Transcript Presentation - North Carolina Community Health Center Association

A Safer Approach to Chronic
Pain Management
Tom Wroth MD, MPH
Jerry McKee Pharm.D., M.S., BCPP
NCCHCA Annual Conference
Asheville, NC
June 23, 2012
Objectives
At the completion of this discussion, attendees will be able
to
• Understand the need for practices to approach chronic
pain management in a systematic way
• Understand the scope and clinical significance of chronic
pain management issues nationally and in North
Carolina
• Describe the CCNC chronic pain initiative and its goals
• Relate how specific practice level interventions can
successfully and appropriately address the needs of
chronic pain patients
Chronic Pain
• Chronic pain is defined as persistent pain,
which can be either continuous or recurrent and
of sufficient duration and intensity to adversely
affect a patient's well-being, level of function,
and quality of life.(Wisconsin Medical Society Task Force on Pain Mgt, 2004)
Why Should Health Centers
Focus on Chronic Pain?
• Common medical problem in the community
– ~10% of adults
– Leads to significant disability
• Increased prevalence in health center populations
(Medicaid, Medicare, Uninsured)
• Co-morbid chronic conditions: DM, CAD, HTN,
Depression
• Changing epidemiology of accidental overdose
Why Should Health Centers
Focus on Chronic Pain?
• Source of burnout and frustration for
providers and staff
• Source or RISK for practices
– Medical licensure and privileging
– Medico-legal risk: accidental overdose
• We are a Patient Centered Medical Home
– Team based care
– Collaborative care model
The Challenge: There is
not enough time…
With a typical panel of primary care patients• 10.6 hours per day for chronic disease
care
• 7.4 hours per day for preventive care
• 4.6 hours per day for acute care
Chronic pain management requires time and
teamwork
Challenges: Clinicians can
Foster Misuse
• Confrontation phobia
– Fear of damaging physician-patient
relationship
– Trouble saying “No”
– Not skilled in discussing addiction
• Enabling behaviors
– Physicians desire to relieve distress/pain
Chronic Pain and CoMorbidities
• Depression – Prevalence of 35-50%
• Anxiety – increased prevalence
– Associated with avoidant coping pattern
• Substance abuse – increased prevalence
• Sleep Disorders
– Lack of restorative sleep perpetuates chronic
pain and reduces function
• Personality disorders
• Hx of childhood abuse
Definitions





Misuse-use for purpose other than intended (get
high)
Abuse- harmful use of a drug (drinking and
driving)
Tolerance-body adapts to a certain dose such
that more is needed to achieve the same effect
Physical Dependance- withdrawal occurs when
substance is stopped
Addiction-behavioral term- denotes psychological
dependence, compulsive use, for reasons other
than therapeutic use
How Prevalent is Misuse?
Addiction
2-5%
Abuse 20%
Aberrant
behavior 40%
Total Pain
Population
US Prescription Overdoses
CDC Vital Statistics, Nov 2011
•15,000 deaths annually
•In 2010, 1 in 20 used
pain killers for
nonmedical purposes
•Enough prescription
painkillers were
prescribed in 2010 to
medicate every American
adult around-the-clock
for a month.
Drug overdose death rate --United States, 2008
Source: Len Paulozzi, CDC Nov. 2011
Unintentional Overdose Deaths Involving
Opioid Analgesics, Cocaine and Heroin
United States, 1999–2007
14,000
Opioid analgesic
12,000
Deaths
10,000
Cocaine
8,000
6,000
4,000
Heroin
2,000
0
'99
'00
'01
'02
'03
Year
National Vital Statistics System, http://wonder.cdc.gov, multiple cause dataset
Source: Len Paulozzi, CDC Nov. 2011
14
'04
'05
'06
'07
Unintentional drug overdose death rates and
total sales of opioid analgesics in morphine
equivalents by year in the U.S.
Deaths/100,000
Opioid sales (mg/person)
8
7
6
5
4
3
2
1
0
800
700
600
500
400
300
200
100
0
'90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07
Source: Len Paulozzi, CDC Nov. 2011
North Carolina Poisonings
Leading Causes of Injury Deaths
(by Number of Deaths, All Ages, North Carolina Residents: 2010)
Unintentional Motor Vehicle Crashes
1,301
Suicides
1,160
Unintentional Poisoning
947
Unintentional, Other & Unspecified*
855
Unintentional Falls
854
Homicides
183
147
536
Unintentional Suffocation
Unintentional Drowning
Total Deaths = 5,983
* Unintentional Other and Unintentional Unspecified are two separate categories. Other comprises several smaller defined causes of death, while
Unspecified refers to unintentional deaths that were not categorized due to coding challenges.
Source: NC State Center for Health Statistics, Death file 2010; Analysis by Injury Epidemiology and Surveillance Unit
Unintentional Poisoning Deaths by County: N.C.,
1999-2009
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2009
Analysis by Injury Epidemiology and Surveillance Unit
Data Source: ARCOS Data
Source: Farhad Modarai¹, Karin Mack¹, Leonard Paulozzi¹, Scott K. Proescholdbell²
Mortality Rates of Unintentional and Undetermined Opioid Overdoses and
Dispensation Rates of Opioid Analgesics*: North Carolina Residents, 2009
*Source:
Mortality data: State Center for Health Statistics, NC Division of Public Health, 2009
Population data: National Center for Health Statistics, 2009
Prescription dispensation data: Controlled Substances Reporting System, 2009
Analysis:
KJ Harmon, Injury Epidemiology and Surveillance Unit, Injury and Violence Prevention
Branch,, NC Division of Public Health
1400
1200
Number of Times in which a Drug was
Mentioned as a Cause of Death: N.C., 2010*
All Drugs 100%
1000
Other Synthetic
Opioids, 14%
800
Methodone,
16%
600
Other Drugs,
26%
400
Other Opioids,
36%
200
Heroin, 3%
Cocaine, 12%
0
Total
Illicit
*Categories are not
mutually exclusive
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 2010
Analysis by Injury Epidemiology and Surveillance Unit
Licit†
†Includes licit drugs that are
misused/abused
Combining CSRS and OCME data

By combining prescription records with toxicology data,
we were able to get an idea of how many cases had a
prescription for the drug(s) that contributed to their
death.
33
heroin
clonazepam
36
13
diazepam
49
19
morphine
Drug
contributed
Deaths
per drug to ___
deaths
hydrocodone
91
51
fentanyl
Cases who filled a
prescription for drug
within 60 days of death
78
25
95
37
121
cocaine
alprazolam
128
69
methadone
180
42
oxycodone
205
127
0
50
100
150
200
Number of cases
250
Chronic Pain Initiative
CCNC and Project Lazarus:
Chronic Pain and Community Initiative
What is the Chronic Pain Initiative?

A set of inter-related programs designed to improve the medical care
received by chronic pain patients, and in the process, to reduce the
misuse, abuse, potential for diversion and overdose from opioid
medication.
Key program components:
Clinical
Community Focus
Primary Care Physician Toolkit
Take only your own medications
Emergency Department Toolkit
Keep medications in a safe place
Care Management Toolkit
Education on dangers of opioids
Network CPI Champion
Model is based on proper assessment, diagnosis, and treatment plan with
Pain agreement as necessary
Community Care of North Carolina (CCNC), in
conjunction with non-profit organization Project
Lazarus, is responding to some of the highest drug
overdose death rates in the country through its
Chronic Pain Initiative (CPI).
Goals
 Reduce opioid-related overdoses
 Optimize treatment of chronic pain
 Manage substance abuse issues (opioids)
Project Lazarus/Chronic Pain Initiative
Model
Epidemiologic
Surveillance
Program
Evaluation
Community
Awareness
Overdose
Rescue
Overdose
Prevention
and
Diversion
Control
Project Lazarus. First Site – Wilkes
County. Accidental poisoning deaths decrease
by more than 65% after start-up
Source: Wilkes Co. Health Department; NC SCHS; CDC Wonder
Wilkes Recipients of Opioids*: As deaths go down,
patients continue to get their pain medication
Source: NC CSRS and Project Lazarus
Project Lazarus Expands: in 2012 joins
North Carolina’s Medicaid Authority (CCNC)
for statewide implementation
Project Lazarus – Strategies to
community coalitions
Chronic Pain Initiative – Strategies
to health care providers
Community awareness
Provider education
Coalition formation and development
ED policy change
Diversion control
Expanded access to drug treatment
Pain patient support
Patient risk reduction
Why are we looking at replication?

Evidence exists that the Wilkes County approach is changing conditions in ways
that will reduce misuse, abuse, diversion and overdose from prescription opioids.

Changes in how medical professionals manage chronic pain patients and monitor their prescription
use.


Change in policy and practice within ED of Wilkes Regional Medical Center

Increased access to Naloxone and understanding of when and how to use

Pill take-back days

Community awareness, coalition building for community education
Reduction in unintentional poisoning deaths, especially those stemming from
narcotics prescribed by providers based in Wilkes County
Cost of Hospitalizations for
Unintentional Poisonings: NC,
2008
 Average cost of inpatient hospitalizations
for an opioid poisoning*:
$16,970.
 Number of hospitalizations for unintentional
and undetermined intent poisonings**:
5,833
 Estimated costs in 2008:
$98,986,010
Does not include costs for hospitalized substance abuse
*Agency for Healthcare Research and Quality
** NC State Center for Health Statistics, data analyzed and prepared by K.
Harmon, Injury and Violence Prevention Branch, DPH, 01_19_2011
Prepared by Project Lazarus through an unrestricted educational grant from Purdue Pharma LP: NED101356
Key Ingredients in Chronic Pain Initiative


Establishment (or prior existence) of a community coalition that is able to develop
and implement effective strategies to reduce substance use

A sense of urgency among local actors who have influence

Dedicated manager of the coalition with skills in process and content
Appropriate strategy for achieving a change in prevailing medical practice re:
treatment of chronic pain patients (PCP and ED locations)

Tailored to local conditions

Includes education on the extent of the problem in the community and the role of
providers in limiting supply and opportunities for diversion

Includes useful tools that providers can adopt (e.g., Medication Agreements, guidelines
for proper script writing)

Explicit recommendations for hospital policies that limit dispensing of narcotics
(especially to ED patients)

Take advantage of leverage points in larger environment (e.g., CSRS, Medicaid lock-in
policy)

Key Ingredients in Chronic
Pain Initiative

Makes effective use of various partners in carrying out strategies
including but not limited to:
 Public health department – multiple strategies
 County Medical Director – to reach physicians and ED
 Medical providers – to change their own practice and educate other
providers
 Pharmacist – to other pharmacies in community
 Law enforcement
 Schools
 Behavioral Health, Prevention and Treatment Programs and
Organizations
Can coalitions help
reduce Rx drug abuse?
 Counties with coalitions had 6.2% lower rate of ED visits
for substance abuse than counties with no coalitions (but
this could be due to random chance)
 However, counties with a coalition where the health
department was the lead agency had a statistically
significant 23% lower rate of ED visits (X2=2.15, p=0.03)
than other counties
 In counties with coalitions 1.7% more residents received
opioids than in counties without a coalition.
 Coalitions may be useful in reducing the harms of Rx drug
abuse while improving access to pain medications at the
same time.
 More professional coalitions may have a greater impact on
reducing Rx drug harms.
Data Sources: NC Health Directors Survey, NC DETECT (2010), CSRS (2008-2010)
Contents of the Toolkit


General information

Managing chronic pain

Proper prescription writing

Precautions
Tools for managing chronic pain patients

Universal Precaution for Prescribing and Algorithm for assessing and managing pain

Pain Treatment Agreement

Format for progress notes

Medication flowsheet

Personal care plan

Prescriber and Patient education materials

Screening Forms and Brief Intervention

Naloxone Prescribing

Controlled Substance Reporting System (CSRS)
Primary Care Tool Kit
• Physician toolkit for treating chronic pain patients
• Encourage the use of Pain Treatment Agreements with chronic pain
patients
• Encourage use of Provider Portal
• Encourage use of Controlled Substance Reporting System (CSRS)
• Encourage the assignment of pharmacy home for chronic pain patientslock-in program
Emergency Department Tool Kit
• Care management for pain patients visiting ED
• ED policy that restricts the dispensing of narcotics
• Encourage the Use of the CSRS by ED physicians
• Encourage the Use of Provider Portal in the ED
• Identify Chronic Pain Patients and Refer for Care Coordination based
on ED assessment
Care Management Tool Kit

Provide support to ED identification of chronic pain patients- referrals to
PCP or specialty services

Provide care management for patients identified by PCP practice as CPI
patient; consider pharmacy lock-in program

Ongoing care management for Medicaid patients with narcotic prescriptions
above threshold pain patients via TREO data

Educate PCPs and providers in utilization of Chronic Pain Tool Kit
Emergency Department
Policy
 Non-narcotic pain medication for “frequent
fliers.”
 Prescriptions for narcotic or sedating
medications that have been lost, stolen or
expired will not be refilled in the Emergency
Department
 Referrals to Primary Care Providers Accepting
New Patients.
 Prescriptions necessary only in limited quantities
 North Carolina Controlled Substances Reporting
System, checked for any prescription for a
controlled substance
Contact
 Dr. Mike Lancaster
 [email protected]
 Fred Wells Brason II
 [email protected]
 www.communitycarenc.org
 www.projectlazarus.org
Controlled Substance Reporting
System (CSRS)
Controlled Substances Reporting System
NCGS 90-113.70-76
• Passed in August 2005
• Reporting began July 2007
• Required all dispensers to report to a
centralized data base
• Weekly reporting began 01/02/10
CSRS Data Overview
• Over 84,000,000 prescriptions in the
database (started July 1, 2007)
• Approx. 17.5 million per year
• Over 2,750,000 queries have been made
of the system
• Over 11,300 dispensers and practitioners
currently registered to use the system
• Averaging 2,300 queries per day
Top 10 Controlled Substances Dispensed in North Carolina:
Number of Prescriptions, CSRS 2010
4,302,868
HYDROCODONE
2,451,678
OXYCODONE
1,757,764
ALPRAZOLAM
1,604,778
ZOLPIDEM
1,097,151
BENZODIAZEPAM
847,974
LORAZEPAM
705,301
METHYLPHENIDATE
671,662
AMPHETAMINES
613,350
PROPOXYPHENE
571,192
DIAZEPAM
0
500,000
1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 5,000,000
Source: Preliminary data: NC Controlled Substances Reporting System, Nov. 2011
Doctor Shopping*: Trends for Schedule II
Patients with Multiple Prescribers and Dispensers
Source: NC CSRS
*Based on number of prescribers AND number of pharmacies within each 6 month period for schedule II.
How to contact the CSRS
• www.nccsrs.org
• Call Bill Bronson, John Womble, or Devon
Scott
919.733.1765
• E-mail
[email protected]
[email protected]
[email protected]
Step-by-Step Approach to
Improving Chronic Pain
Management
Principles of Chronic Disease
Management
• Use clinical information systems to Identify
the population
• Identify best practices and develop
practice guidelines
• Create team based approach with defined
roles
• Define measures that will reflect
performance improvement and report back
to team
• Develop tools to support self management
Step 1: Use Information
Systems to Identify the
Population
• Use EMR or practice management
software query to identify the number of
patients with chronic pain
– Chronic Pain Syndrome – 338.4, back pain,
headache, neck pain, fibromyalgia *ICSI Guideline
– Encourage providers to code 338.4 in addition
to specific diagnosis
– Look at # patients per provider or practice to
identify your hot spots
Identify the Population:
Chronic Pain on
Problem List
One Center has a high prevalence of opioid prescribing
Step 2: Identify Best Practices
• Start a workgroup with a clinical champion
• Identify practice guidelines
– North Carolina Medical Board
– Institute for Clinical Systems Improvement
– Specialty societies: AAFP
– Washington Medical Directors Group
The NC Medical Board
• Position statement 2008
• 2010: 30% of NCMB infractions were due to improper
prescribing
• Medical board advises:
– Clear documentation of history and physical, review
of records, documentation of prescriptions, response
to treatment, clear indication for treatment
– Use of practice safeguards (contracts, UDS, CSRS)
– Identifying high risk patients and referring as
necessary (pain management or substance abuse)
– Identifying “red flags”
Guidelines
• Institute for Clinical Systems Improvement
(ICSI)
– Healthcare Guideline: Assessment and
Management of Chronic Pain, 2011
• Washington State Medical Directors:
– Interagency Guidelines on Opioid Dosing for
Chronic Pain, 2010
• American Pain Society
– Guidelines for the Use of Opioid Therapy in
Patients with Chronic Pain, 2009
Step 2: Identify Best Practices
• Assessment:
– Functional assessment- SF-36
– Risk for Misuse
•
•
•
•
•
Opioid Risk Tool
DIRE, COMM, SOAP
Baseline Urine Drug Screen
NC Controlled Substance Reporting System
Department of Corrections Website
– Depression and Substance Abuse Screen
• PHQ9, CAGE
Decision Support
Risk Assessment, Depression Screen,
NC CSRS, UDS, Pain Contract
Step 2: Identify Best Practices
• Management
– Treatment agreement
– Safe opioid prescribing
• < 100 mg MED, Drug combinations
– Monitoring High Risk Patients
• Urine Drug Screen
• NC CSRS
– Guidelines for referral to
• Pain management
• Substance Abuse
• Mental Health
“Rational Prescribing Practices”
Framework for prescribing medications with
abuse potential
• Have a clear clinical indication
• Assess risk using validated tools
• Establish therapeutic agreement
• Monitor and assess regularly
• Document appropriately
• Be willing to intervene
Flinch JW, Prmary Care Clinics of N America, 1993
Step 3: Create a “Care
Pathway” that Uses a Team
Based Care Approach
• Provider
– Code Chronic Pain 338.4
– Excellent documentation of assessment and
management
– Management decisions
• Start, Continue, or Stop opioids
• Referral
• Safe opioid prescribing
– Identify high risk patients for monitoring
Step 3: Care Pathway
• Nursing:
– Obtain Urine Drug Screen at defined intervals
– PHQ9, Functional Assessment Tool
• Nursing/Care Management/Pharmacy
– Opioid Risk Tool
– NC CSRS report to provider (must be done by
pharmacist or provider)
– Department of Corrections report to provider
• Quality/Administration: Quality data
reporting and feedback
Use Tools to Identify Gaps in
Care
Decision Support:
‘What needs to be done’
Step 3: Define measures that will reflect
performance improvement and report back
to team
• How do you know if you are improving
care?
– % patients on opioids with risk assesment
(ORT or PHQ9)
– % patients on opioids with pain management
agreement
– % patients on opioids with Urine Drug Screen
in 12 months
Incorporate Pain Measures into
Quality Plan
% Patients with Contract
Step 4: Self Management
Support
• Use “Collaborative Care Model” to develop
written plan of care for patient
– Set personal goals related to function
– Improve sleep
– Increase physical activity
– Manage stress
– Decrease pain
» ICSI, Healthcare Guideline: Assessment and Management of Chronic
Pain, 2011
• Referral to community resources, cognitive
behavior therapy, physical therapy, support
groups
Step 5: Collaborate with
Community Partners
• “It takes a village to take care of a chronic
pain population’’
– CCNC Chronic Pain Initiative
• Use medical management committee to develop
common guidelines
• Use CCNC care managers as referral source
• Meet with ER Physicians
• Identify suboxone providers
• Project Lazarus: Naloxone rescue initiative
Step 6: Collaborate with Pain
Management Specialists
• Identify specialists in your area
• Share your guidelines for assessment,
management, and referral
• Develop consultation relationships where
information can be shared on high risk
patients
PHS Pain Management
Specialty Clinic
• 7 month experience with integrated pain
management specialist
– ½ day every 2 weeks
– Internal referrals of high risk patients with
specific management questions
– Goal of consultation
• Increase capacity of primary care provider to care
for chronic pain patients
• Develop management plan
• Identify patients that would benefit from
procedures or other referrals
PHS Pain Management
Specialty Clinic
• Preliminary Results:
– 46 patients with average of 2.9 visits
– Structured assessment and management
protocols with care management support
– Improved confidence and capacity in practice
– Improved utilization of pain contracts,
assessment tools
– Decreased risk associated with aberrant
patient behaviors
PHS Pain Management
Specialty Clinic
• Functional assessment
– Baseline SF-36 = 28.9
– Mean increase = 3.7
• Depression
– Mean PHQ9 = 12
– Mean change in PHQ 9 score = -5
• Risk assessment
– % with CSRS issue = 4.3%
– % with unexpected findings on UDS = 32.6%
Conclusions
 There is a public health need for
practices to improve management
of chronic pain
 Team based care and care
pathways can help providers
improve care
 Practices should collaborate with
community partners and
specialists to help manage the
population
Questions
?
76