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TACKLING PAIN MANAGEMENT A Multimodal Approach

Noah Nesin, MD, FAAFP VP of Medical Affairs, PCHC Felicity Homsted, PharmD, BCPS Chief Pharmacy Officer, PCHC

DISCLOSURES

Dr. Homsted serves as a 340B Program Subject Matter Expert for the Apexus 340B Prime Vendor Program

GENESIS OF THE OPIATE CRISIS

“Pain as the 5th Vital Sign” will likely become the Bloodletting of the 21st century

•  A widely-adopted practice intended to improve care causing a cascade of unanticipated harm

CONTROLLED SUBSTANCE STEWARDSHIP:

A coordinated effort to promote the appropriate use of controlled substances, improve patient outcomes, reduce misuse and abuse, and decrease patient morbidity and mortality attributed to these high-risk medications.

Adapted from APIC definition of antimicrobial stewardship by KariLynn Dowling PharmD.

ACUTE VS. CHRONIC PAIN

Acute •  Severity closely associated with tissue

damage

•  Emotional component •  Pain scales validated

•  Low risk of addiction

•  WHO ladder approach well studied •  Processed in pain matrix

•  Amenable to pharmacologic and non-pharmacologic treatment aimed at tissue damage

•  Dose dependent risk of overdose

Chronic •  Severity unrelated to tissue

damage •  EMOTIONAL COMPONENT •  Pain scales not validated •  Significant risk of addiction •  WHO ladder approach not

studied at all •  Processed in emotion/reward

areas of brain •  Dose dependent risk of

overdose

PUBLIC HEALTH APPROACH

Between 2000 - 2016 •  Prescription opioid overdose deaths in US increase 265% in men, 400% in women

•  Maine leads nation in prescribing long acting opioids @ 21.8 Rx/100 people

•  60 to 65 pills for every man woman and child in Maine annually

•  Opioid overdose deaths in Maine are now at 1 a day

•  Over 1000 babies born with NAS in Maine each year

•  More than half the crime in Maine is drug related

•  Dramatically increased need for family support services and child protective intervention

•  16,000 Mainers on > 100 MME daily for chronic pain

•  28,000 Mainers with OUD with capacity to treat 3500 to 7000

•  NIH estimates 70% of people with chronic pain receive improper treatment

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NUMBER NEEDED TO KILL & ABUSE RATES

•  NNK 550 for any dose of chronic opioid

•  NNK 32 for >200 MME

•  Lifetime prevalence of OUD for people on daily opioids for chronic pain is 35% •  0.35 x 16,000 = 5600

•  May be higher due to adverse selection

•  Almost certain to be a very high percentage of people taking it for psychological reasons

•  Very high prevalence of trauma/PTSD

SOME INTERESTING NUMBERS

•  Start an opioid today, 1 in 15 chance of being on it a year from now

•  NNT 4.6 for post op pain using 15 mg oxycodone •  NNT 1.6 for post op pain using Ibuprofen 200 mg + APAP

500 mg •  66% of pills abused by adolescents come from friend or

family

OVER-PRESCRIBING

•  Over-prescribing for wisdom tooth extractions leads to 100 million excess doses/year

•  Orthopedic day surgery patients receive an average of 30 opioid pills and take an average of 11

•  80% of C-section patients report taking less than half of prescription, >50% report taking none

•  70% of thoracic surgery patients report taking less than half of prescription, 40% report taking none

• Almost everybody keeps their excess pills

REMEMBER HOW WE GOT HERE

1.  Opioids promoted as gold standard of treatment for chronic pain •  no evidence to support that claim

2.  No ceiling dose •  no evidence to support that claim

3.  Very low (<1%) risk of addiction when opioids used for chronic pain •  no evidence to support that claim

4.  Consider “pseudoaddiction” to explain alarm behaviors •  no evidence to support that claim

RESPONSE TO PRESCRIPTION DRUG CRISIS

Education

Treatment

Prevention Harm Reduction

An interdisciplinary controlled substance review process was implemented in February 2013 with the goal of decreasing

inappropriate prescribing of opioids and the associated patient morbidity and mortality.

Enforcement

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CSI PROGRAM OVERVIEW

Controlled Substance Initiative (CSI) Committee

Chief medical officer, chief psychiatrist, pharmacy residents, physicians, mid-level

practitioners, and care managers

Provider-patient controlled substance

agreements

Controlled substance policies with provisions for

oversight

Proactive case reviews based on referrals and QI

reports

Pharmacist-driven, resident-managed array of clinical and administrative services

CSI IMPACT

•  Retrospective chart review: 93 cases involving opioids reviewed in a 90-day period5

•  Dose reductions suggested in 78 cases •  At three-month follow-up, 76% of dose reductions

implemented •  32% of patients had the prescription eliminated completely

•  Overall: 60% reduction in opiate and benzo prescriptions organization wide

•  Ongoing research: premature deaths (<60 years) involving opioids •  Preliminary results: 50% decrease between 2013 and

2015

PATIENTS ON CHRONIC OPIOID PRESCRIPTIONS

1340

1253 1137

1320 1379

1112 1057 1035

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PATIENTS ON CHRONIC BENZODIAZEPINE PRESCRIPTIONS

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PREMATURE DEATHS WITH OPIOID USE

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2013 2014 2015

OTHER TREATMENTS

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ALTERNATIVE TREATMENT CONSIDERATIONS

•  Trauma informed care/ ACEs

•  EMDR (in PTSD)

•  CBT

“BUT NOTHING ELSE WORKS”

• Antidepressants

• Anticonvulsants

• NSAID

• Counseling

• Physical Therapy

• Manipulation

• Support Groups

• Exercise

• Weight Loss

• Acupuncture

• Massage

• Chiropractic

• Tai Chi

• Mindfullness

• Yoga

PCHC EXPERIENCE:

•  Provider impact

•  Practice security

•  New addiction focus

•  Awareness of suffering

IMPACT ON THE HOUSEHOLD & COMMUNITY

•  Controlled Substance Initiative

•  HRSA Substance Abuse Expansion Grant

•  Rapid Access Suboxone Treatment Center

•  NAS outpatient treatment clinic

•  Naltrexone pilot for women released from county jail

•  Partner in MCPC, Caring for ME, MICIS, Maine Opiate Collaborative

•  CHLB/ BACSWG

A PATH FORWARD

The Island of Opioids

Reduce pain related distress, disability and suffering. Offer empathy, encouragement, mentorship, hope.

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Time

Role of Emotion

in the Intensity

of Chronic

Pain

Insight

Emotional/ Psychosocial

Factors

Suffering

NOAH’S UNOFFICIAL AND LIKELY DERIVATIVE CHRONIC PAIN AND

SUFFERING PRINCIPLE WHAT RESPONDING TO SUFFERING REQUIRES

•  Engagement as a whole person

•  Emotional intelligence

•  Self-awareness

•  Sense of purpose

•  Humility

•  Patience

“RESPONDING TO SUFFERING”

EPSTEIN AND BACK, JAMA, DEC. 22/29,2015

Diagnosing and Treating •  Identify a problem and propose a treatment to restore

health and normal function o  Tests, referrals, procedures, surgeries, meds o Do something!

•  May lead to frustration or sense of inadequacy in managing chronic pain

•  Our own emotional reactions may intrude •  Distancing

o More referrals o  Longer appointment intervals o Blame the patient

RESPONDING TO SUFFERING

Turning Toward •  Recognize suffering

•  Ask for the story

•  Be present

•  Honor their experience

•  Recognize their strength

•  Be authentic

•  Humility

•  Non-abandonment

•  Spirituality

•  Connection

•  Loyalty

•  “Sustained compassionate engagement”

Refocusing and Reclaiming

•  Help them to access sources of strength and resiliency

•  The things that are important •  Redefine goals focused on

enhancing meaning •  Take back control •  Learn from the illness •  Integrate their values •  Acknowledge ambiguity •  Challenge self-perceptions •  Hope

“Those who have a why to live, can bear with

almost any how.”

Viktor E. Frankl

Man's Search for Meaning

QUESTIONS?