1. IMPLEMENTATION OF A PAIN ADVISORY BOARD IN A RESIDENCY CLINIC Brittany McIntyre MD, Maria Thekkekandam MD MPH, Jeffrey Walden MD Cone Health Family Medicine Residency  Greensboro, North Carolina Our providers generally find prescribing chronic opioids dissatisfying, and feel that medical school poorly prepares us for this task. Our clinic has a low rate of having chronic narcotic-receiving patients sign controlled substances contracts (35%), and of ensuring compliance via urine drug screens (14%). There are inequalities in our selection of patients for contracts and drug screens, especially in the areas of patient gender, payer source, and age. Men are much more likely to have a contract signed (48.6% of men vs. 28.2% of women). Medicaid patients have higher rates of drug screens (35.3%) and contracts (52.9%) than patients with other payer sources (16.9% aggregate UDS, and 26.5% aggregate contracts). Rates of both contracts and drug screens decline with increasing patient age. Senior residents (PGY-2 and PGY-3) are more likely than faculty physicians to have patients with signed contracts and documented urine drug screens. Aggregate drug screen rate in patients of senior residents is 25%, compared to 14% in faculty patients. Likewise, aggregate contract rate among patients of senior residents is 46.2%, compared to 22.5% of faculty patients. Our project is a work in progress, with remaining tasks to include: Holding monthly PAB meetings to create a clinic opioid prescribing policy. Updating our controlled substances contract. Presenting at residency conferences to introduce the new policy. Re-evaluating provider satisfaction and number of patients with UDS and controlled substances contract on file after implementation of the above tasks. Comparing our policy with that of local pain management clinics to identify areas of improvement. The PAB also plans to review patient records on provider request. It would be interesting to survey other local residency programs regarding their opioid- prescribing policies and attitudes. Because having a Pain Advisory Board is not a widespread idea, we would like to share this resident-driven initiative with other residency programs. METHODS Provider Surveys Surveyed all 32 physicians (8 faculty and 24 residents) by having them rate the following questions on a 10-point scale (10 = very positive, 1 = very negative) How satisfying is it to you to prescribe and manage chronic opioid therapy? How comfortable are you in managing chronic opioid therapy? How well do you feel you understand the medical indications for chronic opioid therapy? What is your level of anxiety around chronic opioid management? How well do you feel medical school prepared you to manage chronic opioid therapy? Primary Outcomes: Date of last UDS (if within last year) Presence of signed controlled substances contract Subgroup outcomes: Training level of primary care provider (PCP) Age Sex Payer source Additional patient information: Smoking status Race Body-Mass Index (BMI) Number of PCP visits in last year Number of emergency room (ER) visits in last year Benzodiazepine on medication list Comorbid psychiatric diagnoses Chart Reviews We extracted data from our electronic medical record (Epic) in order to obtain a list of all Family Medicine Center (FMC) patients with an opioid on their medication list. We elected to exclude patients whose only opioids were tramadol or codeine, and patients under the age of 18. We randomly assigned each patient a numerical identifier using a random number generator, and we then systematically reviewed these patient charts. Our target number of study patients was 100, which is 10% of the total pool of patients with an opioid on their medication list. Patients were selected for the study if they received an opioid medication from an FMC provider for at least six weeks duration within the last year. Patients were excluded if they did not receive the medication from an FMC physician, were nursing home patients, received opioids for an acute condition (defined as lasting less than six weeks), or if they subsequently transferred management of their chronic pain condition to a pain management specialist. The following data was obtained for study-eligible patients: 1,551 patients with opioid on medication list Excluded: Tramadol & codeine (508) Age <18 (17) 1,026 eligible for chart review 7,614 FMC patients 555 charts reviewed (random order until target # identified) Excluded: Not FMC prescriber (266) Not a chronic med (179) Nursing home patient (6) Deceased (4) 100 eligible patients Patient Selection Algorithm Pain is the most common complaint leading patients to seek care in the United States [1] and strong opioids are prescribed for pain at 9% of all office visits.[2] The elderly and women are more likely to experience chronic pain and be prescribed strong opioids for the treatment of their pain.[3] Opioid use is generally accepted and established care in the treatment of acute and postsurgical pain as well as in palliative care.[2,4] Opioid use in chronic, non- cancer pain has been more controversial. Opioid usage has been associated with multiple adverse outcomes (nausea, vomiting, constipation, opioid-induced allodynia and hyperalgesia, respiratory depression) as well as lower quality of life and higher rates of depression and health care utilization among chronic opioid users.[5,6] Furthermore, there are increasing concerns for misuse, abuse, diversion for sale, and risk of addiction among opioid users.[5] Nonmedical use of controlled substances has surpassed illicit drug use among drug abusers. At our 2014 program retreat, residents brought up concerns about patient safety and provider satisfaction around our current opioid-prescribing policy. All residents, including incoming interns, are expected to prescribe chronic opioids despite often having had no prior experience or focused education on prescribing narcotics. Residents expressed frustration that our clinic does not yet have a clear-cut policy on prescribing opioids, leading to various attitudes and styles of prescribing chronic opioids. Current guidelines suggest the use of regular urine drug screens (UDS) prior to the initiation of opioids, with at least yearly testing thereafter, as well as the use of written agreements between patient and prescriber as part of an ongoing treatment plan for all patients receiving chronic opioid medications. These written agreements should clearly delineate appropriate intervals for follow-up, refill parameters, and using only one provider and pharmacy.[5] Based on these concerns, a resident-initiated working group was formed to review our clinic’s current policy. This new working group was labeled the Pain Advisory Board (PAB), and would consist of 12 residents and 1 faculty advisor. The goals of the PAB would be to update the opioid policy, review and revise our clinic’s current controlled substances contract, and teach the policy to residents. The PAB would also provide advice about prescribing opioids to prescribers on an as-needed basis. After performing a MEDLINE and EMBASE literature search, we found no current examples of anything resembling a Pain Advisory Board that guides residency clinic providers in this area. BACKGROUND Patient Characteristics Average Age: 56 years (range 21-88) Average BMI: 34.5 kg/m 2 (range 16.2-63.0) Average PCP Visits: 6.4 visits (range 1-15) Average ER Visits: 2.5 visits (range 0-37) Smoking: 31% Race: 46% white, 54% black Gender: 65% female, 35% male Benzodiazepine Use: 37% Comorbid Psychiatric Diagnosis: 58% RESULTS We hypothesized that providers are dissatisfied and uncomfortable with prescribing chronic opioids due to insufficient knowledge about their indications and effects; providers were unlikely to consistently adhere to patient safety guidelines of controlled substances contract and yearly UDS; and a clear-cut, PAB-driven opioid-prescribing policy would improve patient safety and increase provider satisfaction with managing these prescriptions. Our primary outcome is to increase both the number of urine drug screens and controlled substances contracts in all patients being prescribed chronic opioids. Our secondary outcome is to increase provider satisfaction. We were also interested in evaluating if provider level of training or patient demographics played a role in prescribing practices and having a UDS or contract on file, with the goal of standardizing practices when clinically appropriate. PURPOSERESULTS (continued) CONCLUSIONSFUTURE DIRECTIONS 1. 1.Noble M et al. Long-Term Opioid Therapy for Chronic Noncancer Pain: A Systematic Review and Meta-Analysis of Efficacy and Safety. Journal of Pain and Symptom Management. 2008; 35 (2): 214-227. 2. 2.Parsells Kelly J et al. Prevalence and characteristics of opioid use in the US adult population. Pain. 2008;138(3):507–513 3. 3.Kodner C. Common Questions About the Diagnosis and Management of Fibromyalgia. Am Fam Physician. 2015; 91(7); 472-478. 4. 4.Furlan et al. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006 May 23; 174(11):1589-1594. 5. 5.Berland Daniel and Rodgers Phillip. Rational Use of Opioids for Management of Chronic Nonterminal Pain. Am Fam Physician. 2012 Aug 1;86(3):252-258. 6. 6.Scherrer et al. Change in opioid dose and change in depression in a longitudinal primary care patient cohort. Pain: February 2015- Volume 156, Issue 2, p 348-355. REFERENCES