1. Opioids in chronic pain
QI conference
11/16/2016

2. Quality improvement, next steps
42% of last years QI projects lead to change in practice
Today, we’re going to build off of a case from last year
OPIOIDS FOR CHRONIC PAIN
UDM/PMP
Autotext/provider checklist
Clear expectations for patients
Provider follow through
Shared guidelines on PMP/UDM/contract

3. Goals To understand the basics of a PDSA cycle
To create a PDSA cycle for dealing with opiate prescribing for chronic pain.

4. Road Map Presentation (10 min) PDSA group projects (25 min)
Large group discussion (15 min)

5. WHY: WHO: :: previous guidelines unclear
:: limited evidence on long-term use in chronic pain
:: big pharma made it more confusing
:: patient morbidity and mortality
narcotic pain prescriptions quadrupled
overdose deaths from the same also quadrupled
:: provider frustration and concern
WHO:
:: primary care
:: outpatient setting
:: chronic pain patients >18 yo and no palliative
= ½ all opiate scripts
Cdc recommendations
Target population

6. NOT SUFFIECIENT EVIDENCE FOR NARCOTICS IN CHRONIC LONG TERM PAIN
What we do know:
non-pharmacologic and non-opioids DO work for long term pain
CBT/exercise/apap/NSAIDS/ anticonvulsants etc…
opiods are risky:
dose dependent risk for OD:
compared to 1-19 MME/day
:: = 1.31 risk of OD death
:: = 1.92
:: = 2.04
benzo+ opiates = more death
bad in hepatic/renal dysfunction, elderly, pregnancy
3. We can determine those at risk and help avoid risk
PMP/UDM/contracts/naloxone
buprenorphine/methadone
Cdc recommendations
What we know

7. Cdc recommendations DETERMINING WHEN TO INTIATE/CONTINUE
1. non-pharm and non-opioids first
2. before opioids are started establish realistic treatment goals
for pain and function, discuss d/c if risks >benefits, only continue if improvement in pain and function happens
3. before and during discuss known risks and realistic benefits,
co- responsibilities
OPIOID SELECTION/DOSAGE/DURATION/FOLLOW-UP
4. start with IR, not ER/LA
5. start with lowest effective dosage. If up to 50 MME re-evaluate,
avoid up to 90 MME/justify/consider pain consult
6. long-term opioid use often begins with acute pain. For acute pain
IR and 3-7 days only.
7. re-evaluate risks/harms 1-4 weeks of starting opioids, or if
escalation. Evaluate Q3 months to optimize/taper/d.c
ASSESSING RISK AND ADDRESSING HARMS
8. before starting and periodically evaluate for risk of o/d:
hx of o/d, hx of substance use d/o, >50 MME/d, benzo use
offer naloxone
9. Review PMP at initiation and every 3 months to every prescription.
10. UDM at least annually
11. avoid benzodiazepine and opiate prescriptions together “whenever
possible”
12. offer/arrange MAT +CBT for those with opiate use disorder
Cdc recommendations 12
RECOMMENDATIONS

8. CDC TOOLS FOR PROVIDERS

9. CDC TOOLS FOR PROVIDERS

10. STANDARDIZE OUR PROCESS
For chronic pain patients

11. STANDARDIZE OUR PROCESS
PLAN
Visit template
Nurse care plan
Timing udm/pmp/contract/MME calc DO
How will this be implemented?
All clinics? All providers? When?
STUDY
How to confirm participation?
Which outcomes to study?
Are they improving?
ACT
When should we review?
What should we do next if no improvement?
STANDARDIZE OUR PROCESS
For chronic pain patients

12. Goals To understand the basics of a PDSA cycle
To create a PDSA cycle for dealing with opiate prescribing for chronic pain.