1. Primary Care and Comprehensive Pain Plan
Nicole Gastala, MD
FQHC – inherit pt population with chronic pain and addiction – patients do not care about preventative health if they are suffering from addiction

2. Objectives Training Goals:
To increase knowledge of chronic pain protocols within an office-based primary care setting
To enhance the understanding of the participants in use of medication assisted therapy
To increase the knowledge of participants in the benefits of opioid dependence maintenance therapy.
Training Objectives:
At the conclusion of the training, the participants will have a better working knowledge of the use of medication in assisting with withdrawal while the patient is undergoing counseling with the goal of tapering and abstinence.
At the conclusion of the training, the participants will have more skills in understanding office-based comprehensive pain plans
My goal today is to first discuss how to manage a chronic pain population and incorporate aspects of the CDC guidelines and discuss the role of primary care providers in treatment of addiction. Because there is great overlap between the two -

3. Chronic Pain and the Public Health Crisis
Estimated affects 11.2% of adult US population
3-4% of adult US population on long term opioid
Lack of evidence for greater than 12 weeks of treatment
more than 165,000 people died of overdose related to opioid pain medications in US
In 2013, 1.9 million persons abused or were dependent on prescription opioid pain medication
In primary care, opioid dependence ranged from 3-26%
“One person dies every 19 minutes from prescription drug use.” (Straussner, 2014)
The CDC guidelines were in response to the opioid public health crisis – significant data showing harms related to opioid therapy.
Opioid Use Disorder Diagnostic Criteria A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Opioids are often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use. 3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects. 4. Craving, or a strong desire or urge to use opioids. 5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids. 7. Important social, occupational, or recreational activities are given up or reduced because of opioid use. 8. Recurrent opioid use in situations in which it is physically hazardous. 9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of an opioid. Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision. 11. Withdrawal, as manifested by either of the following: a. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal). b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.
Chronic Pain and the Public Health Crisis

4. Non pharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain
Consider opioid therapy only if expected benefits for both pain and function are anticipated
The evidence has shown the opioid therapy only decreases chronic pain by a few points, does not bring to zero.
CDC Guidelines

5. Establish realistic treatment goals with all patients, goals should include when, and how opioid will be discontinued
Provide patient education, if no clinically meaningful improvement in pain and function, opioid medication will be discontinued
The evidence has shown the opioid therapy only decreases chronic pain by a few points, does not bring to zero.
CDC Guidelines

6. Participate in open and honest discussion about benefits and risks related to all treatments. Discuss availability of treatment options.
Educate patient on their responsibility for managing pain management/therapy
CDC Guidelines

7. Evaluate risk factors, consider use of opioid risk tools, consider hx of addiction
Check PMP/PDMP for “Dr. Shopping”, multiple ER visits, Dental visits, multiple prescriptions from various towns, or areas
CDC Guidelines

8. Routine use of urine drug testing/oral swabs- helpful to identify correct use of prescribed and non prescribed meds - Best to use prior to writing Rx
Avoid concurrent benzodiazepine and opioid prescribing- can lead to overdose, high risk for diversion.
Black Box warning on concurrent benzodiazepine and opioids
CDC Guidelines

9. Use IR opioids when starting- Do not use ER/LA for acute pain
Arrange for treatment of opioid use disorder if needed- be prepared prior to appointment if possible
Use IR opioids when starting- Do not use ER/LA for acute pain
Black Box warning on concurrent benzodiazepine and opioids
CDC Guidelines

10. Start low and go slow- use caution and reassess frequently
Acute pain: prescribe no more than needed- 3 days or less should be sufficient more than 7 days should be rare
Chronic pain: re evaluate frequently, every 1-4 weeks then monthly then every 3 months.
CDC Guidelines

11. Instituting guidelines into practice

12. Instituting guidelines into practice
Construct a process and work-flow
If possible, create a care team
Create a checklist in EMR
Create a protocol if patient fails
Create a controlled substance agreement
Consistency, Consistency, Consistency
Reference Protocol/Work Flow
Instituting guidelines into practice

13. Drug Testing Urine Drug Screen – Instant vs. Send out
Liquid chromatography–mass spectrometry 
Drug Testing

14. Tools to use in practice
Brief Pain Inventory
CAGE-AID
Modified Instrument of Activities of Daily Living Scale
Opioid Risk Tool
Pain Disability Index
Tools to use in practice

15. Pain team: BHC, RN, LPN, MD, PA, ARNP, Nurse Care Mgr
Weekly review of Chronic and Acute pain patients
Review of inconsistent drug screens
Time to discuss challenging cases
Plan of care for the following week
Weekly Staffing

16. 58 y/o M with PMHx of COPD on home O2, morbid obesity, OA who transfers care – currently on hydrocodone-acetaminophen 7.5 mg-325 mg – max 6 per day
47 y/o M with morbid obesity, DM2, Depression, Anxiety, Ankylosing spondylitis – currently on hydrocodone- acetaminophen 7.5 mg – 325 mg q6 hrs prn
46 y/o F with hx of gastric bypass, anxiety, previously a CNA, newly diagnosed hx of opioid abuse. Husband has ankylosing spondylitis…
Case Studies

18. Medication Assisted Treatment

19. “Do no harm”

24. Figure 1. US counties with physicians with waivers to prescribe buprenorphine.
Note: data source: Drug Enforcement Administration, July Map date: September 2013.
At least 1 buprenorphine provider
No buprenorphine providers
ANNALS OF FAMILY MEDICINE ✦ ✦ VOL. 13, NO. 1 ✦ JANUARY/FEBRUARY 2015 28

25. Opioid Pharmacology Buprenorphine/naloxone (Suboxone)
Type of opioid receptors:  Mu  Kappa  Delta −Addictive effects of opioids occur through activation of mu receptors −Role of kappa and delta receptors in addictive process not well defined
Buprenorphine/naloxone (Suboxone)

27. How Does Buprenorphine Work?
High Affinity for Mu Opioid Receptor
Competes with other opioids and blocks their effects
Displaces heroin or other opiates from receptors (This can produce withdrawal if patient has opiates in system)
Slow Dissociation from Mu Opioid Receptor
Prolonged therapeutic effect
> 24 hours
“Ceiling Effect” on Opiate Effects
Poor drug for intoxication purposes
Safer in an overdose
Formulated with Naloxone
Naloxone is poorly absorbed if taken orally
Naloxone blocks opiate effects if injected

29. Clinical Uses of Buprenorphine
Withdrawal & Detoxification
Maintenance
Prevents withdrawal
Diminishes craving
Does not produce a “high”
Blocks (or reduces effect of) heroin
Increases treatment retention

30. Buprenorphine, Methadone, LAAM: Urine Testing for Opioids
100
All Subjects 80
LAAM 60
Buprenorphine
49%
40%
Hi Methadone
Mean % Negative 40
39%
Lo Methadone
Levacetylmethadol (LAAM) synthetic opioid similar to methadone – removed from market for life threatening ventricular rhythm disorder 20
19% 1 3 5 7 9 11 13 15 17
Study Week
Adapted from Johnson, et al., 2000

31. Opioid Agonist Medications
Rolley Johnson et al., NEJM, 343(18): , 2000
90% Reduction in Heroin Use

34. Take Home Points for MAT
Helps with withdrawal while patient is undergoing counseling and substance treatment with the end goal of tapering and abstinence
Buprenorphine/Naloxone is safe and effective in suppressing withdrawal symptoms and blocking the effects of illicit opioids
Safe Medication
Overdose with Buprenorphine/Naloxone has a low likelihood of clinically significant problems. Morbidity and mortality are linked to use with other drugs such as benzodiazepines.

35. Take Home Points for MAT
Patients can continue to function on medication leading to stabilization in home/work environment
Does not cause disruption in cognitive and psychomotor performance or end-stage organ damage
Diversion potential exists but is less than prescribed opioids or methadone
Can be done in the primary care office setting after receiving appropriate training
You have the ability to change patient outcomes in your community!

36.
Primary Health Care, Inc - Marshalltown
Thank you!

37. Reference Protocol/Work Flow

38. Controlled Substance Agreement
Create a controlled substance agreement
Controlled Substance Agreement