Taking some of the pain out of pain management

A new law went into effect here in Washington state this week – a law regarding requirements and safety checks for prescribing chronic opioids for patients.  I was surprised to learn that our state has one of the highest death rate from prescription opiates, and that of all the opiates methadone appears to be the worst.

When the new law went live on Monday, we were already in compliance. Knowing that the law was coming, our primary care department, and our clinic in particular, have been developing a system to deal with the new requirements and have been trying it out for a few months. As with everything else we do, we knew this needed to flow and to have a sequence that everyone follows in a standard way.

We started with the requirement that all providers do CME or other self-study program on the latest evidence-based recommendations for chronic pain management.  Some of us have done the AAFP modules on pain management, and our organization is sponsoring a whole day CME event on the topic this month; that program will include the specifics of the Washington state law as well.

Fortunately, the specifics of the law seem to follow evidence-based guidelines.  It requires regular (at least annual) visits for each patient to review the risk for addiction or abuse, to discuss the "contract" or agreement about the prescriptions and the rules, do a drug toxicology screen and an assessment of function and pain control, and to provide education about the medications and screening for side effects.

Our system as it is evolving is for our staff and our central pharmacy (which helps with refills and chronic medication monitoring) to note when patients are due to be seen to get refills for chronic opioids and to have the patient scheduled for a linked visit with our clinic pharmacist and the MD.  Our schedulers, RNs and MAs as well as the pharmacists are on board to do this scheduling piece correctly.

When patients arrive for the visit, a medical assistant takes them to the lab for a point-of-care urine drug screen and then rooms them with vitals.  We've developed a standard rooming template for the visit, which is imported into the record and prompts staff and physician to follow protocol.

The pharmacist then goes in with the patient to do most of the visit and fulfill most of the requirements.  By the time the pharmacist is finished, the urine screen is ready, and the pharmacist does a hand off (preferably in front of the patient, but at least in person), noting any red flags and recommendations and giving the results of urine screen.  Before the doctor enters the room and reviews the pharmacist's recommendations and the drug screen with the patient, if no changes are anticipated, the doctor gives the go ahead to the pharmacist to ready and print the prescription for 3 months (if that's the interval approved) and have them ready for him or her to sign by end of visit.

What I really like about this so far is that patients are all getting the same good quality review and care, and I can spend a little more time with the patient going into some depth about comorbidities with the pain and medications.  Our pharmacist is so good at this that I can take her recommendations and, after some discussion with the patient, make a meaningful decision about continuing or changing the therapy.

I'm sure we will continue to refine the process with repeated PDSA cycles and change as we learn, but it's far more organized than what we've done in the past.  The worst scenario in the past tended to be when a patient on chronic opioids also had depression or another chronic condition, and we would try to address everything in one visit. Now we devote the entire visit to the pain management and can decide if it's once a year or more often, depending on the patient.

Posted at 01:46PM Jan 04, 2012 by Kim Leatham, MD  |  Comments[0]