Utility of a Sole Provider Program in the Treatment of Chronic Non-Cancer Pain

1. Utility of a Sole Provider Program in the Treatment of Chronic Non-Cancer Pain  Anthony A.D. Noya, MD CPT (P), MC NHMA 14th Annual Conference

2. The opinions and assertions expressed herein are my private views and are not to be construed as official or as reflecting the views of the U.S. Army Medical Corps or the U.S. Army at large. I do not have any conflicts of interest. Sources of funding: None.

3. My Background Born and raised in New England – parents came to U.S. from Cuba in the 1960’s. College and Medical School in New England – ROTC and HPSP Scholarships. Family Medicine Residency in Augusta, GA – Eisenhower Army Medical Center. Little to no training in/exposure to Chronic Pain during medical school and residency training. Moved to Fort Polk, LA – Bayne-Jones Army Community Hospital (BJACH) in 2007. Comment on this slide my reasons for joining the Army This country has been great to my family and I see military service as a way of paying back my debt of gratitude. The funding of my education. ROTC gave me the opportunity to develop leadership skills and build confidence. Mention here the benefit of practicing medicine in the Military Healthcare System Patients have no co-payments, no deductibles, excellent access to quality care, and an excellent core pharmacy formulary. It is an ideal environment – don’t have to worry about overhead, medical malpractice costs, dealing with reimbursement struggles, or patient’s inability to pay for care. Mention here percentage of Hispanic soldiers in the military (about 10%) and in the U.S. Army (about 11%). Comment on this slide my reasons for joining the Army This country has been great to my family and I see military service as a way of paying back my debt of gratitude. The funding of my education. ROTC gave me the opportunity to develop leadership skills and build confidence. Mention here the benefit of practicing medicine in the Military Healthcare System Patients have no co-payments, no deductibles, excellent access to quality care, and an excellent core pharmacy formulary. It is an ideal environment – don’t have to worry about overhead, medical malpractice costs, dealing with reimbursement struggles, or patient’s inability to pay for care. Mention here percentage of Hispanic soldiers in the military (about 10%) and in the U.S. Army (about 11%).

4. Presentation Outline  Increase Awareness of the complexity of treating chronic non-cancer pain. Familiarization with the Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Non-Cancer Pain. Bayne-Jones Army Community Hospital Sole Provider Program Case Example.

5. Keep this image in mind when you see a patient with the complaint of pain. The goal of successful treatment is to address the snowball early in it’s course with a goal-oriented multidisciplinary approach focusing not solely on biological, but also on the psychosocial components of the pain syndrome. By doing so, you can prevent the snowball from getting too big and out of hand.Keep this image in mind when you see a patient with the complaint of pain. The goal of successful treatment is to address the snowball early in it’s course with a goal-oriented multidisciplinary approach focusing not solely on biological, but also on the psychosocial components of the pain syndrome. By doing so, you can prevent the snowball from getting too big and out of hand.

6. Backdrop Pain is #1 reason why Americans visit the office and the number one reason why they come away disappointed Pain’s burden on society - $100 billion/yr 5th Vital Sign – late 1990’s Prescriptions for NSAIDs and Opiates for chronic musculoskeletal pain increased 4-fold between 1980 and 2000 Prescription opioids are fastest growing form of drug abuse Annual Cost of Chronic Pain in the U.S. is estimated to be $100 billion – healthcare expenses, lost income, lost productivity. Attention to effectively addressing pain arose in the late 1990’s – It was determined at that time that there was undertreatment of pain described in the literature and it was felt that something had to be done about it. In 1999, in an attempt to improve pain management, the Veterans Health Administration instituted “Pain as the 5th Vital Sign” initiative – requiring a 1 to 10 scale be used at all encounters. Studies have shown there has been no improvement in overall pain management as a result of this implementation. Comparing data from 1980 and 2000 there is evidence to show that our prescribing of NSAIDs and potent opioids (such as hydrocodone, oxycodone, and morphine) for chronic musculoskeletal pain increased from 2% to 9% of visits to outpatient providers. There has been no increased prevalence of musculoskeletal problems. Therefore, this shows that our threshold for prescribing NSAIDs and opiates has decreased. Preliminary analyses of data from a large nationwide commercial health plan suggest that opioid therapy is more concentrated than any other prescribed therapy, with 5% of enrollees with chronic pain accounting for 70% of all the opioids consumed in a year. It also appears that a minority of patients discontinue opioid therapy after taking it for 90 days. As many teenagers start nonmedical use of prescription opioids as start cannabis. I hope this presentation will help you have a better understanding of this complexity of treating chronic non-cancer pain and awareness of the current guidelines to help ensure that you are providing high quality and safe care. Annual Cost of Chronic Pain in the U.S. is estimated to be $100 billion – healthcare expenses, lost income, lost productivity. Attention to effectively addressing pain arose in the late 1990’s – It was determined at that time that there was undertreatment of pain described in the literature and it was felt that something had to be done about it. In 1999, in an attempt to improve pain management, the Veterans Health Administration instituted “Pain as the 5th Vital Sign” initiative – requiring a 1 to 10 scale be used at all encounters. Studies have shown there has been no improvement in overall pain management as a result of this implementation. Comparing data from 1980 and 2000 there is evidence to show that our prescribing of NSAIDs and potent opioids (such as hydrocodone, oxycodone, and morphine) for chronic musculoskeletal pain increased from 2% to 9% of visits to outpatient providers. There has been no increased prevalence of musculoskeletal problems. Therefore, this shows that our threshold for prescribing NSAIDs and opiates has decreased. Preliminary analyses of data from a large nationwide commercial health plan suggest that opioid therapy is more concentrated than any other prescribed therapy, with 5% of enrollees with chronic pain accounting for 70% of all the opioids consumed in a year. It also appears that a minority of patients discontinue opioid therapy after taking it for 90 days. As many teenagers start nonmedical use of prescription opioids as start cannabis. I hope this presentation will help you have a better understanding of this complexity of treating chronic non-cancer pain and awareness of the current guidelines to help ensure that you are providing high quality and safe care.

7. Chronic Noncancer Pain Pain unrelated to cancer that persists beyond the usual course of disease or injury (3 to 6 or more months of pain) It may or may not be associated with a pathologic process Psychosocial comorbidities Rarely cure patients What is the best treatment approach? Let’s go over some definitions in order to lay the groundwork for the rest of the presentation. We will go over the best treatment approach in a little bit. Lets continue with some more important definitions.Let’s go over some definitions in order to lay the groundwork for the rest of the presentation. We will go over the best treatment approach in a little bit. Lets continue with some more important definitions.

8. More Definitions Physical Dependence – Withdrawal symptoms Addiction – maladaptive behavior to satisfy a craving for the drug Chronic, neurobiological disease Genetic, psychosocial, and environmental factors The following definitions relate more specifically to issues that can be seen when chronic opiates are prescribed.The following definitions relate more specifically to issues that can be seen when chronic opiates are prescribed.

9. More Definitions Pseudoaddiction – Relief-seeking behaviors that resolve upon institution of effective analgesic therapy Substance Abuse – Use for purposes that are not those for which prescribed (e.g. getting high) Tolerance – Adaptation resulting in a gradual need to increase the dose to obtain the same effect

10. More Definitions Misuse – Use of a medication other than as directed Aberrant drug-related behavior – A behavior outside the boundaries of the agreed upon treatment plan Hyperalgesia – An increased response to a stimulus which is normally painful

11. Clinical Guidelines for the Use of Chronic Opioid Therapy(COT) in Chronic Non-Cancer Pain(CNCP) The Journal of Pain, Vol 10, No 2 (February) 2009; pp 113-130. The American Pain Society and the American Academy of Pain Medicine multidisciplinary panel of 21 experts Literature through November 2007 8,034 abstracts, 14 systematic reviews, and 57 primary studies reviewed The American Pain Society, in partnership with the American Academy of Pain Medicine commissioned a multidisciplinary panel to develop evidence-based guidelines on Chronic Opiate Therapy for adults with Chronic Non-Cancer Pain. These recommendations are based on a systematic evidence review and were published in the Journal of Pain in February 2009. We will not be able to cover these guidelines extensively in this short period of time. However, I do recommend referring to this journal article as well as the appendices for a complete review of this topic. The American Pain Society, in partnership with the American Academy of Pain Medicine commissioned a multidisciplinary panel to develop evidence-based guidelines on Chronic Opiate Therapy for adults with Chronic Non-Cancer Pain. These recommendations are based on a systematic evidence review and were published in the Journal of Pain in February 2009. We will not be able to cover these guidelines extensively in this short period of time. However, I do recommend referring to this journal article as well as the appendices for a complete review of this topic.

12. Patient Selection and Risk Stratification History, physical examination and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction COT is an option if CNCP is moderate or severe, pain is having adverse impact on function or quality of life, and potential therapeutic benefits outweigh or are likely to outweigh harms Benefit-to-harm evaluation documented before and during COT Patient-centered Care! Risk vs. Harm Analysis. There are clear situations where harms outweigh potential benefits for particular patients. In these cases, COT should not be initiated and/or it should be discontinued with an appropriate wean. Risk stratification is a vital but underdeveloped skill for many clinicians. This is an area where there is a knowledge/awareness gap and more education and training should be devoted to attainment and enhancement of this skill. If a patient is not responding to a treatment plan within a few days/weeks, consider multidisciplinary referrals early. And always consider psychosocial factors since they are strong predictors of outcomes and prognosis. The factor that appears to be most strongly predictive of drug abuse, misuse, or other aberrant drug-related behaviors after initiation of COT is personal or family history of alcohol or drug abuse. Younger age and presence of psychiatric conditions are also associated with aberrant drug-related behaviors in some studies. Case: 35 y/o male with personality disorder, anxiety, and chronic pain – back, knee, wrist. Vs. 60 y/o with chronic disabling OA despite nonopioid therapies whose history reveals no significant psychiatric comorbidities, major medical comorbidities, or personal or family history of drug abuse or addiction.Patient-centered Care! Risk vs. Harm Analysis. There are clear situations where harms outweigh potential benefits for particular patients. In these cases, COT should not be initiated and/or it should be discontinued with an appropriate wean. Risk stratification is a vital but underdeveloped skill for many clinicians. This is an area where there is a knowledge/awareness gap and more education and training should be devoted to attainment and enhancement of this skill. If a patient is not responding to a treatment plan within a few days/weeks, consider multidisciplinary referrals early. And always consider psychosocial factors since they are strong predictors of outcomes and prognosis. The factor that appears to be most strongly predictive of drug abuse, misuse, or other aberrant drug-related behaviors after initiation of COT is personal or family history of alcohol or drug abuse. Younger age and presence of psychiatric conditions are also associated with aberrant drug-related behaviors in some studies. Case: 35 y/o male with personality disorder, anxiety, and chronic pain – back, knee, wrist. Vs. 60 y/o with chronic disabling OA despite nonopioid therapies whose history reveals no significant psychiatric comorbidities, major medical comorbidities, or personal or family history of drug abuse or addiction.

13. Use of Psychotherapeutic Interventions CNCP is a complex biopsychosocial condition Routinely integrate psychotherapeutic interventions, functional restoration, interdisciplinary therapy, and other adjunctive nonopioid therapies When pain is accompanied by comorbidities, impaired function, or psychological disturbances, COT is likely to be most effective as part of a multidisciplinary treatment plan that addresses all of these domains. Cognitive-behavioral therapy is the best-studied psychological therapy and is consistently shown to be effective for CNCP. It often focuses on helping patients cope with chronic pain to improve function. Other potentially beneficial psychological therapies include progressive relaxation, and biofeedback. Barriers to obtaining multidisciplinary care include high costs, limited availability in the United States, and frequent lack of insurance coverage. As you’ll hear about in a little bit, at the Army Community Hospital where I work, and potentially at any military treatment facility, this is not an obstacle. At my facility, our biggest obstacles seem to be clinicians’ awareness of what services are available and our patient’s lack of motivation to travel in order to obtain the standard of care. When pain is accompanied by comorbidities, impaired function, or psychological disturbances, COT is likely to be most effective as part of a multidisciplinary treatment plan that addresses all of these domains. Cognitive-behavioral therapy is the best-studied psychological therapy and is consistently shown to be effective for CNCP. It often focuses on helping patients cope with chronic pain to improve function. Other potentially beneficial psychological therapies include progressive relaxation, and biofeedback. Barriers to obtaining multidisciplinary care include high costs, limited availability in the United States, and frequent lack of insurance coverage. As you’ll hear about in a little bit, at the Army Community Hospital where I work, and potentially at any military treatment facility, this is not an obstacle. At my facility, our biggest obstacles seem to be clinicians’ awareness of what services are available and our patient’s lack of motivation to travel in order to obtain the standard of care.

14. Identifying a Medical Home and When to Obtain Consultation Patients on COT should identify a clinician who accepts primary responsibility for their overall medical care This clinician may or may not prescribe COT, but should coordinate communication among all clinicians involved in the patient’s care Clinicians should pursue consultation, including multidisciplinary pain management, when patients with CNCP may benefit from additional skills or resources that they cannot provide Plug for Continuity of Care, Family Medicine, and Primary Care in general – Studies show that patients do better when they have continuous access to a clinician who provides comprehensive care for the large majority of their health care needs and who coordinates care when the services of other health care professionals are needed. Patients with CNCP use health services more frequently, and have more comorbidities than those without CNCP. Studies show that effective primary care is the bedrock of any well-developed healthcare system and in my opinion it is the “best defense” against the “snowball effect” of chronic pain. Plug for Continuity of Care, Family Medicine, and Primary Care in general – Studies show that patients do better when they have continuous access to a clinician who provides comprehensive care for the large majority of their health care needs and who coordinates care when the services of other health care professionals are needed. Patients with CNCP use health services more frequently, and have more comorbidities than those without CNCP. Studies show that effective primary care is the bedrock of any well-developed healthcare system and in my opinion it is the “best defense” against the “snowball effect” of chronic pain.

15. Bayne-Jones Army Community Hospital – Fort Polk, LA Fort Polk is a Combat Training Center that trains and deploys combat units About 9,000 active duty soldiers and a total of about 23,000 healthcare beneficiaries including family members and retirees Demographics play a role Rural vs Metropolitan, Age (young), Psychosocial Stressors The hospital supports the units that are responsible for the major training center as well as units on post that deploy. Located in a rural area. Generally young patient population with multiple psychosocial stressors. All of these factors increase risk of narcotic abuse/addiction.The hospital supports the units that are responsible for the major training center as well as units on post that deploy. Located in a rural area. Generally young patient population with multiple psychosocial stressors. All of these factors increase risk of narcotic abuse/addiction.

16. Medical Home Model Improved provider to patient ratios by utilizing multiple sole providers Key Partnerships – Managed Care/Case Management, Department of Behavioral Health, BJACH Pharmacy, and local Pain Specialists Nurse case management provides patient education, coordination and continuity of care for more complex patients Behavioral Health offers Complimentary & Alternative Management Approach (CAMA) Group Therapy sessions weekly Sole Providers are Primary Care Physicians. Chiropractic Clinic is Opening for Active Duty Soldiers. Committee with members from all the key partnerships meets monthly to discuss ways to improve program and to discuss difficult cases. Most recent meeting in March, we approved edits to our Sole Provider Agreement so that it is more in line with the clinical guidelines. Focus on Function & Safety, with a Multidisciplinary and Biopsychosocial Approach. Sole Providers are Primary Care Physicians. Chiropractic Clinic is Opening for Active Duty Soldiers. Committee with members from all the key partnerships meets monthly to discuss ways to improve program and to discuss difficult cases. Most recent meeting in March, we approved edits to our Sole Provider Agreement so that it is more in line with the clinical guidelines. Focus on Function & Safety, with a Multidisciplinary and Biopsychosocial Approach.

17. Conclusion Safe and effective therapy requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion Target psychosocial factors Identify a medical home for all chronic pain patients Knowledge is power – Awareness and acknowledgement of the challenges related to the treatment of chronic noncancer pain are vital in order to improve outcomes and limit adverse effects. Risk vs Benefit Analysis at all times must be implemented. The single pronged approach to pain management is ineffective. A multidisciplinary goal-oriented approach managed from a primary care/medical home standpoint with a biopsychosocial perspective is the key to success.Knowledge is power – Awareness and acknowledgement of the challenges related to the treatment of chronic noncancer pain are vital in order to improve outcomes and limit adverse effects. Risk vs Benefit Analysis at all times must be implemented. The single pronged approach to pain management is ineffective. A multidisciplinary goal-oriented approach managed from a primary care/medical home standpoint with a biopsychosocial perspective is the key to success.

18. References Chou, R, et al. Clinical Guidelines for the Use of Chronic Opiod Therapy in Chronic Noncancer Pain. J Pain. February 2009; 10(2):113-130. http://www.painmed.org/pdf/noncancer_opioid_guidelines.pdf Disorbio JM, Bruns D, Barolat G. Assessment and Treatment of Chronic Pain: A physician’s guide to a biopsychosocial approach. PPM. March 2006:1-10. Bonakdar RA. Non-pharmacolgic Pain Management. Lecture notes from presentation given at 2009 AAFP Scientific Assembly. Sullivan MD. The quest for rational chronic pain pharmacotherapy. General Hospital Psychiatry. 2009;31:203-205. Editorial. Caudill-Slosberg MA, et al. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. JIASP. June 2004;109(3):514-519. Jackman RP, Purvis JM. Chronic Nonmalignant Pain in Primary Care. Am Fam Physician. 2008;78(10):1155-1162, 1164. http://www.aafp.org/afp/20081115/1155.html Benedict DG. Walking the Tightrope: Chronic Pain and Substance Abuse. JNP. September 2008;4(8):604-609. Gelfand SG. Medscape Commentary: The Pitfalls of Opioids for Chronic Nonmalignant Pain of Central Origin. Posted 02/25/2002. http://www.medscape.com/viewarticle/425468 Memorandum. OTSG/MEDCOM Policy Memo 09-064, 04 AUG 2009, subject: Use of Opioid Medications in Pain Management. MEDDAC Regulation. MEDDAC Reg 40-99, 27 SEP 2009, subject: Medical Services Sole Prescriber Program.