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Primary Care Based Pain Teams Jeremiah C. McKelvey, PharmD


Disclosure

Nothing to Disclose


Learning Objectives Review the growth and development of the “Opioid Renewal Clinic” Describe benchmark Opioid Pain Care and Renewal Clinics Discuss the impact/outcomes of the Opioid Pain Care and Renewal Clinics


Pain Management In the late 90’s Opioids?!


Opioid Pendulum

Avoidance

No ceiling

(Prior to 1990’s)

Total fear of prescribing opioids even in dying patients

(1990’s)

Balance/Risk Stratification

Opioids only 1 part of a comprehensive multimodal treatment plan

Widespread use of opioids using cancer model of treatment


Managing PAIN in Primary Care in 1998:

The Birth Of The “Opioid Renewal Clinic� Concept JC& VHA Mandate to Manage pain Policies Guidelines Expectations Little training in managing Pain No experience with opioids

Brief Visits Complicated Patients Clinical Reminders Minimal Resources


Clinical Pharmacist Managed Service at The Philadelphia VA Medical Center

Start-up date: September 2001


Goal: To Support Pcps Managing Patients With Chronic Noncancer Pain Requiring Opioids

Assist with management of challenging patients requiring structured prescribing and monitoring of longterm opioid therapy –Patients with aberrant drug related behaviors to r/o substance misuse vs. pseudoaddiction vs. addiction –Patients with h/o addiction, recent addiction, active addiction –Patients with complexity (e.g., psych co-morbidity) Wiedemer NL, et al. Pain Med. 2007;8:573-584


Pharmacy Pain Management Clinic Procedure 1.0 FTE Clinical Pharmacist Paul Harden, Pharm.D.

Eligibility Work-up & Pain Diagnosis Opioid Treatment Agreement Baseline Urine Drug Test

PCP CONTINUES TO BE RESPONSIBLE TO PRESCRIBE OPIOID

Strategies Individualized Opioid Treatment Agreement Frequent Visits Prescribing opioids on short term basis i.e. weekly or bi-weekly

Random UDT Pill Counts Co-management with addiction services


Pharmacy Pain Management Clinic (cont’d) Accepted Aberrant Behavior -Structured Monitoring of Opioid Renewals Complicated Cases Opioid Rotation Opioid Titration Difficulty Obtaining Renewals

Rejected Stable patient with No Issues to Address False Positives – No Actual Aberrant Behavior Extensive Aberrant Urine Drug Screens: Recommend ARU, OTP


Clinical Pharmacist – Responsibilities  Facilitate Renewal  Recommend Opioid Increase or Decrease  Prescribe Adjuvant Therapy  Order Urine Drug Screen  Order Relevant Labs & Monitor Lab Results  Discharge Stable Patients Back to PCP or Switch to Tele – Pain  Recommend Opioid Discontinuation


Note Template PHARMACY PAIN MEDICATION MANAGEMENT CLINIC NOTE Opioid Contract Provider/Team: Diagnosis: Level of Analgesia - Pain Scale (NRS 0-10): Average: Best: Worst: Goal: Pain Type: []Burning []Shooting []Throbbing []Stabbing []Cramping Location: Current Medications:

Past Medications (Outcomes): Adjunctive Therapies/Medications: Adverse Drug Events/Side Effects: SH: Functional Ability: Relevant Labs: Aberrant Behavior: (Urine Drug Screens) Complete Care/Consults: Assessment: Plan:


Pharmacy Pain Medication Management ClinicTotal Clinic Referrals 341 Total Unique Patients CY 2009

170 Non-Aberrant

171 Aberrant

Aberrant Non-Aberrant


Reason for Referral 170 Non-Aberrant Patients 54%

100 50

33%

92 13%

22

0 Renewals

Rotation

56

Titration


Aberrant Outcomes 2002-2006 DATA

2009 DATA

Aberrant

47% (n=366)

50% (n=171)

Non-Aberrant

53% (n=418)

50% (n=170)

2002-2006 DATA

2009 DATA

Resolved

40%

57%

Self Discharged

28%

26%

Clinic Discharged

25%

13%

Referred to Addiction Service

7%

4%


Pharmacy Pain Management Clinic Philadelphia VA Medical Center Articles generated from the program  Wiedemer N, Harden P, Arndt R, Gallagher R . The Opioid Renewal Clinic: A Primary Care, Managed Approach to Opioid Therapy in Chronic Pain Patients at Risk for Substance Abuse. Pain Medicine. 2007;8 (7): 573-584  Barth KS, Becker,WC, Wiedemer,NL,Mavandadi,S, Oslin,DW, Meghani,SH, Gallagher,RM. "Association between urine drug test results and treatment outcome in high risk chronic pain patients on opioids" Journal of Addiction. 2010; 4 (3):167-173  Meghani SH, Wiedemer NL, Becker WC, Gallagher, RM. Predictors of Resolution of Aberrant Drug Behavior in Chronic Pain Patients Treated in a Structured Opioid Risk Management Program. Pain Medicine. 2009;10(5):858-865  Becker WC, Meghani SH, Barth KS, Wiedemer NL, Gallagher, RM. Characteristics and outcomes of patients discharged from the opioid renewal clinic at the Philadelphia VA Medical Center. American Journal on Addictions. 2009;18(2):135-139


What’s in a Name?  The Opioid Renewal Clinic

 Pharmacy Pain Management Clinic

 Wiedemer,NL, Harden,PS, Arndt,IO, Gallagher,RM, The Opioid Renewal Clinic: A Primary Care Managed Approach to Opioid Therapy in Chronic Pain Patients at risk for Substance Abuse. Pain Medicine. 2007;8:573-584

 Opioid Pain Care Clinic  Primary Care/Opioid Case Management Program  Controlled Substance Renewal Program  Opioid Pain Care and Renewal Clinics


Opioid Pain Care Clinic Denver VA Medical Center – VA ECHCS


Multidisciplinary Team  Pharmacy (1.0 FTE)

– Jeremiah McKelvey, Pharm.D. – William Gersch, Pharm.D.

 Psychology (1.0 FTE)

– Michael Stroud, PhD – Chrisana Olson, PhD

 Medical Support Assistant (1.0 FTE) – Jordan Dosch

 Consultation from the Interdisciplinary Pain Team as needed


Clinic Eligibility Treatment with opioids for chronic noncancer pain Expressing multiple or recurrent aberrant drugrelated behaviors and/or history of substance abuse Consult placed by PCP (DEN MC/AUR CBOC) –Willing to co-manage their patients


Clinic Objectives  Support primary care provider  Individualized structured treatment plan

– Medication Management – Pharmacy – Cognitive Behavioral Therapy – Psychology – Case Management – Increase activity and improve function

 Adherence to the Opioid Agreement and resolution of aberrant behaviors  Decrease inappropriate utilization of health care resources


Program Evaluation/Preliminary Outcomes  Facility – Pain Contacts (Telephone, provider, ED)

 Patient – Consults – Discharged • Resolution of aberrant behaviors • Continued aberrant behaviors • Self discharged/declined follow-up

 Provider – Survey


Facility: Pain Contacts [N=55; enrolled (10/08 – 10/09)] Pain Contact

Six months prior

Six months post

Percent Change

Telephone

313

76

- 75.7%

Provider

143

39

- 72.7%

ED

28

12

- 57.1%

Total

484

127

- 73.8%


Patient: Aberrant Behaviors [N=55; enrolled (10/08 – 10/09)] At enrollment

6 months after enrollment

Percent change

Aggressive complaining about the need for higher doses

29

1

- 96.6%

Multiple unsanctioned dose escalations

26

1

- 96.2%

Requesting specific medications

16

3

- 81.3%

Concurrent abuse of illicit drugs

9

6

- 33.3%

143

20

- 86%

Aberrant behavior

Total


Patient: Consults (10/08 – 03/11) N=221  Completed – 173

– Demographic data

• ~85% Male • ~85% Comorbid psych disorder • ~55% Chronic back/neck pain

– Currently enrolled – 96 – Discharged – 77

 Cancelled/Discontinued – 45

– No aberrant behaviors, not from PCP/needs to establish care with PCP, SA/methadone maintenance, not on opioids, services not available, entered in error, etc

 Pending – 3


Patient: Discharged N=77  Resolution of aberrant behaviors and stable on current medication regimen (~44%) – Brief Pain Inventory – 24/29 – Opioids not indicated/not effective – 5

 Continued aberrant behaviors/nonadherence of the Opioid Therapy Agreement (~30%) – Opioids discontinued

 Self discharged/declined follow-up

– No longer receiving opioids from VA ECHCS (~26%)


Brief Pain Inventory (N=24)


Brief Pain Inventory (N=24)


Brief Pain Inventory  Q3 – current pain  Q4 – worst pain in the last 2 weeks  Q5 – least pain in the last 2 weeks  Q6 – average pain in the last 2 weeks  Q7 – how much relief have pain treatments or medications provided in the last 2 weeks  Q8 – how much has pain interfered with your:

– A- General Activity, B-Mood, C-Walking ability, D- Normal Work (includes both work outside the home and housework), E-Relations with other people, F-Sleep, G-Enjoyment of Life, H-Self-Care


Patient Outcomes: Things You Just Can’t Put A Number On…  “This is the most pain relief I’ve experienced in 15 years”  “You saved my life… thanks for getting me off that methadone”  “Thank you guys… you are good at what you do… you are true professionals”  “I got a job and I’m heading back to school in the Fall”  “If you ever have a seminar and you need to have someone talk about what you do, let me know, you guys are great… have been great, this is a great thing you guys are doing”  “You've helped me a lot, thank you, I wish I could find someone like you down there”


Provider Survey Comments  “This service is invaluable! I have used it and appreciate it greatly”  “Excellent program, but more importantly a great resource for the providers who have questions about management of chronic pain…”  “… has been extremely helpful w many of my narcotic questions, and difficult patients.”  “For my very difficult pain patient, this resource has been a life saver. It is resulted in higher satisfaction for the patient and the provider. This has overall improved my relationships with these patients. I would definitely support expanding the program if extra resources are available!”  “Appreciate the cautious, methodical and reliable approach used in this clinic- very helpful for difficult patients.”  “I appreciate that the ORC is readily accessible…"  Outstanding service! HUGE help in pt management! they do a wonderful job of assisting patients with their pain control. Keep up the good work!!”  “wow, this clinic is fantastic--pts and providers are happier, fewer demands for narcotic escalation; kudos to the opioid staff and… who has done a bang up job-… DESERVES A LARGE RAISE AND THANKS”


Other “Opioid Renewal Clinics” Method of opioid renewals for low risk/stable patients on stable dose of opioids Primary care based – managed by Nursing Opioid Agreement established Baseline urine drug test/ Random testing Renewals mailed out monthly Face to face visit every 6 months


Summary: Opioid Pain Care and Renewal Clinics  Program has been replicated throughout the VHA  Different models depending on need and resources  Need: Standardize the opioid renewal process – Patient population: High risk/complex vs. low risk/stable – Biopsychosocial model – Utilization of risk mitigation strategies

 Resources: Staff – Pharmacist, NP, PA, RN, Psychologist


Primary Care Based Pain Teams