Last Updated: Jan 31, 2017
Note: Guest blogger Jennifer Stephens, DO, is a General Internist in Allentown, PA, with Lehigh Valley Health Network (LVHN) and a PAMED member. In addition to her clinical practice, she is also the Medical Director of Lehigh Valley Physician Group (LVPG) and the LVHN ACO. She is dedicated to the promotion of team-based, high value care centered on patient-centric principles.
Dr. Jennifer Stephens was one of the winners of PAMED’s “Top Physicians Under 40” Award in 2016.
It is estimated that more than 116 million Americans suffer from chronic pain. Recognizing that, more than half of all chronic non-cancer patients receive their pain care from non-specialist Primary Care providers.
To support clinicians, the American Pain Society/American Academy of Pain Medicine—along with several government agencies—have independently published opioid therapy guidelines. Unfortunately, the adoption of opioid stewardship and risk reduction strategies among PCPs is limited, even for patients at increased risk of misuse.
A study of the period from 1997 to 2007 revealed the milligram per person use of prescription opioids in the United States to have increased by more than 400 percent. Opioid prescribing rates showed the greatest increase in physical medicine and rehabilitation, followed by family practice, general practice, and internal medicine.
Unfortunately, risk-mitigation strategies surrounding opioid medications were not aggressively implemented in the first decade of 2000. We are now subsequently facing a public health crisis; the Pennsylvania state coroners association recently noted nearly 2,500 overdose deaths in 2014.
To manage chronic non-cancer pain appropriately, risk-reduction recommendations include appropriate documentation, regular urine drug testing, risk evaluation, routine utilization of the PA Drug Monitoring Programand a structured refill protocol.
In order to support our primary care providers through these clinical challenges, a team of primary care clinicians developed a primary care pain 'toolkit'. It includes standardized documentation on all the recommended areas for opioid stewardship, in addition to clinical guidance on weaning and tapering off opioids, patient education and addiction / linkage to treatment resources.
To further the impact, we took the burden of documentation development off clinicians and have embedded the recommended guidelines and tools into the point of care electronic medical record (e.g EPIC). Additionally, we have centralized our resources and integrated the toolkit into an educational strategy for our clinicians.
Despite all that has occurred, it is still documented in literature that PCP adherence to standards for pain care documentation and compliance with risk-mitigation strategies are low. Primary care providers cite concerns about patient addiction and opioid misuse as major challenges in managing patients with chronic non cancer pain. In addition, many feel they have insufficient training in prescribing opioids.
To combat the clinical inertia, please know that the toolkit concepts are readily translatable to any network or health care system. The concept is to simply put your information in an easily accessible format. Coupled with education, such as the PAMED Opioids for Pain Campaign, any organization can create the resources needed to support their providers.
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- American Pain Society (APS) and the American Academy of Pain Medicine (AAPM). Evidence review: Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. Chicago, IL: APS. Available at:
http://americanpainsociety.org/uploads/education/guidelines/chronic-opioid-therapy-cncp.pdf. Accessed May 3, 2016.
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http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Accessed May 3, 2016. doi: 10.15585/mmwr.mm6501a1
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http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm309742.htm. Updated March 1, 2013; Accessed May 20, 2016.
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http://www.washingtontimes.com/news/2016/may/4/fda-advisers-reconsider-training-for-painkiller-pr/?page=all#pagebreak. Accessed May 23, 2016.
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- Pennsylvania Medical Society. Pennsylvania guidelines on the use of opioids to treat chronic noncancer pain; 2014. Accessed May 3, 2016. (PAMED note: These guidelines were updated by the commonwealth on June 11, 2018. The current guidelines can be accessed at https://www.health.pa.gov/topics/Documents/Opioids/Non-cancer%20Pain%20Guidelines%20Final.pdf
- Pennsylvania Medical Society. Prescribing guidelines for Pennsylvania. Geriatric pain: opioid use and safe prescribing. January 2016. Available at: https://www.health.pa.gov/topics/Documents/Opioids/OpioidGuidelinesGeriatrics.pdf . Accessed May 3, 2016.
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