1. Erin Lund, MD, MPH Joe Matel, MD Karl Greer, MD Val Ebel, MD Ellie Wiener, MD

2.  No financial relationships to disclose

3.  Santa Rosa Family Medicine Residency  Sonoma County, CA  Santa Rosa Population ~170,000  12:12:12 + integrative med fellow  FQHC clinic site SRCHC  Sutter Hospital primary inpatient site

4.  Identify patients who exceed 90 MED in our practice and find ways to safely decrease patients to below 90 MED  Better support residents in identifying and treating chronic pain patients  Consider systemic change within our organizations regarding identification, education, and treatment of patients with chronic pain and addiction

5.  Opioids killed > 16,000 in 2013 (CDC)  The combination of benzos and opioids are particularly dangerous  Opioids are nearly 7% of all prescribed meds in the US (American Journal of Prev Med)  Primary care providers prescribe nearly 50% of the 289 million opioid prescriptions  Chronic pain is a major source of dissatisfaction in primary care  We need to teach residents/students a safer way to prescribe and better ways to treat pain

6.  1 in 4 residents of the county has opiate Rx  460,000 opiate Rx’s filled annually in the county  Non-fatal ER visits for opiates increased by 73% between 2009 and 2014  Non-fatal ER visits and hospitalizations for unintentional opiate overdose higher than CA average  44 opiate related deaths annually  Heroin abuse on the rise in the county especially among young people  Rising rates of neonatal abstinence syndrome (twice the state average)

7.  2016 CDC guidelines now recommend <90 morphine equivalent dose/day (MED)  Higher doses carry higher risk of unintentional overdose  Dose related risk for developing opiate use disorder  Risk of death from overdose 0.25% for patients on >100 MED/day  Calculate MED using one of many tools: http://agencymeddirectors.wa.gov/mobile.html “OpioidCalc” App in the Apple store (“Opioid converter” Android)

8.  Previous teaching was scant and disjointed  Many residents lacked confidence and got different advice from different preceptors  Residents often inherit patients on high doses of opiates and these usually get continued for years  Formal curriculum for Chronic Pain didn’t exist  A few disjointed lectures on  LBP  HA  Integrative Medicine approaches  The result was residents didn’t have a structured approach for managing chronic pain patients and lacked confidence

9.  Safer Prescribing of Opiates  Avoid new starts for chronic pain (lack of evidence of benefit)  Keep duration of treatment to under 90 days for acute pain  Taper patients currently on opiates to safer doses (<90 MED)  Identify Problem Use and offer treatment with buprenorphine (or referral for methadone)  Prevent overdose deaths with naloxone  Blame the drugs, not the patients

10.  Pre-Clinic Teaching Sessions (CLIPS)  Resident Lectures on Addiction and Chronic Pain  Faculty Development Session on Buprenorphine  Buprenorphine Training for residents and faculty  Clinic Opiate Oversight Committee review of resident patients  Rotating in pregnancy addiction clinic  Experiences at local treatment programs  Pain management experiences  CAM clinic exposure/IM approach for alternative therapies

11.  Managed Medicaid requirement  Organization created a coalition of providers interested in or having expertise in treating chronic pain  Focus on:  Patients > 120 MED  Resident patients  Aberrancy  Addiction  Complex pts (socially, psych, difficult to control)  Interesting cases

12.  Started residency-wide curriculum consisting of 30 min pre-clinic teaching sessions July 2015  Feb 2016 was chronic pain/addiction month  12 topics selected regarding pain, addiction, opioids, alternatives and limiting overdose  Pre and post survey to test residents’ knowledge and comfort in managing chronic pain, addiction and opiates  Positive feedback by residents/students and faculty leading sessions

13. Initiate opioid therapy for chronic pain only if the patient has tried and failed other therapies and the potential improvement of pain and function outweigh the risks. Prior to considering prescribing: Review med hx, pain hx, prior records, run PAR, obtain UDS Assess pain and function status: physical exam, validated questionnaires (PEG: Pain, Enjoyment, General activity and/or Graded Chronic Pain Scale) What prior non-opioid txs have been attempted? Localize and specify source of pain. Think: Is this an appropriate diagnosis for chronic opioid treatment? (Evidence doesn’t support use for non-specific back pain, headaches or fibromyalgia) Evaluate Risks: Opioid Risk Tool (ORT): Based on hx of substance abuse, sexual abuse, psych illness, age. Highly sensitive and specific for determining risk for opioid-related aberrant behaviors (91% of those who scored high risk demonstrated aberrant behavior vs. only 6% of low risk). Sleep Risk Assessment (STOP BANG: Snore, feel Tired, Observed apnea, high BP, BMI, Age, Neck circumference, Gender male): OSA increases risk of respiratory depression with opioids PHQ-2 or 9: Evaluate risk of misuse due to mental health issues Consider medication interactions. Benzos generally contraindicated. If potential benefits outweigh risks, at opioid initiation (rarely 1 st visit): Patient signs a pain tx agreement (have MA print): Agree on and document treatment goals; single prescriber; no early refills, determine exit strategy for taper/ when to stop Review risks (“Medical Risks of Long-term Opiate Use OPG download”) Start low, go slow! Start w/ short-acting only Safe Opioid Initiation (1) C.L.I.P.S. Updated 2/16 E. Wiener

14. Monitor improvement of pain and function. Treatment based only on the pain scale may lead to escalating dosages with worsening function and quality of life. Goals of long-term treatment: Determined by patient and provider at initial visit and regularly re- evaluated. Ask pt in their own terms, what is goal? (i.e. ability to play 1 round of pool, care for grandkids, walk around block etc.) Clinically Meaningful Improvement (CMI) = at least 30% improvement in pain AND function compared to initiation of treatment or latest dose change, based on PEG/ GCPS questionnaires. If CMI not met, re-evaluate therapy (escalate or decrease dose, switch or stop opioid due to failed tx) Monitoring: Frequency depends on pt and their risk. Generally q 1-3 months Compliance: UDS, pill counts, run PARs, assess for Opiate Use Disorder (using DSM5 criteria) Assess and document function and pain scales using validated tools Calculate morphine equivalent dose (MED) and record in chart. If above 80mg MED/day (that’s 8 Norco 10 or 6 Percocet 10), proceed w/ caution + explore other tx options. Do not escalate above 120 MED. MED >100mg/ day has a 9x  risk of death relative to pts on low-dose therapy. Consider rx for naloxone for all pts, especially high risk Think: Is patient connected with other resources? MH, chronic pain groups, CAM clinic, long-term tx (i.e. joint replacement, epidural) Recommendations from: OR Pain Guidance, OPMC, CA Med Board, AMDG 2015 Check out “Guidelines Flowchart” and many other resources at http://www.oregonpainguidance.com/tools-to-download/ Long-Term Monitoring (2) C.L.I.P.S. Updated 2/2016 E. Wiener

15.  Residents and Faculty were surveyed before and after the CLIPS month on chronic pain/addiction

19.  Expand Rotational Experiences in 2016-17 year  Expand didactic sessions throughout the year  Empower residents to use clinic EMR data to actively manage their chronic pain patients  Involve residents in the OOC review process as a learning experience  Faculty buprenorphine training scheduled for July 2016  Institutionalize policy for naloxone prescribing for all patients on chronic opiates

20.  What are you doing at your institutions to address the opiate epidemic?  How are you teaching residents to manage chronic pain?