Chronic Pain Management in Primary Care

1. Chronic Pain Management in Primary Care Bill McCarberg, MD Founder Chronic Pain Management Program Kaiser Permanente San Diego, California Adjunct Assistant Clinical Professor University of California School of Medicine San Diego, California President Western Pain Society

2. The Problem • 65 million chronic pain patients in the United States • 6000 pain specialists • 120,000 primary care providers • The next major advancement in pain medicine will be in the training and expertise of the primary care provider - family medicine, internist, ob/gyn, pediatrics, nurse, nurse practitioner, physician assistant

3. Barriers to Treatment • Knowledge • Regulation • Bias

4. Chronic Pain Conundrum The most difficult issue now facing physicians “…whether and how to prescribe opioid therapy for chronic pain that is not associated with terminal disease, including pain experienced by the increasing number of patients with cancer in remission.” Ballantyne JC, Mao J. N Engl J Med. 2003;349:1943-1953.

5. Opioids in Chronic Pain • Strong push to use more opioids • Federation of State Medical Boards • Medical Boards encourage use—Intractable Pain Acts • Still controversial • May Day Project • Increased use and awareness of prescription drug abuse • Physician and, patient fear, bias, misunderstanding— Rush Limbaugh • Regulatory oversight is real

6. Old Teaching All patients get addicted to narcotics Side effects limit effectiveness Save until pain is really bad - tolerance Pain is not life threatening New Thoughts Almost no one gets addicted to opioids Side effects can be managed Treat pain early - tolerance is exaggerated Pain kills Opioid Analgesia—1990s

7. Old Teaching All patients should be given a trial of opioids No ceiling effects for opioids High pain levels require opioids as first-line agents Even addicts do well on opioid therapy New Thoughts In some patients, risks may be too high for opioids As doses increase, effects lessen; hypersensitization Pain levels alone do not dictate opioids Significant practice issues in monitoring patients on opioids Opioid Analgesia—2000s

8. Practice Issues • Limited time • Pain is one of many problems • Unrealistic expectations • Adversarial relationship • Disability, handicap, Internet

9. Top Concerns Among PCPs (N=248) n=208 n=185 n=168 n=150 n=79 Bhamb B, et al. Curr Med Res Opin 2006;22(9):1859-65.

10. Primary Care and Chronic Pain • Only providers able to cope with the number of patients with chronic pain • Limited time but multiple, repeated exposures to patient and family • Seen patients in crisis • Aware of coping mechanisms • Know family members

11. Primary Care and Chronic Pain • Practicing disease management models and not threatened • Uniquely positioned to deal with health care and the undertreatment of pain

12. Chronic Disease Others 14% 9% 8% 10% 11% 6% Primary Care 86% 91% 92% 90% 89% 94% Condition ASCVD Stroke Hypertension Diabetes COPD Asthma Data based on 1996 Medical Expenditure Panel Surveys. Annals of Family Medicine Vol 2 Suppl 1 March/April 2004

13. Pain Specialist Nurses Primary Clinician Psychiatrist Spine Surgeon Neurologist Pharmacist Physiatrist Social Worker Psychologist Anesthesiologist Occupational Therapist Physician Assistant Physical Therapist Interdisciplinary Pain Management Integrated Coordinated

14. Legal • 5th Vital Sign • Joint Commission on Accreditation of Healthcare Organizations • Decade of Pain Control and Research • AB 487 • Litigation

15. Opioid Literature - homogeneous • Noncancer Pain - heterogeneous • Cancer

16. The Four A’s of Treatment Outcomes • Analgesia (pain relief) • Activities of Daily Living (psychosocial functioning) • Adverse effects (side effects) • Aberrant drug taking (addiction-related outcomes) Passik & Weinreb, 1998

17. Aberrant Behavior Probably less predictive • Aggressive complaining about need for higher doses • Drug hoarding during periods of reduced symptoms • Requesting specific drugs • Acquisition of similar drugs from other medical sources • Unsanctioned dose escalation 1 – 2 times • Unapproved use of the drug to treat another symptom • Reporting psychic effects not intended by the clinician Probably more predictive • Selling prescription drugs • Prescription forgery • Stealing or borrowing another patient’s drugs • Injecting oral formulation • Obtaining prescription drugs from non-medical sources • Concurrent abuse of related illicit drugs • Multiple unsanctioned dose escalations • Recurrent prescription losses After Portenoy, in press.

18. Substance Abuse Issues Complicate Pain Treatment • Trust issues • Differentiating between analgesia and other effects of opioids • Dysfunctional family issues • Legal issues

19. What is the Risk of Addiction? • Boston Collaborative Drug Surveillance Project: Porter and Jick, 1980. NEJM • 4 cases of addiction in 11,882 patients with no prior history of abuse who received opioids during inpatient hospitalization • Dunbar and Katz, 1996. JPSM • 20 patients with both chronic pain and substance abuse problems on chronic opioid therapy

20. What is the Risk of Addiction? • Dunbar and Katz, 1996. JPSM • Nine out of 20 abused medication • Of the 11 who did not abuse the medications, all were active in recovery programs with good family support

21. Spectrum of Risk of Addictionor Aberrant Behavior ~ 45% <1% HIGH Long-term exposure to opioids in addicts, Dunbar and Katz LOW Short-term exposure to opioids in non-addicts Porter and Jick Where is your patient?

22. Can You Define Addiction? 45 year old female with achiness everywhere, disabled, poor sleep, daytime fatigue, having trouble functioning at home. 4 Vicodin a day used to work, now 8 Vicodin does not help the pain.

23. Can You Define Addiction? 55 year old male with back pain, S/P a two level laminectomy followed a year later by a fusion and the pain continues. He is out of town and runs out of his Percocet®. He develops nausea, tremors, diarrhea, a low grade fever and begins to hallucinate.

24. Pseudo-Addiction Pattern of drug seeking behavior of pain patients receiving inadequate pain management that can be mistaken for addiction • Cravings and aberrant behavior • Concerns about availability • “Clock-watching” • Unsanctioned dose escalation Weissman DE, Haddox JD. Oploid pseudo addiction- an iatrogenic syndrome. Pain 1989;36:363.

25. Addiction • Neurobiologic disease • genetic, • psychosocial • environmental factors • Characterized by: • Impaired control over drug use • compulsive use, • continued use despite harm • craving Consensus Document The American Academy of Pain Medicine The American Pain Society The American Society of Addiction Medicine

26. DSM-IV Substance Dependence • Tolerance • Physical dependence/withdrawal • Used in greater amounts or longer than intended • Unsuccessful attempts to cut down or discontinue • Much time spent pursuing or recovering from use • Important activities reduced or given up • Continued use despite knowledge of persistent physical or psychological harm 3/7 required for diagnosis 5/7 common in non-addicted pain patients Sees and Clark, J Pain and Symptom Management 1993

27. Differential Diagnosis of Aberrant Drug-Taking Attitudes and Behavior • Addiction • Pseudo-addiction (inadequate analgesic) • Other psychiatric diagnosis • Encephalopathy • Borderline personality disorder • Depression • Anxiety • Criminal Intent (Passik & Portenoy 1996)

28. PAIN MANAGEMENT TREATMENT PLAN AGREEMENT COVER SHEET Date initiated: _______________ Purpose: The purpose of this Agreement is to prevent misunderstandings about certain medicines I will be taking for pain management. This is to help both my doctor and me to comply with the law regarding controlled medications. I understand that this Agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my doctor undertakes to treat me based on this Agreement.

29. LEVEL 1 PAIN MANAGEMENT TREATMENT PLAN AGREEMENT I, _______________________ hereby acknowledge that my physician, __________________ has informed me that ___________which is being prescribed for my diagnosis of ________________ involves possible risks. These risks are listed on the cover sheet of this treatment plan agreement. Because of the potential problems of dependency and/or overuse, I agree to use this medication no more frequently than _________________ unless specified by future agreement with my physician. I will inform any health care providers that treat me that I am taking the medication(s) listed above, and that I have a Medication Agreement with my doctor. I will seek refills of the above medication from _______________ .

30. LEVEL 2 PAIN MANAGEMENT TREATMENT PLAN AGREEMENT I, __________________________________ hereby acknowledge that my physician, (Patient name) _______________________________, has informed me that s/he is concerned with (Physician name) my prescription drug usage. S/he has advised me of available counseling for this issue. I will seek refills of the medication listed below from _______________________________ or his/her representative at the medical (Physician name) office at _________________________________, and not from any other provider. (Location) I am aware taking this medication involves certain risks, and these risks are listed on the cover sheet of this treatment plan agreement. I will not use any illegal substances, including, but not limited to marijuana, cocaine, methamphetamines, or heroin. I will not share, sell, or trade my medication with anyone. I will inform any health care providers that treat me that I am taking the medications listed below, and that I have a Medication Agreement with my doctor. I will not attempt to obtain any controlled medicines, including opioid (narcotic) pain medicines, narcotic cough medicines, controlled stimulants, or antianxiety medicines from any other source. I will safeguard my pain medicine from loss or theft. “lost” or “ stolen” medications suggest medication abuse and the medicine may not be replaced.

31. I agree that I will use my medicine as prescribed, and will not take more than prescribed. I understand that use of my medicine at a greater rate than prescribed may result in my being without medication for a period of time. I understand that if this occurs I may experience withdrawal symptoms. I hereby agree that I will use _______________________________________________ Name of drug(s) ______________________________________________________________________ no more frequently than __________________________________________________ sig or other range (e.g., #tablets/day, #tablets/month) ______________________________________________________________________ unless specified by future agreement with my prescribing physician. I am taking this medication to treat my problem of ____________________________________. (Diagnosis or problem, e.g., chronic back pain) I agree that refills of my prescriptions for pain medicine will be made only at the time of an office visit or during regular office hours. No refills will be available during evenings or on weekends. I understand that it is desirable to make refill requests one week before they are due. I am aware that communication will occur in such a manner as to discourage any other physicians from dispensing medication to me except in cases of emergency. I agree to follow these guidelines, and that they have been fully explained to me. All of my questions and concerns regarding treatment have been adequately answered. I understand that if I break this Agreement, my doctor may stop prescribing these pain-control medicines and no further such medications may be prescribed by Kaiser Permanente physicians or filled at Kaiser pharmacies. I understand that should I fail to abide by the above usage plan that my membership in the Kaiser Permanente Health Plan may be subject to termination.

32. Follow-up issues I agree to schedule and keep appointments with prescribing physician as instructed. I agree to schedule and keep appointments with consulting health care providers, laboratory tests and diagnostic tests as recommended by prescribing physician. I realize that all of the medications have potential side effects, and I will have the recommended laboratory studies required to keep the treatment as safe as possible. I agree to attend Chronic Pain Management Program classes. Compliance issues I agree that I will submit to a blood or urine test if requested by my doctor to determine my compliance with my program of pain control medicine. I will bring all unused pain medicine to every office visit. Adding more restrictions: I understand that I must request medication refill 7 (seven) days in advance. I agree to use _______________________________________ Pharmacy, located at ________________________, for filling prescriptions for all of my pain medicine. I understand that I will only get 1 (one) week's supply of medication at one time. I understand that only I am allowed to pick up my medications, and that I will be asked for a photo identification. My signature below indicates that a copy of this document has been given to me.

33. Conclusions • Pain specialists are the best trained to deal with complicated, complex chronic pain patients • Interdisciplinary pain care gives the best pain relief, functional improvement, and cost

34. Conclusions • Interdisciplinary pain treatment has become a single provider working with multiple specialists