Featured Articles: Pain Management/Opioids

They Couldn’t Win for Losing – Until…

Monday, February 12, 2018   (0 Comments)
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Lynn Gerlach, Tamarack Communication

- an interview with Dr. Kristin Miller, CMO, Siskiyou Community Health Center

 

While some healthcare providers are only now beginning to address the prescription opioid crisis, this is the story of an Oregon CHC that has been struggling to do a good job with that challenge for years – and it was burning out their providers. But this medical director re-ignited the effort in 2013 and, working hand-in-hand with her administrative leaders, she finally found success.

 

Grants Pass, Oregon, a beautiful town with a big opioid diversion and addiction problem, has a dynamite community health center, Siskiyou CHC. From the CHC’s inception in the 1970s, Dr. Jim Shames served many years as CMO. He left Siskiyou CHC at the height of Oregon’s opioid prescribing, but he didn’t forget about the problem. Convinced the rise of opioid prescribing for pain required monitoring and a concerted effort among healthcare providers to understand and address it, Shames was instrumental in helping to develop the Oregon Pain Guidance (OPG).

 
Several Medical Directors came and went at Siskiyou over the years – and so did a lot of providers. The Siskiyou administration, under the leadership of the late Kurt Higuera, finally had to face the stark fact: They were losing their providers to burnout, much of it due to opioid-dependent pain patients.

 

By then Oregon had a Prescription Drug Monitoring Program (PDMP), but the health center did not have access to practice-wide or cumulative data from it to track prescribing patterns or MED levels. They had no way of knowing whether their high risk-patients were actually filling their naloxone prescriptions, or which of their patients had died from opioid overdose. The county didn’t even have a coroner. But the opioid patients kept coming.

 

In 2013, Dr. Kristin Miller became CMO. With the support of her administration, she chose to address the opioid epidemic as a recruitment and retention issue: What could Siskiyou do differently about the opioid challenge to attract good providers who would enjoy their practice in Grants Pass and stay?

 

Dr. Miller inherited a success story-in-progress and has kept it moving forward. Two keys to Siskiyou’s ultimate success in grappling with the opioid challenge were the Oregon Pain Guidance, which meets monthly, and reliable support from the health center’s Coordinated Care Organizations (CCOs). OPG developed helpful new prescribing guidelines, now reflected in those of the CDC: no benzos or muscle relaxers with opioids, and a 90-MED limit.

 

And Dr. Miller inherited another golden opportunity: OPG had already selected Siskiyou CHC to be a pilot site to test those guidelines – with a grant to support it. OPG provided experienced consultants to come on site each week to help the clinic team implement the guidelines, starting with a key prescriber at each clinical site.

 

When the initial grant period ended in 2015, Siskiyou CHC hired a highly-respected consultant on opioid abuse issues. She helped educate the entire staff and suggested some changes regarding urine drug testing and assessment of functioning. Slowly, the clinical team was able to lower doses for some high-MED patients. The administration’s ongoing willingness to pay the consultant motivated the providers.

 

Soon the health center identified key providers to meet with a consultant bi-monthly, a practice that still continues. In this way they maintain momentum and continue to move forward, integrating behavioral health with pain management, for example. Together they have developed a weekly pain education class open to the entire community.

 

One stumbling block was an EHR that wouldn’t allow them to collect MED data, so they built a custom template for that. Each provider now has a cap on the number of opioid patients he/she is expected to see, and the CHC honors that cap. Bi-monthly, they all see the big roster, including MEDs, naloxone use and more. As a team, they track their progress.

 

Today the staff has successfully tapered a number of opioid patients and is starting to accept a few new ones. Acknowledging the burden of opioid pain patients on private practices and small healthcare operations, Siskiyou sticks to its patient cap per provider and simply does what it can to address a community-wide issue.

 

Oregon’s CCOs reimburse well for Medication-Assisted Treatment (MAT). Two Siskiyou providers actively offer MAT, and a handful of others are waivered to provide back-up. A small group of patients are now off opioids and on buprenorphine. Patients are offered the opportunity to meet with the consultant along with their providers, which has helped with difficult conversations. Ultimately patients are given the choice to accept the new guidelines or leave the program. Some leave. But some of those patients have discovered that the entire region is now onboard with MED limits and benzo and muscle relaxer protocols – and they have returned to the Siskiyou program.

 

The story is now more “success” than “failure,” but it’s not perfect. Very few opioid patients are covered by private insurance, and often their drug screens aren’t covered. More disconcerting is the preauthorization requirement for buprenorphine. Dr. Miller said, “There’s no preauthorization required to start taking opioids, but then, when they get in trouble and we can offer a path to success, they need preauthorization to start!” And the CHC still cannot access the cumulative data they need from the PDMP. They still don’t have data on which of their patients have overdosed, and they still don’t have a coroner.

 

But the new opioid program is doing its job: Providers are less likely to burn out, and they are staying at Siskiyou. In fact, they seem to be enjoying the competitive nature of the bi-monthly tracking system. Siskiyou is now studying the health coach model that La Clinica uses successfully and will probably adopt it. And the CCO has provided some very part-time drug counselors who have made a difference. Over all, Dr. Miller and her providers are feeling like winners again.

 

 

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