1. Chronic Pain Management Project at the Underwood-Memorial Hospital Family Medicine Residency Program Gina Gill Glass, MD John R. Armando, LCSW 2006 STFM: NorthEast Region Mtg.

2. UMH Family Medicine Community-based residency program 12 Residents 5 Physician Faculty 1 Behavorial Science Faculty Underserved patient population

3. Goals of Chronic Pain Management Project Improve quality of care of chronic pain patients on opioid analgesics Reduce frustration of attendings, residents and staff Meet state and federal documentation requirements regarding use of long-term opioid analgesics

4. Initial Pain Management Packet Pain Management chart divider Informed Consent and Agreement for Long- Term Use Opioid Analgesics Baseline Pain Assessment tool Medical record release Patient education handout

5. Project Implementation Met with all residents, faculty and staff to introduce project Initial packets with new Pain Management chart divider utilized for all patients on chronic opioid therapy as they presented to FMC starting March 2006 PADT TM (Pain Assessment and Documentation Tool) to be used as pain management progress note for follow-up visits once Pain Management divider on chart

6. Project Implementation– cont’d Lectures: –Biopsychosocial Perspective on Chronic Pain –Psychology of Pain Case Management –Health Psychology Students/ Interdisciplinary Teams –Weekly Phone contact w/ pain assessment –Patient Centered –Increased Activity/movement –Stress Management –CBT

7. Background: Physician Knowledge and Attitudes Regarding Pain Mismanagement and under-medication persist despite scientific progress Opiophobia is prevalent Negative psychologic traits re pain patients (esp. authoritarianism, & intolerance of ambiguity)

8. Self-Identified Challenges & Knowledge and Attitudes Survey Subscales: –Knowledge (knowledge re tx of pain and pain behaviors) –Authoritarianism (paternalistic or doctor-centered perspective) –Ambiguity (difficulty tolerating ambiguous data) –Trust (Difficulty trusting the patient) –Frustration (experience of emotional distress)

9. Self-Identified Challenges in Treating Chronic Pain In response to the question, “What do you find most challenging about treating patients with chronic pain?” Most common answers were related to: 1.Authoritarianism 2.Trust 3.Ambiguity

10. Knowledge and Attitude Survey The highest number of incorrect answers were on questions related to: 1.Trust 2.Knowledge 3.Authoritarianism

11. Chart Audit 3/28/06 – 9/13/06 47 packets given/26 completed - 55% completion

12. Summary of Observations Data from preliminary chart audit suggests that enrolled patients had improved follow-up and documentation as well as decreased number of early refills and missed/cancelled appointments

13. Summary of Observations – continued Barriers encountered during pilot project include: –Only 55% completion initial packet and 50% utilization of PADT TM (Pain Assessment and Documentation Tool) for follow-up visits –Provider preference for doctor-centered approach –Limitations of office scheduling system

14. Summary of Observations – continued Possible solutions include: –Continued education for patients, staff, and providers regarding patient-centered approach –Electronic Health Record –Ability to schedule patients for follow-up visits at least 3 months in advance –Expanding case management program

15. Questions/Comments