San Francisco Safety Net Chronic Pain Management Education Day

1. San Francisco Safety Net Chronic Pain Management Education Day Finding Common Ground in the Gray Zone

2. Welcome!

3. Why are we here today?

4. Why are we here today?

5. Objectives • Identify and manage risk factors for opioid misuse • Respond to patient behaviors that are concerning for opioid misuse • Support patients in managing substance use disorders • Examine systems-level interventions that support safe pain management • Develop policies or procedures in your own clinic to improve pain management practices

6. Shape of the Day • Keynote • Case-based panel • Break • Lecture • Lunch • Facilitator breakout • Small Groups • CURES Table

7. Disclosures None of the speakers have financial disclosures to report

8. Managing the Risks of Opioid Prescribing

9. Mr. Anderson • 46 year old man discharged from LHH 8 days ago • Requesting refill of pain medications • Hospitalized 4 mo ago s/p MVA • Right femur fracture • Pelvic fracture • Multiple rib fractures • s/p surgical fixation of fractures • BZD, EtOH, opiates in blood and urine drug test

10. Mr. Anderson • Discharged to Laguna Honda • Discharged from rehab 8 days ago • Currently with pain in right leg, right chest • Leg pain constant ache, worst in cold • Able to walk 2 blocks • Increased irritability due to pain • Poor sleep

11. Mr. Anderson • Medications: • MS contin 100mg TID • Oxycodone 30mg q6 hrs PRN • No change in this regimen over 10 weeks at LHH

12. Mr. Anderson • Drank 2-4 beers daily before accident, none since • h/o heroin use, none for 3y before accident • Occasionally buys prescription opioids on the street, had taken Morphine the day before the accident • Occasional benzodiazepine use “when they’re around” • 1 ppd cigarettes • Unemployed, on GA, applying for disability • Mother with cocaine and EtOH dependence

13. Who is at high risk for harm from opioids?

14. Characterizing Risk of Opioid Misuse

15. What We Don’t Want Opioid Use Disorder (abuse, dependency) I prescribe opioids to my patient Diversion HARM

16. How Common is the Bad Stuff Fishbain et al. Pain Medicine; 9(4): 444-59. 2008

17. Risk Assessment • Purpose of Risk Assessment • Prior to initiation of opioids • Ongoing monitoring • How to do it • Formal instruments • Clinical evaluation • Underlying principle: universal precautions • Guidelines (APS, AAPM), 2009 Chou et al. 2009. Journal of Pain. 10(2): 113-30.

18. Risk Assessment Instruments • Lots of them • Screener and Opioid Assessment for Patients with Pain (SOAPP) – 24 items • Pain Medication Questionnaire (PMQ) – 26 items • Prescription Drug Use Questionnaire –Patient Version (PDUQP) – 24 items • Opioid Risk Tool (ORT) – 5 items • Diagnosis, Intractability, Risk, Efficacy (DIRE) – 7 items • Alturi & Sudarshan – 6 items

19. Two Options: Opioid Risk Tool (ORT) • Scoring patients: • low risk (0-3) • medium (4-7) • high (≥ 8) • High risk: • 91% sensitivity for ADRB • Positive LR 14 Webster LR, Webster RM. Pain Med. 2005;6(6):432-442

20. Second Option Not willing to try non opioid modalities Always asking about opioids (inc 1st visit) Upset when denied opioids Requesting particular med • Atluri Tool • 6 clinical criteria • Focus on opioids • Opioid overuse • Other substance use • Low functional status • Unclear etiology of pain • Exaggeration of pain • Score >3 OR of 16 for opioid misuse ER visit for pain; Use up own supply too fast History of drug/EtOH abuse Currently using marijuana Feels need for benzos On disability or applying Pain “everywhere” Non-physiologic distribution Atluri SL et al. Pain Physician 2004; 7:333-338.

21. Risk Assessment Tools • Clinical Evaluation • Pain clinic study comparing: SOAPP-R, ORT, PMQ and a 45-min semi-structured interview with a psychologist • Psychologist’s evaluation of risk was the most sensitive predictor for later discharge from pain clinic • Note: psychologist had 27 years of clinical experience • 6 years in substance abuse Jones et al. The Clinical Journal of Pain. 2012; 28(2): 93-100.

22. Substance Use Screening • Single Item screeners • NIDA: “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” • NIAAA: “How many times in the past year have you had more than 4/3 drinks in a day?”

23. Substance Use Screening

24. Our Patient ORT score: 18 = HIGH RISK

25. Second Option Not willing to try non opioid modalities Always asking about opioids (inc 1st visit) Upset when denied opioids Requesting particular med • Atluri Tool • 6 clinical criteria • Focus on opioids • Opioid overuse • Other substance use • Low functional status • Unclear etiology of pain • Exaggeration of pain • Score >3 OR of 16 for opioid misuse ER visit for pain; Uses up own supply too fast History of drug/EtOH abuse Currently using marijuana Feels need for benzos On disability or applying Pain “everywhere” Non-physiologic distribution Atluri SL et al. Pain Physician 2004; 7:333-338.

26. What to do with the risk evaluation? Atluri et al. Pain Physician; 2012; 15: ES177

27. Our Patient • High risk for “ADRBs” • Options • Taper off opioids • Continue opioids with close monitoring • Frequent Utox (q month) • Short refill interval (q 2 weeks) • Frequent CURES report (3-4 times per year) • Patient Agreement and Informed Consent with explanation of reasons for discontinuation (i.e. no show, refusal of alternative treatments, abnormal Utox results)

28. How do we assess and understand the impact of psychosocial issues on the pain experience?

29. Psychosocial Assessment • Brief Intervention vs. Detailed Psychosocial Assessment • Brief Intervention in Primary Care Behavioral Health • Review presenting problem/referral question • Assess/strengthen supports • Identify/build coping skills

30. Detailed Psychosocial Assessment(may be gathered over time by various team members) • Presenting problem/referral question • Culture/family history • Educational/work history • Relationship history/interpersonal issues • Trauma history • Substance use history • Psychiatric/medical history • Current: • Symptoms • Supports • Coping skills

31. Mr. Anderson’s Psychosocial Assessment

32. Culture/family history • Born in Ohio, family background Irish/German/Danish • No strong cultural/religious affiliations • Middle of 3 kids, father left when pt. was 7 • Mother and siblings moved around • Educational/work history • Completed 10th grade, fair grades • Has worked odd jobs, • mostly house painting • Currently on GA, in SRO

33. Relationship history/interpersonal issues • Married twice, now lives with female partner • History of anger management problems including • IPV with partners • No longer speaks to siblings • Feels angry/disappointed with medical • system for not curing his pain • Trauma history • Vague memories of IPV between parents, mother verbally and physically abusive, sexual assault by an older man age 11

34. Substance use history • ”I’ve tried everything” • Drank 2-4 beers daily before accident, none since • •  H/O heroinuse, none for 3 years •Occasionally buys prescription • opioids on the street (Morphine) • Occasional benzodiazepine use   • 1 ppdcigarettes

35. Psychiatric history • Long history of depressive sx, “I’ve been depressed all my life” • No history of manic episodes, no psychiatric hospitalizations • On various antidepressants with little effect • Intermittent suicidal ideation, one non-lethal gesture as adolescent

36. Current Symptoms • Depressed feelings, feeling “empty”, feeling like no one cares/no point in living, but no clear suicidal plan • Reports daily “mood swings”, but not mania • Feels that pain is intolerable, nothing helps • Angry that “system” is not helping him, feels abandoned by medical team for “withholding” medication

37. Psychosocial Assessment: Strengths • Support • Has female partner of 3 years • Has one “buddy” he sees quite regularly • Coping skills • Intelligent, resourceful • Reasonably good eating/exercise habits • Has managed to reduce/abstain from substances since the accident • Can respond to encouragement, support

38. Psychosocial Assessment: Findings • Does NOT currently meet criteria for major depression, more likely dysthymia • Not acute PTSD (“complex PTSD”) • Borderline personality features • Mood instability • Interpersonal issues, extremes • Impulse control problems, suicidal thoughts/gestures • Chronic feelings of emptiness • Expectation/fear of abandonment

39. Patient’s Experience of Pain • May experience pain as unrelenting, not distinguishing between physical and emotional pain • Feels that no one/nothing can help • May test limits to see if can influence you • May see things in extremes, you are “a wonderful provider” when increasing meds, a “%#&^!?!” when setting limits

40. Discussing Risk Issues Use understanding of pt. when discussing limits and risk issues • Interpersonal • The relationship is paramount • Stress partnership, trust, working together, listen to pt’s concerns • Put in the context of caring for pt; communicate respect

41. Splitting, Thinking in Extremes • Recognize the patient’s “all-or-nothing” thinking;help to find middle ground “It’s not exactly black and white. Let’s weigh the risks and benefits of going up on your dose together. We have to find a way to find some balance between how it helps and what the downsides are.”

42. Testing (Will you abandon me?) • Clear limits, consequences, structure helpful “I want to be able to work with you to find our best options over time. The only way I can do that is if we have some agreement about how we’re going to do this.” • Consciously give patient choices when possible “Would you prefer to take your meds twice a day or three times a day?”

43. Countertransference • Understand your personal reactions • Don’t let yourself be provoked by testing • Don’t take patient’s anger at/rejection of you as a failure

44. How do we minimize the risks if we do prescribe? • Clear patient-provider agreement • Frequent visits • Monitor function, not just pain score • Urine drug testing • CURES reports • Pill counts

45. How can we use Naloxone to reduce the risk of death by overdose?

46. Lay Naloxone for Overdose Prevention • Readily reverses opioid overdoses • Patient & provider support • Training easy & effective • Frequent reversals reported • Community-level mortality reduced Bazazi et al., J Health Care Poor Underserved 2010. Seal et al; Coffin et al., JUH 2003. Green et al., Addiction 2008. Enteen et al., JUH 2010. Walley et al., BMJ 2013; Albert et al., Pain Med 2011

47. Fatal Opioid Overdose Rates by Naloxone Implementation Walley et al. BMJ 2013; 346: f174.

48. DOPE Project Dispensing 1993-2012

49. Heroin Related Deaths: SF 1993-2010 Naloxone distribution begins *Data compiled from San Francisco Medical Examiner’s Reports, www.sfgsa.org**no data available for FY 2000-2001

50. Potential Behavior Changes • Risk of non-fatal opioid overdose • U.S. Army Fort Bragg • EMS/ED visits in SF • Syringe sharing in Seattle • Model • Overdose may influence behavior