Appropriate Opiate Prescribing: Managing Chronic Pain in a FQHC Connie Valdez, PharmD, MSEd, BCPS Mary Kay Meintzer, LPC, LAC

Take Home Points 1) Develop a structured chronic pain management program 2) Interdisciplinary team improves safety and provider satisfaction 3)You are never obligated to prescribe a controlled substance

Sheridan Health Services Nurse-managed Federally Qualified Community Health Center Partnership with University of Colorado College of Nursing Interprofessional, integrated care model Providers – APN, PA, MD, DDS Nursing – case management, public health Pharmacy – Clinical PharmD and pharmacy student interns Behavioral Health – LCSW, MSW, LPC, and addiction counselor credentials Support staff Patient population: Provide care for uninsured, Medicaid, Medicare and ARTS patients

SHS’s Chronic Pain Management Model Includes providers, behavior health clinicians, clinical pharmacist, nurse, medical assistant and pharmacy students We worked collaboratively to develop the following: standard operation procedure curriculum for collaborative medical visits methods to ensure patient safety patient/provider expectations forms to use during pain visits standards to consistently document chronic pain visits interprofessional team to address patient concerns

VA/DoD clinical practice guideline for management of opioid therapy for chronic pain Evaluation: Comprehensive history and physical examination General medical history (age, gender, history of present illness, past medical and surgical history, medications, allergies, family and social history, etc.) Additional focused assessments (past psychiatric history, medications, substance use history, mental status examination, review of diagnostic studies, evaluation of occupational risks) Adequate trial of non-opioid therapy Urine drug test Assessment for suicide risk Assessment of pain using numerical rating scale 0-10 Assessment of contraindications to opioid therapy

SHS’s Chronic Pain Management Parameters for safe prescribing: No narcotics on the first visit Morphine equivalents calculated and documented at every visit No more than 120 morphine equivalents prescribed No opioid use for conditions not supported by literature, i.e. fibromyalgia Urine toxicology performed at baseline and then randomly (minimally 2 times per year) Prescription Drug Monitoring Program (PDMP) review performed and documented at every visit Naloxone prescription and education provided for patient and family No prescriptions for benzodiazapines in conjunction with opioids Sleep apnea assessment for patients using opioids Controlled substance agreement signed annually Monthly visits required

SHS’s Chronic Pain Management Methods to ensure patient safety: Use EHRs and PDMPs to Enhance Clinical Care & Data-Driven Decisions Chronic pain work-up Perform PDMP to identify all controlled substances and doses to evaluate possible misuse, abuse or breach of CS agreement identify when next opioid prescription is due Review EHR reconciliation of opioid dose and fill date from PDMP with EHR calculate morphine equivalents/day assess if annual pain agreement is current or needed identify date of last urine toxicology screen determine if patient has received a prescription for naloxone

SHS’s Chronic Pain Management Methods to ensure patient safety: Select appropriate medications for the patient based on patient specific factors and formulary considerations Pharmacy assessment Medication therapy review to assess treatment options and safety Long acting vs short acting opioids Opioid conversions Bowel regimen Formulary considerations Non-opioid pain treatments

SHS’s Chronic Pain Management Methods to ensure patient safety: Identify higher risk patient populations Provider assessment Pregnancy Adolescence Restrictive lung disease, sleep apnea Persistent mental illness (more than moderate depression, anxiety) Need for high dose opiates Current or history of substance abuse

SHS’s Chronic Pain Management Methods to ensure patient safety: Selecting appropriate management for the patient Provider assessment cont. Substantiate the diagnosis (from patient records, imaging, etc.) Reinforce or recommend pain treatment with non-opioid modalities (including topical drug therapy treatments) Provide referrals to physical therapy, behavioral health, acupuncturist, healing touch, etc. Provide patient education Identify red flags

SHS’s Chronic Pain Management Shared Medical Visits (SMV) Program: Based on CareOregon curriculum, modified to include expertise of guest speakers (addictions counselor, PT, healing touch RN) All chronic pain patients must complete the interprofessional SMV group visit “course” for a series of 6 sessions Patients enrolled in the 6 session SMV program are integrated into the team, they established guidelines for the group (i.e. how many classes can be missed, how late someone can arrive, etc.) Each SMV is billed as a medical visit (provider evaluates the patient at each visit and provides a two week prescription at the end of the visit) The SMV group meets every 2 weeks until the 6 session “course” is completed and then the patient transitions to maintenance phase with monthly interprofessional medical visits

SHS’s Chronic Pain Management Curriculum for the 6 Session Shared Medical Appointment Program Introduction, Chronic Pain & Combination Therapy Turning Down the Intensity of the Pain Message (Physical Therapy) Being an Effective Partner in your Care (PCP) Use of Medications and Dependence (Addictions Specialist) Identifying and Eliminating Triggers (Alternative Medicine) Restoring/Increasing the Body’s Ability to Block Pain Messages Developing a Personal Plan (Individual sessions)

SHS’s Chronic Pain Management Curriculum for the 6 Session Shared Medical Appointment Program Baseline patient questionnaire Weekly homework assignments for patients Tips on managing chronic pain Pain logs Stretching and mindfulness breaks every 15-20 minutes Condensed into 90 minutes, 30 minutes for individuals one-on-one visits with provider

Outcomes: collaborative visits 87.5% self report increase in knowledge regarding dangers of opioid pain medication (subjective measure). POEM is an objective measure: increase across several domains when compare pre/post test. 100% of patients had documented review of the PDMP 100% of patients signed a controlled substance agreement 100% of patients had documented urine toxicity screen.

Take Home Points 1) Develop a structured chronic pain management program 2) Interdisciplinary team improves safety and provider satisfaction 3)You are never obligated to prescribe controlled substance