Opioids in chronic pain QI conference 11/16/2016

Quality improvement, next steps 42% of last years QI projects lead to change in practice Today, we’re going to build off of a case from last year OPIOIDS FOR CHRONIC PAIN UDM/PMP Autotext/provider checklist Clear expectations for patients Provider follow through Shared guidelines on PMP/UDM/contract

Goals To understand the basics of a PDSA cycle To create a PDSA cycle for dealing with opiate prescribing for chronic pain.

Road Map Presentation (10 min) PDSA group projects (25 min) Large group discussion (15 min)

WHY: WHO: :: previous guidelines unclear :: limited evidence on long-term use in chronic pain :: big pharma made it more confusing :: patient morbidity and mortality 1999-2010 narcotic pain prescriptions quadrupled 1999-2010 overdose deaths from the same also quadrupled :: provider frustration and concern WHO: :: primary care :: outpatient setting :: chronic pain patients >18 yo and no palliative = ½ all opiate scripts Cdc recommendations Target population

NOT SUFFIECIENT EVIDENCE FOR NARCOTICS IN CHRONIC LONG TERM PAIN What we do know: non-pharmacologic and non-opioids DO work for long term pain CBT/exercise/apap/NSAIDS/ anticonvulsants etc… opiods are risky: dose dependent risk for OD: compared to 1-19 MME/day :: 20-49 = 1.31 risk of OD death :: 50-99 = 1.92 :: 100-199 = 2.04 benzo+ opiates = more death bad in hepatic/renal dysfunction, elderly, pregnancy 3. We can determine those at risk and help avoid risk PMP/UDM/contracts/naloxone buprenorphine/methadone Cdc recommendations What we know

Cdc recommendations DETERMINING WHEN TO INTIATE/CONTINUE 1. non-pharm and non-opioids first 2. before opioids are started establish realistic treatment goals for pain and function, discuss d/c if risks >benefits, only continue if improvement in pain and function happens 3. before and during discuss known risks and realistic benefits, co- responsibilities OPIOID SELECTION/DOSAGE/DURATION/FOLLOW-UP 4. start with IR, not ER/LA 5. start with lowest effective dosage. If up to 50 MME re-evaluate, avoid up to 90 MME/justify/consider pain consult 6. long-term opioid use often begins with acute pain. For acute pain IR and 3-7 days only. 7. re-evaluate risks/harms 1-4 weeks of starting opioids, or if escalation. Evaluate Q3 months to optimize/taper/d.c ASSESSING RISK AND ADDRESSING HARMS 8. before starting and periodically evaluate for risk of o/d: hx of o/d, hx of substance use d/o, >50 MME/d, benzo use offer naloxone 9. Review PMP at initiation and every 3 months to every prescription. 10. UDM at least annually 11. avoid benzodiazepine and opiate prescriptions together “whenever possible” 12. offer/arrange MAT +CBT for those with opiate use disorder Cdc recommendations 12 RECOMMENDATIONS

CDC TOOLS FOR PROVIDERS

CDC TOOLS FOR PROVIDERS

STANDARDIZE OUR PROCESS For chronic pain patients

STANDARDIZE OUR PROCESS PLAN Visit template Nurse care plan Timing udm/pmp/contract/MME calc DO How will this be implemented? All clinics? All providers? When? STUDY How to confirm participation? Which outcomes to study? Are they improving? ACT When should we review? What should we do next if no improvement? STANDARDIZE OUR PROCESS For chronic pain patients

Goals To understand the basics of a PDSA cycle To create a PDSA cycle for dealing with opiate prescribing for chronic pain.