Transforming Pain Management in Missouri’s FQHC Medical Homes

Written by:
Lara Kerwin
UMKC School of Pharmacy
Pharm.D. Candidate 2015
MPA Rotation Student, June 2014

In 2009, 180 million hydrocodone and oxycodone prescriptions were written in the United States. Alarming as that is, the statistics do not stop. More than 40% of opioid prescribing is not from pain specialists1, and now, more people die from opiate overdose than from motor vehicle accidents.

In 2010, The Centers for Disease Prevention and Control (CDC) cited that the amount of hydrocodone sold that year could supply every adult American with 5mg every 4 hours for a month.2 Also in 2010, Missouri’s overdose death rate was 17 for every 100,000 people – higher than the national average at 12.4 per 100,000.3 To fix the overdose epidemic, the CDC recommended implementing 1) a pain clinic law, and 2) a prescription drug monitoring program. Missouri currently has neither.3

On Wednesday, June 11, the Missouri Primary Care Association (MPCA) hosted a learning session on quality improvement measures for chronic pain management in Missouri’s Federally Qualified Health Center medical homes. Four healthcare centers are participating in this pilot project, running from January 2014 – February 2015. Project objectives are to implement evidence-based medicine and standardized pain-screening tools, increase utilization of electronic health records, improve patient and provider satisfaction, emphasize improving patient functionality in (independent) activities of daily living and quality of life, and improve opioid prescribing. Three essential elements of this project pose it for success.

Team-based approach
A tenet of this pilot program is the integration of all members of the health care team. Chronic pain moves beyond tissue damage to involve both emotional and sensory aspects. Previously, to treat pain was to give a pain pill, to neglect comorbidities that affect pain, or to avoid addressing pain appropriately altogether. Among conference attendees were physicians, pharmacists, nurse practitioners, psychologists, nurses, administrative personnel, information technology specialists, and other professionals. These participants are experts and leaders in their respective fields. With these healthcare experts, the project aims to utilize the “biopsychosocial” model and address comorbidities (including mental health) to provide comprehensive pain management from every angle.

Advanced management through technology
In addition to using the electronic health record whenever possible, the project also plans to use Pro-Act© (from Care Management Technologies) and an advanced urine drug screening system from Ameritox:

  • Pro-Act. This interface sorts and organizes patient Medicaid data relevant to each healthcare center. It allows each healthcare center to track prescribing and refill practices for each patient while flagging “Quality Indicators” to prompt clinical review and eliminate gaps in care. It is customizable and compatible with many electronic health record platforms. Pro-Act© offers many pharmacotherapy clinical resources, and it especially lends itself to psychotropic medicine review (which is a patient population with consistently documented co-morbid chronic pain).
  • Ameritox. Ameritox goes beyond providing the traditional work place urine drug screen (UDS) data by utilizing mass spectroscopy to analyze relative amounts of parent compound and metabolites in urine samples. Levels are cross-referenced with a database of “prescriptionally-compliant” samples to review if the patient is compliant, abusing, or potentially diverting. This UDS system also tracks for anomalies and offers genetic testing for suspected poor or rapid metabolizers.

Dispelling misconceptions and resetting patient and prescriber expectations
Opioid use and prescribing has collected its share of negative connotations and correlations over the years, especially when abuse and misuse are rampant. The project is working to eliminate these misconceptions about opioids, opioid prescribing, and chronic pain:

  • “All pain patients are drug seekers.”
    Actually, they are seeking adequate care.
  • “More pain medicine is better.” / When a prescriber does not prescribe an opioid, he or she “did nothing to treat my pain.”
    Not all patients are candidates for opioids, especially if there is a history of drug abuse and addiction – even nicotine; physical therapy and exercises may be a better option. Some pain may stem from a mental health issue or an unmanaged comorbidity. Further, opioid use in patients with chronic respiratory conditions, like COPD, puts those patients at even higher risk of respiratory depression.
    Take home point: there is more to treating chronic pain than opioids.
  • Prescriber: “Well, I have to give them something.” / “I want to maintain access to care.”
    Fear of opioid withdrawal is not a reason to prescribe opioids. Withdrawal is treatable if it becomes a problem. Maintaining access to care should always be championed, but in a responsible and evidence-based manner of prescribing.
  • Patient: “You’re referring me to a psychologist? My pain is not all in my head.”
    While the patient’s pain may not be rooted in a psychological issue, pain is a multi-faceted condition that demands analysis of biological, psychological, and social causes in order to provide the best care for the patient.
  • Concept of “curing pain” to the patient becomes a concept of “pain management.”
    Each healthcare center will develop their own plans to achieve the proposed project objectives by February 2015. If implementation is effective, this project could be applied statewide and provide a fiscally viable, clinically and socially responsible patient-centered model for chronic pain management for the state of Missouri.

Sources:
1. Study: Almost half of all narcotic prescriptions written by 5% of opioid prescribers. Drug Store News. http://www.drugstorenews.com/article/study-almost-half-all-narcotic-prescriptions-written-5-opioid-prescribers Published June 10, 2014. Accessed June 11, 2014.
2. Paulozzi LJ, Jones CM, Mack KA et al. Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999—2008. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR). November 4, 2011: 60(43); 1487-1492. Available from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm. Accessed June 11, 2014.
3. Prevention Status Reports 2013: Prescription Drug Overdose – Missouri. Centers for Disease Control and Prevention. Atlanta, GA: US Department of Health and Human Services; 2014 Available from http://www.cdc.gov/stltpublichealth/psr/prescriptiondrug/2013/MO-pdo.pdf. Accessed June 11, 2013.

 

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