House of Pain? A Standardized Approach to Chronic Pain In the Patient-Centered Medical Home MAJ Meghan Raleigh, MD 17 MAR 2014
Make this house your own!
Objectives Review key components in PCMH Identify barriers to comprehensive pain management Identify Universal Precautions approach to chronic pain Increase comfort level with delivering multidisciplinary care to chronic pain patients utilizing the PCMH model Recognize available practice tools / resources
PCMH Key Components Access to Care Care Team and Staffing Chronic Disease Care Electronic Medical Records Group Visits Patient-Centered Care Patient Self-Management Practice Efficiency Quality and Safety
Intro Pain is the primary reason Americans seek health care Over 116 million Americans suffer chronic pain Opioids widely prescribed for chronic pain, even in high-doses not shown to affect pain (Gomes 2011) Daily dose of opioid is strongly associated with opioid-related mortality (Gomes 2011) Institute of Medicine report concluded that effective treatment of chronic pain demands a cultural shift from physicians & patients
Why are these patients challenging? We expect them to be: Time-consuming Deceitful Demanding Exploitive Difficult Non-adherent Manipulative Abusive Impossible to Drug-seeking please These beliefs are formed as early as medical school (Evans 2011)
Barriers to Comprehensive Pain Management Insufficient time Inadequate pain assessment No objective measures of pain Concern of drug-seeking behavior Concern of addiction Concern of prescription abuse/misuse Lack of pain management training News media coverage about opioid overdoses Fear of regulatory scrutiny or investigation
Universal Precautions Approach First introduced by Gourlay & colleagues in 2005 10 step approach to all patients with chronic pain Allows for unbiased applications of treatment plans to chronic pain patients Includes regular monitoring Reduces under-treatment of pain when opioids are necessary Zakaroff 2014; Gourlay 2005
Universal Precautions Approach Diagnose with appropriate differential Psychological Assessment Including Risk of Addictive Disorders Informed Consent Treatment Agreement Pre- and Post- Intervention Assessment of Pain Level and Function Appropriate trial of Opioid Therapy +/- Adjunctive Medication Zakaroff 2014; Gourlay 2005
Universal Precautions Approach C td Reassessment of pain score and level of function Regularly assess the four A s of pain medicine (Passok 2000) Analgesia Activity Adverse effects Aberrant Behavior Periodically review pain diagnosis and comorbid conditions, including addictive disorders
So how do we implement this in the PCMH? Tenets of PCMH: Teamwork Coordination, integration of care Working to the top of training scope Utilization of clinical decision support tools Patient self-management Quality Improvement
Standardized Approach to the Chronic Pain Patient Identify patients on opioid therapy (OT) for >90 days Establish clinic informed consent, pain contract, & individual treatment plan Establish no telephone refill policy Internal Behavioral Health Consult to address barriers to treatment plan & comorbid conditions Pharm D to address polypharmacy & make med recs Physical Therapist to assist w/functional assessment/goals N trition
Identifying patients Patients on opioids > 90 days 2010 VA/DoD CPG no longer distinguishes nonmalignant chronic pain and cancer-related chronic pain Identified by provider Identified by clinic (ie, calling in for refills, during pre-huddle appointment scrubs) Proactive identification Pharm-D looks up patients who have been on OT for >90 days, calls to recommend PCM appointment to set up appointment
Before the Visit Identify patients In huddle, pre-visit scrubs Set expectation about new clinic policy Pain contract No phone refills Via phone or Secure Messaging
Before the Visit Continued Collect info prior to visit Pharm D can get PDMP report Have patient fill out standardized survey for pain assessment / functional assessment / depression screen Utilize Secure Messaging to send forms & copy of pain contract Clinical Assistant can get baseline UDS this is our clinic standard of care for chronic pain Review records Inquire what patient goals for the visit are
The Visit Clean Slate Set the tone for a positive relationship History & Focused Physical Evaluate for contributing co-morbidities Sleep disorders Depression Anxiety PTSD Personality disorders Substance use disorder (or history)
The Visit Clean Slate Pain & Functional Assessment Review pre-visit forms Review Mechanism of Pain Discover what is the most important to patient Functional goals Pain reduction Improved sleep Improved family relationships/emotional well being
The Visit Clean Slate c td Set realistic expectations FUNCTION, not elimination of pain Make follow up appointment What is the goal of the next visit? Pain contract / informed consent/ treatment plan Can be done by clinical assistant / Pharm D Treatment plan may evolve over time
Pain Journal
Pain Contract Having standard clinic policy removes stigma of pain agreement Over 60% of chronic patients comply with their pain contracts (Hariharan 2007) Include informed consent! Add section with patient-specific treatment plan Add alternate sole-provider One copy to patient, one copy in EMR If at a Military Treatment Facility (MTF), may restrict to that MTF and listed providers
Pain Contract c td Review risk/benefits List precautions Driving safety Occupational safety (remember appropriate profiling for Active Duty) Security & safe-keeping of drugs NO use of alcohol or benzodiazepines while on opioids Consequences of noncompliance Maintain continuity - DON T kick patient out of clinic Increase visits / change approach aggressively manage pain without using opioids if needed PCMH team members can assist with this so that it doesn t take up provider visit time
Treatment Plan Informed Consent Side effects of opioids Sedation Dizziness nausea Constipation Hyperalgesia (increased pain) Physical dependence Delayed gastric emptying Hormonal dysfunction Erectile dysfunction Abuse Tolerance Respiratory depression
Treatment Plan Pharmacologic Non-opioids opioids Non-Pharmacologic Relaxation techniques Biofeedback CBT / IBT Journaling Support Groups Lifestyle Changes Exercise Weight loss CAM Acupuncture/BFA Spinal manipulation massage PM&R Heat/ice TENS Hydrotherapy Assistive devices Specialty Referral Physical Therapy Pain Management Other
Treatment Plan Leave room for functional goals Include recommended consultants PT / PM&R Ortho Pain med Rheum List all meds on plan Patient, PCM, & alternate all sign Give copy to patient (can send via Secure Message) Scan into EMR Review/revisit as needed
Your back still hurts?
Barrier: Drug-Seekers Pain contract / treatment agreement/ care plan Office policy with scripts Documentation Frequent visits, small quantities Use one pharmacy No early refills; pill counts utilize pharm D PDMP UDS Required consultation w/other specialties as indicated
Scripted Responses Your pain has been at a for months/years. Usually it s not possible to completely eliminate pain. Let s shift focus to getting your pain to a more tolerable level. How does that sound to you? I do not feel comfortable prescribing for this diagnosis, however we can try a prescription for instead which should also help.
Barriers: Insufficient Time Homework for patient: Pain diary Collect info prior to visit Phone or Secure Messaging Use standardized surveys Utilize pharm D to review PDMP Clinical assistant can do UDS Plan q2 week visits initially to reassess, reexamine then space out as appropriate
Barriers: Insufficient Time C td Screener can review pain contract & treatment plan with patient Utilize group visits (consider VTC) sleep class pain school Utilize Comprehensive Care Plan (CCP)Tab in AHLTA documents changes Requires tech training
Standardized Surveys Opioid Risk Opioid Risk Tool Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R ) Current Opioid Misuse Measure (COMM ) Function Oswestry Disability Questionnaire Pain eval Brief Pain Inventory
Opioid Risk Tool Low risk: 0-4 Opioid Risk Tool Score if Femal e Score if Male Mod risk: 4-7 High risk: 8 Family History of Substance Abuse Personal History of Substance Abuse Alcohol Illegal Drugs Prescription Drugs Alcohol Illegal Drugs Prescription Drugs 1 2 4 3 4 5 3 3 4 3 4 5 Age (mark box if 16-45) 1 1 Webster 2005 History of Preadolescen t Sexual Abuse 3 0 Psychological Disease ADHD; OCD; Bipolar Disorder; 2 2
Patient Education Not limited to provider Starts with first visit Include family / caregivers Put goals in writing for patient & EMR Reinforce with office staff, IBHC, Pharm D Get creative w/barriers utilize videos, telecounseling Patient self-management Familydoctor.org: safe storage of opioids (trifold) Painmed.org This never ends!
Provider Education Opioid Risk Evaluation & Mitigation Strategy (REMS) soon to be mandatory Utilize PCMH resources: Pharm D, IBHC Grand Rounds Telemedicine consultation Pain ECHO program Free CME (AAFP) Pain Week This never ends!
Questions?
Resources VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy (OT) for Chronic Pain (2010): includes pocket cards & guidelines, referral fact sheets, tapering fact sheets, side effect fact sheet: http://www.healthquality.va.gov/cot. Opioid Risk Instruments (including Opioid Risk Tool (ORT) and SOAPP-R): http://www.opioidrisk.com/node/1209 State Monitoring Drug Programs: http://www.pmpalliance.org/content/state-pmpwebsites
Resources Continued REMS Physician Education Sample Patient Medication Management Agreement: www.painedu.org/tools Pain diary: http://www.painedu.org/downloads/nipc/pain _Notebook.pdf Patient education from painmed.org:http://www.painmed.org/patientce nter/patienteducation/patient_education_main. aspx
References 1. Evans F, Whitham JA, David RM et al. An evaluation of Family Medicine residents attitudes before and after a PCMH innovation for patients with Chronic Pain. Fam Med. 2011 Nov-Dec;43(10):702-11. 2. Gomes et al. Opioid and Drug-Related Mortality in Patients with Non-Malignant Pain. Arch Intern Med. 2011; 171:686-91. 3. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005 Mar-Apr;6(2):107-12. 4. Hariharan J et al. Long-term opioid contract use for chronic pain management in primary care practice. A five year experience. Journal of General Internal Medicine. 2007; 22:485-490. 5. Passok SD, Weinreb HJ. Managing chronic nonmalignant pain: Overcoming obstacles to the use of opioids. Adv Ther. 2000; 17(2):70-83. 6. NCQA http://www.ncqa.org/programs/recognition/patientcenteredmedicalhomepcmh.aspx 7. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005 Nov-Dec; 6(6):432-42. 8. Zacharoff KL. A Systematic Approach to the use of opioids in the treatment of chronic pain. February 19, 2014. http://www.painedu.org/articles_timely.asp?articlenumber=19. Accessed February 21, 2014.