Pain Management and JPS

1
Pain Management and JPS

• Presentation by
• Brandt Oliver
• UTA Intern

2
The Concerns

• Chronic pain has become a leading healthcare
  issue in the nation.
• Chronic pain has drastically increased the use of
  narcotic-only drug treatments nationally.
• These two issues are increasingly affecting the
  JPS Healthcare System.

3
The Question

• If JPS creates a dedicated Pain Management Center
  will it lead to better quality of life for CHC
  patients and will the number of prescriptions of
  pain controlling narcotics decrease also?

4
Chronic Pain Prevalence in the US

• An estimated 50 million to 75 million people live
  with chronic pain, defined as constant pain
  lasting at least three months.
• Among adults, 90 suffer pain at least once a
  month and 42 have daily pain 22 of all primary
  care patients have chronic pain.
• 80 of Americans believe their aches and pains
  are "just part of getting older" and 28 percent
  believe there is no solution to their pain.
• Less than half (42) of people who visit their
  doctor for pain believe that their doctor
  completely understands how their pain makes them
  feel.

The Arthritis Foundation, "Pain In America
Highlights from a Gallup Survey,"
www.arthritis.org, 2000
5
Chronic Pain Prevalence in the US
Pain Facts Figures Incidence of Pain, as
Compared to Major Conditions, www.painfoundation.o
rg, January 2007
6
Chronic Pains cost to society

• Persistent pain affects approximately 30 of the
  U.S. population annually1.
• It has created substantial disability and
  societal costs related to decreased work
  productivity, absenteeism, and increased
  healthcare utilization.
• Chronic pain costs the U.S. 100 billion a year
  in health care expenses, lost income and
  productivity2.
• The average cost for chronic back pain for
  Workers Compensation is 7,000 8,0002.

1. Kerns, Thorn, and Dixon. Psychological
Treatments for Persistent Pain An Introduction.
JOURNAL OF CLINICAL PSYCHOLOGY IN SESSION,
Vol. 62(11), 13271331 (2006) 2. Pain Facts
Figures Incidence of Pain, as Compared to Major
Conditions, www.painfoundation.org, January 2007
4.
7
Controlled Substance Abuse

• Drug Abuse Statistics
• The DEA has reported a 40 rise in prescriptions
  of Hydrocodone in the last five years.
• Abuse of prescription drugs accounts for
  approximately 35 of the total drug abuse problem
  in the United States.

HAMMER, DAVID, Advocates Demand Funding for Pain
Treatment, CBS Health Watch, Jul. 21, 2006
8
Opioid Abuse Case Study

• Study revealed that there is significant abuse of
  opioids
• Out of 100 patients, 24 of the patients abused
  opioids, and frequent abuse was seen in 50 of
  these patients, in spite of controlled substance
  contracts and additional interventional
  techniques.

L Manchikanti, V Pampati, K S Damron, B Fellows,
R C Barnhill, C D Beyer, Prevalence of opioid
abuse in interventional pain medicine practice
settings a randomized clinical evaluation., Pain
Physician. 2001 Oct
9
Drug Diversion Sources
10
Non-medical use of Prescriptions
1. Laxmaiah Manchikanti, MD. Prescription Drug
Abuse What is Being Done to Add ress This New
Drug Epidemic? Testimony Before the
Subcommittee on Criminal Justice, DrugPolicy and
Human Resources. Pain Physician. 20069,287-321
11
8 Year change in Prescription Narcotic sales
12
Payments for Prescription Drug Use
13
Federal Drug Control Spending
1. Laxmaiah Manchikanti, MD. Prescription Drug
Abuse What is Being Done to Add ress This New
Drug Epidemic? Testimony Before the
Subcommittee on Criminal Justice, DrugPolicy and
Human Resources. Pain Physician. 20069,287-321
14
JCAHO

• JCAHO believes that, Unrelieved pain has
  enormous physiological and psychological effects
  on patients. Effective management of pain is a
  crucial component of good care.
• JCAHO also asserts that, Research clearly shows
  that unrelieved pain can slow recovery, create
  burdens for patients and their families, and
  increase costs to the healthcare system.

14th Annual Meeting of the American Society of
Pain Management NursesMarch 18-21, 2004. Nurse
Reporter. Vol. 1 Issue 3 June 2004
15
Provider Response to Pain Management

• Would be great if it could happen.
• If the AMA came in and audited how I prescribe
  narcotics I would be very worried.
• I sometimes feel like a drug dealer.
• The amount of pain management education I
  received was very limited.
• I dont want to lose my license.
• This population is hard to manage.

16
Consequences of Mismanaged or Under-Managed Pain

• Mismanaged or under treated pain can result in
• Extensive, costly, unhelpful work-ups and
  treatment
• Dysfunction in family, vocational, and social
  life
• Mental and physical suffering
• Increased disability costs
• Increased yearly expenditures

17
Benefits of Appropriate Pain Treatment

• Saves lives - patients in severe pain who are not
  treated have been known to commit suicide to end
  their suffering.
• Reduces the chances of developing additional
  physical problems or making existing problems
  worse.
• Reduces suffering for patients and families.
• Returns the patient to being in charge of his or
  her life.
• Allows the patient to become more productive in
  society - through work, family life, or social
  activities.
• Reduces the cost of medical care.

18
Patient Referrals

• Reasons for a pain center referral
• The mere mention of the patients name strikes
  fear in the hearts of the office staff.
• You run late with the patient every time the
  patient comes to see you.
• The patient is inconsistent or has poor
  compliance with the treatment regimen.
• Multiple physicians are treating the same or
  related conditions.
• The patient has multiple visits to the urgent
  care center or to the emergency room or has
  multiple hospitalizations.

19
Comprehensive Pain Program (CPP)

• Clinical Evaluation
• The current guidelines recommend that chronic
  pain patients be evaluated by healthcare
  professionals with specialized training in
  chronic pain management.
• The initial evaluation should be performed by a
  qualified physician and psychologist.
• The evidence continues to accumulate that the
  most effective treatment for chronic pain
  patients is found within an integrated
  interdisciplinary pain rehabilitation program.

John D. Loeser, MD. Comprehensive Pain Programs
Versus Other Treatments for Chronic Pain. The
Journal of Pain, Vol 7, No 11 (November), 2006
pp 800-801
20
Clinical Evaluation of CPP

• Clinical Team Make-up
• Pain Specialist MD
• Psychologist
• Neurologist
• Physical Therapist
• Occupational Therapist
• Pain Specialist RN
• Dietician
• Social Worker

21
Patients Pain Care Plan of CPP

• Care Plan Process
• Assess patients understanding of their disorder
• Perform a psychological exam
• Prescribe pharmacological interventions
• Treat patient with physical and occupational
  therapy
• Perform higher level interventional pain
  management procedures
• Educate and empower patient to take active role
  in their own recovery
• Involve family and community to help with
  patients treatment

Gatchel and Okifuji. Evidence-Based Scientific
Data Documenting the Treatment and
Cost-Effectiveness of Comprehensive Pain Programs
for Chronic Nonmalignant Pain. The Journal of
Pain, Vol 7, No 11 (November), 2006 pp 779-793
22
Success of CPPs

• Researchers found a more than 33 reduction in
  pain-related clinic visits in the HMO setting in
  the year following the completion of CPPs with a
  strong cognitive behavioral orientation.
• Another study reported a substantial 50 decline
  in pain-related clinic visits following a
  comprehensive rehabilitative treatment.
• 60 to 90 of CPP patients do not seek any
  additional therapy for pain within 1 year
  following the treatment.

Gatchel and Okifuji. Evidence-Based Scientific
Data Documenting the Treatment and
Cost-Effectiveness of Comprehensive Pain Programs
for Chronic Nonmalignant Pain. The Journal of
Pain, Vol 7, No 11 (November), 2006 pp 779-793
23
Success of CPPs

• Almost half of conventionally treated patients
  require surgery or hospitalization compared to
  16 -17 of CPP patients.
• Annual medical costs following a CPP have been
  shown to be reduced by 68
• Evaluating the average return to work rate from
  20 different clinical studies shows that on
  average 67 of CPP patients return to work
  compared to only 27 of non CPP patients

Gatchel and Okifuji. Evidence-Based Scientific
Data Documenting the Treatment and
Cost-Effectiveness of Comprehensive Pain Programs
for Chronic Nonmalignant Pain. The Journal of
Pain, Vol 7, No 11 (November), 2006 pp 779-793
24
Success of CPPs
25
Successful Pain Center

• Massachusetts General Hospital (MGH) Pain Center
• Don Cornuet, Director
• Interventional Pain Clinic
• Diverse pain population
• Provide a true consult service
• Recently changed to a non-narcotic treatment plan

26
MGH Pain Center (cont.)

• Why MGH changed to a non-narcotic plan?
• Traditional Narcotic Management
• Clogs up capacity of Pain clinic
• Few spaces available for new patients
• Ongoing pain care with narcotics can go on
  literally forever
• Patients are kept in a medicated state
• High EM Levels for a cycling population loses
  money for the clinic

27
MGH Pain Center (cont.)

• MGH Mantra
• Treat one episode at a time
• Separate script for each medical need
• Increase functionality of patient
• PT is extensively used
• Alternative medicine
• i.e. Acupuncture
• Occupational Therapy

28
MGH Success Statistics

• Visit mix
• Dec. 06 ? 53 Follow ups
• Dec. 07 ? 46 Follow ups
• New Patients
• Dec. 06 ? 18
• Dec. 07 ? 25
• Procedures
• Dec. 06 ? 23
• Dec. 07 ? 29
• DNKA rate
• Dec. 07 ? 22
• Jan. 08 ? 13

29
Current Status of Pain Management at JPS

• In 2004, the Musculoskeletal Clinic opened at the
  JPS Sports Medicine Clinic
• Within a year, majority of the 2000 patients were
  taking CSNAs to control musculoskeletal pain.
• At the time an initiative was undertaken to
  create a new pain management scheme for the Stop
  Six and FHC clinics.

30
Pain Management Initiative

• ID all patients receiving 60 doses of CSNAs per
  month
• ID all CSNA patients with musculoskeletal
  nocioceptive, neuropathic, and nocleceptive pain.
• Develop a care plan using guidelines from the
  Federation of State Licensing Board of 2004
• Removal of Oxycontin and Soma from formulary
• Present care plan to PT board for approval
• Opening of a large Sports Medicine and
  Musculoskeletal clinic to perform a thorough
  evaluation of patients

31
Clinic Requirements of Initiative

• The requirements will include
• Full time Physical Therapy
• Case manager to monitor CSNA patients
• On-site psych evals for addiction screening and
  co-morbid Condition Assessment
• Consulting for acupuncture, orthopedics, and
  anesthetic procedures
• Consulting for PMR (Polymyalgia rheumatica)

32
JPS Controlled Substance Agreement

• Requirements
• Patients can only receive narcotics from one
  provider and one pharmacy
• Refills are only given at each office visit
• Urine tests are done monthly
• Patients must provide proof that they are
  involved in other pain treatment modalities
• Patients cannot obtain any controlled substances
  from any non-physician sources

33
Diamond Hill Hydrocodone Prescriptions
Total of 2705 Prescriptions
34
CHC Hydrocodone Prescriptions
Total of 13289 Prescriptions
35
Why should JPS have a dedicated Pain Center?

• Patient Quality of Life
• Prescription abuse and the costs of dispensing
  unneeded prescriptions
• JCAHO and Government requirements
• Supporting providers
• Pain Patients clog Health Centers
• The image of JPS

36
Recommendations to coincide with a Pain Center

• Group Visits
• Use the same model of the Diabetic Group Visits
• Bring in pain patients under a strict CSNA
  regimen for group assessments
• Larger numbers of patients can be seen and have
  their meds refilled quickly
• Provides a cost efficient way of seeing a large
  population of people

37
Recommendations to coincide with a Pain Center

• Provide more institutional pain treatment
  education to physicians
• 90 of physicians rate their education in pain
  management as poor, and more than 70 rate their
  residency training as fair or poor.
• 75 of physicians believe a lack of familiarity
  with patient assessment for pain to be the major
  barrier to effective pain management, and 61 are
  reluctant to prescribe opioids.
• In 2003, AMA created a free continuing education
  program for doctors to learn more about treating
  pain, and 84,000 doctors signed up in the first
  six months.

HAMMER, DAVID, Advocates Demand Funding for Pain
Treatment, CBS Health Watch, Jul. 21, 2006
38
Conclusion

• Bottomline
• Having a pain management center is becoming the
  standard of care for the industry
• Pain management centers and programs increase the
  quality of life for pain patients
• A Comprehensive Pain Program can reduce aberrant
  drug behavior and increase patient quality life
• Treating pain extensively can possibly reduce
  healthcare costs