1. Taking the Pain Out of Chronic Pain Management: A Curricular Approach Geoffrey Jones, MD James Hall, PhD 44 th STFM Annual Spring Conference April 28, 2011

2. Objectives Recognize the difficulties residents face when treating those with chronic pain. Utilize available practice tools to effectively manage chronic pain patients. Appreciate the benefits of an interdisciplinary team effort in caring for chronic pain patients. Identify curricular approaches that can be effective in educating resident providers in therapy options for these patients.

3. Background Chronic Pain is epidemic in U.S. Lack of best practices Lack of education and training in primary care Historic concerns/biases with opioid prescribing Shortage of primary providers and specialists for those with chronic pain

5. Date Rate by Unintentional Poisoning, U.S.

6. Deaths by Drug Type, U.S.

7. Our Program Small, rural residency in western NC Based in county community hospital Family Health Center is NCQA Level III PCMH- recognized Mixed-model Behavioral Health Geographic center of opioid misuse in the state Widespread practice variability among providers Resident survey/NIPPD project

8. Resident Survey Borrowed tool from journal article Survey conducted before curriculum began and 3 years after start of implementation Small sample size, but useful for our purposes Upshur et al. Primary Care Provider Concerns about Management of Chronic Pain in Community Settings. J Gen Intern Med 2006; 652-655.

9. Resident Survey Knowledge and attitudes about patient-related problems in chronic pain Rx. Patient and practice issues with prescribing opioids. Behavioral co-morbidity perceptions Satisfaction with treatment of these patients Rating of education in medical school and residency.

12. Resident Survey-Patient Patient factor attitudes were essentially unchanged Residents believe that certain patient-related challenges (time, behavioral health, compliance, occupational) do limit their ability to achieve optimal pain control

13. Before

14. After

15. Resident Survey- Provider and Practice Systems Problems Significant shift in view of difficulty coordinating care, lack of evidence-based guidelines, time for dealing with issue, assessing pain levels Every measure in this category declined in terms of being viewed as a barrier

16. Resident Survey-Opioid Prescribing Addiction concerns remained the same Diversion fears INCREASED Side effects and safety concerns about the same

17. Resident Survey-Opioid Prescribing Still uncertain about appropriateness of prescribing Lack of systems, enforcement effects decreased Still viewed hassle and time as an issue Likeliness to prescribed remains the same

18. Resident Survey-Overall Average respondent satisfaction rating doubled after curriculum put in place (.67 vs. 1.3) No one was Very Satisfied in either survey. Medical School training insufficient by 70% of respondents Residency Training perception certainly has improved Success?

19. Before

20. After

21. Now What? Endeavored to create a practice/program curriculum Created an interdisciplinary team within the practice to coordinate and guide our efforts Focused initially on practice systems as it seemed most urgent Educational components were developed and implemented simultaneously Process is dynamic and flexible

22. Curriculum Objectives Appropriately define and evaluate chronic pain patients Demonstrate appropriate prescribing of controlled substances Demonstrate appropriate use of pain scale, pain agreements, functional assessments Describe how individual attitudes/biases affect care of those with chronic pain Rank as important and valuable an interdisciplinary care model in treating those with chronic pain

23. Creating the “Team” Brought together Behavioral Health, FP faculty and resident providers. Draws upon collective expertise and ability to integrate care Has met regularly for the past 3 years Tasked with creation of practice systems and educational program for providers and patients. Work has evolved with the program/practice needs

24. Team Members Medical Director/Program Director, practicing FP FNP with many long-term care facility and patients with chronic mental health issues PhD psychologist with interest/expertise in chronic pain PsyD psychologist Behavioral Health faculty member LCSW Behavioral Health faculty member Resident provider(s)

25. Practice Systems Improved documentation through EHR templates Creation of practice guidelines for prescribing Pain Agreement development and integration with EHR Incorporation of best practices available Provider enrollment in NC Controlled Substance Reporting System Development of patient information about chronic pain management in our practice

34. Controlled Substance Prescribing Defines Chronic Pain for our practice Outlines steps for new patients that must be followed: 1. Medical records 2. Urine drug screen 3. NC database query 4. Use of Chronic Pain Visit template and ORT 5. Pain Management Agreement completion Adherence to NC Medical Board Policy for Management of Chronic Non-malignant Pain

35. NC Medical Board Adopted from Federation of State Medical Boards Guidelines for treatment include Complete patient evaluation Establishment of a treatment plan (contract) Informed consent Periodic review and Consultation with specialists in various treatment modalities as appropriate

38. Educational Tools Didactics Topics: Opioids, Diversion, Functional Assessments, Stress/Emotional Aspects, Non- Pharmacologic Options Structured Patient Interviews Focused precepting and role modeling by faculty Case studies

39. Educational Tools Group Medical Visits Living with Chronic Pain Classes Presentations from community experts i.e. new pain management center Balint process

41. AAFP Pain Series Assessment and Management of Chronic Pain Managing the Chronic Pain Patient At Risk or With a History of Addiction Challenging Issues in Pain Management Pain Management in Special Populations Practical Aspects of Chronic Pain Management: Case Studies Chronic Pain and Depression Fibromyalgia: Challenges in Pain Managemnt

42. Resources Federation of State Medical Board’s “Model Policy for the Use of Controlled Substances for the Treatment of Pain.” Institute of Clinical Systems Improvement, Healthcare Guideline: Assessment and Management of Chronic Pain, 4 th Edition November 2009. AAFP Management of Chronic Pain Series NC Medicaid Controlled Substance Task Force

43. Where are we now? If you build it, they will come, or vice versa!! Much greater provider compliance with practice guidelines Transparency makes things easier Struggling with volume of patients seeking care Resident burnout with topic

44. Where are we now? Maintaining focus on our expertise as primary care providers, NOT pain management experts Self- examination is ongoing process Defined the edges, but not all the same It’s okay to say “No” This stuff is still hard!!

45. What’s Next? Urine drug screen utilization requires evolution Begin Living with Chronic Pain Classes Expand Group Medical Visit model Ongoing group review of tough cases

46. Questions/Comments?