowa City, IA OUTLINE Epidemic / Crisis Foundational Research Developing Decision Support for the APRN Future Plans EPIDEMIC / CRISIS The Epidemic / Crisis Around Opioid Prescription Use 1

2 EPIDEMIC / CRISIS Chronic Pain: 116 million people, cost: $635 billion Drug Abuse: 4.5 million users of nonmedical pain Rx quadrupled Sales of PO (PO) Overdose deaths US has: 4.3% world s population 83% world s oxycodone 99% world s hydrocodone 259 million prescriptions 2012, ½ from PMC COST: $467.7 billion / year OPIOID PRESCRIBING IN THE US: ENOUGH FOR EVERY ADULT AMERICAN TO HAVE A BOTTLE OF PILLS. 2

3 PROGRAM OF RESEARCH Managing Pain While Minimizing Risk of Prescription Opioid Misuse STUDIES : Coexisting Addiction and Pain in People Receiving Methadone for Opiate Addiction (PI) to 2014: Experiences of People Living With Chronic Pain While Receiving Opioids from Primary Care (PI) to 2015: The Experiences and Perceptions of APNs Caring for Patients with Coexisting Substance Abuse and Pain (PI) to 2015: Referrals and treatment completion for prescription opioid admissions (Co-PI) : Prescriptive Decision Support for Persistent Pain and Risk for Opioid Misuse (PI) : Preventing Persistent Post-surgical Pain and Opioid Use in Veterans: Effect of ACT (Co-I) : Psychometric Evaluation of New Clinical Pain Knowledge Test (Co-I). 8. SUBMITED K23 NIDA): Decision Support for Responsible Pain Management (PI) STUDY #1: DISSERTATION 2010 TO 2011: COEXISTING ADDICTION AND PAIN IN PEOPLE RECEIVING METHADONE FOR OPIATE ADDICTION (PI). Purpose: To examine the narratives of people who experience chronic pain and are receiving methadone for the treatment of opiate addiction Qualitative interviews, N= 34 methadone clinic participants Two publications 3

4 STUDY # TO 2014: EXPERIENCES OF PEOPLE LIVING WITH CHRONIC PAIN WHILE RECEIVING OPIOIDS TO MANAGE THEIR PAIN FROM PRIMARY CARE (PI). Purpose: Provide the perspectives of patients who live with chronic pain and receive opioids to help manage their pain from primary care. Funded: Nurse Practitioner Healthcare Foundation Qualitative Interviews of Primary Care Patients (N=12) 4

5 STUDY # TO 2014: THE EXPERIENCES AND PERCEPTIONS OF ADVANCED PRACTICE NURSES CARING FOR PATIENTS WITH COEXISTING SUBSTANCE USE DISORDER AND CHRONIC PAIN (PI). Funded: American Society for Pain Management Nursing Purpose: How advanced practice nurses manage patients with coexisting SUD and chronic pain. Issues and challenges Identified problems with present health care protocols Shifting of Patients to the APRN Difficulties in accessing non-medicine ways to manage pain Roles: Educating patients, Facilitating and monitoring changes needed to support patient, Educating other HCP, Implementing risk strategies, Recommendations STUDY #4 REFERRALS AND TREATMENT COMPLETION FOR PRESCRIPTION OPIOID ADMISSIONS Partially funded: Iowa Consortium for Substance Abuse Research and Evaluation Aims: Compare referral rates by HCP with other referral sources for treatment admissions for Rx Opioid misuse Compare completion success rates for Rx Opioid admissions with other substances Design Secondary analysis existing data set (TEDS) referral source & treatment outcome Comparisons PO vs other substances, between groups entering treatment Existing national data set 5 years span (N = 3,000,000) 5

6 RESULTS 2012 TO 2014: REFERRALS AND TREATMENT COMPLETION FOR PRESCRIPTION OPIOID ADMISSIONS HCP account for <10% referrals into treatment for clients admitted for Rx Opiate misuse Rx Opiate clients had lower treatment success than other substance clients Clients referred by HCP had lower success rates St. Marie, B.J., Sahker, E., Arndt, S. (2015). Referrals and treatment completion for prescription opioid admissions: Five years of national data. Journal of Substance Abuse Treatment, doi: PRIOR WORK CURRENT FOCUS Published two studies during post doctoral fellowship Understand experiences of patient SUD & Pain Problem Published two more studies as associate Understanding healthcare referral to treatment and outcomes Understand experiences of APRN Primary focus shifted towards helping clinicians find support to effectively manage pain while minimizing opioid risk. 6

7 BACKGROUND PAIN MANAGEMENT GUIDELINES ARE NOT FOLLOWED Content does not integrate pain management and opioid misuse recommendations Guidelines are too voluminous and cumbersome for routine clinical care PCPs do not know guidelines exist What s an algorithm decision support going to do? STUDY # TO PRESENT: PRESCRIPTIVE DECISION SUPPORT FOR PERSISTENT PAIN AND RISK FOR OPIOID MISUSE (PI). Funded: University of Iowa College of Nursing Dean s Research Award PHASE 1: OPIOID RISK ASSESSMENT DOMAINS PHASE 2: TREATMENT RECOMMENDATIONS Pain Type Medication ORT Score Social System Substance Use Nonmedicine modalities Medication Monitoring Safety Follow up INNOVATION Experts past experiences and evidence based pain guidelines Blends risks assessment and multimodal pain treatment Case based reasoning combined with similarity search High order of importance and priority to social components (not yet in US Guidelines) Prior or current SUD for overall risk assessment (triage) 7

8 WHY ARE DECISION SUPPORTS IMPORTANT? LIMITED AND BOUNDED RATIONALITY Links the limit to our ability for rational and optimal decisions to Information we have Small capacity of working memory compared to long-term memory Time availability to make decisions This DS-RPM will assist in clinical decision making for these two difficulty public health problems. STUDY #7 PSYCHOMETRIC EVALUATION OF NEW CLINICAL PAIN KNOWLEDGE TEST Partially Funded: Cleveland Clinic PI: Esther Bernhofer Co-I: Barbara St. Marie Purpose: To develop and determine the reliability and validity of the Clinical Pain Knowledge Test. Completed content validity Physicians, nurses, advanced practice nurses 95.1% agreement for content relevance In process: reliability and validity STUDY #8: K23 APPLICATION PENDING AT NIDA DECISION SUPPORT FOR RESPONSIBLE PAIN MANAGEMENT (DS-RPM) Purpose: To determine operability, feasibility, and consistency of an expert derived, EBPG decision support tool called, DS-RPM. Assess the operability of the DS-RPM tool. Alpha testing and Beta testing to determine operability, meeting user interface specifications.. Test the feasibility (usability, acceptability) of the DS-RPM. Simulated Patients interactions with PCPs as they use the DS-RPM.. Determine if DS-RPM users treatment plans are more consistent with expert treatment plans than those of non-users. Comparing treatment plans from PCPs randomly assigned to either DS-RPM or TAU groups to expert treatment plans. 8

9 FUTURE RESEARCH Planned Upcoming Research Towards Minimizing Risk FUTURE RESEARCH Test and pilot DS-RPM Go to R01 Complete the Qualitative Data collection and analysis of Veterans Psychometric Evaluation of Clinical Knowledge of Pain Qualitative study to clarify results of Referrals and treatment completion for prescription opioid admissions 9

10 thank you. 10