Daniel C. Roth, D.O., M.B.A., M.S. Board Certified, Pain Medicine Board Certified, PM&R

Transcription

1 Daniel C. Roth, D.O., M.B.A., M.S. Board Certified, Pain Medicine Board Certified, PM&R

2 1. Review new Indiana laws for opioid prescribing 2. Outline pearls for office implementation of best practices and compliance monitoring

3 The MLB rules took effect on December 15, 2013 and apply to: Any patient taking 60 or more opioid pills per month for 3 months Any patient taking a morphine equivalent dose (MED) of 15 mg or more for 3 months

4 Patients that are exempt from monitoring under these rules include those who are: Terminally ill Involved with a palliative care service Managed in a hospice program Residents of a registered nursing home

5 1. Do your own evaluation 2. Risk stratification assess mental health and substance abuse 3. Set functional goals 4. Utilize evidence based treatments 5. Obtain informed consent + sign a treatment agreement 6. Periodic visits are required 7. Remember the 5 A s 8. INSPECT Indiana s prescription monitoring program 9. Urine drug monitoring (UDM) 10. Re-evaluate your patient and their treatment plan when the MED enters the mg/day range; consider consultation

6 Take a thorough history Perform a targeted physical exam Do appropriate tests Obtain and review records of past care

7 Ask your patient to complete a pain assessment survey like the: Brief Pain Inventory

8 Establish a working diagnosis Tailor a treatment plan to functional goals that your patient identifies Review your plan from time to time.

9 2. Risk Stratification for all. Assess both the mental health status and risk for substance abuse in each patient with a diagnosis of chronic p MENTAL HEALTH ASSESSMENT RISK FOR SUBSTANCE ABUSE

10 Chronic pain may be caused, influenced or modulated by Depression (PHQ-2, PHQ-9) Post Traumatic Stress Disorder Anxiety/Panic Disorder (GAD-7)

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12 2. Risk Stratification for all. Assess both the mental health status and risk for substance abuse in each patient with a diagnosis of chronic p Ask patients about any past or current history of substance abuse (alcohol, Rx meds, or illicits) prior to initiating treatment for chronic pain with opioids ORT Opioid Risk Tool SOAPP Screener/Opioid Assessment for Patients in Pain (starting opioids) COMM Common Opioid Misuse Measure (pts already using opioids) These survey tools will be available at:

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15 2. Risk Stratification for all. Assess both the mental health status and risk for substance abuse in each patient with a diagnosis of chronic p The use of chronic opioids in high risk patients is discouraged unless the underlying issues are appropriately addressed. Specialty consultation may be appropriate.

16 Working together with your patient, determine: Specific Achievable Functional Goals * Assess progress at each visit * Reframe expectations: A realistic Pain Score target isn t zero!

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18 Utilize available first-line pharmacologic options before prescribing opioids Give strong consideration to non-pharmacologic options in addition to the medications available

19 AVOID opioids in patients with: Chronic headache Chronic low back pain Chronic pelvic pain Fibromyalgia Functional bowel disorders (IBS) OPIOIDS Use non-opioid pharmacologic agents and other treatment modalities for pain management in these situations.

20 When an opioid trial is warranted, use the lowest dose possible to reduce pain and improve functioning. Discontinue opiates if pain does not improve or if functional goals are not met. Always have an EXIT strategy! Don t begin a treatment that you are not prepared to stop!

21 Discuss the risks and benefits of opioid treatment with your patients, including common adverse effects. Provide a clear explanation to help patients understand key elements of their treatment plan. Counsel women of child-bearing age about the potential for fetal opioid dependence and neonatal abstinence syndrome (NAS).

22 Long term benefit of treatment with opioids has not been established One prescriber, one pharmacy Medication is for patient s use only; no sharing or selling meds Keep medications safe; lost or stolen Rx will not be replaced Renewals are contingent on scheduled appointments No phone refills There is potential for addiction, and abstinence syndrome if the medication is stopped abruptly Prescription Drug Monitoring (INSPECT) will be reviewed regularly Participation in Urine Drug Monitoring, as directed Failure to follow policies or lack of functional benefit with the treatment will result in discontinuation of the opioid trial (taper)

23 Evaluate patient progress Monitor compliance Set clear expectations Q 3-4mo, if stable (minimum) Q 1-2mo, if changing meds; more often as needed

24 Affect (screen for mental illness & substance use) Activities of Daily Living Analgesia Adverse effects Aberrant drug use behaviors

25 Use INSPECT regularly for new and established patients to detect unsafe patterns of medication use. Tracks all controlled substance prescriptions filled state-wide. INSPECT is free and easy to use; INSPECT reports are required initially and annually (begins 12/2014) as the minimum. Consider more often!

26 Chronic Pain Guidelines function most effectively when the process you implement applies to all chronic pain patients... Universal Precautions

27 UDM is a useful objective tool that complements your other risk assessments. Discussion with patients regarding the need for UDM should legitimately be based on their SAFETY

28 Face-to-face review to reassess your patient if pain is poorly controlled or there is lack of functional improvement Formulate/document a revised assessment and treatment plan Discuss the increased risk for adverse outcomes with higher opioid doses if that is what you plan to do

29 Opioid adjustments may include: a slow wean, modified dose (up/down) or rotation to another formulation Collaboration with a mental health professional, as needed. Referral to a pain management specialist for evaluation/treatment. Referral to an addiction specialist for evaluation when a substance use disorder is suspected.

30 Patient mortality risk is more pronounced for patients that have any of the following active co-morbid issues: Benzodiazepine use Illicit substance use/abuse Alcohol overuse/abuse Untreated mental health issues (e.g. depression, hx of suicide) Chronic respiratory problems (e.g. Asthma, COPD, OSA, CHF) Be curious and regularly seek out this information from your patients and their families

31 Lack of Time Lack of knowledge Patient expectations Decreased patient satisfaction Strained physician-patient relationship Physician belief that opiates are safe Physician belief that this change is not necessary

32 A comprehensive Clinical Resource to assist you in managing your patients with chronic pain

33 Educate office staff Protocol for new patients Protocol for existing patients Refill policy Lost scripts Missed visits Drug Monitoring Ceiling for opioids? Benzo policy

34 Letter Policy Framed around safety to them, their family and their community

35 ALWAYS refer for Chemical Dependency Evaluation & Treatment Non-judgmental Empathetic care Do not abandon your patient

36 Controlled substances & Alcohol/sedatives Benzodiazepines & Opiates in same patient Starting a medication w/o an EXIT strategy Writing a script without all the information required to prescribe safely

37 Universal Precautions First, Do No Harm

38 Interventional Procedures Flouroscopically guided TFESIs, ILESIs, Facets, SI Joints, Neuromodulation, etc. Topical Transdermal Compounded Agents Including: Ketamine, Amitriptylline, Diclofenac, Ketoprofen, Gabapentin, Baclofen, Cyclobenzaprine, Bupivicaine, Tetracaine, Nifedipine, etc..

39 Indiana s Prescription Drug Monitoring Program: Fishman SM. Responsible Opioid Prescribing A Physicians Guide 2009 Drugs for Pain. Treatment Guidelines from the Medical Letter: April 2010; 8(92) Institute of Medicine (IOM) of the National Academy of Sciences (NAS). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research. Washington, DC: National Academies Press, 2011 American Pain Society (APS) and American Academy of Pain Medicine (AAPM). Clinical Guideline for the use of Chronic Opioid Therapy in Chronic Non-cancer Pain. Journal of Pain 2009 Feb; 10(2): Federation of State Medical Boards (FSMB). Model Policy for the Use of Controlled Substances for the Treatment of Pain. Washington, DC: The Federation, 2004 American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRAPM). Practice Guidelines for Chronic Pain Management: An Updated Report by the ASA Task Force on Chronic Pain Management and ASRAPM. Washington, DC: ASA & ASRAPM, 2010 Gourlay DL & Heit HA. Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Medicine. 2005: 6: Webster LR & Webster RM. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Medicine 2005; Nov-Dec; 6(6):

40 Webster LR. Eight Principles for Safer Opioid Prescribing. Pain Medicine 2013; 14: Bohnert AS, Valenstein M. Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths. JAMA, April 6, (13): Results from the 2009 National Survey on Drug Use and Health: Summary of National Findings. U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration; Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Assessment and Management of Chronic Pain, Fifth Edition. Bloomington, MN: The Institute, 2011 National Opioid Use Guideline Group (NOUGG). Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, Version 5.6. Ottawa, Canada: National Pain Centre, April 30, 2010 Utah Department of Health (UDOH). Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain. Salt Lake City, UT: February 2009 Berland D, Rodgers P, Rational Use of Opioids for Management of Chronic Nonterminal Pain. Am Fam Physician Aug 15; 86(3): Jackman RP, Purvis JM, Mallett ES, Chronic Nonmalignant Pain in Primary Care. Am Fam Physician Nov 15; 78(10):