Transcript PAIN PROGRAM IN A PRIMARY CARE SETTING

Karel Schram, PAC
10/13/13
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Identify the complex issues associated with
pain management
Overview of recommendations for a pain
program
Identify strategies in reducing risk when
prescribing opiates
Review suggested documentation guidelines
Pain is the number one
complaint that brings a
patient to the doctor.
Due to the shortage of pain
management specialists the
primary care provider must
take a more active role in
treating pain.
There is one pain
specialist for every
23,000
patients in pain.
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Standard of Care for PCP to address pain
issues
Under-insured not accepted by pain clinics or
extraordinary wait to get in (6-12 mos.)
Pain clinics do not do on-going medication
management
Program guidelines to address risks and
follow standards of care
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Clinic Providers
Reluctance To Treat
Pain
-Time Consuming
-Unfamiliar with meds
-Afraid of Opiate sideeffects
-Substance Abuse
Issues
-Diversion Issues
-Reputation-not wanting
to be known as “easy”
for pain meds
-Fear of DEA Reprisals
-Differences in cultural
expressions
(over-reactions, etc.)
-Personal beliefs (“Pt’s
should be more stoic”)
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“Model Policy for Use of Controlled Substance for
Treatment of Pain”-The Federation of State Medical
Pain Management Boards
Endorsed by:
American Academy of Pain Medicine
Drug Enforcement Administration
American Pain Society
National Association of State Controlled Substances
Authorities
This policy includes guidelines for:
1)
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6)
Treatment Plan
Informed Consent & Agreement for Treatment
Periodic Review
Consultation
Documentation/Medical Records
Compliance with controlled substances laws
and regulations.
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“The Model Policy is designed to communicate
certain messages to licensees: that the state
medical board views pain management to be
important and integral to the practice of medicine;
that opioid analgesics may be necessary for the
relief of pain; that the use of opioids for other
then legitimate medical purposes pose a threat to
the individual and society; that the physicians
have a responsibility to minimize the potential for
the abuse and diversion of controlled substances;
and that physicians will not be sanctioned solely
for prescribing opioid analgesics for legitimate
medical purposes. In addition, this policy is not
meant to constrain or dictate medical decisionmaking.”
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“Accordingly, this Model Policy has been
revised to emphasize the professional and
ethical responsibility of the physician to
assess patients’ pain….”
“For purposes of this policy, the inappropriate
treatment of pain includes: non-treatment,
under-treatment, over-treatment, and the
continued use of ineffective treatment.”
“….the Board expects that Physicians
incorporate safe-guards into their practices to
minimize the potential for the abuse and
diversion of controlled substances.”
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“Allegations of inappropriate pain
management will be evaluated on an
individual basis….”
“The Physician’s conduct will be evaluated to
a great extent by the outcome of pain
treatment.”
“The management of pain in patients with a
history of substance abuse or with a comorbid psychiatric disorder may require extra
care, monitoring, documentation, and
consultation with, or referral to an expert in
the management of such patients.”
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Type of Pain
Treatment History
Co-Morbid Conditions
Resources
Med List
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P.T.
TENS
Counseling
Massage
Injections
Meds
Surgery
Acupuncture
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Non-Opioids
 Tylenol
 NSAIDS
 Cox-2 Inhibitors
 Muscle Relaxers
 Topical
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Tramadol
Hydrocodone
Codeine
Oxycodone
Oxymorphone
Hydromorphone
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Morphine
Methadone
Fentanyl
Oxycodone
Oxymorphone
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Anti-epileptic
Antidepressants
Muscle Relaxers
Benzodiazepines
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Used in many pain management programs
Quick tool for provider to assess risk level for
various pain patients
Help for easier tracking of patients
Cross coverage benefits
More integration of Pain Case manager
Provides minimum monitoring guidelines
Provider determined
Varied Risk Levels: Low, Medium, High, No
opioids
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Risk Level -Low:
Compliant without aberrancies an no history of
substance abuse or misuse
Low risk of drug misuse
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2.
 >Monitoring needs:
 Annual MAPS (Pharmacy Screening)/PHQ
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(Depression Screening)
Annual Urine Drug Screen
Random Medication Counts
Annual Medication Agreement
Visit with provider a minimum of every 6 months
Behavioral Health and Case Manager involvement as
needed
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Risk Level – Moderate
1.
2.
3.
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Compliant without any current aberrancies or active
problems
History of Substance Abuse but is in solid recovery
(no use for 12 months). Recovery must be evaluated
and confirmed by Behavioral Health.
Dose of Methadone > 60 mg or Morphine >120 mg
 Monitoring needs:
 MAPS every 6 months
 UDS every 6 months
Random med counts
Annual Medication Agreement/PHQ (Depression Screening)
Visit with provider every 3 months
Behavioral Health involvement as determined by Behavioral
Health recommendations
Case Manager visits as needed
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2.
3.
Risk Level – High:
Close Monitoring due to a history of
aberrancies and or at high risk for Substance
Abuse.
6 months of solid recovery confirmed by
Behavioral Health
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> Monitoring needs:
 Monthly visits with random med counts, as requested
by provider
 Urine Drug Screen and MAPS (Pharmacy Screening)
every 3-4 months
 Evaluation by a Certified Addiction Counselor ASAP and on
going visits as recommended by BH
Pain Case Manager visits regularly
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2.
3.
Risk Level- Unacceptable: All Opioids have
been discontinued
2 or more aberrancies or at discretion of
provider
Patient currently abusing or misusing
substances
Uncontrolled or sever psychiatric illness
To include:
 Medical History and Physical
 Diagnosis, therapeutic and laboratory results
 Evaluations and Consultations
 Treatment Objectives
 Discussion of risks and benefits
 Informed Consent
 Treatments
 Medications (including date, type, dosage and quality
prescribed)
 Instructions and agreements
 Periodic Reviews
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Analgesia: Pain at worst and pain at best on a
0-10 scale
Activities of daily Living:
Adverse effects:
Adjuvants:
Aberrant Behaviors:
Affect (psych): co-morbid mood disorders,
personality disorders and status of DX
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Psych Status/Mood
Counseling Status
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Medication and dosing
Efficacy
Pain scale; at its worst and at its best.
Non Pharmacologic Treatments
 P.T./ROM
 Massage
 Topicals (OTC, Compound)
 Chiropractic/OMT
 TENS
 Relaxations/Visualization Meditation
 Aromatherapy
 Acupuncture/Reflexology
 Non-opiate Meds
 Herbals
Limitations and Improvements in:
 Limitations
 Activities of Daily Living
 Function
 Quality of Life
 Sleep
 Interactions with others
 Sex
 Enjoyment in life
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Illicit Drug use, current or past history
Drug Screen Results
Lost Meds
Med Overuse/Early Refill Requests
Meds not prescribed
Violation of Med Agreements
Reluctance to try non-pharmacologic treatment options
Brand Request
Unusual “allergies” to meds
Obvious misuse i.e.: sharing, selling, trading.
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POSSIBLE SIDE EFFECTS/CONDITIONS THAT
MAY DEVELOP
REQUIREMENTS FOR THIS TREATMENT
(1). Agree to obtain these prescriptions from this
clinic only
(2). Use the same pharmacy
(3). NOT use illegal street drugs, agree to blood or
urine tests
(4). Agree to discuss your case with other health
care providers
(5). Lost, stolen, or damaged medications WILL
NOT be replaced
Marijuana Position Statement
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Hackley Community Care Center recognizes the many opinions
surrounding the use of marijuana, medical or otherwise.
We respect the choices individuals make in regards to their health
care. We work to help our patients achieve a healthy body, mind
and spirit. Therefore we do not condone the use of marijuana,
medical or otherwise, as it does not promote a healthy lifestyle nor
does it reflect the family values that we represent.
We will work with our patients to help them eliminate the use of
marijuana. We sincerely believe that each individual has the
ability to achieve a more joyful and prosperous life without the
use of marijuana. So please work with us as we assist you in
exploring and attaining a healthier and happier lifestyle.
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Acute Pain-Acute pain
is the normal,
predicted
physiological response
to a noxious chemical,
thermal or mechanical
stimulus and typically
is associated with
invasive procedures,
trauma and disease, it
is generally time –
limited.
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Addiction-Addiction is a
primary, chronic,
neurobiologic disease, with
genetic, psychosocial, and
environmental factors
influencing its development
and manifestations. It is
characterized by behaviors
that include the following:
impaired control over drug
use, craving, compulsive use
and continued use despite
harm. Physical dependence
and tolerance are normal
physiological consequences of
extended opioid therapy for
pain and are not the same as
addiction.
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Chronic Pain-Chronic
pain is a state in which
pain persists beyond the
usual course of an acute
disease or healing of an
injury or that may or
may not be associated
with an acute or chronic
pathologic process that
causes continuous or
intermittent pain over
months or years.
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Pain-An unpleasant
sensory and
emotional experience
associated with actual
or potential tissue
damage or described
in terms of such
damage.
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Physical Dependence-Physical dependence is a state
of adaptation manifested by drug class-specific signs
and symptoms that can be produced by abrupt
cessation, rapid dose reduction, decreasing blood
level of the drug, and/or administration of an
antagonist. Physical dependence, by itself, does not
equate addiction.
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Pseudo-addiction-The iatrogenic syndrome resulting
from the misinterpretation of relief seeking
behaviors as though they are drug-seeking behaviors
that are commonly seen with addiction. The relief
seeking behaviors resolve upon institution of
effective analgesic therapy.
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Tolerance-Tolerance is a physiologic state resulting
from regular use of a drug in which an increased
dosage is needed to produce a specific effect or a
reduced effect is observed with a constant dose over
time. Tolerance may or may not be evident during
opioid treatment and does not equate with addiction.
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Substance Abuse-Substance abuse is the use of any
substance(s) for non-therapeutic purposes or use of
medication for purposes other than those for which it
is prescribed.
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Control – loss of
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Craving – can also be present in dependence.
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Compulsive – unauthorized use, closing, frequency,
preoccupation with med.
Continued use – in spite of negative consequences
such as over dose, deterioration in functioning,
impairment of relationships, etc.
Per Penelope Ziegler, M.D.
(Board Certified Addiction Psychiatrist)
- The key factor between substance use and
substance abuse in pain management is
affect on level of function.
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Providers still vary in treatment styles and beliefs
Some reluctance by Providers to sign schedule II scripts
Providers-when to refer, when not
Providers vs. pain-who handles psych meds
Capture report-contacting patients who don’t follow up
Standard UDS-cost vs. necessity
Pain brochure and hand-outs
Urgent visit algorithms for pain patients
ER interface
EHR customization
Time-seeing patients vs. admin. (now 18-25 per day)
Risk management: ongoing surprise med counts, S.A.
referrals, etc.
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University of Michigan Pain Guidelines
Responsible Opioid Prescribing, A Guide for
Michigan Physicians by Scott M. Fishman, MD,
2009
Interagency Guideline on Opioid Dosing for
Chronic Non-cancer Pain: An educational aid to
improve care and safety with opioid therapy, 2010
Federation of State Medical Board Policy
Statement
American Academy of Pain Management
Discussion
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Thank you!