1. Larry Halverson, MD Gabrielle Curtis, MD Cox FMR Springfield MO
L57A: Constructing, Improving, Analyzing and Benefitting from a Chronic Pain Registry
Larry Halverson, MD
Gabrielle Curtis, MD
Cox FMR
Springfield MO

2. Disclosures
Neither presenter has anything to disclose

3. Introduction
Summarize efforts to improve care of people who attend our PCMH and take daily opioids for chronic pain (CPODO).
Measureable outcomes in our patients.
Measureable outcomes in our resident learners.

4. Chronic Pain Management Improvement Efforts
Defined CP and CPODO
Created an “atypical registry” (symptom rather than diagnosis - lumped vs. split)
Analyzed scope of problem - education and planning
Practice improvements
Refill protocols
Group visits
Pharmacologists help

5. Scope of Problem August 2011
1570 patients Chronic Pain
1146 patients (73%) CPODO
Some on very high doses!

6. Stratification Pain scores – not discriminatory
Functional ability – not “sensitive”
Daily dose of opioids
> 200 MEQ mgs/day
Significant - 3 x’s increase in opioid-related mortality relative to low daily doses*
Manageable (# 82 patients by spring of 2011)
*Gomes et. Al. Arch Intern Med. 2011;171:686-91

7. Converting daily dose into morphine equivalent mgs/day (MEQ mg/day)
Conversion factors (our preferred formulary)*
tramadol 0.1
codeine 0.25
hydrocodone 1.0
morphine 1.0
oxycodone 1.5
methadone 3.0
fentanyl patch 0.25=75; 0.50=150; 0.75=225
1.0=300
*CONSORT Clin J Pain 2008;24:521-7

8. Our Goals Spring 2011 Avoid starting chronic opioids
Stop increasing >200 MEQ mg/day
Manage refills better
Encourage continuing care of people with CPODO
Help people reduce their daily opioid dose (focus on those >200 MEQ mg/day)

9. Measureable Patient/Practice Improvements
N = 102 all patients >200MEQ mg/day managed > 6 months
N=78 active managed patient results

10. Measureable Patient/Practice Improvements
N = 102 all patients >200MEQ mg/day managed > 6 months
N=78 active managed patient results 78

11. Of the 57 patients who have reduced, most are now <200 MEQ mg/day

12. Quantitative Dose Reduction of 75 Patients

13. Economic Benefit Of just one drug reduction for 75 “actively managed” patients!!
$301,490/year
$826/day
$24,780/month

14. FMCC Totals

15. Current Economic Impact of FMCC – 47,752 MED
$1,719,000 per year
$4775 per day
$143,250 per month

16. Patient Quote
“I think these group visits should be required for all people who are prescribed opiates.”
(this patients has reduced from 345 Meq mg/day to 165 Meq mg/day over 16 months)

17. Resident Impact 1996
“I was very naive about the problem of opioid addiction and diversion when I first left residency.”

18. 2003
“I was trained in residency to provide escalating doses of narcotics to treat non-cancer pain, and to use long acting and breakthrough doses for this. Changes in my practice patterns from patient experiences with this approach and participation in education within the residency regarding narcotic use have led to less prescription at lower doses, with plans to reduce/stop medications that would not have been reduced or stopped 10 years ago. I have found our current functional assessment to be mostly useless even if I use it, and the DIRE score to be extremely helpful in looking at a patient in a somewhat objective manner.”

19. 2009
“I do not believe physicians should dismiss patients from their practice for breaking their narcotic agreement or use of illicit drugs. That is just an excuse to not deal with the complexity of social and psychological issues that these patients have. I do agree with discontinuing the medications if there is a breach, but not firing a patient. Every patient, including those who abuse legal and illegal drugs, have other medical problems (HTN, DM, COPD, acute illnesses) that require management, and nobody better to take care of these issues than family physicians.”

20. 2012
“I feel comfortable diagnosing and treating chronic pain. I believe that a patient's medication should be between the patient and the doctor and the government should keep out of it. If I have a new patient and they say that they have chronic pain, I do not continue their chronic pain medication unless I have adequate records and I agree with the diagnosis and treatment plan.”

21. Resident Impact Initiation of improvements – 2008 Comparisons:
Cox FMR graduates (35)
Cox FMR graduates 2009-current (43)
Non-Cox FMR graduates (14)

22. Do you accept new patients taking daily opioids?

23. Do you initiate opioids for chronic pain?

24. Do you use a medication agreement or narcotic contract?
Do you use an abuse risk assessment tool?

25. Do you dismiss patients who violate your medication agreements or contracts?

26. Do you order urine drug screens regularly?
Do you think urine drug screens are useful in patient management?

27. Do you know how many of your patients are taking daily opioids?
Do you calculate daily morphine equivalents when dosing opioids?

28. Do you agree with an FDA proposal to limit daily opioids to <90 days?
Do you agree with an FDA proposal to limit daily opioids to <100 MED?

29. Areas of Resident Significance Likert Scale 0-6
Do you feel guilty or anxious when refilling chronic opioid prescriptions? NONSIGNIFICANT
Are you successful in helping people reduce or quit taking opioid medications? NONSIGNFICANT
Would you be interested in CME programs to improve your comfort with managing people with chronic pain?
Would you like to attend a CME program to increase your knowledge about appropriate use of opioid medications?
Do you enjoy caring for people with chronic pain? NONSIGNIFICANT (trending at p = 0.065)…..Post-Improvement is not always improved.
Age……p =
Pre-Intervention 43.69, SD 7.798, 95% CI
Post-Intervention 31.09, SD 6.070, 95 CI
Other SD , 95% CI
Do you feel you were prepared (or are becoming prepared) to deal with requests for opioid medications when you were a resident? P =
Pre-Intervention 2.31 SD 1.745, 95% CI
Post-Intervention 3.49 SD 2.004, 95% CI
Other 3.86 SD 1.748, 95% CI

30. Summary and… Questions?