2. Learning Objectives:
1. Describe the relationship between prescription
drug morbidity and mortality and the under-
treatment of pain.
2. Identify measurement-based care as standard
of care in pain medicine and describe how to
measure pain, mood and function in every
clinical encounter.
3. Evaluate how new state and federal policy
changes will likely allow more prudent and safer
use of opioids for chronic, non-cancer pain.
3. Disclosure Statement
• All presenters for this session, Dr. Alex
Cahana and Dr. Gary M. Franklin, have
disclosed no relevant, real or apparent
personal or professional financial
relationships.
7. My disclosures
• I
am
not
opio-‐phobic
• I
am
not
opio-‐philic
• I
am
not
needle-‐phobic
• I
am
not
needle-‐philic
• I
am
agnos3c
to
chi
gong
and
tai
chi
• ‘I
just
wanna
know
how
my
pa3ents
are
doin’
• Because
if
I
don’t
measure
outcome
I
believe
my
prac3ce
is
not
medically,
financially
or
ethically
sustainable
• Standard
of
Care
needs
to
be
codified
8. Today:
• Situa3on
• Model
of
Care
• Value
• Future
17. Newborns
with
Drug
Withdrawal
(GeneraEon
Rx)
Washington
State,
1990-‐2009
5
4
Rate
per
1,000
live
births
3
2
1
0
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
Source: Washington State Department of Health, Comprehensive Hospital Abstract Reporting System
18. WA
State
Healthy
Youth
Survey
Frequency
of
Use
to
Get
High
Past
30
days
Grade
10
Sabel J, Banta-Green C. CSTE
2009
21. • People die from Rx
100 Overdoses Every
Day in the US
• Rx Pain Killer
14,800 Deaths in
2008
Source: CDC Vital Signs: overdoses of prescription opioid pain relievers -
1999-2008
22. For Every One Death :
10 Treatment 32 Emergency
admissions for dept visits
abuse
1 Death
130 People who 825 Non-
Misuse/abuse medical users
Source: CDC Vital Signs: overdoses of prescription opioid pain relievers -
1999-2008
24. Today:
• Situa3on
• Model
of
Care
• Value
• Future
25.
26. Revise
our
pracEce
model
• System is • Coordinated care
fragmented (PCMH)
Patient activation
• Care is inconsistent
• Collaborative care
(Telepain/ECHO)
• Cost is
unsustainable • Measurement based
care (CPAIN /
PainTracker)
27. Coordinated,
CollaboraEve
Pain
Management
The Patient
Measurement-Based Care Prescription Monitoring Tools
Primary
Care
Providers
Nurse Care
Coordinator
Pain s UDT
Tracker EDIE
CPAIN PMP
DNIC
Pain
Specialists
Structured
2ndOpinion TelePain Interdisciplinary
RX Reviews Consultation & CME Pain
Management
Increasing Level of Care
Lower Costs
38. 1.
Coordinated
care:
Pilot
data
Pain Disability Anxiety Depression Opioid use
Well engaged -6% -45% -44% -50% -56%
Minimally
engaged +28% +55% +10% +28% +1%
Not engaged +29% +29% No f/u No f/u -3%
40. 2.
ECHO/TelePain/ROAM
N = 94
N = 95
6 Mean
=
4.7
Mean = 4.5
N = 94
SD = 0.6 Mean = 4.3
SD = 0.7
SD = 0.7
5
4
Mean Rating
3
2
1
0
Learning best practice Developing clinical Comfortable teaching
care expertise others what I've learned
Participants Rated Level of Agreement on a 5-point Scale: 1 = Not At All, 5 = To a Large Degree
41. 2.
ECHO/TelePain/ROAM
N = 85 N = 84 N = 84 N = 85 N = 86
Mean = 4.6 Mean = 4.4
6 Mean = 4.3 Mean = 4.4 Mean = 4.5
SD = 0.7 SD =0.7 SD = 0.7 SD = 4.5 SD = 0.6
5
4
Mean Rating
3
2
1
0
Reduced Reduced Provider's Decreased Through early
patient travel for emergency appropriate use visits by and effective
specialty care room visits of testing patients to patient
and testing specialists interventions
Providers Rated Agreement on a 5-point Scale: 1 = Strongly Disagree, 5 = Strongly Agree
45. 3.
PaEent
Reported
Outcome
Estimated Savings per Claim over Duration of ER Group (N = 373) ID Group (N = 373) DR Group (N = 373)
Disability
Total Cost of Illness per Claim (2010 US $) $66,525 $121,829 $233,600
Average Savings - $55,304 $167,075
% Saved - 45% 72%
Theodore, in press
46. Today:
• Situa3on
• Model
of
Care
• Value
• Future
48. WA
State
legislaEon
(2876):
• Mandates
Educa3on
and
Guidelines
• Mandates
TeleHealth
• Mandates
Opioid
tracking
• Mandates
Measurement
at
each
encounter
53. State
ED
informaEon
exchange
No controlled
Registration Reveals Physician reviews substances
Patient’s ED chart ED care guidelines
Patient on EDIE
flagged for doctor medical screening
Usual Triage exam by ED physician
ED case manager talks to
patient prior to discharge
Patient Discharged
54. State
ED
informaEon
exchange
“Please
review
Jane
Doe”
24 hour referral line compiled and
Reviewed for appropriateness Program Coordinator
researched.
ED Physician calls PCP
PCP
Recommendations
ED Care Guidelines Committee
ED Care Guidelines Chaplin ED Nurse ED Physicians
Patient’s Primary Care Physician
Psych Nurse Pharmacist Medical Director
56. Revise
our
pracEce
model
• System is • Coordinated care
fragmented (PCMH)
Patient activation
• Care is inconsistent
• Collaborative care
(TelePain/ECHO)
• Cost is
unsustainable • Measurement based
care (CPAIN/
PainTracker)
58. !"#$%&%'#(')$*+$#,-'.*/)(#$")*0',"*+$#,-,"$*/(%1$2*3"45678**
Current Level of Knowledge1 Level of Interest in
Learning 2
Mean (SD)
Mean (SD)
Assessment and management of genetic-biologic-psychological-social components 2.18 (1.0) 4.25 (0.85)
commonly involved in development and maintenance of complex chronic pain
disorders
Pathophysiology of chronic pain versus acute pain 2.34 (1.0) 4.25 (0.85)
Use, interpretation, and application of measurement based tools when completing a 1.72 (0.9) 4.16 (0.88)
comprehensive pain assessment
Multispecialty treatments and approaches for the care of chronic pain 2.12 (1.0) 4.37 (0.75)
Types and roles of medications used for pain, including opioids and non-opioids. 2.29 (1.1) 4.56 (0.63)
Types and role of non-medication treatment for chronic pain 2.23 (1.0) 4.52 (0.70)
Common primary care clinical pain disorders 2.43 (1.0) 4.35 (0.85)
Pain Medicine as a chronic illness specialty with knowledge and skills including 2.02 (1.1) 3.84 (1.06)
diagnosis of complex complaints, complex medical and surgical illnesses, and both
consultative and continuing multidisciplinary treatment.
Learning more about pursuing a Residency in Pain Medicine - 2.85 (1.35)
!
*
1 Scale = 1-Poor, 2-Fair, 3-Good, 4-Very Good, 5-Excellent
2 Scale = 1-Not Interested, 2-Little Interest, 3-Neutral, 4-Somewhat Interested, 5-Very Interested
60. Take
Home
Message:
• Coordinated,
collabora3ve,
measurement
based
model:
• 50%
decrease
in
deaths
from
opioids
• 65%
decrease
in
coun3es
par3cipa3ng
in
TelePain
• 56%
decrease
in
opioid
prescrip3on
rate
• 56%
decrease
in
opioid
related
ER
visits
• 50%
increase
in(see attached, for North American
Spine Society 2012 Outstanding Paper Award)
global
health
ra3ng
1
year
aker
treatment
61. It
ain't
what
you
don't
know
that
gets
you
into
trouble.
It's
what
you
know
for
sure
that
just
ain't
so.
Mark
Twain