Transcript Title of Presentation - Collaborative Family Healthcare Association

Session #E2c
Friday, October 11, 2013
Innovative Approach of Managing High Risk
Chronic Opioid Users in a Residency Practice
Erin Inglis, MDa, Jessie Burch, PharmDb, Nida Awadallah, MDc, ,
Vanessa Rollins, PhDd, Myra Bodegahl, MSWe
aAssistant
Professor, Division of Family Medicine, University of Colorado School of Medicine
b Assistant Professor, University of Wyoming School of Pharmacy
c Assistant Professor, Division of Family Medicine, University of Colorado School of Medicine
d Assistant Professor, University of Colorado School of Medicine, The Colorado Health Foundation,
Doctorate of Psychology, Rose Family Medicine
e Masters of Social Work, The Colorado Health Foundation, Rose Family Medicine
Collaborative Family Healthcare Association 15th Annual Conference
October 10-12, 2013
Broomfield, Colorado U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Objectives
• Describe challenges to managing chronic opioid
therapy in primary care and residency education.
• Describe elements of multidisciplinary chronic pain
treatment.
• Describe development and implementation of our
committee.
• Describe typical interventions, preliminary outcome
data, challenges to implementation of committee
recommendations, and effect on physician
satisfaction and education.
Introduction
• Burden of chronic pain can not accurately be
estimated but it is a significant social and
economic problem
• Challenging to treat, especially in a residency
setting
• Providers and patients often dissatisfied with
treatment process
• Safety concerns with opioid abuse and
overdose
Chronic pain treatment in a
residency setting
What was the problem?
• Wide variation of training experience and
comfort level
• Lack of continuity of care
• Little to no access to pain management
specialists
• Patients with multiple co-morbidities
• Insurance limitations
Preliminary Intervention
• Developed a pain management policy to
include:
– Initial patient evaluation guidelines
– Chronic opioid treatment agreement
– Evaluation tool for patient’s risk of abuse
– Pain level assessment tool
– Intermittent urine drug testing
Initial Patient Evaluation
Opioid Risk Tool
Calculating Morphine Equivalents
• Morphine is the standard for equianalgesic
comparison
• Determine the total daily dose (TDD) of each
opioid the patient takes and convert to oral
morphine equivalents (ME)
• Example equianalgesic conversion
– Oxycodone 20 mg = 30 mg ME
– Percocet 10/325 mg PO q6h PRN and patient
takes 4 tabs daily
– TDD = oxycodone 40 mg = 60 mg ME
Patient Case
• Casey is a 45 yr old female that presents to your office with
a history of chronic pain looking to establish care with you
• PMH: hypertension and depression, fibromyalgia, low back
pain since a MVA 5 years ago
• Current medications: HCTZ, Vicodin, citalopram
• FMHx: EtOH and cocaine abuse by her father
• SH: 2-3 EtOH drinks most days of the week but denies
having an EtOH problem
Patient Case
• How would you assess her risk for opioid abuse?
• Which of the following risk categories would you place her
in with regards to opioid prescribing?
A) Low Risk
B) Medium Risk
C) High Risk
Patient Case
• Casey is a 45 yr old female that presents to your office with
a history of chronic pain looking to establish care with you
• PMH: hypertension and depression, fibromyalgia, low back
pain since a MVA 5 years ago
• Current medications: HCTZ, Vicodin, citalopram
• FMHx: EtOH and cocaine abuse by her father
• SH: drinks 2-3 EtOH drinks most days of the week but
denies having an EtOH problem
Patient Case
• How would you assess her risk for opioid abuse?
– Variety of validated risk tools
– Our practice uses the Opioid Risk Tool (ORT)
• Which of the following risk categories would you place her
in with regards to opioid prescribing?
A) Low Risk
B) Medium Risk
C) High Risk
Initial Outcomes
• Improvement but adherence to policy limited
by lack of continuity
• Continued frustration with the process
• Physicians found it difficult to make long-term
decisions because of lack of continuity
• Lack of time during busy clinic days to review
drug testing and PDMP data
Follow-Up Interventions
• Formed Pain Management Committee (PMC)
– Consists of residents, attending physicians, pharmacist,
social worker, and psychologist
– Generated a pain management registry
– Monthly meetings: review of 5-7 patient charts
followed by open discussion
• Patients are chosen for review based on provider request or
policy guidelines
– Review of clinic visit notes, drug screens, self
management goals, PDMP data, and aberrancies
– Generate recommendations for future management to
PCP or next visit provider
Follow-Up Interventions
• Created a‘Pain Management Toolbox’that is
easily accessible to entire practice
–
–
–
–
Pain management policy
Additional guidelines
Supporting documents
List of resources
• Increased resident/physician education on pain
management
Monitoring Guidelines
Urine Drug Testing
• Guidelines established for frequency of
monitoring in-house urine drug screens
• When urine drug screen not what was
expected then sample sent for confirmatory
testing
• Frequently the test ordered from the lab was
only another screen and not confirmatory
• Challenge identifying CPT codes for specific
confirmatory tests
Aberrant Behaviors
Patient Case Continued
• After careful assessment, the decision was made accept Casey as a
patient and prescribe her Vicodin
• She agrees to and signs the Chronic Opioid Treatment Agreement
• At 3rd monthly visit, her in-office urine drug test is negative for
hydrocodone despite stating she is taking the medication as prescribed
• You send out a confirmatory urine drug test, which is also negative for
hydrocodone
• When you discuss the results over the phone, she admits to increasing
her dose without discussing it with you and running out of her Vicodin
1 week early
• You review the agreement again and see her the following month
• At this visit, you review the PDMP and see that she has received other
prescriptions for Vicodin from 2 outside providers over the past month
Patient Case Continued
• What would you do?
A. Continue to prescribe her Vicodin regularly
B. Tell patient she has had at least 2 minor aberrancies,
refer to a pain management specialist and stop
prescribing Vicodin
C. Discuss the aberrancies and try to come to a resolution
with patient that you both agree on
Typical PMC Interventions
• No concerns:
– Continue current treatment plan
– Reassess in 12 months
• Moderate or high risk with no aberrancies:
– Consider tapering to a lower risk dose
– Adjuvant treatments
– Assess for psychosocial barriers and comorbid
disease states
– Consider referral to pain management specialist
– Reassess in 3-6 months
Typical PMC Interventions
• 2 minor or 1 major aberrancies:
– Dismissal from pain management program with or
without taper and referral to pain management
specialist
PMC Outcome Data
• Registry of 130 patients taking chronic opioids
• To date: 35 have been tapered off
• Continue to monitor other high risk patients
Resident/Physician Education
• Monthly meetings of the PMC
• Bimonthly PMC meetings with entire practice
• Chronic pain modules (AMA)
– https://cme.ama-assn.org/Education.aspx
• First year residents receive several PM talks
during their first few months of residency
• Methadone management talk in the second
year of residency
Physician Satisfaction
• Overall improved significantly
– More comfortable with managing chronic pain
than before the PMC existed
– Residents feel more comfortable managing
chronic pain after graduation
• Pressure taken off individual providers as
major decisions made by the PMC
• Safer prescribing given routine review by PMC
Future Direction
• Develop a policy for chronic pain patients with
concomitant use of benzodiazepines
• Review validated risk tools for patients with
active substance abuse receiving chronic
opioids
• Improve utilization of self-management goals
• Evaluate patient satisfaction
Conclusions
• Developing a chronic pain registry, pain
management committee, and toolbox can
help manage complex chronic pain patients in
a residency or large practice setting
– Improved patient safety
– Improved provider satisfaction
Questions?
Session Evaluation
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before leaving this session.
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