1. ACP Quality Champions on Chronic Pain Management focus on Safe Opioid Prescribing Practices
Ena Mahapatra, M.D., M.S., F.A.C.P
John H Stroger J Hospital of Cook County
Assistant Prof of Medicine, Rush University

2. No Financial disclosures No conflicts of Interest

3. First and last encounter
New patient visit 1/2016
54 yr old Male
BMI 38
High risk for OSA
Multiple joint pain: Neck , Back, B/L hips and B/L Knee
Osteoarthritis of both knees
Mild DJD of C spine
No Hip or LS spine pathology in X-rays
On Opioids since 3/2014 : Morphine and Hydrocodone
Takes Morphine- helps him sleep at night, does not help with pain
Hydrocodone 1 tab Q 6hrly
ILPMP checked, and single pharmacy noted from our system
Able to function only with daily Opioid

4. Discrepancies History Never had Physical Therapy
Quit Cocaine in 1988 but tested positive for cocaine in 7/6/2015
Tested negative for opioids in 1/25/16
Denies constipation- not taking any stool softeners
Never had Physical Therapy
No Opioid agreements done
On expressing concern about OSA , says he can stop taking morphine at night

5. Digging Deeper
3/2014: Tramadol during ER visit for knee pain, back and neck pain
8/2014: Tylenol #3 added to Tramadol , by resident (PCP)
12/2014: Acetaminophen-Hydrocodone 325 mg-5 mg started
7/2015: Positive for cocaine
8/2015: Seen in Pain clinic
Started on Morphine ER 15 mg Q12
Acetaminophen-Hydrocodone 325 mg-5 mg Q6 continued
Diclofenac Na 75 mg TID and Gabapentin 400mg TID added
9/2015: Acupuncture at the pain clinic with some relief
1/2016: Started getting knee injections in Pain clinic
PCP to follow on Opioid prescription

6. Doctor Shopping I discussed this case with the pain specialist
Started with opioid taper
Morphine and hydrocodone stopped
Pt prescribed only Tylenol # 3
Patient requested change to a new Physician after this first visit with me

7. CDC Guidelines and ACP Center for Disease Control:
3/2016:Guidelines to help primary care physicians address chronic pain and safe opioid use
American College of Physicians:
Supported a Quality Improvement training for a group of primary care physicians to become Quality Improvement champions
ACP Quality Connect: Chronic Pain

8. Quality Improvement Intervention in General Medicine Clinic (GMC) Stroger Hospital

9. Goal
To improve Safe Opioid Prescribing practices by the providers and increase the use of the Institution’s Controlled substance Agreement form

10. Baseline Survey Physicians in 3/2016
Institution’s Controlled Substance Agreement form
19% of providers

11. Opioid prescriptions in GMC
32%
35%
31%
31%
56%

12. Opioid prescriptions in GMC
65%
85% 7%

13. Baseline Survey Physicians in 3/2016
Comments from different providers about using Agreement form:
Time consuming
Useless
Cannot find it , then have to print then have to go over it
I am using my own version(as auto-text function)
I am using modified version
Patient got insulted
It is easy to use
Made it easier to deal with pain med seeker
I have no plans to give any opioid to any patient in GMC
I never had to give any opioid to my patients
Used it once , better to have a separate day for discussing this
We should have our own GMC pain center to address this
I refer to pain clinic if they want any opioid

14. QI Project: Method 3 PDSA-QI Interventions done
Patient charts were reviewed for scanned copy of completed Institution’s Agreement forms in 3 time frames
Analysis for Number of Safe Opioid Prescription

15. Safe opioid prescription
Identification of patients on Opioids
Use of Institution’s Controlled substance Agreement forms
Use of Tools for Risk assessment
Use of Tools for Performance evaluation

16. 3 Intervention periods 5/1-5/30/16: Physicians
6/1-6/30/16 : A team in PCMH
7/20-8/17/16: Nursing staff

17. Intervention #1: Providers
March 29th 2016 and May 25th 2016
Educational presentation and workshop:
Increase awareness of chronic pain management and opioid misuse
Primary care providers in Division of General Internal Medicine

18. Educational Intervention: Objectives
Define Chronic Pain
CDC guidelines and Recommendations 03/16
Modalities of chronic pain management
Safe Opioid Prescription in Primary care:
Starting, Monitoring and Stopping
Establishing goals of treatment
Risk assessment
Institution’s Controlled substance Agreement forms
Illinois Prescription Monitoring Program

19. Intervention #2: One Team Easy Access to Opioid Agreement Packet
The second cycle of intervention was started on 6/1/16
The intervention to:
Only one team of the Patient Centered Medical Home (PCMH) of GMC
‘Opioid Agreement Packet’ was developed
Informing about easy access to ‘Opioid Agreement Packet’ during morning huddle

20. Opioid Agreement Packet
(A) Simple and easy tool to identify patient on opioids by the nursing staff during registration to the clinic
(B) Nationally well used “Opioid Risk Survey Tool” (Questionnaire developed by Lynn R. Webster, MD to assess risk of opioid addiction. Webster LR, Webster R. Predicting aberrant behaviors in Opioid‐treated patients: preliminary validation of the Opioid risk too. Pain Med. 2005; 6 (6): 432)
(C) Pain Enjoyment General activity-PEG scale (nationally well used survey adapted from Krebs EE, et al. J Gen Intern Med. 2009)
(D) 2 Education handouts from CDC for patient and provider
(E) Institution’s Controlled substance Agreement form

21. Tool to identify patient on opioids by the nursing staff in GMC

22. Opioid Risk Survey Tool
Please check off the boxes to all that apply to you.
Female
Male
Family history of substance abuse?
Alcohol 1 3
Illegal drugs 2
Prescription drugs 4
Personal history of substance abuse? 5
Age between years
History of preadolescent sexual abuse
Psychological disease?
ADHD, OCD, bipolar, schizophrenia
Depression
SCORING
Total Points .
0-3 Low Risk
4-7 Moderate Risk
> 8 High Risk

23. Pain Enjoyment General activity PEG scale

24. Educational handout for patient and provider from CDC

25. Educational handout for patient and provider from CDC

26. Institutional Patient Agreement Form

27. Intervention #3 : Nursing staff
The 3nd cycle of intervention was started on 7/19/16
Same educational presentation to increase awareness of chronic pain management and opioid misuse :
Nursing staff of all the teams involved in PCMH of GMC
Announcement was made to Primary care providers of GMC:
Easy availability of Opioid Agreement packets
Now to be placed in each patient exam room by nursing staff

28. Process
The patient on Opioid is identified at the intake by nursing staff
Opioid Agreement packets placed along with the chart of the patient for the provider to address
Completed packets placed in folders for scanning

29. Analysis Number of completed Opioid Agreement packets
Number of patients given opioid prescription

30. Analysis PDSA Cycle Date of Educational activities/Intervention
Educational Intervention
Time period
Number of Opioid agreement completed
Number of PEG scale
completed
Number of Risk survey completed
Number of Opioid prescribed
1st PDSA
3/29/16 and 5/25/16
Educational Presentation about CDC guideline and workshop done to faculty of DGIM during Division faculty meetings
5/1/16 -5/30/16 5 44
2nd PDSA
6/1/16
Team based intervention during hurdle about Opioid Agreement Packet, and these given to the nursing staff of the team for easy availability
6/1/16 -6/30/16 3  0 43
3rd PDSA
7/19/16
Educational presentation to Nursing staff of all teams ( 6 teams) and Opioid Agreement Packet placed in each examination rooms to increase accessibility, and this was announced to the faculty
7/20 – 8/17/16 7 2 1
(low risk) 28

31. Analysis

32. Results Completed Institution’s Agreement form
11% ( 5/44) in 1st PDSA
25% (7/28) in 3rd PDSA
Educational intervention and easy access to the Institution’s Agreement form lead to
14% increase in the number of completed Institution’s Agreement form
66% improvement of successful completion of Institution’s Agreement form
A trend towards decrease in number of opioid prescriptions

33. Limitations Limitation in tracking completion of Opioid Agreement
The Institution’s Controlled substance Agreement form was manually collected after completion
Not routinely scanned into the electronic medical record of the patients
Prescription Information available only from our own institution’s pharmacy
No information about prescriptions filled at other pharmacies

34. Barriers Time constraints:
Some providers did not use the Opioid Agreement Packet
Some Providers could only complete a part of the opioid agreement packet
Complex patents with multiple medical problems

35. Conclusion
It is possible to change the trend in current practice of opioid prescription with simple measures
Increasing awareness
Easy access to resources
Support for the providers
Team work

36. Future Plans Continue with our quality improvement efforts
Improve safe opioid prescribing practices
Address concern of prescribing providers
Recognize opioid dependency and abuse
Including Opioid Agreement Packet to the electronic medical record
Pill counting
Urine drug testing
Calculators for opioid dosage in morphine milligram equivalent
Referral to specialist (Psychiatrist/pain clinic/Medication Assistant Treatment programs/Behavioral health counselor, etc.).

37. Acknowledgements A special thanks to everyone who helped make this possible
ACP
Dr. S. Mathew, Chair of DOM
Dr. S Irons, Chair of DGIM
Dr. M Davidovich ,Medical Director of GMC
Ms. B. Hardy, Nursing Coordinator
GMC staff
Primary Care Providers