1. 1 RECOVERY BASED PAIN MANAGEMENT AT CENTRAL CITY CONCERN Rachel Solotaroff, MD, MCR Medical Director, Central City Concern April 29, 2014

2. 2 Recovery-Based Pain Management  Combine activity-based and mindfulness-based approaches  Provide education and services to enable new choices  Utilize supportive and positive peer relationships  Foundational concepts of Hope, Power and Responsibility  Index the program to the need and readiness of the individual  Integrated MH, SA and primary care  Utilize medication-assisted treatment

3. 11/12/2010 3 Level One Level Three Hot Sauce/Suboxone Weekly Acupuncture RENEW Monthly Group Visits with OT/PCP Behavioral Health Assessment Monthly “Activity Groups ” Primary Care Only q 2-3 mo visits Chronic Pain Recovery Pyramid Level Two Low addiction risk: Good self-management Good support Good function/activity Low addiction risk BUT: Low self-management Low social supports Low function/activity High addiction risk: Brief relapse Early Recovery Minimal support Graduation Criteria: -- Level 3: completion of Hot Sauce -- Level 2: Progress toward goals Engaged in Behavioral health (if nec) Reduction in opiate dosage Risk Management -- UDS – q 3 months -- pill count – q 6 months -- ADR’s – q 3 months -- PDMP: annually Risk Stratification Method for Chronic Pain and COT

4. How Does Risk Stratification Occur? 4  Controlled Substances Review Committee: Reviews all episodes of serious misuse or misconduct Reviews all requested new starts on chronic opiate therapy Provides guidance for complex pain management cases  Benefits:  Provides uniform, standardized approach to prescribing  PCP’s relieved at no longer having to “go at it alone”; “makes being strict less personal”; “enables discussions around public health concerns”

5. 11/12/2010 5 Income & Employment Volunteering, Training, Jobs CP Identified at Intake: -- ROI’s -- CP acknowledgemt -- BH Screen: ORT PHQ GAD-7 PTSD Screen OT Assess CSRC Reviews Data and recommends: -- No Controlled Substances + Care Plan Recs -- OR -- -- Controlled Substances + Level of Care + Care Plan Recs: Hot Sauce/Suboxone (Level 3) RENEW Provider Groups (Level 2) Primary Care Only (Level 1) Other recs such as BH, medication regiment, monitoring guidelines, etc. Behavioral Health Chronic Pain Recovery Program Road Map PCP Appt #1 PCP Appt #2 4 weeks If + BH Screen H&P, Record Review, UDS, OPDMP query

6. Thank you! rachel.solotaroff@ccconcern.org 6

7. Hot Sauce Model and Curriculum 7  12-week Level One A&D group, in primary care setting  Facilitated by CADC  Support and clinical supervision from outpatient A&D program  By referral only (controlled substance agreement violation, early recovery, otherwise high risk)  Zero tolerance for absences, dirty UDS

8. Hot Sauce Model and Curriculum TopicKey Concept 1 Goals of Hot Sauce What is Addiction Benefits/Dangers of Chronic Opiate Tx Self-care, self-growth, self-love are necessary for recovery and pain management 2 Creating SupportRecovery is more than not doing drugs. Pain management is more than taking chronic opiates 3 Recovery/Pain Management Thinking (Cravings and Triggers) Our thoughts, feelings and attitudes generate actions 4 Containing PainComplementary medicine options are useful for pain management 5 Handling StressDemonstrate what you do to decrease stress 6 Stages of Change What changes have improved your mind, body and spirit?

9. Hot Sauce Model and Curriculum TopicKey Concept 7 12 Step Groups and Other Support GroupsBeing able to learn from other people, being able to help others 8 Pain and the BrainPain and the brain are connected. Relaxation, Qi Gong, meditation decrease pain 9 Relapse Prevention (esp. violation of controlled substances agreement) Truthfully take the time to think things through thoroughly 10 Partnership with Your DoctorDo I believe my doctor wants me to get better? 11 Raising the Bar“I am not my disease” 12 What Has Been Learned? Do you use methods to manage pain and have a good life? “I love the life I live and I live the life I love” -- Muddy Waters

10. RENEW Model and Curriculum 10  12 Monthly groups in primary care setting  Facilitated by Occupational Therapist or other QMHP  Support and clinical supervision from Behavioral Health Medical Director  PCP may attend group, or may see patients individually after group for brief medication management visit  Focus on mindfulness and activity-based approaches to managing pain  Patients encouraged to come to at least one “Wellness Group” per month in addition to their group provider visist

11. 11 RENEW Model and Curriculum Topic 1 Pros and Cons What is Chronic Pain 7 Treatment for Insomnia How to fix your Sleep Position 2 Mindfulness and Non-judgmental Stance, Body Image Deep Breathing 8 Health and Nutrition 3 Communicating about Chronic Pain Pain Scale, Pain Journal (and homework) 9 Time Management Tips Life Pie Chart 4 Treatments for Chronic Pain Chronic Pain Interventions: Stress Reduction 10 Barriers to Fitness Tai Chi QiGong 5 The Role of Anticipatory Pain Pacing, Adapting and Delegating 11 Effective use of distraction Increase blocking messages Aromatherapy 6 Unhelpful Thinking Styles Affirmations Low Cost and No Cost Pleasurable Activities List 12 Graduation Book Lists

12. 11/12/2010 12