Transcript University of Colorado Chronic Pain

The 10 Principles of Chronic Pain
Management
Primary Care Operating Committee
Strategic Initiative Project, UCH/UPI/SOM
Peter C. Smith, MD
Assistant Dean for Clinical Affairs,
Assistant Medial Director, UPI
Managing chronic pain is hard
• Highly prevalent
• A diverse set of interrelated pathologies across the biopsycho-social spectrum
• Incomplete explanatory models
• Complex regulatory and documentation requirements
• Therapeutic options feel limited, some interventions
may exacerbate chronic pain
• Primary Care providers are under trained & resourced
• Patient experience of pain is real
– But so are addiction, diversion, disengagement
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 & 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
cufamilymedicine.org/chronicpain
Principle #1:
Good Primary Care Practice
• Do I have to?
– Yes
Principle #1:
Good Primary Care Practice
• Foundational Primary Care (5 C’s)
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–
–
–
–
Contact (first)
Comprehensive – bio-psycho-social
Coordinated – specialty, ancillary; avoid iatrogenesis
Collaborative – team based care
Continuous healing relationships
• Good clinical stewardship
– A good H&P, clinical curiosity, record review, meaningful
documentation
– Keep up to date on Dx, DDx and management of painful conditions
• “The good physician treats the disease; the great physician treats
the patient who has the disease.”
– Osler
Principle #2:View Pain as a
Centrally Mediated Sensory Experience
• “Pain
is all
in your
head!”
“Vision
is all
in your
head!”
– A centrally medicated sensory experience
•
•
•
•
•
Punctum caecum
Conversion blindness
“Seeing red”
Hallucination
Optical illusions
https://serendip.brynmawr.edu/bb/contrastcolor/
Principle #2:View Pain as a
Centrally Mediated Sensory Experience
• Like vision, all pain is a sensory experience
– Pain is the experience of sensory stimuli…
• …transmitted by the PNS and spinal chord…
• …interpreted by the CNS…
• …in the context of…
– other sensory input and
– the neuro-chemical consequences of past experience.
– Like vision, the brain creates “best guess” based on
complex input in face of encoded neural network shortcuts
– Like vision, this experiential system can be fooled/
damaged/malfunction:
• chronically maladaptive
• uncoupled from protective purpose
Principle #2:View Pain as a
Centrally Mediated Sensory Experience
• Common Pathway for chronic pain?
– “Neural Sensitization”, plasticity
– Increased potentiation, decreased inhibition, networked shortcuts
– Can exist with or without ongoing peripheral disease / damage
• Multiple hypotheses of mechanisms
– Gate Control theory; Neuro-behavioral feedback loops;
Evolutionary stress & avoidance; Imprecise encoding; conditioned
response, etc
– Neuro-Immunological (“Myalgic Encephalopathy”)
• Role of micro-glial cell-neuron interactions and inflammatory markers
– Dysregulation  pain activation  increased by opioid exposure
– Appear to play a role in opioid tolerance
– Epigenetic influence on neuro-immunologic processes
Principle #2:View Pain as a
Centrally Mediated Sensory Experience
• Predisposing Factors:
– The “neuro-behavioral-epigenetic substrate”
• Gender, Social gradient, SES & other SDH
• Trauma: Psychological, Emotional, Physical, Sexual,
Neglect, Cumulative effects of Adverse Childhood Events
(A.C.E., www.acestudy.org)
• The pain experienced from centrally mediated
neural sensitization is real
• Opioids may stimulate/enhance/trigger it in
those predisposed
Principle #3:
Cultivate Empathy & Therapeutic Relationships
• Hawthorn and Placebo effects
• Help patients develop…
– Insight
– Self efficacy/SMS knowledge and skills
– Functional and behavioral goals
• Address “heartsink” phenomenon
– Provider self care / “Doorknob Mindfulness”
– Be aware of transference & counter transference
• 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 (e.g. COAW)
• 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
•
“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.
•
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, Substance use disorders,
Addiction
– Trauma
• Consider other contextual/behavioral issues
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–
–
–
–
–
–
Mindset
Self care, Family/social supports
Stressors
Sleep
Activity
Employment
Etc.
Principle #5:
Patient and Condition Centric Management
• Diagnosis: DSM IV AXIS construct:
I.
II.
III.
IV.
V.
“X’
Primary Psychiatric, incl. substance use / addiction
Personality / developmental disorders
Medical, presenting etiology and relevant co-morbidities
Stressors
Function
“Axis X”: The Substrate…
•
•
•
•
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
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–
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–
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PT/OT, PM&R, OMT, Massage, Exercise prescription, heat/cold
Mindfulness/Meditation, Biofeedback, Hypnosis, sleep hygiene
Counseling, Support group, Care Mgt, Addiction referral, Group visits
Pain clinic referral, injections, acupuncture, TENS, ablation, etc
Other behavioral based approaches
• Pharmacologic
– Non-opioid Pain Mgt
• Analgesics, relaxants, antidepressants, triptans, antiepileptics
• Newer Rx/indications: clonidine, minocycline, oxybate, milnacipran, LDN
• 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, poor substrate
– 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
– Aberrant behavior is a symptom in need of a diagnosis
Principle #6: Risk Based Assessment and
Management of Patients on Opioids
• Assessment tools for aberrant behavior risks
– Psychiatric comorbidity:
• Depression: PHQ9
• Anxiety: GAD-7
• Substance use:
– DAST-10 (illicits)
– AUDIT-C (etoh)
• Other (Bipolar, schizophrenia, personality d/o, etc)
– Assessment tools 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
• CDC Guidelines (3/2016)
http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm?s_cid=rr6501e1er_w#B1_down
• DORA: Prescribing and Dispensing Opioids
• Develop & maintain competence:
– Careful H&P, Diagnose/Assess Risk, Pain, and Function: “4 A’s”
– CME /Zoom (cufamilymedicine.org/chronicpain) Password: DFMzoom!
• 1st Wednesdays from 5-6pm
• Multidisciplinary case conference
– Palliative Care, Pain,
– Addiction, Psychology,
– Pharmacy
• Didactic
Principle #7:Comply with State and Federal Law
and Medical Board Guidelines
• DORA: Prescribing and Dispensing Opioids
• Ensure dose, quantity, & refills improve function &
condition, at lowest effective dose and quantity
– If high dose (>120mg), formulation (patch, methadone) or
> 90 days
• Assess function and compliance w/opioid trial
• Monitor closely: pt agreement, function, PDMP, periodic UDS
• Educate all patients on:
– Risks (including addiction), benefits and alternatives
– Proper use, storage, disposal
– Diversion
Principle #7: Comply with State and Federal
Law and Medical Board Guidelines
• DORA: DISCONTINUING OPIOID THERAPY
– When:
•
•
•
•
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
• Dismissal = 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
• Standardized Assessments
– PHQ, GAD, DIRE, ORT, AUDIT, DAST, 4A’s flowsheets
• Includes “4 A’s” instrument
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–
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Analgesia
ADLs - function
Adverse effects –side effects and severity
Assessment – overall provider assessment
• Key assessment data flow directly into new note
templates for tracking. Working on synopsis view.
• ORADER
Principle #8:
Standardized Documentation in EPIC
• Common Patient Treatment Agreement:
– Letter “PC Opioid Medication Partnership
Agreement”, document in FYI tab
• 3 Epic note templates:
– Comprehensive visit, Follow up visit, A&P
• 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
• Support risk based management (frequency of f/u, etc)
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 to practice directors
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
•
CU Guidelines, Policies, Procedures
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•
Clinical Links
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•
Courses
Zoom Webinars & Didactics: DFMzoom!
EPIC
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•
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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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–
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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
cufamilymedicine.org/chronicpain