Pain Management - Journey toward Understanding
Monday, March 18, 2013
Posted by: Joy Ingram
by Lynn Gerlach, Member Services Manager
The first NWRPCA member I met after starting this job four years ago was a physician – Mike Maples, to be specific. He was in Seattle for a meeting and, as a veteran of our Membership Committee, he generously came over to meet me and get me started on my new Member Services career. Casting about for something to say to a member, and completely naïve about community health centers, I asked Mike, “What’s the biggest issue facing our health centers right now?” He might have said creating enough parking spaces for the patients or choosing the right telephone system, for all I knew at the time. But he said, “pain management,” and I thought, what on earth is he talking about?
Fast forward to 2013. Oh, what four years can do! Last week I sat down with a group of clinicians on fire about ending the epidemic of opioid prescribing for chronic pain and the related issues of addiction, diversion, and death. They represented our CHCs, Swedish Addiction Recovery Services, and the University of Washington, including the Center for Pain Relief and Project ROAM. The five were planning a day of pain management training in Anchorage for May 18, the opening day of our Spring Primary Care Conference. They plan to call the workshop “Chronic Pain after Opioids.” This time I had some understanding of what they were talking about, and I knew what they were putting in place was a full day of instruction, inspiration and guidelines that could revolutionize pain management in our health centers.
The Pieces Begin to Fit Together
Mike Maples wasn’t the only member who told me early on that pain management is a huge issue. Others told me they have contracts with pain patients, but they just don’t work. Some have told me their providers can’t agree on protocols. One leader said, “We have no problem with pain management; we simply don’t treat pain patients.” To say I was puzzled is an understatement.
At one of our conferences I met Dr. Kevin Zacharoff of Pain EDU, and I realized I’d run across a real resource for our frustrated health center workforce. Dr. Zacharoff penned a series of authoritative articles on pain for this web site, introduced in QuickNotes. They remain some of the most popular articles we’ve ever posted on our site. His The Pathophysiology of Pain has been accessed 20,000 times! And then the “opioid REMS” (Risk, Evaluation and Mitigation Strategy) came out, and Dr. Zacharoff summarized the new program for us. His article began with some startling facts:
- In 7 states, the number of people dying from prescription pain medication overdoses has surpassed the number of motor vehicle-related deaths.
- The number of emergency department visits for overdoses of “legal” drugs (prescription and over-the-counter) now equals the number of visits for illicit substance overdose: 1,000,000 visits per year for each category.
- Nearly 1/3 of people who use illicit drugs for the first time begin by using prescription drugs: 7 of 10 people get these drugs from the medicine cabinet.
Success at one of our own CHCs
I was beginning to understand the gravity of the problem. By then it was May 2012, and NWRPCA sought out a leader of a successful quality improvement program within one of its CHCs. Dr. Malcolm Butler, Medical Director at Columbia Valley Community Health, received our Summit Award for cutting in half, in the space of one year, the number of deaths in his health center directly related to opioid pain medication prescribed by his staff. I now understood that “pain management” included a challenging mix of chronic pain patients, addictive drugs with analgesic properties, physicians trying to balance empathy with prudence, and entire health center staffs tip-toeing around potentially explosive situations.
I urged Dr. Butler to explain his work and his position on opioid prescribing on this web site and in our newsletter. He submitted Opioid Redux, the most popular article ever published in QuickNotes. Just when that article was published, I coincidentally received an invitation from Group Health Research Institute to consider attending their National Summit on Opioid Safety right here in Seattle. I contacted the summit organizer, Senior Investigator Michael Von Korff, ScD, and invited him to respond to Opioid Redux. He did, with co-author Roger Rosenblatt, MD, MPH, MFR, Professor & Vice Chair, UW Department of Family Medicine. Their piece, Opioids for Chronic Pain: the Status Quo is Not an Option, attracted even more attention to our web site than Dr. Butler’s original article. I knew I was onto something.
Pain on the National Stage
It was not until I actually attended the National Summit on Opioid Safety in October 2012 that I fully appreciated (and now partially understood) what “pain management” is all about. I learned that physicians had been taught, 20 years ago, that opioids are a safe treatment for chronic non-cancer pain and are not likely to be particularly addictive. I also learned that much of the messaging about opioids was coming from the pharmaceutical companies producing them. And then I learned about the statistics: the steady rise in opioid-related deaths since 1990 directly correlates with the rise in the per capita sales of opioid analgesics; 90% of chronic pain is not effectively treated with opioids; when the state of Washington essentially capped opioid dosages at 120 MED, opioid-related deaths dropped by 60% in the first year.
By the end of that summit, participants had worked together to agree upon a set of principles for prescribing opioids. I detailed those principles and described the summit presentations in an article on this web site called National Summit on Opioid Safety: a “hair-on-fire” situation. With the exception of the two articles mentioned above, it became the most-read article on our web site in 2012. Clearly people were hungry for information about the efficacy of opioid prescribing for pain management. I committed then to two steps on behalf of our health centers:
- To develop whatever partnerships I could to bring wisdom and best practices on this subject to our members.
- To push for effective training opportunities for our members on a topic that has consistently remained on the top of their hot-button list for four years: pain management.
Training for our CHCs
Now, with the enthusiastic help of Dr. Malcolm Butler and the generous support of the University of Washington, Group Health Research Institute, Swedish Family Medicine Residency and other partners, I am able to invite our member health centers to Anchorage, Alaska, on May 18 for an entire day of practical, unvarnished training in how to stop the epidemic of unnecessary and ineffective opioid prescribing. The six-hour workshop will build on the Principles for Safe Opioid Prescribing developed at Group Health’s National Summit, which might be summarized as follows: Focus on patient self-care, with the priority on long-term effectiveness rather than short-term pain relief. Put patient safety first, systematically evaluating risks and keeping doses as low as possible, even intermittent if necessary. If long-term opioid use is indicated or already a reality, focus on risk reduction, including relentless attempts to taper or discontinue, and identify and treat any misuse disorders.
The May 18 Intensive Conference Session
Called “Chronic Pain after Opioids,” the full-day workshop will look like this:
- The three-hour morning session, “Permission to Stop Prescribing Opioids,” is planned as follows:
- Dr. Malcolm Butler will describe how his little valley community came together to battle shocking mortality statistics related to opioid prescribing, and introduce a new disease model for chronic
- Dr. David Tauben, Chief, UW Div. of Pain Medicine (interim), Clinical Associate Professor Depts. of Medicine and Anesthesia and Pain Medicine, and Medical Director of the UW Center of Pain Relief, will explain how the science of pain supports this new model, and why opioids are just the wrong tool to treat chronic pain
- Dr. Catherine Howe, MD, PhD, Acting Assistant Professor of Psychiatry and Behavioral Sciences, UW Medical Center, will review how opioids used to treat chronic pain exacerbate any comorbid behavioral illness.
- Finally Dr. Paul Gianutsos, MD, MPH, Interim Program Director of Swedish Family Medicine Residency (Cherry Hill) and Clinical Professor of Family Medicine & Project ROAM researcher, UW, will introduce a new concept of “complex opioid dependency secondary to chronic pain,” which is miring our current primary care practices. Participants should walk away with a much-improved understanding of the dangers of opioid prescribing for chronic non-cancer pain and their causes.
- Following lunch, the team will present a three-hour session to develop a vision for the future and a roadmap to get there.
- Dr. Butler will introduce an optimized care model for the management of chronic pain.
- Dr. Tauben will introduce two specific tools that have been proven effective in pain management.
- Dr. Howe will showcase a successful and cost effective model for managing pain by integrating mental health into primary care.
- Dr. Gianutsos will explain how Suboxone can be used in managing complex opioid dependency secondary to chronic pain.
- Finally the team will walk participants through a real-life case, illustrating both the complexity and the manageability of a chronic pain program without opioids.
The issue of pain management in community health centers will not be fully addressed in a year – not even in two or three years. But I am confident we have now formed the vital partnerships and taken the essential steps to support the health centers that wish to learn how to manage complex chronic pain without endangering patients or contributing to the alarming opioid epidemic facing most communities in the northwest.
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