Opioid Pain Contracts: A Resident Driven Quality Improvement Project A Response to the Opioid Epidemic Dr. Phillip Knouse Dr. Victoria Montgomery
Disclosure None
Objectives Discuss the current Opioid Epidemic Understand the value of pain contracts for the primary care physician Recognize available resources for opioid prescribing habits and managing substance abuse patients
The Opioid Epidemic Opioid-related deaths have more than quadrupled since 2000 More than 2 million people in the US are addicted to prescription opioids More than 12 million report having misused the prescription opioids in 2015 Prescription opioid addiction and misuse are contributing to a resurgence in heroin use and the spread of HIV and hepatitis C
National Center for health Statistics 2017
Drug Overdose Death Rate
Number and age-adjusted rates of drug overdose deaths by state, US 2016
The Roots of the Epidemic
Risk Factors for Prescription Opioid Abuse and Overdose
How is the Opioid Epidemic being targeted?
Illinois Prescription Monitoring Program
Controlled Substance Schedules Schedule I Not currently accepted for medical use, very high potential for abuse Ex: Heroin, LSD, Ecstasy Schedule II / II N High potential for abuse that can lead for severe psychological/physical dependence Ex: Next slide Schedule III / III N Less potential for abuse, moderate/low physical dependence Tylenol w/ codeine, buprenorphine (suboxone), Marinol, Ketamine, anabolic steriods Schedule IV Low potential for abuse relative to substances in Schedule III Xanax, Soma, Clonazepam (Klonopin), diazepam (Valium), Lorazpam (Ativan), zolpidem (Ambiem) Schedule V Low potential for abuse and consists mainly of limited quantities of certain narcotics Ex: Robitussin AC, Phenergan w/ Codeine, Cough syrup with codiene
Schedule II / II N (2/2N) High potential for abuse that can lead to severe dependence Schedule II narcotics Hydromorphone (Dilaudid) Methadone Merperidine (Demerol) Oxycodone (Oxycontin/Percocet) Schedule II N stimulants Amphetamine (Dexedrine/Adderall) Methamphetamine (Desoxyn) Methylphenidate (Ritalin) Lisdexamfetamine (Vyvanse) Fentanyl (Sublimaze/Duragesic) Morphine Opium Codeine Hydrocodone Hydrocodone/acetaminophen Tapentadol (nucynta) OxyMorphone (Opana)
Rx Schedule II: not for more than 30 day supply Valid for 90 days after date of issuance No refills Schedule III-V: Up to 5 refills Filled or refilled more than 6 months after day of issuance
Aetna s Super Prescriber Program
OptumRx s Opioid Risk Management Program
Association of American Medical Colleges
Lutheran General Hospital Internal Medicine Residency Opioid Task Force Team: Dr. Jill Patton Dr. John Berry Dr. Gaursh Soni Dr. Ahmed Khattab Dr. Philip Knouse Dr. Victoria Montogmery
Our Project AIM: To increase the use of pain contracts at Nesset Out Patient Internal Medicine by 20% over 6 months in an attempt to In an attempt to: Decrease the volume of opioids prescribed Decrease the length of time patients use opioids Increase adherence to a single provider Reduce risk for opioid addiction and abuse
Our Project Nesset Outpatient center has 2918 (26%) of the patients on schedule 2 narcotics Patients that had been on opioids over a 6 week period were asked to sign a pain contract The project launched on March 1, 2018 and the use of pain contracts will be reassessed on September, 1 2018 (6 months)
Training Provided an 1 hour educational lecture to residents Opioid Epidemic Opioid contracts How to use them, when to use them, how to find them Displayed a 15 minute demonstration video How to approach patients about their drug use How to discuss with patient about pain contracts Provided education to outpatient supportive staff about the project and monitoring Sent multiple reminder emails about the project
Results Increased from 0 contracts to 5 contracts
Barriers Time Issue with time to discuss pain contracts Lack of patient follow up if asked to come back to discuss a pain contract Difficulty of EMR to find location of prior Opioid Contracts Residents did not feel comfort discussing opioid contracts Lack of patient participation Stigma against pain contracts
Outcomes Physicians are not comfortable with the idea of addressing pain contract Agreement protects patient s access to medication and protects the clinician s license to prescribe them Solution: More training for physicians Will extend the study to December 1 st 2018
Pain Contracts
What is a Pain Contract? A documentation of understanding between a doctor and patient. Entails: What medications the agreement includes What risks/benefits of medication Procedures of emergency care Non-adherence
Overview of a Pain Contract 1 provider is giving narcotics Take as prescribed Taking responsibility for refills No additional refills No early refill requests 1 pharmacy Scheduled appointments will be kept No other illicit drugs use Drug screens Terminations clause
Patient s rights Have pain prevented or controlled adequately. Have pain and medication history taken. Have pain questions answered. Know what medication, treatment or anesthesia will be given. Know the risks, benefits, and side effects of treatment. Ask for changes in treatments if pain persists. Receive compassionate and sympathetic care.
Example of Pain Contract
Discussing the Agreement Plan
Before Discussing the Agreement Build the relationship and establish rapport Assess the 6 A s of Opioid Therapy Monitoring 1. Activity 2. Analgesia 3. Affect 4. Adjuncts 5. Adverse effects 6. Aberrant behavior to their drug use
General Guidelines for a Successful Agreement Plan Neutral non-confrontational language A comprehensive pain management plan Emphasize the clinician s responsibility and the agreement protects the patient s access to scheduled medications and protects the clinician s license to prescribe them Describe actions the clinician may take
https://www.youtube.com/watch?v=so7rgnumqqq&feature=youtu.be
CME credit available