Chronic Pain: How Can WE Stop the Suffering? Session # I1 Chronic Pain: How Can WE Stop the Suffering? Meghan Fondow, PhD Ashley Grosshans, LCSW Elizabeth Zeidler Schreiter, PsyD Chantelle Thomas, PhD Kevin Fehr, MD Please insert the assigned session number (track letter, period number), i.e., A2a Please insert the TITLE of your presentation. List EACH PRESENTER who will ATTEND the CFHA Conference to make this presentation. You may acknowledge other authors who are not attending the Conference in subsequent slides. CFHA 18th Annual Conference October 13-15, 2016  Charlotte, NC U.S.A. Collaborative Family Healthcare Association 12th Annual Conference

Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months. You must include ONE of the statements above for this session. CFHA requires that your presentation be FREE FROM COMMERCIAL BIAS. Educational materials that are a part of a continuing education activity such as slides, abstracts and handouts CANNOT contain any advertising or product‐group message. The content or format of a continuing education activity or its related materials must promote improvements or quality in health care and not a specific propriety business interest of a commercial interest. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational material or content includes trade names, where available trade names for products of multiple commercial entities should be used, not just trade names from a single commercial entity. Faculty must be responsible for the scientific integrity of their presentations. Any information regarding commercial products/services must be based on scientific (evidence‐based) methods generally accepted by the medical community. Collaborative Family Healthcare Association 12th Annual Conference

Learning Objectives At the conclusion of this session, the participant will be able to: Describe key steps in implementing a clinic wide shift in chronic pain management initiates Discuss consistency in EHR documentation, deriving opiate pain management registry, systematization of UDS, and opiate medication refill management protocol Explore how multi-disciplinary team meetings have been instrumental in shifting provider attitudes, treatment planning, and prescribing patterns while facilitating reciprocal cross discipline education through a collaborative, supportive work group Collaborative Family Healthcare Association 12th Annual Conference

Bibliography / Reference Sherman, Richard (2011), PAIN:  Assessment & Intervention From A Psychological Perspective, Second Edition Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA, 315(15), 1624-1645. Salvetti, M. D. G., Cobelo, A., Vernalha, P. D. M., Vianna, C. I. D. A., Canarezi, L. C. C. C. C., & Calegare, R. G. L. (2012). Effects of a psychoeducational program for chronic pain management. Revista latino-americana de enfermagem, 20(5), 896-902. http://www.iasp-pain.org/files/Content/NavigationMenu/EducationalResources/IASP_Wait_Times.pdf Jones, T., Lookatch, S., & Moore, T. (2013). Effects of a Single Session Group Intervention for Pain Management in Chronic Pain Patients: A Pilot Study. Pain and therapy, 2(1), 57-64. Continuing education approval now requires that each presentation include five references within the last 5 years. Please list at least FIVE (5) references for this presentation that are no older than 5 years. Without these references, your session may NOT be approved for CE credit. Collaborative Family Healthcare Association 12th Annual Conference

Chronic Pain Overview Pain is considered chronic when it is continuous or recurrent and lasts more than three months. Chronic pain has a negative impact on an individual’s quality of life, affecting sleep, diet, relationships, ability to work and functionality, among other aspects of daily life (Salvetti et al 2012)

Chronic Pain Overview Major public health problem US prevalence: 11.2% (Dowell et al 2016) Opioids have serious risks: from 1999 to 2014 more than 165,000 overdose deaths from pain medications PCPs report concerns about misuse, stress managing chronic pain populations, not enough training US prevalence of chronic pain is estimated at 11.2% of the adult population.  Opiates of commonly prescribed for pain, with approximately 3-4% of the adult US population prescribed long-term opioid therapy. Opioid pain medication use presents serious risks.  From 1999 to 2014, more than 165,000 persons died of overdose related to opioid pain medications in the US Primary care clinicians report concern about opioid pain medication misuse, find managing patients with chronic pain stressful, express concern about patient addiction, and report insufficient training in prescribing opioids.   (above is from the article CDC Guideline for Prescribing Opioids for Chronic Pain…) Chronic pain is a major public health problem Chronic pain affects approximately 100 million people in the US at an annual cost of over 500 billion dollars in direct medical costs and lost income. Chronic pain is a bio-psychosocial condition in which psychological factors play a critical role (above is from article on Effects of a Single Session…) Pain is considered chronic when it is continuous or recurrent and lasts more than three months. Chronic pain has a negative impact on an individual’s quality of life, affecting sleep, diet, relationships, ability to work and functionality, among other aspects of daily life (above is from article on Effects of a psychoeducational program for chronic pain management)

Access Community Health Centers Federally Qualified Health Center (FQHC) in which patients receive a wide array of services in one clinic location (medical, dental, behavioral health, pharmacy, community resources) More than 26,000 people call Access their health care home 3 primary care clinic locations in Madison, WI all certified as Patient Centered Medical Homes 1 in 5 patients met with BHC in 2015 Over 5800 BHC visits in 2015

Access and Chronic Pain Started in 2009 Consisted of BHC Champion and Medical Provider Champion Series of provider meetings exploring their needs surrounding chronic pain management (1 year) Identified systemic issues Identified issues with provider comfort Recognized need for cultural shift in what it means to “treat” chronic pain

What didn’t work Providers compelling BHC involvement Tasked with teaching “coping” to unwilling patients Narcotics contingent on meeting with BHC BHC handoffs How BHC introduced to patient for chronic pain “You think it is all in my head” How BHC involved in conversations regarding narcotics BHC as messenger that narcotics not prescribed

Provider Education Series of videos were created to: provide language for challenging discussions gave framework for appropriate referrals education regarding non-medication treatment options

What didn’t work: Provider Education Placed demands on providers outside of normal work schedule Facilitated an isolated learning experience Do not allow for collegial sharing of the burden

What did work Monthly chronic pain team peer review meetings Forum for discussing challenging patient presentations Open to all staff including nurses and support staff Team review of prescription regimen and brainstorming for treatment options Provided another forum for clarifying best practices surrounding various pain conditions Protected time to ensure that all aspects of patient care related to pain are being prioritized

What did work Strong leadership from CMO and BHC Increased systems change Consistent documentation Routine urine drug screens Ongoing discussions with providers on “compassionate no” Exposing shared struggle amongst providers (decreased shame/guilt) Monitoring patients at higher doses Increased exploration of alternate treatment methods and diagnostic testing

Other BHC Impacts Support and collaboration with PCP colleagues for debriefing before/after challenging patient interactions Support in developing language to communicate plan of care when including the “compassionate no” in regards to opioid prescribing Supporting providers in developing curiosity in patient understanding of their pain diagnosis, impacts on daily functioning, and safety concerns What happens outside of the patient exam room Collaborative Family Healthcare Association 12th Annual Conference

Chronic Pain Groups Pilot Summer 2016 Collaboration between medical provider and BHC Group medical visit Goal: non-medical options for managing chronic pain Topics include understanding pain, sleep, stress, nutrition, communication

Outcomes Consistency in documentation processes by providers > 85% patients with chronic pain dx > 66% patients on registry with standardized documentation Urine Drug Screens 65% in past 6 months (increase from 20% in 2014) Rates of narcotics prescribing similar, but doses declined Results based on chronic pain registry, >6 narcotics prescriptions in past 12 months, data from Q2 2016 Rates of prescribing similar, from around 315 patients to around 275 patients. However, number of patients on higher doses, >100 ME declines significantly, from over 12% to under 5%.

Future Directions Plans to expand services to include universal substance abuse and depression screening SBIRT Consideration of on-site fully integrated physical therapy

Questions?

Session Evaluation Please complete and return the evaluation form before leaving this session. Thank you! This should be the last slide of your presentation Collaborative Family Healthcare Association 12th Annual Conference