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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 Co-Morbidities
• 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?
Total Pain Population
Aberrant behavior 40%Abuse 20%
Addiction 2-5%
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
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
'99 '00 '01 '02 '03 '04 '05 '06 '07
De
ath
s
14
Unintentional Overdose Deaths Involving Opioid Analgesics, Cocaine and Heroin
United States, 1999–2007Opioid analgesic
Cocaine
Heroin
National Vital Statistics System, http://wonder.cdc.gov, multiple cause dataset
Year
Source: Len Paulozzi, CDC Nov. 2011
Unintentional drug overdose death rates and total sales of opioid analgesics in morphine
equivalents by year in the U.S.
012345678
'90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07
0100200300400500600700800
Deaths/100,000 Opioid sales (mg/person)
Source: Len Paulozzi, CDC Nov. 2011
North Carolina Poisonings
Source: NC State Center for Health Statistics, Death file 2010; Analysis by Injury Epidemiology and Surveillance Unit
147
183
536
854
855
947
1,160
1,301
Leading Causes of Injury Deaths (by Number of Deaths, All Ages, North Carolina Residents: 2010)
Unintentional Motor Vehicle Crashes
Suicides
Unintentional Poisoning
Unintentional Falls
Homicides
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.
Unintentional, Other & Unspecified*
Unintentional Poisoning Deaths by County: N.C., 1999-2009
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2009Analysis by Injury Epidemiology and Surveillance Unit
Source: Farhad Modarai¹, Karin Mack¹, Leonard Paulozzi¹, Scott K. Proescholdbell²
Data Source: ARCOS Data
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, 2009Population data: National Center for Health Statistics, 2009Prescription 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
Number of Times in which a Drug was Mentioned as a Cause of Death: N.C., 2010*
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 2010Analysis by Injury Epidemiology and Surveillance Unit
*Categories are not mutually exclusive
†Includes licit drugs that are misused/abused
0
200
400
600
800
1000
1200
1400
Total Illicit Licit†
All Drugs 100%
Cocaine, 12%
Heroin, 3%
Other Synthetic Opioids, 14%
Methodone, 16%
Other Drugs, 26%
Other Opioids, 36%
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.
Combining CSRS and OCME data
Number of cases
Deaths per drug
Chronic Pain Initiative
CCNC and Project Lazarus:
Chronic Pain and Community 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
What is the Chronic Pain Initiative?
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
Community Awareness
Epidemiologic Surveillance
Overdose Prevention
and Diversion Control
Program Evaluation
Overdose Rescue
Source: Wilkes Co. Health Department; NC SCHS; CDC Wonder
Project Lazarus. First Site – Wilkes County. Accidental poisoning deaths decrease
by more than 65% after start-up
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?
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_2011Prepared 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 patients-
lock-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 DepartmentPolicy
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
Source: Preliminary data: NC Controlled Substances Reporting System, Nov. 2011
571,192
613,350
671,662
705,301
847,974
1,097,151
1,604,778
1,757,764
2,451,678
4,302,868
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
DIAZEPAM
PROPOXYPHENE
AMPHETAMINES
METHYLPHENIDATE
LORAZEPAM
BENZODIAZEPAM
ZOLPIDEM
ALPRAZOLAM
OXYCODONE
HYDROCODONE
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
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 interveneFlinch 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
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
76
Questions?