Changing the opioid conversation: A systems approach to make opioid - - PDF document

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Changing the opioid conversation:

A systems approach to make opioid prescribing safer and less stressful

JULIE RICKERT, PSY.D. ASSOCIATE PROFESSOR UND SCHOOL OF MEDICINE AND HEALTH SCIENCES STATEWIDE CAH QUALITY NETWORK MEETING APRIL 20, 2017

Objectives:

• 1. Participants will identify the benefits of using a universal, system

imposed protocol based on the Center for Disease control’s recommendations for opioid prescribing.

• 2. Participants will identify two different strategies or moving from

conflict to cooperation in chronic pain management.

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Quick review of CDC guidelines The problem in a nutshell

Chronic pain is common and is not the same as acute pain. Available treatments are not very effective. Humans will keep escalating behaviors that provide relief from suffering. Behaviors that relieve pain in the short run do not improve functioning in the long run. Behaviors that relieve pain in the long‐run are counter‐intuitive.

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What does the conversation look like now?

WHAT SHOULD THE CONVERSATION LOOK LIKE?

The patient thinks – The provider thinks ‐

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Both are upset because it is personal The patient requests relief from suffering The provider declines due to safety concerns The patient blames the provider

Change the conversation

From: I won’t give you this medication To: ALL patients must participate in the higher risk program to be prescribed this medication. Would you like to be enrolled in our higher risk program?

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WE WANT TO BE ABLE TO OFFER ‐X‐ MEDICATION AND YOUR SAFETY IS VERY IMPORTANT TO US

You can become (remain) eligible for chronic opioid therapy by following our safety protocol If you can’t, we will offer you a safer therapy It is up to you

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What should your protocol look like?

Follow best practices

• CDC Guidelines
• Holton and Veasey (2008)
• Lembke, Humphreys, & Newmark

(2016)

Promote partnership and responsibility Make use of your resources Be part of the system

How do you get there?

Education Build consensus Build procedure Script Support

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Underlying assumptions

All patients deserve to be treated in a respectful and safe manner.

• All patients are innocent until proven guilty.
• All patients, regardless of age, socioeconomic status (SES), gender,

and race are at risk and deserve safe care.

• Universal precautions for other medications like warfarin and

isotretinoin are easily followed.

• A universal system protects patients and physicians.
• Aberrant drug behaviors are a signal that patients need more help

(support, assessment, and monitoring).

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Patient outcomes are important.

Best Outcomes: Physician‐patient relationship Promotion of physical activity and behavioral self‐management Functional goals instead of pain goals

Holton and Veasey 2008

Provider satisfaction is important.

A universal approach reduces some of the interpersonal stresses of using recommended safety practices. A universal approach can also reduce stress for nurses, pharmacists, and other clinic staff.

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Clinic flow is important.

Time management Phone calls Emergencies Laboratory Documentation Billing

Key Evidence‐Base

Evidence suggests that Physician‐Patient Partnership, Physical Activity/ Rehabilitation, and Psychosocial Management are far more important for good patient‐oriented outcomes than pharmacological treatments.

• Holten, K. and Veasey, Sr., G. (2008)

UND CFM: All patient receiving chronic opioids must also have interventions that support these EB changes. American Family Physician has a nice, dense review about chronic

• pioid therapy based on the CDC guidelines.
• Lembke, Humphreys, & Newmark (2016)

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Key Evidence‐Base

Opioids are medications with known risks. Increasing attention has been paid to balance patients’ very real need for relief with safety.

• Dowell, D., Haegerich, T. M., & Chou, R. (2016).

UNDCFM: All chronic opioid prescribing will include universal precautions conceptually modeled after isotretinoin and warfarin precautions.

Key Evidence‐Base

Changing physician behavior in a universal way is challenging – systemic interventions may help.

• Khalid, L., Liebschutz, J. M, et. al. (2015)
• Lasser, K. E., Shanahan, C., et. al. (2016)

UNDCFM: System driven by project champion and nursing team will cue desired changes.

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Program

In order to be eligible to receive chronic opioid therapy at our clinic all patients must contract to:

• Communicate/Partner fully with physician
• Adhere to safety protocols
• Participate in some sort of active self‐management

If this is not acceptable, we are happy to offer lower risk options for pain management.

Safety

Patients must see a physician to receive a prescription Getting opioids from other providers may make patients ineligible for

• ur program – communication is the key.

ND Prescription Drug Monitoring Program accessed at every visit Observation and COMM/ORT monitoring for adverse effects / misuse Urine Toxicology (Ameritox) Specific protocols for changes, emergencies No benzodiazepines or cannabis

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Better CNCP Care

Specific assessment Functional goals developed and reviewed at every visit Chronic disease approach and flare prevention is key. Self‐management menus Pain flare rescue plan Low‐cost and free resources Provider scripts: transition, enhancing motivation, addressing problems

Systems

Care provided within team if resident is not available. Nurse key role: scheduling, assessment and documentation forms, cuing physician behavior. Structured transition, intake, and ongoing visit No emergency (<2 days) opioid prescriptions – proactive approach to flares

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What would you like to see in your own system? What barriers exist?

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What resources do you have? Summary

The nature of chronic pain makes safe and effective chronic pain management very difficult By it very nature conflict is likely – not because patients or providers are bad Guidelines exist but are hard to follow Develop a system to engage patients in maintaining eligibility for risky medications by following safe practices

• Patient is responsible “It’s up to you”
• Provider educates and support and offers alternatives if the patient cannot be

safe

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Major References

Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing

• pioids for chronic pain—United States, 2016. JAMA.

Holten, K. & Veasey, Sr., G. (2008) Managing Chronic Pain: What’s the best approach? The J Fam Pract 57(12):806‐811. Khalid, L., Liebschutz, J. M,, et. al. (2015). Adherence to prescription opioid monitoring guidelines among residents and attending physicians in the primary care setting. Pain Med, 16(3):480‐7. Lasser, K. E., Shanahan, C., Parker, V., Beers, D., Xuan, Z., Heymann, O., ... & Liebschutz, J. M. (2016). A multicomponent intervention to improve primary care provider adherence to chronic opioid therapy guidelines and reduce opioid misuse: A cluster randomized controlled trial protocol. Journal of substance abuse treatment, 60, 101‐109. Lembke A, Humphreys K, Newmark J. Weighing the Risks and Benefits of Chronic Opioid Therapy. American Family Physician. 2016 Jun 15;93(12).

Questions?