Taking the Pain out of Chronic Pain Management From Resident Research Project to Process Improvement

Transcription

1 Taking the Pain out of Chronic Pain Management From Resident Research Project to Process Improvement

2 The First Year Resident asks out loud: What makes Chronic Pain management so hard and distasteful to some many physicians? Where is the formal training to teach residents how to treat patients with controlled substances? Would training help make the task less onerous and improve how residents treat their Primary Care patients that have pain?. The Astute Staff Scientist hears and responds: Sounds like a good idea that you can use as the theme of your Resident research project. And the fun begins..

3 Are we effectively training residents to treat patients with controlled substances? Stephen M. Sittnick, D.O. PGY-2, Family Medicine Resident; Annie Harvey, PhD University of Kansas School of Medicine Wichita, Department of Family & Community Medicine, Via Christi Review/Update as needed the training and guidelines of practice for Residents treating patients with controlled substances Specific Aims are as follows: PURPOSE 1. Determine if guidelines of practice concerning treatment with controlled substances taught to Residents need to be updated 2. Determine if an outcome-based set of metrics can be developed for Residents treating patients with controlled substances-- 3. Determine if there are best practices that can be adopted to initiate a Residency Program Chronic Pain clinic 4. Develop a clinic-wide systems approach for chronic pain management. METHODS and STUDY DESIGN An survey was sent to residents, faulty members, and community physicians using Zoomerang, an online survey service. Reminders were sent. Results were analyzed using MS Excel. RESULTS *Overall response rate was 51% (123 of 242; residents 48%, faculty 73%, community physicians 47%). *Near-unanimous (95%) agreement that there should be formal instruction for residents on how to prescribe controlled substances. *Over three-quarters (78%) of first year residents did not feel they were adequately trained to treat patients with controlled substances while in contrast 100% of third year residents thought they were. *Most (89%) first year residents did not feel comfortable prescribing controlled substances to chronic pain patients, but 67% third year residents did. A *Majority (62%) of respondents intended to treat chronic pain patients in their future practice, but far less used objective metrics to distinguish acute from chronic pain patients and assess abuse risk in their patients treating with controlled substances. *Nearly one in five (18%) respondents does not plan to treat chronic pain patients in their future practice. *Most respondents felt that the predominant barrier to treating chronic pain patients was the huge demands on their staff and themselves. Highlights of Survey Findings SIGNIFICANCE OF FINDINGS: This survey revealed a need to more adequately train Family Physicians to treat their patients with controlled substances. Few Physicians are using objective tools and criteria in assessment and treatment of Pain patients. There is a significant number of respondents that are not confident or willing to treat Chronic Pain Patients. RECOMMENDATIONS: 1. Develop and present a lecture to residents on the subject Treating Patients with Controlled Substances during the annual series of boot camp lectures. 2. Develop a template for Electronic Medical Record (EMR) software for Chronic Pain Management 3. Develop a clinic-wide systems approach for chronic pain management. Results by Number of Respondents BACKGROUND Unspecified resident PGY-1 PGY-2 PGY-3 faculty community physician TOTAL Residents prescribing controlled substances and treating Chronic Pain patients must learn to balance effective pain relief and restoration of function against the potential risk of abuse or diversion. n = I am adequately trained how to treat patients with controlled substances. We sought input from residents, faculty members and community Physicians to determine: strongly disagree 0% 0% 6% 0% 3% 0% 2% disagree 25% 47% 19% 0% 3% 11% 15% a. What training they received b. Their confidence level prescribing controlled substances and treating chronic pain patients neutral 50% 47% 25% 0% 13% 8% 18% agree 25% 6% 44% 100% 52% 40% 40% c. The tools they used to assess and treat their chronic pain patients in their practice. strongly agree 0% 0% 6% 0% 29% 42% 26% I feel comfortable prescribing controlled substances to Chronic Pain patients. strongly disagree 25% 24% 19% 0% 3% 4% 9%

4 Survey Results 1. The survey revealed a need to more adequately train Family Physicians to treat patients with controlled substances and clinic patients with Chronic Pain. 2. Respondents universally believed residents should receive formal instruction on how to treat patients with controlled substances and Chronic Pain Management. 3. Although most respondents planned to treat chronic pain patients, a significantly lesser number felt they had the objective tools to do the job, and a substantial proportion are not interested in treating at all in the future. 4. There is clearly a need for the Family Medicine programs to deliver formal instruction to residents to equip them to properly and confidently prescribe controlled substances and assess and treat chronic pain patients.

5 The Project s Recommendations 1. Develop and present a lecture to residents on the subject Treating Patients with Controlled Substances during the annual series of boot camp lectures. 2. Develop a template for Electronic Medical Record (EMR) software for Chronic Pain Management 3. Develop a clinic-wide systems approach for chronic pain management.

6 The Challenge: Transitioning to a patient centric systems-based approach for managing the chronic pain of our primary care patients. -Develop a proposed plan based on lessons learned from Project -Train Residents and Preceptors -Train Nursing and Admin Staffs -Conduct a Pilot -Gather Feedback from Pilot -Assimilate Tools into EMR -Train all Residents, Preceptors, Nursing and Admin Staff -Deploy the Final Plan

7 Initial Basic Concept Assess the impact that the Patient s Pain on their life Map the Patient s Pain Assess Patient s Risk of abuse of Controlled Substances. Determine past treatments: Pharmacologic, OMT, PT/OT, Epidural, Surgical, Alternative Determine past Imaging Determine past diagnoses Resident Examines Patient and develops proposed Plan Resident presents proposed plan to Preceptor Brief Patient on plan * Initial Assessment visit will be 40 minutes long, subsequent visits 20 minutes long.

8 The Tools

9 This is completed by the patient and updated every pain management appt. thereafter.

10 This is completed by the patient and updated every pain management appt. thereafter. Pain Map

11 This is completed by the physician and updated every pain management appt. thereafter.

12 This is completed by the physician and updated every pain management appt. thereafter.

13 The CAGE Questionnaire Adapted to Include Drugs (CAGE-AID) 1. Have you felt you ought to cut down on your drinking or drug use? 2. Have people annoyed you by criticizing your drinking or drug use? 3. Have you felt bad or guilty about your drinking or drug use? 4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? Score: /4 2/4 or greater = positive CAGE, further evaluation is indicated Source: Reprinted with permission from the Wisconsin Medical Journal. Brown, R.L., and Rounds, L.A. Conjoint screening questionnaires for alcohol and drug abuse. Wisconsin Medical Journal 94: , 1995.

14 Via Christi Family Medicine Pain Management Agreement Patient: D.O.B. Our goal is to reduce your pain and allow you to function more effectively. Your treatment for chronic pain may include prescriptions for controlled substances such as Opiate Pain medications. The purpose of this agreement is to help assure that my care will be optimal toward reaching my goals for pain management. 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. GOALS: My goals for treatment of my pain are: My doctor and I will regularly assess my progress towards meeting these goals. I agree that I will use my medicine at a rate no greater than the prescribed rate and that use of my medicine at a greater rate will result in my being without medication for a period of time. If I think I need more medication, I must consult with my physician first. I will bring all unused medication(s) to every office visit. My doctor may recommend treatments in addition to medication to help me reach my goals (such as physical therapy, exercise, injections). I understand that if I break this Agreement, my doctor may stop prescribing these pain control medicines. In that event, my doctor will taper off the medicine over a period of several days, as necessary, to avoid withdrawal symptoms. Also, a drug-dependence treatment program may be recommended. I will communicate fully with my doctor about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain. I also agree to notify my doctor of any change in my health status, or of other prescribed medications. I will not use any illegal substances, including marijuana, cocaine, etc. I will not share, sell or trade my medication with anyone.

15 I will not attempt to obtain any controlled medicines, including opioid pain medicines, controlled stimulants, or antianxiety medicines from any other health care provider including emergency rooms or urgent care facilities except as specifically authorized by my physician. I will safeguard my medicine from loss or theft. Lost or stolen medicines may not be replaced. A police report is required for stolen controlled substances. My doctor will refill my prescriptions at the appropriate intervals, but only during regular office hours. No refills will be available during evenings or on weekends. Early refills will not be approved unless clinically indicated. I understand that stopping medication abruptly can lead to uncomfortable withdrawal symptoms, so I should not stop taking these medications without discussing it with my doctor. I agree to use Pharmacy, Located at, Telephone Number:, for filling prescriptions for all of my pain medicine. I authorize my doctor to provide a copy of this Agreement to my pharmacy if needed to coordinate my care with them. I agree that I will submit to a blood or urine test if requested by my doctor to assess my continuing adherence to the terms of this agreement. MENTAL HEALTH AND /OR PAIN MANAGEMENT CONSULTANT: A mental health assessment and/or psychological therapy may be recommended. If I am currently involved in mental health therapy, or if I enter such therapy, I may be asked to authorize my mental health practitioner to exchange information regarding my condition and treatment with my physician. DRIVING & OPERATING EQUIPMENT: Many medications can cause drowsiness and/or very relaxed state of mind causing operation of equipment or vehicles to be dangerous. I agree to refrain from driving or operating dangerous equipment for 72 hours after any change in medication dosage and whenever I feel drowsy. I consent to the use of opioid pain medicine for my condition, and have read, understand and agree to abide by this agreement and understand the uses, effects, potential side effects, and the safe usage of the medication being prescribed. I understand that failure to abide by this agreement may result in termination of prescriptions and possible termination of services by Via Christi Family Medicine. Patient Signature: Date: Physician Signature: Date:

16 The Final Plan

17 Process Map for Initial Assessment Visit 1. ESTABLISHED patient needing pain management 2. Resident -- instructs nurse to review Patient Packet with patient -- requests 40 appt for Pain Management at bottom of fee ticket 3. Nurse -- dispenses Patient Packet, emphasizing no forms, no visit --assesses whether pt able to complete forms --gives release request to patient (if needed) --orders labs in NextGen --sends patient for UDS (SubAb+PainMgmt) Yes 4. Patient able to complet e forms? No 7. Patient presents for appointment 6. TWO days before appt, Front desk calls pt saying may have to reschedule if forms not complete 5b. Front desk --schedules 40 initial pain appointment --notes in EPIC paperwork given to pt today (or referred to SW for form completion); possible pain candidate 5a. Front desk --schedules pt with Social Work for help completing forms 8. Front desk adds Pt Pkt, clinician forms, preceptor checklist to fee ticket sleeve 13. Resident -- prescribes pharm/non-pharm Tx -- revises PMA with pt -- signs & has pt sign PMA -- gives pt copy of PMA -- requests f/u appt for Pain Management on fee ticket -- checks dummy PM code on charge slip -- gives paper Patient Packet & PMA to MedRecords -- 15a. Front Desk --makes 20 or 40 f/u appt 15b. Medical Records scans forms into Consults Pain Folder 9. Nurse --rooms Patient --assesses pain (PQRST) --checks K-TRACS --opens Adult Office Visit Pain --opens Pain Window & reviews 12. Preceptor confirms -- Disability index & pain map complete? -- Is pain adequately controlled? -- Patient abuse risk complete? -- Pain Mgmt Agreement signed? -- Was UDS obtained? -- Is pathology linked to treatment? -- Can patient titrate down? -- Is there a non-pharm treatment? -- Are Goals of Tx established? --Does pt need referral to pain specialist? --Does psych pathology need addressed? --Is pt suitable for continued pain care? 9. Resident -- interviews patient -- completes ORT -- completes DIRE -- completes CAGE-AID as needed -- completes H&P, ROS and PE -- determines pathology/ treatment link-up, diagnosis and Plan. 10. Resident and patient establish Goals of Treatment and enter onto PMA 11. Resident meets with Preceptor to --determine suitability --confirm diagnosis and treatment plan.

18 Process Map for Follow-Up Visit 1. Patient presents for FOLLOW-UP appointment 2. Front desk --checks in patient for 20 or 40 follow-up visit -- adds any updated Pt Pkt forms, preceptor checklist to fee ticket sleeve 3. Nurse --rooms patient --assesses pain (PQRST) --reviews pain meds, pt compliance with treatment plan --checks K-TRACS --opens Adult Office Visit Pain --opens Pain Window & reviews 6. Resident adjusts Rx or non-pharm treatment 7. Resident and patient update and sign Pain Management Agreement as needed 5. Preceptor confirms -- Disability index & pain map updated? -- Is pain adequately controlled? -- Patient abuse risk UTD? -- Pain Mgmt Agreement UTD & followed? -- When was last UDS and its results? -- Is pathology linked to treatment? -- Can patient titrate down? -- Is there a non-pharm treatment? -- Are Goals of Tmt UTD? --Does pt need referral to pain specialist? --Does psych pathology need addressed? --Is pt suitable for continued pain care? 4. Resident --completes H&P, ROS and PE --reviews goals of treatment with patient --reviews any recent Lab, PT/OT or imaging results since last appointment 8. Patient provides samples -- UDS for Substance Abuse -- UDS for Pain Management if physician determines need 9. Resident --requests f/u appt for Pain Management on fee ticket -- checks dummy PM code on charge slip 10. Patient checks out at Front Desk, making f/u appt as required

19 Brief Case Studies Case #1-59 year old Grandmother on long term Percocet treatment is in clinic for Initial Pain Assessment (IPA). She presents with her Chronic Knee Pain. After working through protocol with the Patient the resident is surprised to learn that her goals for treatment are simple. She just wants her pain reduced enough to get down on the floor and play with her Grandchildren. Case#2-52 year old female with long standing back pain treated with Tramadol presents for her IPA. The resident following the protocol discovers the lack of any past comprehensive work-up. Spinal x-rays show the patient to have a significant vertebral fracture and lab results reveal a Vitamin D deficiency. Case#3- A 30 year female presents to the clinic to establish care as a new patient. The resident decides to utilize the protocol of the IAP because of the patient s report to the Nurse that she needs to take care of her chronic pain problem. Following the protocol allows the nursing staff and resident to discover the patient has made multiple trips to local ERs. Halfway through the detailed history the patient storms out of the clinic.

20 I wish to acknowledge the advice and assistance of: -Members of the Via Christi Family Medicine Research Committee: Dr. Knabe, Dr. Curry, Dr. Duggins, Dr. Harvey -Members of KU School of Medicine Staff: Dr. Kellerrman, Ms. Terry Ast, Dr. Doug Wooley, -Residency Directors: Dr. Stovak and Dr. Stephens -Residents of Via Christi Family Medicine Program -Nursing and Administrative Staffs of Via Christi Family Medicine Program -Our Wonderful Patients