Collaborating in the management of the chronic pain patient

1. Collaborating in the management of the chronic pain patient Spokane Pain Conference September 2014

2. Panelists: Ms. Brandy Woods, B.S.; CDP Clinical Supervisor at Spokane Addiction Recovery Centers, SPARC Ms. Lisa F. Parker, CDP Executive Director at Breakthrough Recovery Group Darin Neven, MD Medical Director Sacred Heart Emergency Medical Services and Consistent Care Program Lynda Williamson, DO Family Physician and Consultant in Chronic Pain Management, The Pain Clinic at the VA

3. Spokane Prescribed Opioid Task Force In 2008 & 2009: Spokane had the highest death rate per capita in Washington State associated with prescribed opioids • Sponsored and coordinated by the Spokane County Medical Society • Meeting 4-6 times a year since 2010 • Provided the Uniform Pain Management Agreement, Drug Take-back Days, Public Forum with Law Enforcement • Brought together medical & dental community leadership, law enforcement representatives, substance abuse treatment community, community court and child protective services

4. Objectives: • At the end of this presentation participants will :~ be able to describe when co-management of a chronic pain patient with behavioral services is recommended~ be aware of the breadth of community social services available for assistance with management of chronic pain patients~ be able to describe how to make a referral of a chronic pain patient to community social services or behavioral health services

5. Case 1 • T.M. is a 54 yr old C. M. who had 23 visits to the E.D. in 14 months. All visits were associated with chronic, intractable pain and falls. • The chronic pain source: due to congenital hip dysplasia and is now s/p 2 hip replacements. The 2nd hip replacement failed after 5 years causing 3-inch leg length discrepancy. • Each ED visit results in rx for hydrocodone and sometimes injection of toradol +/- analgesic opioid.

6. The evidence: • Imaging documents: unilateral prosthetic hip with failed labrum component, surgical revision indicated • Femoral component appears to have good integrity securely situated • 3” Leg-length discrepancy results, causing severe antalgic gait • Dentition in poor repair PMHX: • HTN, uncontrolled • 1st prosthetic hip at 22 yrs of age, • 2nd prosthetic hip at 42 yrs of age • COPD, untreated, over 40 pack yrhistory • Pneumonia/bronchitis 3 times past 20 months • Hx of alcoholism: heavy use/abuse at 20-23 yrs of age • Meth-amphetamine abuse for months to years over 3 different periods of time • Fractured left proximal humerous, date NOS, suspect due to falling • Anxiety disorder, untreated/unmanaged

7. What would you do next?

8. Consistent Care • Referred to Consistent Care program due to frequent ED visits. CC program referred TM to orthopedic surgeon • Consistent care also arranged for PCP at CHAS Clinic

9. Orthopedic Surgeon • Saw TM once and referred him for pain management and primary care work-up for surgery

10. Primary Care: • Consistent Care program referred TM to CHAS clinic. • He attend ONE appointment and reported he felt embarrassed, ashamed, offended, and afraid to return to CHAS

11. Discussion

12. Pre-op Exam: • Pain not managed • Dental decay extensive, high risk for infection • Smoking 1 ppd • COPD untreated • Falling frequently due to hip instability and leg-length difference of 3+ inches. Many of these falls were associated with getting in/out of home bathtub • Appears to be very anxious

13. Social history: • Disabled, medicaid insurance • legal issues with methamphetamines including 1-6 years in prison several times, remote hx of etohism, denies any use of alcohol in over 20 years • Married to younger wife (35yrs of age) with 2 daughters 4 & 6 years old. Spouse awarded TANF to allow her to be pt’s care provider (TANF extended 3 times!! (unprecedented) • Illiterate, less than 4th grade reading ability • Poverty

14. What would you do next? How would you control his pain? What other care would you recommend?

15. Problem: Pain Management • Pain management—”can I have just 2 or 3 hydrocodone a day?” • Review of records demonstrate past year of ZERO to 40 mg of morphine/day with pain level consistently reported at >7/10 • Trial of Morphine Sulfate-ER 15mg q 12 hrs • Pt reported this worked well, but doesn’t last all day or night, “Could I please just have a couple of hydrocodone for break-thru pain?”

16. What would you do next?

17. Pain Management • NORCO 7.5/325mg 2/d, then 3/d, For 2 months, then: • MS-ER 15mg TID, and Norco 7.5/325mg #14/28d. For 6 months, then: • MS-ER 15mg in AM, mid-day and 30mg at HS

18. Monitoring: • urine toxicology demonstrated consistency with prescribed medications for 15 months. • Then had dental extraction of all of his teeth with sedation by nitrous oxide in two visits. • The next urine toxicology demonstrated no MS, pt reported that it was making him too irritable for his family to tolerate him • Toxicology Evidence of: methamphetamines

19. Social issues: • The children’s elementary school called CPS- both parents were referred to Substance abuse out-pt treatment. • Pt only able to attend 3d/wk due to hip pain from taking the bus • 3 months of out-pt treatment for substance abuse completed by TM but spouse did not complete.

20. Case 2 26 yoCauc.Femalewith chronic pain Chronic pain source: “pelvic pain associated with child birth” 3 years ago Primary care provided by a community health clinic, now referred for pain management due to hydrocodone 5/500mg tabs 3-4/day after 3 years is no longer effective

21. History: • PMHX: • Full-term, NSVD 3 yrs ago, healthy child. Prescribed hydrocodone for pelvic pain after childbirth • 2 prior first-trimester abortions • Multiple dental procedures • Social Hx: • Single mother, never married • Father of her child ismissing or unknown • Completed high school • Works in a bingo hall • Smoker, ½ ppd x 10 yrs. Denies etoh. Denies illicit drug use.

22. The evidence: Physical exam: Imaging: Labs: Medications: • Normal: neuro, CV, resp, skin, M/S, GI, GU, Pelvic • Pelvic plain films are unremarkable • None • Oral birth-control, hydrocodone 5/500mg 3-4/day x 3 years

23. What would you do next?

24. Re-cap of Objectives: • When is co-management of a chronic pain patient with behavioral services recommended?

25. Where can health care providers find Needed Case management And specific Community Services? • Community social services are available for assistance with management of chronic pain patients • Most chronic pain patients will have co-morbidities in the behavioral health domain and the prescribing physician may be the last one to know

26. The REFERRAL: ~ How is a referral made for a chronic pain patient to community social services or behavioral health services?

27. THANK YOU FOR THE WORK YOU DO~ Now get the help your patient needs and lighten your load!