Transcript General Approach to Pain Management

University of Colorado Primary Care
Chronic Pain Guidelines
The 10 Principles of Chronic Pain
Management, Part 1
Managing chronic pain is hard
• Highly prevalent
• Incomplete explanatory models
• Patient experience of pain is real
– But so are addiction and diversion, often disengaged
• Primary Care providers are under trained & resourced
• Complex regulatory and documentation requirements
• Therapeutic options are limited, some interventions
may exacerbate pain
• A diverse set of interrelated pathologies across the biopsycho-social spectrum
10 Principles of Chronic Pain
Management at University of Colorado
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Good Primary Care Practice
View Chronic Pain as Centrally Mediated Sensory Experience
Cultivate Empathy and Therapeutic Relationships
Identify and Manage Psychological Co-Morbidity
Patient AND condition centric management
Risk-Based Assessment & Management of Patients on Opioids
Comply with State/Federal Law and Medical Board Guidelines
Standardized Documentation in EPIC
Data Driven Monitoring and Improvement
Team Based Care
Principle #1:
Good Primary Care Practice
• Foundational Primary Care (5 C’s)
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Contact (first)
Comprehensive - biopsychosocial
Coordinated – ancillary, avoid iatrogenesis
Collaborative – team based care
Continuous healing relationships
• Good clinical stewardship
• “The good physician treats the disease; the great
physician treats the patient who has the disease.”
– Osler
Principle #1:
Good Primary Care Practice
• Do I have to?
– Yes
• As primary care we specialize in our patients.
• Our sacred duty is to help our patients get healthier.
• Our employers, clinical partners (DFM/SOM/UPI/UCH),
and the primary care specialty organizations have
made it clear that we cannot “opt out” of this
responsibility.
• As with any chronic condition, complexity and risk may
indicate referral/consultation
• There are not enough specialists to do this work.
Patient-to-specialist ratio = 30,000:1
Principle #2:View Pain as a
Centrally Mediated Sensory Experience
• “Your pain vision is all in your head!”
– The Experience of Vision Analogy
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Blind spots
Optical Illusions
The Invisible Gorilla
Conversion blindness
“Seeing Red”
Hallucination
http://www.theinvisiblegorilla.com/videos.html
https://serendip.brynmawr.edu/bb/contrastcolor/
Principle #2:View Pain as a
Centrally Mediated Sensory Experience
• All pain is a sensory experience
– Pain is the experience of sensory stimuli…
• …interpreted by the central nervous system…
• …in the context of…
– other sensory input and
– the neuro-chemical consequences of past experience.
– CNS creates “best guess” based on complex input in
face of encoded neural network shortcuts
– If this experiential system is fooled/
imprecise/augmented/damaged/malfunctioning:
•  chronically maladaptive, uncoupled from protective
purpose
Principle #2:View Pain as a
Centrally Mediated Sensory Experience
• Common Pathway? “Central Sensitization”
– Hallmark of chronic unremitting pain syndromes
– Can exist with or without ongoing peripheral
disease/damage/derangement
• Multiple hypotheses of mechanisms
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Gate Control theory
Neuro-behavioral feedback loops
Evolutionary stress/avoidance
Imprecise encoding/conditioned response
Neuro-Immunological (“Myalgic Encephalopathy”?)
• Role of Glial cells
– Dysregulation  pain activation  increased by opioid exposure
– Appear to play a role in opioid tolerance
Principle #3:
Cultivate Empathy & Therapeutic Relationships
• The neuro-behavioral-epigenetic substrate
– Gender, Social gradient, other SES & SDH
– Trauma: Psychological, Emotional, Physical,
Sexual, Neglect, Adverse Childhood Events
(A.C.E.)
• All of these appear to predispose to the
central sensitization phenomenon
• The pain experienced from central
sensitization is real
Principle #3:
Cultivate Empathy & Therapeutic Relationships
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Hawthorn and Placebo effects
Develop self efficacy/SMS knowledge and skills
Develop insight
Goal setting –physical/social function, behaviors
Transference & counter transference
Address “heartsink” phenomenon
Provider self care / “Doorknob Mindfulness”
Specific practice-based interventions
Principle #3:
Cultivate Empathy & Therapeutic Relationships
• Therapy:
– Cognitive Behavioral, Dialectical Behavioral,
Acceptance & Commitment (CBT, DBT, ACT)
– Web, apps, groups
• Self Management Support
– SMS education/ groups
• Trauma Informed Care:
– Respect, permission, transparency, control, boundaries
• Positive psychology approaches
– Strengths Based Practice
– Reinforcement
– Positive B.A.T.H.E. technique
Principle #3:
Cultivate Empathy & Therapeutic Relationships
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“B.A.T.H.E.”
– Background: What is going on in your life?
– Affect: How does that make you feel?
– Trouble: What about it troubles you most?
– Handling: How are you handling that?
– Empathy: That must be very difficult.
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The Positive BATHE
– Best - What’s the best thing that’s happened to you this week/since I saw you?
– Affect or Account - How did that make you feel/How to you account for that?
– Thankfulness - For what are you most grateful?
– Happen - How can you make things like that happen more frequently?
– Empathy or Empowerment - That sounds fantastic. I believe you can do that.
Stuart MR, Lieberman JA. The Fifteen Minute Hour: Therapeutic Talk in Primary Care
Principle #4:
Identify & Manage Psychological Co-Morbidity
• Screen, diagnose, and treat:
– Depression, anxiety, bipolar, other
– Substance use disorders, Addiction
• Rx, Alcohol, Tobacco, Illicits, stimulants, hypnotics
– Trauma
• Consider other contextual/behavioral issues
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Mindset
Self care
Stressors
Family/social supports
Sleep
Activity
Employment
Etc.
Principle #5:
Patient and Condition Centric Management
• Diagnosis: DSM IV AXIS is a useful construct:
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I: Primary Psychiatric, incl. substance use / addiction
II: Personality / developmental disorders
III: Medical – presenting etiology and relevant co-morbidities
IV: Psycho-social stressors
V: Level of Function
“Axis X”: The Substrate…
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Trauma/ACE history
History of medical care experience
Coping mechanisms
Interaction of multi-axis co-morbidity…etc
• Improvement in physical & social functioning is primary
goal of therapy
Principle #5:
Patient and Condition Centric Management
• Non-Pharmacologic
• Pharmacologic
– Non-opioid Pain Mgt
• Analgesics, relaxants, antidepressants, triptans, antiepileptics
• Newer Rx/indications: clonidine, minocycline, oxybate, milnacipran, etc
• Website: University of Utah Guide, CU Pearls
– Opioids - Long and short acting
• Treat ALL Axes aggressively to maximize function and
minimize harm
Principle #6:
Risk Based Assessment and Management of Patients
on Opioids
• Initiation:
– Avoid if possible for chronic pain, esp. if at risk of aberrancy or adverse
events
– Don’t start something you aren’t prepared to monitor aggressively and
stop if ineffective
– Always consider initiation to be a BRIEF trial
• Minimize duration of therapy/dispensing for acute pain
• Risk Stratification: adverse events, aberrant behavior
– DSM IV Axis analogy
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Psychiatric & Medical co-morbidity
Psychosocial stressors, personality/developmental issues
Level of function
“Axis X” – the substrate
– Aberrant behavior is a symptom in need of a diagnosis
Principle #6: Risk Based Assessment and
Management of Patients on Opioids
• Assessments for Risk of aberrant drug-related behavior
– Psychiatric comorbidity:
• Depression: PHQ9
• Anxiety: GAD-7
• Substance use:
– DAST-10 (illicits)
– AUDIT-C (etoh)
• Other (Bipolar, schizophrenia, personality d/o, etc)
– Assessments for Poor substrate:
• Opioid Risk Tool (O.R.T.)
• Diagnosis/Intractability/Risk/Efficacy (D.I.R.E.) Score
• Adverse Childhood Events (A.C.E.) Score (with caution)
Principle #6: Risk Based Assessment and
Management of Patients on Opioids
• Risk of adverse events/overdose
– Morphine Dose Equivalent (M.D.E.) > 100mg/day
• GlobalRph, PDMP, coming soon to epic
– ORADER: Opioid Related Adverse Drug Event Risk
Geriatric (age > 65)
Significant Obesity (BMI > 35)
Significant Psychiatric Disorder
(e.g. depression, anxiety, panic, bipolar, schizophrenia)
Substance Abuse
(e.g. alcohol, illicit drug use)
Central Nervous System/Cognitive Disorder
(e.g. stroke, dysphagia, neuromuscular disease, dementia)
Respiratory Disorder
(e.g. sleep apnea, COPD/emphysema, asthma, cystic fibrosis, obesity hypoventilation
syndrome)
Sedating Medications
(e.g. benzodiazepines, hypnotics, sedating antihistamines, muscle relaxants, etc)
Principle #6:
Risk Based Assessment and Management of Patients
on Opioids
Low/Medium/High/Extreme
Principle #7:Comply with State and Federal Law
and Medical Board Guidelines
• DORA: Prescribing and Dispensing Opioids
• Develop & maintain competence:
– Careful H&P, Diagnose/Assess Risk, Pain, and Function: “4 A’s”
– cufamilymedicine.org/chronicpain for CME /Zoom
• Ensure dose, quantity, and refills are appropriate to improve
the function and condition, at lowest effective dose and
quantity
• Re-evaluate > 90 days: may not be as effective. If advanced dose
(>120mg), formulation (e.g. transdermal) or duration:
– Assess function and compliance w/opioid trial
– Monitor closely: pt agreement, function, PDMP, periodic UDS
• Educate all patients on:
– Risks and benefits, Proper use, addiction, alternatives, storage/disposal,
diversion
Principle #7: Comply with State and Federal
Law and Medical Board Guidelines
• DISCONTINUING OPIOID THERAPY
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Underlying painful condition is resolved;
Intolerable side effects emerge;
Poor response in pain or quality of life/function
Aberrancy
– Tapering:
• Employ a safe, structured regimen through the prescriber or an addiction
or pain specialist. There is a risk of patients turning to street drugs or
alcohol abuse if is not done with appropriate supports.
• NALOXONE
– “Colorado law strongly encourages prescribers…to educate on the use of an
opiate antagonist for overdose, including but not limited to risk factors and
recognition of overdose, calling emergency medical services, rescue breathing
and administration of an opiate antagonist.”
Principle #7: Comply with State and Federal
Law and Medical Board Guidelines
• Dismissal: Colorado Medical Board Guideline
– “It is the policy of the Colorado Medical Board (“Board”) that the proper discharge
of a patient from a provider’s practice includes the following elements:
• In writing, delivery confirmation
• Agree to provide 15-30 days of emergency coverage while obtains new PCP
• If possible, provider provides referral information to possible new providers.
• Notify that patient records will be sent to the new provider upon receipt of
written authorization “
• IN ADDITION!
– Must be non-discriminatory and not jeopardize their well-being, or you risk being
charged w/medical abandonment, civil rights violations, ADA, etc.
– Exceptions exist for threatening/criminal/violent behavior
– Typically = dismissal from entire system, “qualifying life event” for CU Anthem
• ANY DISMISSAL ACTIVITY MUST GO THROUGH RISK MGT
– (303) 724-7475 = “4-RISK”
Principle #8:
Standardized Documentation in EPIC
• Common Patient Treatment Agreement:
– Letter “PC Opioid Medication Partnership
Agreement”, document in FYI tab
• 2 Epic note templates:
– Comprehensive visit & Follow up visit
• Flexible to integrate with your workflow preferences
• Pick-n-click lists for easy compliance with DORA guidelines
• Support problem based charting for cross-system
communication
• Risk Categories provide guidance on:
– Frequency of each visit type
– Frequency of refills
– Frequency of assessments and testing
Principle #8:
Standardized Documentation in EPIC
• Standardized Assessments
– PHQ, GAD, DIRE, ORT, AUDIT, DAST in flowsheets
• Includes “4 A’s” instrument
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Analgesia –best, worst, current, average pain
ADLs - function
Adverse effects – common side effects and severity
Assessment – overall provider assessment
• Key assessment data flow directly into the note
templates for tracking
Principle #9:
Data Driven Monitoring and Improvement
Controlled Substances Registry
Primary Care Metro
10/31/2014-12/31/2015
• Registry:https://spsites.uchealth.org/bi/clinical/Dashboards/Forms/ByAudience.aspx
• Modified version:
Opioid?
Rx Class
(All)
(Multiple Items)
Count of ORDERING_DATE
Clinic
Lowry
ORDERING_DATE
Qtr1
Qtr2
5
4
5
36
4
3
2
11
2
8
13
7
3
14
8
10
181
18
60
314
65
30
45
Qtr3
Qtr4
Grand Total
– Distributed monthly
10
12
70
97
5
8
23
40
– Plan to add MDE, registry inclusion/exclusion, PDMP checked date, assessments
5
12
42
64
AF Williams
Lone Tree IM
Seniors
Anschutz
Lone Tree FM
Boulder
Westminster
Childrens
WISH
Grand Total
PCP
Patient1
ABRAHAM, ADAM T
ALBERTSON, GAIL A
COMBS, BRANDON P
CORBIN, LISA W
DE LA CRUZ, SCOTT B
KUTNER, JEAN S
LIN, CHEN-TAN
MAHIDHARA, NIVEDITA D
MATLOCK, DANIEL DAVID
MOLES, MATTHEW J
MURPHY, EDWARD N
OVERHOLSER, LINDA S
SCHILLING, LISA M
SCHORR-RATZLAFF, WAGNER J III
SWIGRIS, RACHEL E
TANAKA, DAVID J
PAT_MRN_ID MED_NAME
AUTHPROV
NEXTAPPT
LAST_URINE_TOX_LAB
Agreement signed? Agreement Print Date
45
893
45
10
7
8
11
6
14
8
10
3
11
8
9
265
25
78
460
78
38
67
68
18
8
15
27
3
21
13
16
4
37
11
18
358
25
119
629
117
77
90
49
1230
66
1772
91
41
21
32
86
22
61
41
36
16
98
25
74
1329
95
358
2006
314
161
184
1
119
5346
240
73
39
57
135
33
104
75
69
26
160
52
111
2133
163
615
3409
574
306
386
1
279
9241
Principle #10:
Team Based Care
• Pre-visit data collection
– What:
• PDMP delegation, UDS, Standardized Assessments/Screeners, Self management
support, risk stratification support, registry management
– Who:
• RN, MA, CM, SW, Pharmacist, PAR/CTA
– Where/When:
• At home, in waiting room, in exam room, bookended or other distinct nonphysician visits
– How:
• On paper, directly into EPIC, MHC?, Tablet pilot
• Psychosocial support
– Motivational interviewing, BATHE-ing, positive behavioral techniques,
trauma informed care, strength based practice, SMS group visits,
RN refill visits, integrated services
• Coaching:
– Elisabeth Benoit: [email protected]
One stop shopping:
cufamilymedicine.org/chronicpain
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CU Guidelines, Policies, Procedures
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Clinical Links
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Courses
Zoom Webinars & Didactics
EPIC
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Pharmacy, External guidelines, Pt Ed, Naloxone
CME
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Principles
Risk Calculator
Assessments
Patient Agreement
PDMP delegation instructions/links
Dismissal guidance
Team-based care workflows
Assessment/flowsheet use
Note Templates
UDS
Pt Agreement
MDE
Patient Agreement/FYI Tab
Multimedia
Patient and family support sections
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Self management support, tools, tips
Medication safety and safe disposal
Avoiding and Recognizing overdose, incl. BLS basics and Naloxone
10 Principles of Chronic Pain Management
at University of Colorado
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Good Primary Care Practice
View Chronic Pain as Centrally Mediated Sensory Experience
Cultivate Empathy and Therapeutic Relationships
Identify and Manage Psychological Co-Morbidity
Patient AND condition centric management
Risk Based Assessment and Management of Patients on
Opioids
Comply with State and Federal Law and Medical Board
Guidelines
Standardized Documentation in EPIC
Data Driven Monitoring and Improvement
Team Based Care