1. Mary Lynn Barrett LCSW, MPH Valerie Krall, LPA, LPC MAHEC Family Medicine Residency Program Asheville, NC

2. To what degree is the issue of prescribing controlled substances a problem in your residency/clinic? 1. Minimal 2. Moderate 3. Significant 4. Improving due to recent policy changes/interventions

3. Objectives  Discuss how we use a controlled substances agreement to promote accountability with patients and guide practice.  Attendees will be able to describe how to use pain assessments to guide treatment.  Attendees will be able to discuss different ways of using an electronic medical record to monitor patients.

4. Background  Frustration  Community Issues  FHC Policy

5. Initial Meeting Multidisciplinary Team Establish goals Review former policy to amend Promote CONSISTENCY Adopt Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Non cancer Pain (“Clinical Guidelines”) (Journal of Pain Vol 10, No 2, February 2009, pp 113- 130) Amend Controlled Substances Agreement (CSA)

6. New/Amended Policy Defined CS: narcotics, amphetamines, and benzos Use “Clinical Guidelines” to guide policy To whom is CSA given, and when – 2 nd prescription for same CS – When a 2 nd CS used in same pt – New pts coming into practice on a CS – Pts on CS’s w/no CSA in chart Review content of CSA w/ each pt

7. New/Amended Policy con’t Institute use of: Initial Assessment Packet-(Initial Form, SOAPP, CSA, Pt. Goals, Resp & Self Mgmt/Informed Consent, Pt. Ed.) Ongoing Assessment forms (scale and diary) Emphasize use of pill counts and UDSs Use of different lab for UDSs Use Chronic Pain code 338.4

8. To what degree does your program have a policy for prescribing controlled substances? 1. No policy 2. Have policy, but inconsistently followed 3. Have clear policy, consistently followed

9. Clinical Guidelines for the Use of Chronic Opioid Therapy (COT) in Chronic Non Cancer Pain  Patient Selection and Risk Stratification Rec’s  Informed Consent and Opioid Management Plans Recommendations  Initiation and titration of COT Recommendations  Methadone Recommendation

10. Clinical Guidelines for the Use of Chronic Opioid Therapy (COT) in Chronic Non Cancer Pain  Monitoring Recommendations  High-Risk Patients Recommendations  Dose Escalations, High-Dose Opioid Therapy, Opioid Rotation, and Indications for Discontinuation of Therapy Recommendations

11. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Non cancer Pain  Opioid-Related Adverse Effects Recommendation  Use of Psychotherapeutic Co-interventions Recommendation  Driving and Work Safety Recommendation

12. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Non cancer Pain  Identifying a Medical Home and When to Obtain Consultation Recommendations  Breakthrough Pain Recommendation  Opioids in Pregnancy Recommendation  Opioid Policies Recommendation

13. FHC Adaptations / Recommendations  Incorporated all guidelines in policy and added some FHC-specific guidelines  Methadone Recommendation: reviewed by consultant at each visit  Monitoring Recommendations: High Risk: 4 UDS’s a year Low Risk: 1-2 times a year

14. FHC Recommendations Dose Escalations… Recommendations – Consider pharmacotherapy consultation for drug modifications Opioid-Related Adverse Effects Recommendation – Use Ongoing Pain Assessment Tool at each visit – Help pts. Understand goal of tx Identifying a Medical Home Recommendation only the assigned doctor prescribes ongoing opiates for their patients FHC: Policy for walk-ins or phone requests for meds running out

15. Didactic Presentation Components Clinical director lead speaker “Chronic Pain Management Guidelines for Treatment at FHC” Pharm D- Initiating and Titrating Drug Therapy for Chronic Pain Behavioral Medicine Survey

16. Didactic Presentation  Outline- used Guidelines  Inserted Audience Response Questions before certain sections when reviewing guidelines to gauge residents: Pt. selection & Risk Stratification Recs ○ The times that you don’t used the CSA, what are the reasons: Don’t know when to use it Don’t know where the form is Feels awkward Not enough time

17. To what degree does your program provide consistent training on prescribing controlled substances? 1. No specific training 2. Training done as needed during patient care 3. Occasional didactics related to topic 4. Specific, regularly scheduled training on policy and other issues

18. Didactic Presentation Monitoring Recommendations: – How often do you use any monitoring techniques? Always, Often, Sometimes, Never – Even if there is a legitimate reason for COT, I never prescribe for pts w/a history of drug abuse true, false Opioid-Related Adverse Effects Recs – How often do you refer pts on COT to behavioral medicine? Always, Often, Sometimes, Never

19. Pharmacotherapy  Initiating and Titrating Drug Therapy For Chronic Pain Consider types of pain and appropriate pharmacotherapy Consider co-morbid conditions that may affect pain management Assessment Adjusting Pain Meds Clinical Pearls for Pain Meds Drugs to avoid

20. Use of EMR to Monitor Progress Reports generated for each provider re:  Use of chronic pain code  How many pt’s with chronic pain code have CSA  Created AALERT  Use of ongoing pain assessments  Give reports at clinic teams / rotation

21. AALERT sample pt 8/2/11 15 :55 -Multiple alerts noted on chart. Pt should only be scheduled with PCP. Only PCP can refill narcotics, without exception. Many requests for early refills d/t sudden OOT work trips, coming into office without appt and demanding refills, overusing meds. -Dr. D.

22. AALERT sample pt con’t  12-1-11 spoke w/ Dr. D who states pt is NOT to have any early refills. Agrees pt needs to be discharged from practice if he cont's to call asking for refills. Before pt could be called back to relay this, pt arrived at clinic requesting refills, stating rx “blew away when he was changing his tire”. Dr. F and V.K. met w/ pt to relay Dr. D's statement and informed pt he would be DC'd from practice if he con’t to call to request refill before reg appt on Dec 26. Pt stated he may choose to “find another doctor anyway”.--vlk  3/30/12 pt will be seeing new pcp at next visit. new pcp needs to read AALERT in chart and take a good history and physical from pt to fully understand his history. –Dr. D.

23. What challenges most impede the use of monitoring tools (UDS, pill counts, data base)? 1. Lack of awareness tools 2. Discomfort with use of tools/client interaction 3. Not think necessary for care 4. Few obstacles, tools used often

24. Ongoing Monitoring Options  Numbers of AALERTS  Using chronic pain code, 338.4  UDSs ordered before and after training  CSAs on pts w/ chronic pain codes (eventually reports for all CS, started w/ opioids)

25. Ideas in progress  Created flow sheet  “No More Controlled Substances”  Teaching intern class alone  “CQI” reporting at clinic team meetings  3 rd years create AALERTs on most difficult pts  Having time set aside in didactics and on rotation to create AALERTS rotation  Regular didactic from addiction medicine specialist  Giving pts handout listing local SA tx providers (also available by zip code via SAMHSA)

26. Ideas in progress/Future  Providing pts w/ list of non-pharm rx options  Providing pts w/ handouts on meds consistently  SBIRT  Getting all providers access to state data base, apply during SA didactic and on rotation  Case review worksheet  Pain management online modules  Pain clinic grant run by mid level (submitted)  Require meds brought to all visits

27. Challenges  Consistent buy-in across clinical providers  Large program, many residents, faculty, community preceptors, mid-levels  Lots of ideas  Not always follow AALERTS  Work group vs. formal CQI measures

28. AAFP Chronic Pain Management Guidelines By the completion of residency training, a family medicine resident should:  Understand the pathophysiology and treatment of various types of chronic pain(Medical Knowledge).  Demonstrate empathy and compassion towards the patient with chronic pain (Interpersonal and Communication Skills, Professionalism).  Apply his or her knowledge of pain and systems to the care of the patient with chronic pain (Patient Care).

29. AAFP Chronic Pain Management Guidelines  Conduct a chronic pain chart review to identify strategies for improved care (Practice Based Learning and Improvement).  Appropriately utilize available community resources to optimally manage pain (Systems-Based Practice).

30. Attitudes The resident should develop attitudes that encompass: An acknowledgment of the subjective and individual nature of pain. An appreciation of the psychosocial effects of pain and the therapeutic value of empathy. An appreciation of the risk for abuse and addiction within the profession.

31. Skills In the appropriate setting, the resident should demonstrate the independent ability to: 1. Accurately monitor pain and function. 2. Evaluate opioid abuse risk using a validated screening tool. 3. Effectively establish a chronic pain contract. 4. Properly interpret urine toxicology screening tests. 5. Perform a chart review and adjust treatment plans based on diagnosis and risk for opioid abuse. 6. Treat and monitor pain patients at the highest risk for abuse. 7. Prescribe narcotic alternatives (e.g. methadone). 8. Perform joint injection techniques. 9. Treat special populations.

32. Small Group Discussion  How might you incorporate some of the ideas into your practices.  Pick one idea to use or something to change and discuss why you chose it and how you plan to use it  What has worked in your programs?

33. Handouts  FMDRL Policy Controlled Substances Agreement Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Non Cancer Pain AAFP Curriculum Recommendations for Chronic Pain Mgmt Pain Assessment Packet Ongoing Pain Assessment Form Controlled Substances Case Review No More Controlled Substances Agreement

34. References  AAFP Recommended Curriculum Guidelines for Family Medicine Residents: Chronic Pain Management www.aafp.org/cg  American Pain Foundation painfoundation.org  Chou, et. al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Non Cancer Pain. Journal of Pain 2009; Vol 10 (2): 113-130.

35. References  Duffy, L. Controlled Substance Prescribing Handbook. University of South Alabama College of Medicine Department of Family Medicine. 2nd Ed., 2011  Gourlay, D., Heit, H., Almahrezi, A. Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain. Pain Medicine, Vol 6, No 2, 2005.

36. References  Gourlay, D., Heit, H., and Caplan, Y. Urine Drug Testing Clinical Practice: The Art and Science of Patient Care. 4 th Ed. (CME program) California Academy of Family Physicians in cooperation with PharmaCom Group, Inc. May 2010.  SAMHSA treatment locator http://www.samhsa.gov/treatment/index. aspx