Implementing Pain and Opioid Management Guidelines in Primary Care Practice

Implementing Pain and Opioid Management Guidelines in Primary Care Practice

Objectives 1. What is the issue? 2. Why use a dedicated dissemination & implementation process? a. Historical perspective Cooperative Extension System b. OPHIC s history EvidenceNow/H2O results 3. Does anyone want this service & what are we measuring? 4. What have been the results so far?

How Did We Get Here?

US Drug Overdose Deaths In the US, drugs are the leading cause of accidental death, prescription opiates make up the majority of accidental drug deaths. Men more than women Age 35 to 56 > 64,000 in 2016 Heroin & Fentanyl rising More Americans than died in Vietnam Natural & Synthetic Opioids

States with highest opioid prescriptions Ten of the highest prescribing states for pain medications are in the South. Regional variation in use of prescriptions cannot be explained by the underlying health status of the population

OK s #1 Prescription is hydrocodone Following surgery or a procedure, the average consumption of opioid analgesics is 4 pills, yet 30 pills are normally prescribed.

Opioid-Related Deaths in Oklahoma 9 th leading cause of death in OK, equal to lung cancer Good, but Not Good Enough Opioids surpassed MVAs as the #1 accident related cause of death in young men. For every opiate death there are 15 hospitalizations, 26 ED visits, 115 people who abuse or are dependent, and 733 nonmedical users. This adds up to $4.35 million in healthcare related costs

What Can We Do? OK Prescription Drug Planning Workgroup Prescribing Guidelines Do No Harm Understand science-based guidelines Implement office processes that activate the guidelines Measure and track your effectiveness

Do No Harm Program Program of OU s Oklahoma Primary Healthcare Improvement Cooperative (OPHIC) and ODMHSAS Focus on primary care practices In-practice support to implement Pain and Opioid Guidelines Measurement & Feedback on current practice Academic Detailing The science behind guidelines Practice Facilitation Implementing roles & procedures Technical Advise Making EHR document, remind, and track Research to practice practice to research

What Can We Do & Why Use OPHIC? Cooperative Extension Service (aka County Extension Agents) Nationwide system of linking teaching, research and outreach to improve US agricultural processes since 1914 Educational arm of the U.S. Department of Agriculture Funded and guided by a national, state, & local government partnership Oklahoma Primary Healthcare Improvement Cooperative - OPHIC Statewide system established in 2014 designed to assist primary care practices with evidence-based quality improvement (QI) similar to the Cooperative Extension Service Based at OUHSC s Oklahoma Clinical & Translational Science Institute (OCTSI) Funded and guided by a national, state, & local government partnership

Disseminating and Implementing Patient Centered Outcome Research Fund cooperatives to provide quality improvement support to small and medium primary care practices within a defined geographic service area to: 1. Disseminate and implement Patient-Centered Outcomes Research (PCOR) clinical and organizational findings into primary care practice to improve healthcare quality, with an initial focus on cardiovascular care, and 2. Build primary care practices capacity to receive and incorporate other PCOR clinical and organizational finding in the future.

Aligned with the Million Hearts initiative Touching 8 million lives 5,000 primary care practices 7 Regional Collaboratives in 12 states 272 -> 227 Practices ABCS Measures OPHIC Model of Change Support

H2O Learning System Support Plan Select measure, timely goals for improvement Support implementation of data-based learning in practice Provide change (learning) resources Practice Dashboard Detail aids for ABCS guidelines Teamwork, QI skills, and tools provided by PEAs and PAs EHR maximization for data and workflow HIE connectivity for measuring and benchmarking

H2O Support @ 6/14/2018 Type of Support Contacts Academic Detailing 447 Administration 674 Close-Out Meeting 334 EHR Data Extraction 789 Enrollment 554 Practice Facilitation 5128 Recruitment 51 Survey/Research Data 267 Technology Support 524 Withdrawal Note 15 Grand Total 9035

H2O Outcomes @ 6/14/2018

What Have We Learned? Need specific, measurable, timely goals Learn by doing, take the time Culture of relationship, relationship, relationship Accountability matters Practices and clinicians change with feedback of their data Incorporate measurement and change into daily practice Certified EHR s are not meeting the goals of Meaningful Use Oklahoma s primary health system care is extremely fragile

How Can Do No Harm Help? Education (Dissemination) Neurobiology of pain Pharmacology of analgesics Evidence-based guidelines Implementation Best practices Office processes Team approach frees clinician to counsel Partners Pain and mental health specialists Addiction treatment resources Medical neighborhood Community services and resources

Implementing Pain and Opioid Management Guidelines in Primary Care Practice 20 practices 6-12 months in-practice facilitation Academic detailer Measure and track performance Connected to learning community Agree to complete surveys & report measures

New Opioid Message Doctors used to think that opioids were safe and effective when used over long periods of time to treat chronic pain. New information has taught us that long-term use of opioids can lead to multiple problems including loss of pain relieving effects, increased pain, unintentional death, addiction, and problem with sleep, mood, hormonal and immune function. We now know the best treatment for chronic pain is not opioids! The best treatments for chronic pain are non-drug treatments, such as psychological and rehabilitation therapies and non-opioid medications

Pain and Opioid Management Guidelines Do No H A R M Do comprehensive pain assessment, multi-modal pain management plan, treatment goals for improved function. No CNS depressing medications with opioids, no suicides, no overdoses recommend naloxone. Harm reduction by avoiding or by tapering opioids when ineffective, side effects, misuse, opioid use disorder, or behavioral health problems. Agree in writing on opioid risks and benefits, 1 prescriber, 1 pharmacy, refill policy, monitoring visits, side-effect screening, urine drug testing, & OK-PMP. Rx: lowest effective dose, immediate release, fewest pills for 3-7 days for acute pain, < 90 MMED per day for chronic non-cancer pain. Monitor progress toward goal and risk of misuse, OUD, or behavioral health problems; and refer for behavioral health treatment, pain management, or addiction treatment including medication assisted treatment.

Performance Measures Goal Better Pain Care Safer Opioid Prescribing Better Mental Health Care Measure Total Number of Patients Total Chronic Non-Cancer Pain Diagnosis Annual Pain Assessment Multi-Modal Plain Plan 3-Month Pain Monitoring Practice Pain Score Total long-term Opioid Treatment Number with High-dose Opioids Number with multiple prescribers Number with Benzo plus Opioid Risk-Mitigation Protocol Patient informed consent Substance use screening Depression screening Co-Management Addiction Co-Management Behavioral Health

Where are we now? 75 practices (approx. 200 clinicians) expressed interest Screened for active opioid prescribing Must have a certified EHR Evaluation of engagement with other opioid programs 20 practices have enrolled 9 practices have started the intervention

Questions and Comments Steven A. Crawford, MD Steven-crawford@ouhsc.edu F. Daniel Duffy, MD Daniel-duffy@ouhsc.edu