Transcript Pain Management Center Proposal for JPS

Pain Management
and JPS
Presentation by:
Brandt Oliver
UTA Intern
The Concerns
Chronic pain has become a leading
healthcare issue in the nation.
 Chronic pain has drastically increased
the use of narcotic-only drug
treatments nationally.
 These two issues are increasingly
affecting the JPS Healthcare System.
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The Question

If JPS creates a dedicated Pain
Management Center will it lead to
better quality of life for CHC patients
and will the number of prescriptions of
pain controlling narcotics decrease
also?
Chronic Pain Prevalence in
the US
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An estimated 50 million to 75 million people live with
chronic pain, defined as constant pain lasting at least
three months.
Among adults, 90% suffer pain at least once a month
and 42% have daily pain; 22% of all primary care
patients have chronic pain.
80% of Americans believe their aches and pains are
"just part of getting older" and 28 percent believe there
is no solution to their pain.
Less than half (42%) of people who visit their doctor
for pain believe that their doctor completely
understands how their pain makes them feel.
The Arthritis Foundation, "Pain In America: Highlights from a Gallup Survey," www.arthritis.org, 2000
Chronic Pain Prevalence in
the US
Pain Facts & Figures: Incidence of Pain, as Compared to Major Conditions, www.painfoundation.org, January 2007
Chronic Pain’s cost to society
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Persistent pain affects approximately 30%
of the U.S. population annually1.
It has created substantial disability and
societal costs related to decreased work
productivity, absenteeism, and increased
healthcare utilization.
Chronic pain costs the U.S. $100 billion a
year in health care expenses, lost income
and productivity2.
The average cost for chronic back pain for
Worker’s Compensation is $7,000 – 8,0002.
1. Kerns, Thorn, and Dixon. Psychological Treatments for Persistent Pain: An Introduction. JOURNAL OF CLINICAL
PSYCHOLOGY: IN SESSION, Vol. 62(11), 1327–1331 (2006)
2. Pain Facts & Figures: Incidence of Pain, as Compared to Major Conditions, www.painfoundation.org, January 2007 4.
Controlled Substance Abuse

Drug Abuse Statistics
The DEA has reported a 40% rise in
prescriptions of Hydrocodone in the
last five years.
 Abuse of prescription drugs accounts
for approximately 35% of the total
drug abuse problem in the United
States.

HAMMER, DAVID, Advocates Demand Funding for Pain Treatment, CBS Health Watch, Jul. 21, 2006
Opioid Abuse Case Study
Study revealed that there is significant
abuse of opioids
 Out of 100 patients, 24% of the
patients abused opioids, and frequent
abuse was seen in 50% of these
patients, in spite of controlled
substance contracts and additional
interventional techniques.
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L Manchikanti, V Pampati, K S Damron, B Fellows, R C Barnhill, C D Beyer, Prevalence of opioid abuse in interventional pain
medicine practice settings: a randomized clinical evaluation., Pain Physician. 2001 Oct
Drug Diversion Sources
Non-medical use of Prescriptions
1. Laxmaiah Manchikanti, MD. Prescription Drug Abuse: What is Being Done to Add ress This New Drug Epidemic? Testimony Before
the Subcommittee on Criminal Justice, DrugPolicy and Human Resources. Pain Physician. 2006;9,287-321
8 Year change in Prescription
Narcotic sales
Payments for Prescription
Drug Use
Federal Drug Control
Spending
1. Laxmaiah Manchikanti, MD. Prescription Drug Abuse: What is Being Done to Add ress This New Drug Epidemic? Testimony Before
the Subcommittee on Criminal Justice, DrugPolicy and Human Resources. Pain Physician. 2006;9,287-321
JCAHO
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JCAHO believes that, “Unrelieved pain has
enormous physiological and psychological
effects on patients. Effective management
of pain is a crucial component of good
care.”
JCAHO also asserts that, “Research clearly
shows that unrelieved pain can slow
recovery, create burdens for patients and
their families, and increase costs to the
healthcare system.”
14th Annual Meeting of the American Society of Pain Management NursesMarch 18-21, 2004. Nurse Reporter. Vol. 1 Issue
3 June 2004
Provider Response to Pain
Management
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“Would be great if it could happen.”
“If the AMA came in and audited how I
prescribe narcotics I would be very worried.”
“I sometimes feel like a drug dealer.”
“The amount of pain management
education I received was very limited.”
“I don’t want to lose my license.”
“This population is hard to manage.”
Consequences of Mismanaged
or Under-Managed Pain
Mismanaged or under treated pain can
result in:
Extensive, costly, unhelpful work-ups
and treatment
 Dysfunction in family, vocational, and
social life
 Mental and physical suffering
 Increased disability costs
 Increased yearly expenditures

Benefits of Appropriate Pain
Treatment
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Saves lives - patients in severe pain who are
not treated have been known to commit
suicide to end their suffering.
Reduces the chances of developing additional
physical problems or making existing
problems worse.
Reduces suffering for patients and families.
Returns the patient to being in charge of his
or her life.
Allows the patient to become more productive
in society - through work, family life, or social
activities.
Reduces the cost of medical care.
Patient Referrals
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Reasons for a pain center referral
 The mere mention of the patient’s name
strikes fear in the hearts of the office staff.
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You run late with the patient every time the
patient comes to see you.
The patient is inconsistent or has poor
compliance with the treatment regimen.
Multiple physicians are treating the same or
related conditions.
The patient has multiple visits to the urgent
care center or to the emergency room or has
multiple hospitalizations.
Comprehensive Pain Program
(CPP)
Clinical Evaluation
 The current guidelines recommend that
chronic pain patients be evaluated by
healthcare professionals with specialized
training in chronic pain management.
 The initial evaluation should be performed
by a qualified physician and psychologist.
 The evidence continues to accumulate that
the most effective treatment for chronic pain
patients is found within an integrated
interdisciplinary pain rehabilitation program.
John D. Loeser, MD. Comprehensive Pain Programs Versus Other Treatments for Chronic Pain. The Journal of Pain,
Vol 7, No 11 (November), 2006: pp 800-801
Clinical Evaluation of CPP
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Clinical Team Make-up
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Pain Specialist MD
Psychologist
Neurologist
Physical Therapist
Occupational
Therapist
Pain Specialist RN
Dietician
Social Worker
Patient’s Pain Care Plan of
CPP
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Care Plan Process
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Assess patient’s understanding of their
disorder
Perform a psychological exam
Prescribe pharmacological interventions
Treat patient with physical and occupational
therapy
Perform higher level interventional pain
management procedures
Educate and empower patient to take active
role in their own recovery
Involve family and community to help with
patients treatment
Gatchel and Okifuji. Evidence-Based Scientific Data Documenting the Treatment and Cost-Effectiveness of Comprehensive
Pain Programs for Chronic Nonmalignant Pain. The Journal of Pain, Vol 7, No 11 (November), 2006: pp 779-793
Success of CPP’s
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Researchers found a more than 33%
reduction in pain-related clinic visits in the
HMO setting in the year following the
completion of CPPs with a strong cognitive
behavioral orientation.
Another study reported a substantial 50%
decline in pain-related clinic visits following
a comprehensive rehabilitative treatment.
60% to 90% of CPP patients do not seek
any additional therapy for pain within 1 year
following the treatment.
Gatchel and Okifuji. Evidence-Based Scientific Data Documenting the Treatment and Cost-Effectiveness of Comprehensive
Pain Programs for Chronic Nonmalignant Pain. The Journal of Pain, Vol 7, No 11 (November), 2006: pp 779-793
Success of CPP’s
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Almost half of conventionally treated
patients require surgery or hospitalization
compared to 16% -17% of CPP patients.
Annual medical costs following a CPP have
been shown to be reduced by 68%
Evaluating the average return to work rate
from 20 different clinical studies shows that
on average 67% of CPP patients return to
work compared to only 27% of non CPP
patients
Gatchel and Okifuji. Evidence-Based Scientific Data Documenting the Treatment and Cost-Effectiveness of Comprehensive
Pain Programs for Chronic Nonmalignant Pain. The Journal of Pain, Vol 7, No 11 (November), 2006: pp 779-793
Success of CPPs
Successful Pain Center
Massachusetts General Hospital
(MGH) Pain Center
 Don Cornuet, Director
 Interventional Pain Clinic
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Diverse pain population
 Provide a true consult service
 Recently changed to a non-narcotic
treatment plan
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MGH Pain Center (cont.)
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Why MGH changed to a non-narcotic
plan?
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Traditional Narcotic Management
• Clogs up capacity of Pain clinic
• Few spaces available for new patients
• Ongoing pain care with narcotics can go
on literally forever
• Patients are kept in a medicated state
• High E&M Levels for a cycling population
loses money for the clinic
MGH Pain Center (cont.)
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MGH Mantra
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Treat one episode at a time
• Separate script for each medical need
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Increase functionality of patient
• PT is extensively used
• Alternative medicine
• i.e. Acupuncture
• Occupational Therapy
MGH Success Statistics
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Visit mix
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New Patients
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Dec. 06  18%
Dec. 07  25%
Procedures
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Dec. 06  53% Follow ups
Dec. 07  46% Follow ups
Dec. 06  23%
Dec. 07  29%
DNKA rate
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Dec. 07  22%
Jan. 08  13%
Current Status of Pain
Management at JPS
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In 2004, the Musculoskeletal Clinic opened
at the JPS Sports Medicine Clinic
Within a year, majority of the 2000 patients
were taking CSNAs to control
musculoskeletal pain.
At the time an initiative was undertaken to
create a new pain management scheme for
the Stop Six and FHC clinics.
Pain Management Initiative
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ID all patients receiving 60 doses of CSNAs
per month
ID all CSNA patients with musculoskeletal
nocioceptive, neuropathic, and nocleceptive
pain.
Develop a care plan using guidelines from
the Federation of State Licensing Board of
2004
Removal of Oxycontin and Soma from
formulary
Present care plan to P&T board for approval
Opening of a large Sports Medicine and
Musculoskeletal clinic to perform a thorough
evaluation of patients
Clinic Requirements of
Initiative
The requirements will include:
 Full time Physical Therapy
 Case manager to monitor CSNA patients
 On-site psych evals for addiction screening
and co-morbid Condition Assessment
 Consulting for acupuncture, orthopedics,
and anesthetic procedures
 Consulting for PMR (Polymyalgia
rheumatica)
JPS Controlled Substance
Agreement
Requirements:
 Patients can only receive narcotics from
one provider and one pharmacy
 Refills are only given at each office visit
 Urine tests are done monthly
 Patients must provide proof that they are
involved in other pain treatment modalities
 Patients cannot obtain any controlled
substances from any non-physician sources
Diamond Hill Hydrocodone
Prescriptions
Diamond Hill Hydrocodone Prescriptions for the past 6 Months
1200
Hydrocodone Scripts
1000
800
600
400
200
0
to
rH
rF
rG
to
to
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oc
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oc
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rE
rD
to
to
rB
rA
rC
to
to
to
oc
D
oc
D
oc
D
oc
D
oc
D
* Total of 2705 Prescriptions
CHC Hydrocodone
Prescriptions
CHC Total Prescriptions of Hydrocodone for the last 6 months
3500
3000
2500
2000
1500
1000
500
0
Scripts of Hydrocodone
l
ra
nt
H Ce
CC ton
g
lin ts
t
Ar
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Vi
6 pus
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w
rth
No
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FH as
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* Total of 13289 Prescriptions
Why should JPS have a
dedicated Pain Center?
Patient Quality of Life
 Prescription abuse and the costs of
dispensing unneeded prescriptions
 JCAHO and Government
requirements
 Supporting providers
 Pain Patients clog Health Centers
 The image of JPS
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Recommendations to
coincide with a Pain Center
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Group Visits
Use the same model of the Diabetic
Group Visits
 Bring in pain patients under a strict
CSNA regimen for group assessments
 Larger numbers of patients can be
seen and have their meds refilled
quickly
 Provides a cost efficient way of seeing
a large population of people
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Recommendations to
coincide with a Pain Center
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Provide more institutional pain treatment education to
physicians
 90% of physicians rate their education in pain
management as poor, and more than 70% rate their
residency training as fair or poor.
 75% of physicians believe a lack of familiarity with
patient assessment for pain to be the major barrier to
effective pain management, and 61% are reluctant to
prescribe opioids.
 In 2003, AMA created a free continuing education
program for doctors to learn more about treating pain,
and 84,000 doctors signed up in the first six months.
HAMMER, DAVID, Advocates Demand Funding for Pain Treatment, CBS Health Watch, Jul. 21, 2006
Conclusion
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Bottomline
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Having a pain management center is
becoming the standard of care for the
industry
Pain management centers and programs
increase the quality of life for pain patients
A Comprehensive Pain Program can reduce
aberrant drug behavior and increase patient
quality life
Treating pain extensively can possibly
reduce healthcare costs