mitigating risk when managing high dose, chronic pain patients
TRANSCRIPT
Webinar November 1, 2017
Mitigating Risk When Managing High Dose, Chronic Pain Patients
Ryan Thurber Polsinelli PC
Jeffrey Fitzgerald Polsinelli PC
Elizabeth S. Grace, MD, FAAFP
Medical Director, CPEP [email protected]
Blame and Enforcement
Rhetoric is high
– Top priority of Attorney General Jeff Sessions
– State AG and medical boards increasingly active
President declared public health emergency (10/26/17)
Health Affairs (10/8/2017)
– Blame hospitals (treat as hospital-acquired condition)
60 Minutes – Washington Post (10/15/2017)
– Blame manufacturers and distributors
But patients need treatment for pain
– Some People Still Need Opioids Slate (8/17/2017) 2
Blame and Enforcement
Tension exists between anti-opioid rhetoric and fact that treatment of pain is important
Some patients have chronic pain, and opioid analgesic treatment is appropriate
Physicians and supporting organizations can provide the appropriate clinical care, but structural safeguards are needed to reduce legal risk
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Beneficence
Non-Maleficence
Adequately address a patient’s chronic pain
While not harming the patient or putting him and undue risk
While not putting your career at risk
The Physician’s Challenge
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Strategies for Clinicians
Independently and objectively evaluate all patients, including patients who present with established diagnoses and treatment plans
Assess for risk of abuse before prescribing and periodically thereafter
Establish realistic goals regarding symptom improvement and establish measurable functional treatment goals
Check the prescription Drug Monitoring Program (PDMP)
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Strategies for Clinicians
Become familiar with screening for or identifying substance use disorder
– Be knowledgeable about addiction treatment resources in your area
Avoid prescribing opioids with benzodiazepines and/or other CNS sedating medications
Know your own vulnerabilities
Don’t ignore potentially important information
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Strategies for Clinicians
If you do prescribe higher dose opioids, or to patients at higher risk due to other factors, mitigate risk by:
– Assessing for adverse effects
– Prescribe Naloxone
– Document carefully
– Follow organizational policies and procedures
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Tapering Opioids: Who?
Inadequate improvement of pain and function >50 MED without benefit or co-prescribed with a
benzodiazepine Non-adherence with treatment plan Signs of SUD Significant adverse event (e.g., OD) Warning signs of OD (confusion, oversedation, slurred
speech) Condition is resolved https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf; Berna et al. Mayo Clin Proc. 2015;90(6):828-842
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Tapering Opioids: How?
Plans should be individualized General guidelines: decrease by 10% of the
original dose/week Slow down the taper, if necessary; don’t reverse Alpha 2 agonists can reduce withdrawal
symptoms Consult as needed: addiction, OB/Gyn (pregnant
patients), mental health Recognize risk of quickly resuming prior dose
after or during a taper (consider naloxone)
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Multiple benzodiazepines
Benzodiazepine combined with opioids and/or amphetamines
Active or history of substance use disorder
Patients with cognitive disorder
Benzos should be tapered for any patient taking a benzo for 2 weeks or more
Supratherapeutic doses
Tapering Benzodiazepines: Who?
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Tapering Benzodiazepines: How?
Carefully and slowly: watch for withdrawal
See references for potential tapering schedule
Scheduled rather than prn doses
Initiate alternative treatment , e.g., CBT
Suspend (or reverse) if severe anxiety or depression occur
http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b06.html https://www.va.gov/PAINMANAGEMENT/docs/OSI_6_Toolkit_Taper_Benzodiazepines_Clinicians.pdf
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Tapering Benzodiazepines: How?
Supratherapeutic doses (or other complicated patients)
– Consider referral to addictionologist
– Consider admission
– Consider anticonvulsants
http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b06.html https://www.va.gov/PAINMANAGEMENT/docs/OSI_6_Toolkit_Taper_Benzodiazepines_Clinicians.pdf
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Why Doctors Can’t Say No
Often it's easier to just say yes. But there are ways to say no that are better for both physician and patient
http://www.salon.com/2011/11/28/why_doctors_cant_say_no/
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Legal Risk Can Be Mitigated
Physician concerns about their personal exposure are real and appropriate – Encourage open dialogue
– Recognize that opinions can differ
Organizational support is essential – Assist physicians in providing quality care in a
changing environment
– Assist with documentation
– Assist with difficult cases
– Assist with education 14
Legal Risk Can Be Mitigated
Develop policy on use of opioid analgesics to treat chronic pain
Review and assess current patients with chronic pain and current prescription practices
Have a clear process to document basis for high dose prescriptions
Consider additional clinical education
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Chronic Pain Policy
Concise, practical and readable – Physician involvement is critical
Significant discretion on standards – Record basis for potentially controversial
standards
Issues to address – New patient intake
• Geographic limits; prior treatment; medical history
– Criteria for use of treatment agreement
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Chronic Pain Policy
Issues to address – Use of treatment plan, goals and schedule for re-
evaluation • Including assessment of non-opioid options
– Monitoring safeguards (set your own) • PDMP review
• Urine drug testing
• Evidence of diversion or dependence
• Documentation expectations and support process
– Response to suspected diversion
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Chronic Pain Policy
Issues to address – Objective clinical standards, such as
• Maximum dosages and combination of drugs
• Use of short acting and long acting drugs
• Marijuana and illicit drug use
• Evidence of injury or pain
– Standards for referral to pain specialist
– Standards for referral to substance abuse treatment
– Process for lost prescriptions
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Chronic Pain Policy
Issues to address
– Standards for tapering
• Expected timelines
• Standards for exceptions (if any)
– Issues/cases to be addressed by informal peer review
– Patient noncompliance and termination
• Consistency is important
Create policy and ensure it is followed
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Assess Current Practice
Review current high risk patients and prescribing patterns
Identify high risk patients – High dose opioids
– Co-prescribed other sedating medications
– Medical comorbidities that increase risk for adverse events
– Psychiatric comorbidities
– Vague and poorly defined conditions, or conditions for which opioids are not indicated or not typically used
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Assess Current Practice
Tools to review current high risk patients
– Prescriber PDMP self-query
– EHR diagnosis codes or e-prescribing query
– Ask prescribers about their comfort level and/or concerns
Analyze for potential diversion and clinical care (and documentation quality)
Develop plan to address issues or questions (if needed)
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Automate doing the “right thing”
– Process should ease burden on providers
– Process can add significant risk reduction
– Use a process that fits with your organizational culture
Consider documentation checklist
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Documentation for High Dose Prescriptions
Documentation for High Dose Prescriptions
Right Checks Right Chart Note Right Prescription
Patient chart reviewed and
contains:
Note from today’s encounter
contains statement:
Today’s prescription
reviewed:
☐ Current PDMP confirming
no unknown prescriptions
or other physician
prescribing opioids
☐ Urine drug testing dated
within __ days confirming
presence of prescribed
opioids and lack of others
or illicit drugs
☐ Treatment plan and
informed consent
☐ Current 5As of pain
management
☐ Discussed risk of abuse,
addiction or referral for
substance abuse
treatment
☐ About risk of diversion
☐ Addressing titration or
discontinuation of opioid
☐ About need for or
compliance with pain
contract
☐ Today’s prescription is no
higher morphine
equivalents than prior
prescription
☐ Prescription for no more
than __ day period
☐ No prescription for
benzodiazepines or
carisoprodol
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Clinical Education
Make resources available to providers
Develop process to keep up with clinical and regulatory changes
Be creative
– Attend CME
– Prescribing refresher courses
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http://www.cdc.gov/drugoverdose/prescribing/resources.html
– CDC website that includes CDC prescribing guidelines, tools for your practice, and patient education resources.
http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf
– Washington Agency Medical Directors’ Group Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (3rd Ed., 2015)
https://professional.oregonpainguidance.org/wp-content/uploads/sites/2/2014/04/OPG_Guidelines_2016.pdf
– Oregon Pain Guidance Group Pain Treatment Guidelines
http://coacep.org/docs/COACEP_Opioid_Guidelines-Final.pdf
– Colorado ACEP 2017 Opioid Prescribing & Treatment Guidelines
Guidelines and Tools
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https://www.cdc.gov/drugoverdose/pdf/Clinical_Pocket_Guide_Tapering-a.pdf
– CDC Pocket Guide: Tapering Opioids for Chronic Pain
https://www.va.gov/PAINMANAGEMENT/docs/OSI_6_Toolkit_Taper_Benzodiazepines_Clinicians.pdf
– Effective Treatments for PTSD: Helping Patients Taper from Benzodiazepines
https://www.colorado.gov/pacific/hcpf/pain-management-resources-and-opioid-use
– A list of resources from the Colorado Department of Healthcare Policy and Financing.
http://takemedsseriously.org/
– Colorado’s official online resources for information on the safe use, storage and disposal of prescription drugs.
Guidelines and Tools
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Your own state rules and regulations:
– Medical Practice Act
– Licensure board prescribing guidelines
– Prescription drug (controlled substance) monitoring program and related legislation
– Any additional state legislation specific to prescribing controlled substances
Guidelines And Tools
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28 60652243
Webinar November 1, 2017
Mitigating Risk When Managing High Dose, Chronic Pain Patients
Ryan Thurber Polsinelli PC
Jeffrey Fitzgerald Polsinelli PC
Elizabeth S. Grace, MD, FAAFP
Medical Director, CPEP [email protected]