Innovative Approach of Managing High Risk Chronic Opioid Users in a Residency Practice

1. Session #E2c Friday, October 11, 2013 Innovative Approach of Managing High Risk Chronic Opioid Users in a Residency Practice Erin Inglis, MDa, Jessie Burch, PharmDb, Nida Awadallah, MDc, , Vanessa Rollins, PhDd, Myra Bodegahl, MSWe aAssistant Professor, Division of Family Medicine, University of Colorado School of Medicine b Assistant Professor, University of Wyoming School of Pharmacy c Assistant Professor, Division of Family Medicine, University of Colorado School of Medicine d Assistant Professor, University of Colorado School of Medicine, The Colorado Health Foundation, Doctorate of Psychology, Rose Family Medicine e Masters of Social Work, The Colorado Health Foundation, Rose Family Medicine Collaborative Family Healthcare Association 15th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Objectives • Describe challenges to managing chronic opioid therapy in primary care and residency education. • Describe elements of multidisciplinary chronic pain treatment. • Describe development and implementation of our committee. • Describe typical interventions, preliminary outcome data, challenges to implementation of committee recommendations, and effect on physician satisfaction and education.

4. Introduction • Burden of chronic pain can not accurately be estimated but it is a significant social and economic problem • Challenging to treat, especially in a residency setting • Providers and patients often dissatisfied with treatment process • Safety concerns with opioid abuse and overdose

5. Chronic pain treatment in a residency setting What was the problem? • Wide variation of training experience and comfort level • Lack of continuity of care • Little to no access to pain management specialists • Patients with multiple co-morbidities • Insurance limitations

6. Preliminary Intervention • Developed a pain management policy to include: • Initial patient evaluation guidelines • Chronic opioid treatment agreement • Evaluation tool for patient’s risk of abuse • Pain level assessment tool • Intermittent urine drug testing

7. Initial Patient Evaluation

8. Opioid Risk Tool

9. Calculating Morphine Equivalents • Morphine is the standard for equianalgesic comparison • Determine the total daily dose (TDD) of each opioid the patient takes and convert to oral morphine equivalents (ME) • Example equianalgesic conversion • Oxycodone 20 mg = 30 mg ME • Percocet 10/325 mg PO q6h PRN and patient takes 4 tabs daily • TDD = oxycodone 40 mg = 60 mg ME

10. Patient Case • Casey is a 45 yr old female that presents to your office with a history of chronic pain looking to establish care with you • PMH: hypertension and depression, fibromyalgia, low back pain since a MVA 5 years ago • Current medications: HCTZ, Vicodin, citalopram • FMHx: EtOH and cocaine abuse by her father • SH: 2-3 EtOH drinks most days of the week but denies having an EtOH problem

11. Patient Case • How would you assess her risk for opioid abuse? • Which of the following risk categories would you place her in with regards to opioid prescribing? A) Low Risk B) Medium Risk C) High Risk

12. Patient Case • Casey is a 45 yr old female that presents to your office with a history of chronic pain looking to establish care with you • PMH: hypertension and depression, fibromyalgia, low back pain since a MVA 5 years ago • Current medications: HCTZ, Vicodin, citalopram • FMHx: EtOH and cocaine abuse by her father • SH: drinks 2-3 EtOH drinks most days of the week but denies having an EtOH problem

13. Patient Case • How would you assess her risk for opioid abuse? • Variety of validated risk tools • Our practice uses the Opioid Risk Tool (ORT) • Which of the following risk categories would you place her in with regards to opioid prescribing? A) Low Risk B) Medium Risk C) High Risk

14. Initial Outcomes • Improvement but adherence to policy limited by lack of continuity • Continued frustration with the process • Physicians found it difficult to make long-term decisions because of lack of continuity • Lack of time during busy clinic days to review drug testing and PDMP data

15. Follow-Up Interventions • Formed Pain Management Committee (PMC) • Consists of residents, attending physicians, pharmacist, social worker, and psychologist • Generated a pain management registry • Monthly meetings: review of 5-7 patient charts followed by open discussion • Patients are chosen for review based on provider request or policy guidelines • Review of clinic visit notes, drug screens, self management goals, PDMP data, and aberrancies • Generate recommendations for future management to PCP or next visit provider

16. Follow-Up Interventions • Created a‘Pain Management Toolbox’that is easily accessible to entire practice • Pain management policy • Additional guidelines • Supporting documents • List of resources • Increased resident/physician education on pain management

18. Monitoring Guidelines

19. Urine Drug Testing • Guidelines established for frequency of monitoring in-house urine drug screens • When urine drug screen not what was expected then sample sent for confirmatory testing • Frequently the test ordered from the lab was only another screen and not confirmatory • Challenge identifying CPT codes for specific confirmatory tests

20. Aberrant Behaviors

22. Patient Case Continued • After careful assessment, the decision was made accept Casey as a patient and prescribe her Vicodin • She agrees to and signs the Chronic Opioid Treatment Agreement • At 3rd monthly visit, her in-office urine drug test is negative for hydrocodone despite stating she is taking the medication as prescribed • You send out a confirmatory urine drug test, which is also negative for hydrocodone • When you discuss the results over the phone, she admits to increasing her dose without discussing it with you and running out of her Vicodin 1 week early • You review the agreement again and see her the following month • At this visit, you review the PDMP and see that she has received other prescriptions for Vicodin from 2 outside providers over the past month

23. Patient Case Continued • What would you do? • Continue to prescribe her Vicodin regularly • Tell patient she has had at least 2 minor aberrancies, refer to a pain management specialist and stop prescribing Vicodin • Discuss the aberrancies and try to come to a resolution with patient that you both agree on

24. Typical PMC Interventions • No concerns: • Continue current treatment plan • Reassess in 12 months • Moderate or high risk with no aberrancies: • Consider tapering to a lower risk dose • Adjuvant treatments • Assess for psychosocial barriers and comorbid disease states • Consider referral to pain management specialist • Reassess in 3-6 months

25. Typical PMC Interventions • 2 minor or 1 major aberrancies: • Dismissal from pain management program with or without taper and referral to pain management specialist

26. PMC Outcome Data • Registry of 130 patients taking chronic opioids • To date: 35 have been tapered off • Continue to monitor other high risk patients

27. Resident/Physician Education • Monthly meetings of the PMC • Bimonthly PMC meetings with entire practice • Chronic pain modules (AMA) • https://cme.ama-assn.org/Education.aspx • First year residents receive several PM talks during their first few months of residency • Methadone management talk in the second year of residency

28. Physician Satisfaction • Overall improved significantly • More comfortable with managing chronic pain than before the PMC existed • Residents feel more comfortable managing chronic pain after graduation • Pressure taken off individual providers as major decisions made by the PMC • Safer prescribing given routine review by PMC

29. Future Direction • Develop a policy for chronic pain patients with concomitant use of benzodiazepines • Review validated risk tools for patients with active substance abuse receiving chronic opioids • Improve utilization of self-management goals • Evaluate patient satisfaction

30. Conclusions • Developing a chronic pain registry, pain management committee, and toolbox can help manage complex chronic pain patients in a residency or large practice setting • Improved patient safety • Improved provider satisfaction

31. Questions?

32. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!