Primary Care Models for Chronic Pain Treatment Melissa Weimer, DO, MCR

Disclosures Dr. Weimer is a consultant for INFORMed, IMPACT education, and the American Association of Addiction Psychiatry. Dr. Weimer is the medical director of CODA, Inc.

Examples of Integrated Programs Boston Medical Center TOPCARE (Transforming Opioid Prescribing in Primary Care) – Clinical decision support tool ( – Nurse care management – Electronic registry Oregon Health & Science University PROPEL clinic – Pain/Addiction trained internist who sees patients in consultation – SW and MA with additional addiction and pain training – Resident teaching

Examples of Integrated Programs Central City Concern, Portland, OR – Add RACHEL info here VA Connecticut Health Care System Opioid Reassessment Clinic – Pain and addiction trained internist – Advanced practice nurse – Psychiatry – Clinical health psychologist

Key Elements Team approach with pain champion(s) Shared clinic policies and assessment tools – Consensus for a pain “standard of care” – Focus on functional gains – Address opioid safety and efficacy Defined referral process Emphasis on a Multimodal treatment approach Address substance use disorders and have referral options Longer visits After visit care with Case or Care managers

Other ideas E-consults Web-based programs/pain treatments Project ECHO Telemedicine

Case 43 yo female with long history of migraine headaches, high health care utilization, depression, anxiety, sexual abuse as a child, and domestic violence as an adult. Sought outpatient treatment for opioid use disorder 6 months ago but never stopped using acetaminophen/hydrocodone. Currently maintained on daily acetaminophen/hydrocodone and nortriptyline. Continues to have daily, debilitating migraines. Spends most of her day in bed. States that she is unable to stop or cut back on opioids despite trying a few times. Increased depression, mental instability when she stops opioids. Frequently obtains opioids from friends. Her husband is concerned about her use. Oregon Prescription Drug monitoring program (PDMP) shows 3 dental prescribers, 3 physician prescribers, and >4 pharmacies.