University of Colorado Primary Care Chronic Pain Guidelines - PowerPoint Presentation

Slide1

University of Colorado Primary Care Chronic Pain Guidelines

The 10 Principles of Chronic Pain Management, Part 1Slide2

Managing chronic pain is hard

Highly

prevalent

Incomplete

e

xplanatory models

Patient experience

of pain

is real

But so are addiction and diversion, often disengaged

Primary

Care

providers are under trained &

resourced

Complex regulatory and documentation requirements

Therapeutic

options are

limited,

s

ome interventions may exacerbate pain

A diverse

set of interrelated pathologies across the bio-psycho-social

spectrumSlide3

10 Principles of Chronic Pain Management at University of Colorado

Good Primary Care

Practice

View Chronic Pain as Centrally Mediated Sensory Experience

Cultivate Empathy and Therapeutic Relationships

Identify and Manage Psychological Co-Morbidity

Patient AND condition centric management

Risk-Based Assessment & Management of Patients on Opioids

Comply with State/Federal Law and Medical Board Guidelines

Standardized Documentation in EPIC

Data

Driven Monitoring and

Improvement

Team Based CareSlide4

Principle #1:Good Primary Care Practice

Foundational Primary Care (5 C’s)

C

ontact (first)

C

omprehensive

-

biopsychosocial

C

oordinated –

ancillary, avoid

iatrogenesis

C

ollaborative –

team based care

C

ontinuous

healing

relationships

Good clinical stewardship

“

The good physician treats the disease; the great physician treats the patient who has the disease

.”

OslerSlide5

Principle #1:Good Primary Care

Practice

Do I have to

?

Yes

As

primary

care

we

specialize in our patients

.  

Our

sacred duty is to help our patients get healthier.

Our employers, clinical partners (

DFM/SOM/UPI/UCH),

and

the

primary care specialty organizations

 have made it

clear

that

we

cannot

“opt out”

of this responsibility.

As with any chronic condition, complexity and risk may indicate referral/consultation

There are

not enough specialists

to do this work.

Patient-to-specialist ratio

 = 30,000:1 Slide6

Principle #2:View Pain as a

Centrally Mediated Sensory Experience

“Your

pain

vision is all in your head

!”

T

he

Experience of

Vision Analogy

Blind spots

Optical IllusionsThe Invisible GorillaConversion blindness“Seeing Red”Hallucination

http://www.theinvisiblegorilla.com/videos.html

https://serendip.brynmawr.edu/bb/contrastcolor/Slide7

Principle #2:View Pain a

s a

Centrally Mediated Sensory Experience

All pain is a sensory experience

Pain is the experience of sensory stimuli…

…interpreted by the central nervous system…

…in the context of…

other sensory input and

the

neuro

-chemical consequences of past experience.

CNS creates “best guess” based on complex input in face of encoded neural network shortcutsIf this experiential system is fooled/ imprecise/augmented/damaged/malfunctioning: chronically maladaptive, uncoupled from protective purposeSlide8

Principle #2:View Pain as a

Centrally Mediated Sensory Experience

Common Pathway? “Central Sensitization”

Hallmark of chronic unremitting pain syndromes

Can exist with or without ongoing peripheral disease/damage/derangement

Multiple hypotheses of mechanisms

Gate Control theory

Neuro

-behavioral

feedback loops

Evolutionary stress/avoidance

Imprecise encoding/conditioned responseNeuro-Immunological (“Myalgic Encephalopathy”?)Role of Glial cellsDysregulation 

pain activation  increased by opioid exposure

Appear to play a role in opioid toleranceSlide9

Principle #3:Cultivate Empathy & Therapeutic

R

elationships

T

he

neuro

-behavioral-epigenetic substrate

Gender, Social gradient, other SES & SDH

Trauma:

Psychological, Emotional, Physical, Sexual, Neglect, Adverse Childhood Events (A.C.E.)

All of these appear to predispose to the central sensitization phenomenon

The pain experienced from central sensitization is realSlide10

Principle #3:

Cultivate Empathy & Therapeutic Relationships

Hawthorn and Placebo effects

Develop self efficacy/SMS knowledge and skills

Develop insight

Goal setting –physical/social function, behaviors

T

ransference & counter transference

Address “

heartsink

” phenomenon

Provider self care / “Doorknob Mindfulness”Specific practice-based interventionsSlide11

Principle #3:

Cultivate Empathy & Therapeutic Relationships

Therapy

:

Cognitive

Behavioral, Dialectical Behavioral, Acceptance & Commitment (CBT, DBT, ACT

)

Web, apps, groups

Self Management Support

SMS education/ groups

Trauma Informed Care:

Respect, permission, transparency, control, boundariesPositive psychology approachesStrengths Based Practice Reinforcement Positive B.A.T.H.E. techniqueSlide12

Principle #3:

Cultivate Empathy & Therapeutic Relationships

“

b.a.t.h.e

.”

B

ackground

: What is going on in

your life?

A

ffect

: How does that make you feel?Trouble: What about it troubles you most?Handling: How are you handling that?Empathy: That must be very difficult.

The Positive Bathe B

est - What’s the best thing that’s happened to you

this week/since I saw you?Affect or Account - How did that make you feel/How to you account for that?Thankfulness -

For what are you most grateful?Happen - How can you make things like that happen more frequently?Empathy or Empowerment - That sounds fantastic. I believe you

can do that.

Stuart MR, Lieberman JA. The

Fifteen Minute Hour: Therapeutic Talk in Primary CareSlide13

Principle #4:

Identify & Manage Psychological Co-Morbidity

Screen, diagnose, and treat:

Depression, anxiety, bipolar, other

Substance use disorders, Addiction

Rx, Alcohol, Tobacco,

Illicits

, stimulants, hypnotics

Trauma

Consider other contextual/behavioral issues

Mindset

Self careStressorsFamily/social supportsSleepActivityEmploymentEtc.Slide14

Principle #5:Patient

and

Condition

C

entric Management

Diagnosis: DSM IV AXIS is a useful construct:

I

: Primary

Psychiatric,

incl. substance use

/ addiction

II: Personality / developmental disordersIII: Medical – presenting etiology and relevant co-morbiditiesIV: Psycho-social stressors V: Level of Function“Axis X”: The Substrate

…Trauma/ACE historyHistory of medical care experience

Coping mechanismsInteraction of multi-axis co-morbidity…etc

Improvement in physical & social functioning is primary goal of therapySlide15

Principle #5:

Patient

and

Condition Centric Management

Non-Pharmacologic

Pharmacologic

Non-opioid Pain

Mgt

Analgesics, relaxants, antidepressants,

triptans

,

antiepilepticsNewer Rx/indications: clonidine, minocycline,

oxybate, milnacipran

, etc

Website: University of Utah Guide, CU PearlsOpioids - Long and short actingTreat ALL Axes aggressively to maximize function and minimize harmSlide16

Principle #6:

Risk Based Assessment

and Management of

Patients on Opioids

Initiation:

Avoid if possible for chronic pain, esp. if at risk of aberrancy or adverse events

Don’t start something you aren’t prepared to monitor aggressively and stop if ineffective

Always consider initiation to be a BRIEF trial

Minimize duration of therapy/dispensing for acute pain

Risk Stratification: adverse events, aberrant behavior

DSM IV Axis analogy

Psychiatric & Medical co-morbidityPsychosocial stressors, personality/developmental issuesLevel of function“Axis X” – the substrateAberrant behavior is a symptom in need of a diagnosisSlide17

Principle #6:

Risk

Based Assessment and Management of Patients on Op

ioids

Assessments for Risk of aberrant drug-related behavior

Psychiatric comorbidity:

Depression: PHQ9

Anxiety: GAD-7

Substance use:

DAST-10 (

illicits)AUDIT-C (etoh)Other (Bipolar, schizophrenia, personality d/o, etc)Assessments for Poor substrate: Opioid Risk Tool (O.R.T.)

Diagnosis/Intractability/Risk/Efficacy (D.I.R.E.) ScoreAdverse Childhood Events (A.C.E.) Score (with caution)Slide18

Principle #6:

Risk

Based Assessment and Management of Patients on Opioids

Risk of adverse events/overdose

M

orphine

D

ose

E

quivalent (M.D.E.)

> 100mg/dayGlobalRph, PDMP, coming soon to epicORADER: Opioid Related Adverse Drug Event Risk

Geriatric (age > 65)

Significant Obesity (BMI

> 35)Significant Psychiatric Disorder(e.g. depression, anxiety, panic, bipolar, schizophrenia)

Substance Abuse (e.g. alcohol, illicit drug use)Central Nervous System/Cognitive Disorder(e.g. stroke, dysphagia, neuromuscular disease, dementia)

Respiratory Disorder

(e.g. sleep apnea, COPD/emphysema, asthma, cystic fibrosis,

obesity

hypoventilation syndrome)

Sedating Medications

(e.g. benzodiazepines, hypnotics, sedating antihistamines, muscle relaxants,

etc

)Slide19

Principle #6:

Risk Based Assessment and Management of Patients on Opioids

Low/Medium/High/ExtremeSlide20

Principle #

7:Comply

with State and Federal Law and Medical Board Guidelines

DORA:

Prescribing and Dispensing Opioids

Develop

& maintain competence:

Careful H&P, Diagnose/Assess Risk, Pain, and Function

: “4 A’s”

cufamilymedicine.org

/

chronicpain for CME /Zoom Ensure dose, quantity, and refills are appropriate to improve the function and condition, at lowest effective dose and quantityRe-evaluate >

90 days: may not be as effective. If advanced dose (>120mg),

formulation (e.g. transdermal) or duration:Assess function

and compliance w/opioid trialMonitor closely: pt agreement, function, PDMP, periodic UDSEducate all patients on: Risks and benefits, Proper use, addiction, alternatives, storage/disposal, diversionSlide21

Principle #7: Comply

with State and Federal Law and Medical Board Guidelines

DISCONTINUING OPIOID THERAPY

When:

Underlying painful condition is resolved;

Intolerable side effects emerge;

Poor response in pain or quality of life/function

Aberrancy

Tapering:

Employ a safe, structured regimen through the prescriber or an addiction or pain specialist. There is a risk of patients turning to street drugs or alcohol abuse if is not done with appropriate supports

.

NALOXONE “Colorado law strongly encourages prescribers…to educate on the use of an opiate antagonist for overdose, including but not limited to risk factors and recognition of overdose, calling emergency medical services, rescue breathing and administration of an opiate antagonist.”Slide22

Principle #7: Comply

with State and Federal Law and Medical Board Guidelines

Dismissal

:

Colorado

Medical Board

Guideline

“It

is the policy of the Colorado Medical Board (“Board”) that the proper discharge of a patient from a provider’s practice includes the following elements:

In

writing,

delivery confirmationAgree to provide 15-30 days of emergency coverage while obtains new PCPIf possible, provider provides referral information to possible new providers.

Notify that patient records will be sent to the new provider upon receipt of written authorization “IN ADDITION!

Must be non-discriminatory and not

jeopardize their well-being, or you risk being charged w/medical abandonment, civil rights violations, ADA, etc.Exceptions exist for threatening/criminal/violent behaviorTypically = dismissal from entire system, “qualifying life event” for CU AnthemANY DISMISSAL ACTIVITY MUST GO THROUGH RISK

MGT (303) 724-7475 = “4-RISK”Slide23

Principle #8:

Standardized Documentation in EPIC

Common Patient Treatment Agreement:

Letter “PC

Opioid Medication Partnership

Agreement”, document in FYI tab

2 Epic note templates:

Comprehensive visit & Follow up visit

Flexible to integrate with your workflow preferences

Pick-n-click lists for easy compliance with DORA guidelines

Support problem based charting for cross-system communication

Risk Categories provide guidance on:Frequency of each visit typeFrequency of refillsFrequency of assessments and testingSlide24

Principle #8:

Standardized Documentation in EPIC

Standardized Assessments

PHQ, GAD, DIRE, ORT, AUDIT, DAST in

flowsheets

Includes “4 A’s” instrument

Analgesia –best, worst, current, average pain

ADLs - function

Adverse effects – common side effects and severity

Assessment – overall provider assessment

Key assessment data flow directly into the note templates for trackingSlide25

Principle #9:Data Driven Monitoring and Improvement

Registry:

https

://spsites.uchealth.org/bi/clinical/Dashboards/Forms/ByAudience.aspx

Modified version:

D

istributed monthly

Plan to add MDE, registry

inclusion/exclusion,

PDMP checked date, assessmentsSlide26

Principle #10: Team Based Care

Pre-visit data collection

What:

PDMP delegation, UDS, Standardized Assessments/Screeners, Self management support, risk stratification support, registry management

Who:

RN, MA, CM, SW, Pharmacist, PAR/CTA

Where/When:

At home, in waiting room, in exam room, bookended or other distinct non-physician visits

How:

On paper, directly into EPIC, MHC?, Tablet pilot

Psychosocial support

Motivational interviewing, BATHE-ing, positive behavioral techniques, trauma informed care, strength based practice, SMS group visits, RN refill visits, integrated services Coaching:Elisabeth Benoit: Elisabeth.Benoit@ucdenver.edu Slide27

One stop shopping:cufamilymedicine.org/

chronicpain

CU Guidelines, Policies, Procedures

Principles

Risk Calculator

Assessments

Patient Agreement

PDMP delegation instructions/links

Dismissal guidance

Clinical Links

Pharmacy, External guidelines, Pt Ed, Naloxone

CMECoursesZoom Webinars & DidacticsEPICTeam-based care workflowsAssessment/flowsheet useNote TemplatesUDSPt Agreement

MDEPatient Agreement/FYI TabMultimediaPatient and family support sections

Self management support, tools, tipsMedication safety and safe disposalAvoiding and Recognizing overdose, incl. BLS basics and NaloxoneSlide28

10 Principles of Chronic Pain Management at University of Colorado

Good Primary Care

Practice

View Chronic Pain as Centrally Mediated Sensory Experience

Cultivate Empathy and Therapeutic Relationships

Identify and Manage Psychological Co-Morbidity

Patient AND condition centric management

Risk Based Assessment and Management of Patients on Opioids

Comply with State and Federal Law and Medical Board Guidelines

Standardized Documentation in EPIC

Data

Driven Monitoring and Improvement

Team Based Care