ICSI Protocol Acute Pain Assessment and

Opioid Prescribing

February 10, 2014

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Objectives for today’s webinar

•  Introduce the ICSI Acute Pain Assessment and Opioid Prescribing Protocol

•  Recognize pain types that may not benefit from opioid therapy

•  Identify risk assessment tools that will support you and your patient to make the right choices for pain management

•  Understand how to navigate the conversation with your patient

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•  Non-profit quality improvement organization

•  Founded in 1993 by Health Partners, Park Nicollet, and Mayo Clinic

•  Clinical guidelines foundation

•  50+ health care organization members

•  Quality Improvement •  Neutral convener for

collaborative work with all stakeholders

•  www.icsi.org

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Institute for Clinical Systems Improvement

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Webinar Expert Panel

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Dave  Thorson,  MD,    Sports  Medicine-­‐    En6ra  Family  Clinics  Protocol  Work  Group  Leader    

John  Wainio,  DDS,    Duluth,  MN  

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Webinar Expert Panel

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Charles  Reznikoff,  MD,  Internist,  Addic6on  Medicine-­‐    HCMC  

Bret  Haake,  MD,  Neurology-­‐  Health  Partners  and  Regions  Hospital  

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Webinar Expert Panel

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Susan  Van  Pelt,  MD,  Emergency  and  Family  Medicine-­‐    Emergency  Physicians,  PA  

Erin  Krebs,  MD,    Internal  Medicine-­‐    Minneapolis  VA  Health  Care  System  

Opioids by the Numbers

•  In 2010, 7 million people, age 12 and older, were current users of psychotherapeutic drugs taken non-medically

•  Drugs most commonly abused: –  Pain relievers-5.1 million –  Tranquilizers-2.2 million –  Stimulants-1.1 million –  Sedatives- 0.4 million

(National Survey on Drug Use and Health, 2010)

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Opioids by the Numbers

•  7% of high school seniors reported using narcotics other than heroin during the past year. (Monitoring the Future Survey, 2013)

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Opioids by the Numbers

•  The cost of prescribing opioids is significant. Sales of opioids are up 110% from $3.97 billion in 2001 to $8.34 billion in 2012.

•  U.S. emergency room costs are affected. Cases related to opioids increased 299,498 in 2004 to 885,348 in 2011. (Meier B. Profiting from pain. New York Times, June 22, 2013)

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Opioids by the Numbers

Americans, constituting only 4.6% of the world’s population have been consuming 80% of the world’s global opioid supply and 99% of the hydrocodone supply.

Manchikanti, et. al. Therapeutic use, abuse and non-medical use of opioids: a ten-year perspective.Pain Physician. 2010

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Opioids and the Impact on People

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Those  who  have  used  opioids  non-­‐medically  (ages  12-­‐49)  were  19  more  <mes  to  use  heroin  than  others  in  that  age  group.  (0.39%  compared  to  0.02%)    

(SAMHSA  Na<onal  Survey  on  Drug  Use  and  Health,  2013)  

The work of the community

•  MMA •  MDA •  ICSI •  MN Council of Health Plans •  MDH / DHS •  MN Board of Pharmacy •  Steve Rummler Hope Foundation •  And multiple organizations creating policies,

assessment processes, educational opportunities, patient contracts etc.

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Protocol Purpose and Goals

•  Promote optimal patient safety through careful assessment

•  Supportive and collaborative pain management •  Community safety and population health •  Prevention of inappropriate use and over-

utilization of opioids •  Promote shared decision-making

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Scope and Target Population

•  Adult, non-cancer, acute and sub-acute pain outpatient

•  Adult, non-cancer chronic pain patient experiencing unrelated acute pain

•  Adult, non-cancer patient with acute exacerbation of chronic pain

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Conditions to Consider Non-Traumatic Tooth Pain

Pain management options •  Long acting anesthetic •  NSAIDs •  Combination analgesics:

ibuprofen/acetaminophen •  Topical anesthetic •  Antibiotics •  Chlorhexidine antimicrobial mouth rinse

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Minnesota Dental Association

•  Prior to diagnosis and treatment, utilize treatment list on previous slide

•  Obtain diagnosis from a dental provider of the underlying problem as soon as possible

•  Do not prescribe opioids without a diagnosis from a dental provider

•  Counsel patient •  Develop protocols collaboratively

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Conditions to Consider: Chronic pain

•  Consider pain history and refer to pain management plan, if available

•  Confer with prescribing provider •  Avoid prescribing additional opioids •  Refer to ICSI Assessment and Management of

Chronic Pain Guideline •  Utilize team approach to pain management

when possible

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Conditions to Consider

Common conditions almost never indicated for opioids (non-inclusive)

•  Fibromyalgia •  Headache •  Self-limited illness, ie. sore throat •  Uncomplicated back and neck pain •  Uncomplicated musculoskeletal pain

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Opioid Misuse and Addiction

•  Opioids change brain chemistry and response to pain

•  Euphoric and anxiolytic properties •  Opioid tolerance •  Opioid-induced hyperalgesia •  Potential for opioid use disorder

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•  Alcohol use •  Benzodiazepines •  Clearance and

metabolism •  Delirium, dementia,

and falls risk

•  Psychiatric comorbidities

•  Query the PMP •  Respiratory

insufficiency, and sleep apnea

•  Safe driving, work, storage and disposal

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ABCDPQRS Risk Assessment for Opioids

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Low  Risk  

High  Benefit  

High  Risk  

Low  Benefit  

(-­‐,+)   (+,+)  

(-­‐,-­‐)   (+,-­‐)  

Avoid  prescribing  Least  Appropriate  

Avoid  prescribing  Least  Appropriate  

Most  Appropriate  

Provider  Judgment  

Risk/  Benefit  

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Risk factors for Adverse Outcomes

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Appropriate therapy and/or referral

•  Utilize other analgesics, NSAIDs •  Physical, psychological, or other appropriate

interventions and therapies. •  Reassure, and discuss expected duration of pain

episode and warning signs that would warrant medical attention

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Prescription Monitoring Program

•  State resource to review patient prescription history

•  Optimal if it is used consistently •  All states except Missouri •  Future functionality includes more

interoperability between states and integration with EHRs

•  Standardize your organization’s prescribing process

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Patient Support and Education

•  Educate patients on the risks and benefits. •  Consider an Opioid Prescription Patient

Agreement •  Post prescribing policy information for patients •  Involve family members/caregivers as available

and preferred by the patient

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What can you do?

•  Develop personal scripting •  Dialogue with colleagues •  Develop organizational policies/standards for

opioid prescribing and refills •  Collaborate with other clinicians to develop

team-based, patient-centered approach to pain management

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Prescribing Opioids

•  Avoid prescribing more than 3 days or 20 pills •  Low-dose, short-acting •  Tramadol is an atypical opioid and should be

managed appropriately •  Never prescribe long-acting/extended release •  Caution with the elderly •  Primary care to follow up within 3-5 days •  Shared decision-making and reviewing

responsible use, driving, work, storage and disposal with patient

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Thanks to the Work Group!

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Chris  Norton,  Pa<ent  Advisor  

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What questions do you have?

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