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Chronic Pain Management Primary Care Operating Committee Strategic Initiative Project, UCH/UPI/SOM Peter C. Smith, MD Assistant Dean for Clinical Affairs, Assistant Medial Director, CU Medicine 10 Principles of Chronic Pain Management at University of Colorado 1. Good Primary Care Practice 2. View Chronic Pain as a Centrally Mediated Sensory Experience 3. Cultivate Empathy and Therapeutic Relationships 4. Identify and Manage Psychological Co-Morbidity 5. Practice Patient and condition centric management 6. Use Risk-Based Assessment & Management 7. Comply with State/Federal Law and Medical Board Guidelines 8. Use Standardized Documentation in EPIC 9. Use Data for Monitoring and Improvement

10.Practice Team Based Care cufamilymedicine.org/chronicpain Managing chronic pain is hard Highly prevalent The ultimate bio-psycho-social problem Regulatory complexity Therapeutic options inadequate Some interventions may exacerbate chronic pain PCPs under-trained & under-resourced

Patient experience of pain is real But so are addiction, disengagement, diversion Principle #1: Good Primary Care Practice Do I have to? Yes As primary care we specialize in our patients. Our sacred duty is to help our them be healthier. Patients with chronic pain-to-Pain Specialist ratio is approximately 1:30,000 Our employers, clinical partners (SOM/UPI/UCH), and the primary care specialty organizations have made it clear that we cannot opt out of this responsibility. The good physician treats the disease; the great physician treats the patient who has the disease. -Osler

Principle #1: Good Primary Care Practice Foundational Primary Care (5 Cs) Contact (first) Comprehensive bio-psycho-social Coordinated specialty, ancillary; avoid iatrogenesis Collaborative team based care Continuous healing relationships Good clinical stewardship A good H&P, clinical curiosity, record review, meaningful documentation Keep up to date on Dx, DDx and management of painful conditions (Migraine, LBP, fibromyalgia, OA, RA, ACNES, etc) Prevent iatrogenesis Principle #1:

Good Primary Care Practice The #1 practice-based intervention to improve chronic pain care is to socialize and enforce chronic pain/opioid-only visits. Too complex and dangerous to be relegated to oh by the way Principle #1: Good Primary Care Practice Tools to socialize opioid-specific visits: Enforce restrictions on refill/dispense amounts by national and state guidelines, DEA, and payers Patient Agreements Limit refills visits to certain days of the week (T-Th) Avoid refill requests on weekends and Monday holidays Write scripts w/dispense amounts as multiples of 7 Hydrocodone 1 tab BID for 28 days = 56 tabs Hydrocodone 1 tab TID for 28 days = 84 tabs

Hydrocodone 1 tab QID for 28 days = 112 tabs Principle #2: Chronic Pain is a Centrally Mediated Sensory Experience Chronic Pain is a centrally mediated sensory experience Experienced as reality Principle #2: View Chronic Pain as a Centrally Mediated Sensory Experience All pain is a sensory experience Pain is a the experience of one or more sensory

stimuli interpreted by the central nervous system in the context of other sensory input and the neuro-chemical consequences of past experience CNS creates best guess based on complex input in face of encoded neural network shortcuts This experiential system can be wrong/fooled/ damaged/malfunctioning/maladaptive Principle #2: View Chronic Pain as a Centrally Mediated Sensory Experience Your pain vision is all in your head! Analogous to the Experience of Vision

Optical Illusions The Invisible Gorilla Blind spot Conversion blindness Hallucination http://www.theinvisiblegorilla.com/videos.html https://serendip.brynmawr.edu/bb/contrastcolor/ Human Nature Is Essentially. Light Shadow Context

Sensory Stimuli Basbaum et al. Cell 2009; 139: 267- Light Shadow Context Sensory Stimuli Basbaum et al. Cell 2009; 139: 267- Lens/ Retina Optic Nerve Brain

Transmission and Processing Light Shadow Context Sensory Stimuli Basbaum et al. Cell 2009; 139: 267- Lens/ Retina Optic Nerve Brain

Transmission and Processing Experience Nociceptive Neuro pathic Context Sensory Stimuli Basbaum et al. Cell 2009; 139: 267- Nociceptive Neuro pathic Context

Sensory Stimuli Basbaum et al. Cell 2009; 139: 267- PNS Spinal Cord Brain Transmission and Processing Nociceptive Neuro pathic Context

Sensory Stimuli Basbaum et al. Cell 2009; 139: 267- PNS Spinal Cord Brain Transmission and Processing Pai n Experience Nociceptive Neuro

pathic Context Sensory Stimuli Basbaum et al. Cell 2009; 139: 267- PNS Spinal Cord Brain Transmission and Processing Pai n Experience

Micro Glia Nociceptive Neuro pathic Context Sensory Stimuli Basbaum et al. Cell 2009; 139: 267- PNS Spinal Cord Brain

Transmission and Processing Pai n Experience Micro Glia Nociceptive Neuro pathic Context Sensory Stimuli Basbaum et al. Cell 2009; 139: 267-

PNS Spinal Cord Brain Transmission and Processing Pai n Experience Micro Glia Inflammation Nociceptive

Neuro pathic Context Sensory Stimuli Basbaum et al. Cell 2009; 139: 267- PNS Spinal Cord Brain Transmission and Processing Pai n

Experience Micro Glia Inflammation Nociceptive Neuro pathic Context Sensory Stimuli Basbaum et al. Cell 2009; 139: 267- PNS Spinal

Cord Brain Transmission Rewired andNetworks Processing Pai n Experience OPIOIDS Micro Glia Inflammation Nociceptive

Neuro pathic Context Sensory Stimuli Basbaum et al. Cell 2009; 139: 267- PNS Spinal Cord Brain Transmission Rewired andNetworks Processing Pai

n Experience OPIOIDS Micro Glia Inflammation Nociceptive Neuro pathic Context Sensory Stimuli Basbaum et al. Cell 2009; 139: 267-

PNS Spinal Cord Brain Transmission Rewired andNetworks Processing Pai n Experience Context Behavioral Coping,

Beliefs, Support, Attribution Social Determinants, Gradient Chronic Disease Diet Activity Function Sleep Lived Experience, Trauma

Genetics Substances RISK Epigenetics Principle #3 Cultivate Empathy and Therapeutic Relationships Principle #3: Cultivate Empathy & Therapeutic Relationships Chronic pain is influenced by complex bio-psychsocial inputs and plasticity/sensitization. Providers can help address these issues through Hawthorn and Placebo effects

Helping patients develop Insight Self efficacy/SMS knowledge and skills Functional and behavioral goals Addressing the provider heartsink phenomenon Specific practice-based interventions Cultivate Empathy & Therapeutic Relationships Mindfulness Doorknob Mindfulness 1-2 deep breaths to clear the mind and prepare your affect before entering the room, no matter what else has happened to you that day. Mindfulness:

Cognitive & Affective Errors Anchoring: Seize on initial finding and allow to cloud judgment. Attribution: Stereotype based on past experience or what told by colleagues. Transference: Patient transfers emotions for others onto provider (e.g. mistreated, dismissed, etc.) Countertransference: Provider transfers emotions to patient, often but not always a reaction to transference. Brief Positive Psychology Interventions Assess and Address: Attribution, Beliefs & Values Fear and Harm Avoidance (small achievable goals) Reinforce Engaged/active/adaptive behaviors (positive reinforcement) Avoidant behaviors (negative reinforcement/ignore)

Strengths Based Practice Focus: resiliency, hope, respect, trust, growth, capacity building Avoid: whats wrong, trying to fix recurrent/insolvable problems, ignoring value of adversity B.A.T.H.E. Positive B.A.T.H.E. technique Positive B.A.T.H.E. Best Whats the best thing thats happened since I saw you? Affect or Account How did that make you feel/do you account for that? Thankfulness For what are you most thankful?

Happen How can you make things like that happen more often? Empathy and Empowerment That sounds fantastic. I believe you can do that. Stuart MR, Lieberman JA. The Fifteen Minute Hour: Therapeutic Talk in Primary Care Principle #4: Identify & Manage Psychological Co-Morbidity Screen, diagnose, and treat: Depression, anxiety, bipolar Substance use disorders, addiction Trauma Consider other contextual/behavioral issues Mindset Self care, Family/social supports

Stressors Sleep Activity Employment Etc. Additional Behavioral Approaches Therapy: CBT, DBT, ACT (Group/Referral/web based/apps) Self Management Support: SMS Group (e.g. C.O.A.W.) Mindfulness, sleep, complimentary medicine, exercise (yoga/tai chi/graded exercise programs), family/caregiver engagement Trauma Informed Care: Respect, permission, rapport, transparency, respect boundaries, control

Help patients Ex.P.R.E.S.S. themselves Exercise Psychological distress Regain function Emotional well-being Sleep hygiene, Stress management Principle #5: Patient and Condition Centric Management Diagnosis: DSM IV AXIS construct: I. II.

III. IV. V. X Primary Psychiatric, incl. substance use / addiction Personality disorders Medical (presenting etiology and relevant co-morbidities) Stressors Function Axis X: The Substrate Trauma/ACE history History of medical care experience

Coping mechanisms Interaction of multi-axis co-morbidityetc Improvement in physical & social functioning is primary goal of therapy Principle #5: Patient and Condition Centric Management Non-Pharmacologic PT/OT, PM&R, OMT, Massage, Exercise prescription, heat/cold Mindfulness/Meditation, Biofeedback, Hypnosis, sleep hygiene, acupuncture Counseling, Support group, Care Mgt, Addiction referral, Group visits

Pain clinic referral, injections, acupuncture, TENS, ablation, etc Goal setting, positive psychology, ExPRESS, other behavioral based approaches Pharmacologic Non-opioid Analgesics, relaxants, antidepressants, triptans, antiepileptics Newer Rx/indications: clonidine, minocycline, oxybate, milnacipran, low dose naltrexone, etc Website: University of Utah Guide, CU Pearls Opioids - short acting = lower risk Treat ALL Axes aggressively to maximize function and minimize harm Principle #6: Risk Based Assessment and Management Risk of adverse events/overdose

Morphine Equivalent Daily Dose(MEDD) 1-49mg vs 50-99mg vs 100-199mg vs >200mg MEDD coming soon to EPIC; GlobalRph, PDMP ORADER: Opioid Related Adverse Drug Event Risk Geriatric (age > 65) Significant Obesity (BMI > 35) Significant Psychiatric Disorder (e.g. depression, anxiety, panic, bipolar, schizophrenia) Substance Abuse (e.g. alcohol, illicit drug use) Central Nervous System/Cognitive Disorder (e.g. stroke, dysphagia, neuromuscular disease, dementia) Respiratory Disorder (e.g. sleep apnea, COPD/emphysema, asthma, cystic fibrosis, obesity hypoventilation syndrome) Sedating Medications (e.g. benzodiazepines, hypnotics, sedating antihistamines, muscle

relaxants, etc) OPIOID RISK FACTORS: MDE: 40 (0-49 mg=Low, CDC, 2016) Diagnoses: Dementia Sleep Apnea Prescribed: morphine trazodone History of: 8.4oz of alcohol weekly marijuana family history of substance abuse Risk Scores: High Opioid Risk Tool score (26) High risk DIRE score (12)

High GAD-7 (16) Moderately severe PHQ-9 (17) Pertinent neg: Patient does not have a risky BMI Notes: Patient does not have a recent PDMP check or a urine drug screen in the last year. Principle #6: Risk Based Assessment and Management Assessment tools for aberrant behavior risks Psychiatric comorbidity: Depression: PHQ9 Anxiety: GAD-7 Substance use: DAST-10 (illicits) AUDIT-C (etoh)

Well Being Screener Other (Bipolar, schizophrenia, personality d/o, etc) Poor substrate: Diagnosis/Intractability/Risk/Efficacy (D.I.R.E.) Score Opioid Risk Tool (O.R.T.) Adverse Childhood Events (A.C.E.) Score 400mg, PTSD, substance abuse, OSA, BZD use, DIRE+, ACES++, 100mg, DIRE+, PHQ9++, ORADER+ 50mg, DIRE-,GAD+, ORADER+

30mg, DIRE ORADER- ! High Medium Low Principle #6: Risk Based Assessment and Management Low/Medium/High/Extreme Principle #6: Risk Based Assessment and Management Starting opioids: Avoid if possible for chronic pain, esp. if at risk of aberrancy

or adverse events, poor substrate Dont start something you arent prepared to monitor aggressively and stop if ineffective Always consider initiation to be a BRIEF trial Minimize duration /dispensing for acute pain Adverse events & aberrant behavior Aberrant behavior is a symptom in need of a diagnosis Principle #7:Comply with State and Federal Law and Medical Board Guidelines DORA: Policy for Prescribing and Dispensing Opioids CDC: Guideline for Prescribing Opioids for Chronic Pain

Principle #7:Comply with State and Federal Law and Medical Board Guidelines: CDC Quick-Guide 1.Opioids are not first-line or routine therapy for chronic pain 2.Establish & measure goals for pain & function 3.Discuss benefits & risks & availability of nonopioid therapies 4.Use immediate-release opioids when starting 5.Start low and go slow 6.When opioids needed for acute pain, prescribe no more than needed 7.Do not prescribe ER/LA opioids for acute pain

8.Follow-up & re-evaluate risk of harm; reduce dose or taper & discontinue if needed 9.Evaluate risk factors for opioidrelated harms 10.Check PDMP for high dosages & Rx from others 11.Use urine drug testing to identify prescribed substances and undisclosed use 12.Avoid concurrent benzodiazepine and opioid prescribing 13.Arrange treatment for opioid use disorder if needed Principle #7:Comply with State and Federal Law and Medical Board Guidelines: DORA Quick-Guide

1. 2. 3. 4. Develop and maintain competence Verify a provider-patient relationship Utilize safeguards for the initiation of pain management Diagnose/Assess Risk/Assess Pain Nature/intensity/Type/Pattern/Frequency/Duration Past and current treatments Underlying or co-morbid disorders or conditions Impact on physical and psychological functioning

5. Exercise caution > 120mg MEDD or >90 days or unique formula (e.g. patch, methadone) Assess function and compliance w/opioid trial Monitor closely: Pt Agreement, compliance, Function, PDMP, periodic UDS 6. Ensure dose, quantity, and refills are appropriate to improve the function and condition of the patient, at the lowest effective dose and quantity 7. Educate patients regardless of the dosage, formulation and duration of opioid therapy on:

Risks (including addiction), benefits and alternatives Proper use, storage, disposal Diversion CARE Notes: UCH Patient Information Guide on Opioid Treatment for Chronic Pain 8. Naloxone: Colorado law strongly encourages prescribersto educate on the use of an opiate antagonist for overdose, including but not limited to risk factors and recognition of overdose, calling emergency medical services, rescue breathing and administration of an opiate antagonist. 9. DISCONTINUING OPIOID THERAPY When: The underlying painful condition is resolved;

Intolerable side effects emerge; The analgesic effect is inadequate; The patients quality of life fails to improve; Functioning deteriorates; or There is aberrant medication use. Tapering: Employ a safe, structured tapering regimen through the prescriber or an addiction or pain specialist. There is a risk of patients turning to street drugs or alcohol abuse if tapering is not done with appropriate supports. Patient Dismissal Colorado Medical Board Guideline

It is the policy of the Colorado Medical Board (Board) that the proper discharge of a patient from a providers practice includes the following elements: In writing, delivery confirmation Agree to provide 15-30 days of emergency coverage while obtains new PCP If possible, provider provides referral information to possible new providers. Notify that patient records will be sent to the new provider upon receipt of written authorization IN ADDITION! Must be non-discriminatory and not jeopardize their well-being, or you risk being charged w/medical abandonment, civil rights violations, ADA, etc. Exceptions exist for threatening/criminal/violent behavior

Dismissal = dismissal from entire system, qualifying life event for CU Anthem ANY DISMISSAL ACTIVITY MUST GO THROUGH RISK MGT (303) 724-7475 = 4-RISK Principle #8: Standardized Documentation in EPIC Standardized Assessments PHQ, GAD, WBS, DIRE, ORT, AUDIT, DAST, 4As flowsheets Includes 4 As instrument Analgesia, ADLs (function), Adverse effects, Assessment overall provider assessment ORADER Key data flow directly into note templates for tracking.

Principle #8: Standardized Documentation in EPIC Common Patient Treatment Agreement: PC Opioid Medication Partnership Agreement, FYI 3 Epic note templates: Comprehensive visit, Follow up visit, A&P Flexible to integrate with your workflow preferences Pick-n-click lists for easy DORA compliance Support problem based charting; Support risk based management (frequency of f/u, etc) Note templates into BLANK NOTE: Comprehensive Pain Notewriter/APSO Pain Follow Up Notewriter/APSO A&P dot-phrase:

.chronicpainaandp Can pull in with A&P area or dot phrase (.probapnotes) Problem based charting compatible Principle #9: Data Driven Monitoring and Improvement Current Registry Report https://spsites.uchealth.org/bi/clinical/Dashboards/Forms/ByAudience.aspx Problematic, includes all controlled substances Planning Epic Healthy Planet Registry in 2018 Should enhance ability to measure and improve More to come: Morphine Equivalent Daily Dose (MEDD) in EPIC (late 2017) Enhanced MEDD functionality in Rx ordering window Single Sign on PDMP results within EPIC (late 2017)

Principle #10: Team Based Care Pre-visit or rooming data collection What: PDMP delegation, UDS, Standardized Assessments/Screeners, Self management support, risk stratification support, registry management Who: RN, MA, CM, SW, Pharmacist, PAR/CTA Where/When: At home, in waiting room, in exam room, on the phone, or other distinct nonphysician visits How: On paper, EPIC flowsheets, MHC Psychosocial support

Motivational interviewing, BATHE-ing, positive behavioral techniques, trauma informed care, strength based practice, SMS group visits, RN refill visits, integrated services, ExPRESS 10 Principles of Chronic Pain Management at University of Colorado 1. Good Primary Care Practice 2. View Chronic Pain as Centrally Mediated Sensory Experience 3. Cultivate Empathy and Therapeutic Relationships 4. Identify and Manage Psychological Co-Morbidity 5. Patient AND condition centric management 6. Risk Based Assessment and Management of Patients on Opioids 7. Comply with State and Federal Law and Medical Board Guidelines 8. Standardized Documentation in EPIC 9. Data Driven Monitoring and Improvement 10.Team Based Care cufamilymedicine.org/chronicpain

One more thing THC In the USmany of the cannabis productsbear little resemblance to the products that are available for research while the use of cannabis for the treatment of pain is supported by well-controlled clinical trials as reviewed above, very little is known about efficacy, dose, routes of administration, or side effects of commonly used and commercially available products in the United States. Concerns: - Opioid potentiation, tolerance, side effects, long-term effects - UCH/UCD prohibitions and malpractice considerations https://www.nap.edu/read/24625

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