1. Chronic Pain: How Can WE Stop the Suffering?
Session # I1
Chronic Pain: How Can WE Stop the Suffering?
Meghan Fondow, PhD
Ashley Grosshans, LCSW
Elizabeth Zeidler Schreiter, PsyD
Chantelle Thomas, PhD
Kevin Fehr, MD
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CFHA 18th Annual Conference
October 13-15, 2016  Charlotte, NC U.S.A.
Collaborative Family Healthcare Association 12th Annual Conference

2. Faculty Disclosure
The presenters of this session have NOT had any relevant financial relationships during the past 12 months.
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CFHA requires that your presentation be FREE FROM COMMERCIAL BIAS. Educational materials that are a part of a continuing education activity such as slides, abstracts and handouts CANNOT contain any advertising or product‐group message.
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Collaborative Family Healthcare Association 12th Annual Conference

3. Learning Objectives At the conclusion of this session, the participant will be able to:
Describe key steps in implementing a clinic wide shift in chronic pain management initiates
Discuss consistency in EHR documentation, deriving opiate pain management registry, systematization of UDS, and opiate medication refill management protocol
Explore how multi-disciplinary team meetings have been instrumental in shifting provider attitudes, treatment planning, and prescribing patterns while facilitating reciprocal cross discipline education through a collaborative, supportive work group
Collaborative Family Healthcare Association 12th Annual Conference

4. Bibliography / Reference
Sherman, Richard (2011), PAIN:  Assessment & Intervention From A Psychological Perspective, Second Edition
Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, JAMA, 315(15),
Salvetti, M. D. G., Cobelo, A., Vernalha, P. D. M., Vianna, C. I. D. A., Canarezi, L. C. C. C. C., & Calegare, R. G. L. (2012). Effects of a psychoeducational program for chronic pain management. Revista latino-americana de enfermagem, 20(5),
Jones, T., Lookatch, S., & Moore, T. (2013). Effects of a Single Session Group Intervention for Pain Management in Chronic Pain Patients: A Pilot Study. Pain and therapy, 2(1),
Continuing education approval now requires that each presentation include five references within the last 5 years.
Please list at least FIVE (5) references for this presentation that are no older than 5 years.
Without these references, your session may NOT be approved for CE credit.
Collaborative Family Healthcare Association 12th Annual Conference

5. Chronic Pain Overview
Pain is considered chronic when it is continuous or recurrent and lasts more than three months.
Chronic pain has a negative impact on an individual’s quality of life, affecting sleep, diet, relationships, ability to work and functionality, among other aspects of daily life (Salvetti et al 2012)

6. Chronic Pain Overview Major public health problem
US prevalence: 11.2% (Dowell et al 2016)
Opioids have serious risks: from 1999 to 2014 more than 165,000 overdose deaths from pain medications
PCPs report concerns about misuse, stress managing chronic pain populations, not enough training
US prevalence of chronic pain is estimated at 11.2% of the adult population. 
Opiates of commonly prescribed for pain, with approximately 3-4% of the adult US population prescribed long-term opioid therapy.
Opioid pain medication use presents serious risks.  From 1999 to 2014, more than 165,000 persons died of overdose related to opioid pain medications in the US
Primary care clinicians report concern about opioid pain medication misuse, find managing patients with chronic pain stressful, express concern about patient addiction, and report insufficient training in prescribing opioids.
(above is from the article CDC Guideline for Prescribing Opioids for Chronic Pain…)
Chronic pain is a major public health problem
Chronic pain affects approximately 100 million people in the US at an annual cost of over 500 billion dollars in direct medical costs and lost income.
Chronic pain is a bio-psychosocial condition in which psychological factors play a critical role
(above is from article on Effects of a Single Session…)
Pain is considered chronic when it is continuous or recurrent and lasts more than three months.
Chronic pain has a negative impact on an individual’s quality of life, affecting sleep, diet, relationships, ability to work and functionality, among other aspects of daily life
(above is from article on Effects of a psychoeducational program for chronic pain management)

7. Access Community Health Centers
Federally Qualified Health Center (FQHC) in which patients receive a wide array of services in one clinic location (medical, dental, behavioral health, pharmacy, community resources) More than 26,000 people call Access their health care home 3 primary care clinic locations in Madison, WI all certified as Patient Centered Medical Homes
1 in 5 patients met with BHC in 2015
Over 5800 BHC visits in 2015

8. Access and Chronic Pain
Started in 2009
Consisted of BHC Champion and Medical Provider Champion
Series of provider meetings exploring their needs surrounding chronic pain management (1 year)
Identified systemic issues
Identified issues with provider comfort
Recognized need for cultural shift in what it means to “treat” chronic pain

9. What didn’t work Providers compelling BHC involvement
Tasked with teaching “coping” to unwilling patients
Narcotics contingent on meeting with BHC
BHC handoffs
How BHC introduced to patient for chronic pain
“You think it is all in my head”
How BHC involved in conversations regarding narcotics
BHC as messenger that narcotics not prescribed

10. Provider Education Series of videos were created to:
provide language for challenging discussions
gave framework for appropriate referrals
education regarding non-medication treatment options

11. What didn’t work: Provider Education
Placed demands on providers outside of normal work schedule
Facilitated an isolated learning experience
Do not allow for collegial sharing of the burden

12. What did work Monthly chronic pain team peer review meetings
Forum for discussing challenging patient presentations
Open to all staff including nurses and support staff
Team review of prescription regimen and brainstorming for treatment options
Provided another forum for clarifying best practices surrounding various pain conditions
Protected time to ensure that all aspects of patient care related to pain are being prioritized

13. What did work Strong leadership from CMO and BHC
Increased systems change
Consistent documentation
Routine urine drug screens
Ongoing discussions with providers on “compassionate no”
Exposing shared struggle amongst providers (decreased shame/guilt)
Monitoring patients at higher doses
Increased exploration of alternate treatment methods and diagnostic testing

14. Other BHC Impacts
Support and collaboration with PCP colleagues for debriefing before/after challenging patient interactions
Support in developing language to communicate plan of care when including the “compassionate no” in regards to opioid prescribing
Supporting providers in developing curiosity in patient understanding of their pain diagnosis, impacts on daily functioning, and safety concerns
What happens outside of the patient exam room
Collaborative Family Healthcare Association 12th Annual Conference

15. Chronic Pain Groups Pilot Summer 2016
Collaboration between medical provider and BHC
Group medical visit
Goal: non-medical options for managing chronic pain
Topics include understanding pain, sleep, stress, nutrition, communication

16. Outcomes Consistency in documentation processes by providers
> 85% patients with chronic pain dx
> 66% patients on registry with standardized documentation
Urine Drug Screens
65% in past 6 months (increase from 20% in 2014)
Rates of narcotics prescribing similar, but doses declined
Results based on chronic pain registry, >6 narcotics prescriptions in past 12 months, data from Q2 2016
Rates of prescribing similar, from around 315 patients to around 275 patients. However, number of patients on higher doses, >100 ME declines significantly, from over 12% to under 5%.

17. Future Directions
Plans to expand services to include universal substance abuse and depression screening
SBIRT
Consideration of on-site fully integrated physical therapy

18. Questions?

19. Session Evaluation
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Collaborative Family Healthcare Association 12th Annual Conference