1. Appropriate Opiate Prescribing: Managing Chronic Pain in a FQHC
Connie Valdez, PharmD, MSEd, BCPS
Mary Kay Meintzer, LPC, LAC

2. Take Home Points
1) Develop a structured chronic pain management program
2) Interdisciplinary team improves safety and provider satisfaction
3)You are never obligated to prescribe a controlled substance

3. Sheridan Health Services
Nurse-managed Federally Qualified Community Health Center
Partnership with University of Colorado College of Nursing
Interprofessional, integrated care model
Providers – APN, PA, MD, DDS
Nursing – case management, public health
Pharmacy – Clinical PharmD and pharmacy student interns
Behavioral Health – LCSW, MSW, LPC, and addiction counselor credentials
Support staff
Patient population: Provide care for uninsured, Medicaid, Medicare and ARTS patients

4. SHS’s Chronic Pain Management Model
Includes providers, behavior health clinicians, clinical pharmacist, nurse, medical assistant and pharmacy students
We worked collaboratively to develop the following:
standard operation procedure
curriculum for collaborative medical visits
methods to ensure patient safety
patient/provider expectations
forms to use during pain visits
standards to consistently document chronic pain visits
interprofessional team to address patient concerns

5. VA/DoD clinical practice guideline for management of opioid therapy for chronic pain
Evaluation:
Comprehensive history and physical examination
General medical history (age, gender, history of present illness, past medical and surgical history, medications, allergies, family and social history, etc.)
Additional focused assessments (past psychiatric history, medications, substance use history, mental status examination, review of diagnostic studies, evaluation of occupational risks)
Adequate trial of non-opioid therapy
Urine drug test
Assessment for suicide risk
Assessment of pain using numerical rating scale 0-10
Assessment of contraindications to opioid therapy

6. SHS’s Chronic Pain Management
Parameters for safe prescribing:
No narcotics on the first visit
Morphine equivalents calculated and documented at every visit
No more than 120 morphine equivalents prescribed
No opioid use for conditions not supported by literature, i.e. fibromyalgia
Urine toxicology performed at baseline and then randomly (minimally 2 times per year)
Prescription Drug Monitoring Program (PDMP) review performed and documented at every visit
Naloxone prescription and education provided for patient and family
No prescriptions for benzodiazapines in conjunction with opioids
Sleep apnea assessment for patients using opioids
Controlled substance agreement signed annually
Monthly visits required

7. SHS’s Chronic Pain Management
Methods to ensure patient safety:
Use EHRs and PDMPs to Enhance Clinical Care & Data-Driven Decisions
Chronic pain work-up
Perform PDMP
to identify all controlled substances and doses
to evaluate possible misuse, abuse or breach of CS agreement
identify when next opioid prescription is due
Review EHR
reconciliation of opioid dose and fill date from PDMP with EHR
calculate morphine equivalents/day
assess if annual pain agreement is current or needed
identify date of last urine toxicology screen
determine if patient has received a prescription for naloxone

8. SHS’s Chronic Pain Management
Methods to ensure patient safety:
Select appropriate medications for the patient based on patient specific factors and formulary considerations
Pharmacy assessment
Medication therapy review to assess treatment options and safety
Long acting vs short acting opioids
Opioid conversions
Bowel regimen
Formulary considerations
Non-opioid pain treatments

9. SHS’s Chronic Pain Management
Methods to ensure patient safety:
Identify higher risk patient populations
Provider assessment
Pregnancy
Adolescence
Restrictive lung disease, sleep apnea
Persistent mental illness (more than moderate depression, anxiety)
Need for high dose opiates
Current or history of substance abuse

10. SHS’s Chronic Pain Management
Methods to ensure patient safety:
Selecting appropriate management for the patient
Provider assessment cont.
Substantiate the diagnosis (from patient records, imaging, etc.)
Reinforce or recommend pain treatment with non-opioid modalities (including topical drug therapy treatments)
Provide referrals to physical therapy, behavioral health, acupuncturist, healing touch, etc.
Provide patient education
Identify red flags

11. SHS’s Chronic Pain Management
Shared Medical Visits (SMV) Program:
Based on CareOregon curriculum, modified to include expertise of guest speakers (addictions counselor, PT, healing touch RN)
All chronic pain patients must complete the interprofessional SMV group visit “course” for a series of 6 sessions
Patients enrolled in the 6 session SMV program are integrated into the team, they established guidelines for the group (i.e. how many classes can be missed, how late someone can arrive, etc.)
Each SMV is billed as a medical visit (provider evaluates the patient at each visit and provides a two week prescription at the end of the visit)
The SMV group meets every 2 weeks until the 6 session “course” is completed and then the patient transitions to maintenance phase with monthly interprofessional medical visits

12. SHS’s Chronic Pain Management
Curriculum for the 6 Session Shared Medical Appointment Program
Introduction, Chronic Pain & Combination Therapy
Turning Down the Intensity of the Pain Message (Physical Therapy)
Being an Effective Partner in your Care (PCP)
Use of Medications and Dependence (Addictions Specialist)
Identifying and Eliminating Triggers (Alternative Medicine)
Restoring/Increasing the Body’s Ability to Block Pain Messages
Developing a Personal Plan (Individual sessions)

13. SHS’s Chronic Pain Management
Curriculum for the 6 Session Shared Medical Appointment Program
Baseline patient questionnaire
Weekly homework assignments for patients
Tips on managing chronic pain
Pain logs
Stretching and mindfulness breaks every minutes
Condensed into 90 minutes, 30 minutes for individuals one-on-one visits with provider

14. Outcomes: collaborative visits
87.5% self report increase in knowledge regarding dangers of opioid pain medication (subjective measure). POEM is an objective measure: increase across several domains when compare pre/post test.
100% of patients had documented review of the PDMP
100% of patients signed a controlled substance agreement
100% of patients had documented urine toxicity screen.

15. Take Home Points
1) Develop a structured chronic pain management program
2) Interdisciplinary team improves safety and provider satisfaction
3)You are never obligated to prescribe controlled substance