6/1/2013 Disclosures Nothing to Disclose Coordination of Pain Management Strategies with Patients' Primary Care Physician Melanie M. Henry, M.D., M.P.H. UCSF Associate Professor of Anesthesia & Pain Medicine 2 4 Chronic Pain Definition Scope ▫ Pain that persists beyond the course of an acute � Impact of Chronic Pain disease or � To be familiar with the Pain Management Strategies ▫ Pain that persists beyond a reasonable time for an � To realize the importance of Coordination of Care injury to heal or between Pain Specialist and Primary Care Physician ▫ Pain that is associated with a chronic pathologic process that causes continuous pain or ▫ Pain that recurs at intervals of months or years or ▫ Pain that persists > 6 months 3 1
6/1/2013 Chronic pain is a major public health problem in Cost of pain accounts to both healthcare the US delivery costs and costs due to lost productivity $9,680 Incidence of various conditions in US 100 millions $3,210 suffering with (in millions)-2011 100 Chronic pain $4,516 $5,838 conditions $4,048 ~65 Million No Pain Moderate pain Severe pain Joint pain Arthritis pain Functional disabilities Incremental costs compared to patient with no pain Incremental cost per person by pain types (2010) 25.8 16.3 14.5 7 • Annual cost of chronic pain in the US was $635 billion in 2010 • Lost productive time from common pain conditions among active Diabetes Coranory Heart Stroke Cancer Chronic pain workers costs an estimated $61.2 billion per year disease • 76.6% of lost productivity was due to reduced performance at work and not work absence Chronic Pain affects more Americans than diabetes, heart disease and cancer combined 5 6 Lower Back pain is a major case of Chronic pain Chronic Pain management after back surgery is a huge challenge Most commonly reported Pain conditions 28% ~600,000 Americans opt for back operations each year Low back pain is the leading cause of disability 17% 15% in Americans ≤ 45 years Annually, neurosurgeons perform at least 100,000 operations for lumbar disc Low back Migraine pain Neck pain pain disease alone Source: National Health Care Surveys-2011 • 31 million Americans experience low-back pain at any given time • The condition leaves about 2.4 million Americans chronically disabled and another 2.4 million temporarily disabled 30 percent of patients report persistent and chronic back pain despite an apparent adequately-performed surgery 7 8 2
6/1/2013 WHO’s Pain Management guidelines Opioid drug abuse in US After Marijuana, Prescription Opioids PAIN LADDER account for most of the commonly abused Strong oral opioids drugs ± Non-opioids ± Adjuvant Low dose Opioids Illicit drugs ± Non-opioids Prescription or OTC medication ± Adjuvant Non-narcotics Non-opioid ± Adjuvant Prescription Drug Abuse in US, 2010 9 10 Source: Monitoring the Future Survey, 2011; National Survey on Drug Use and Health, 2010 Source: B.5.3 WHO Pain Ladder with Pain Management Guidelines 12 Opioid analgesics are the commonly abused Rx drugs HCAHPS Survey • Hospital Consumer Assessment of • Healthcare Providers and Systems Survey • First national, standardized, publicly reported survey of patients' perspectives of hospital care • IMPACT: Results of survey used to determine payment scale Adapted from National Institute of Drug Abuse Opioid Analgesics are the leading cause of death among cases of unintentional drug overdose 11 3
6/1/2013 14 HCAHPS Survey Questions • How often was your pain well controlled? (Q13) • How often did the hospital staff do everything they could to help you with your pain? (Q14) 13 15 CGCAHPS Survey • The Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey • Measure patient perceptions of care provided by For many patients, treatment of pain inadequate not just because of uncertain a physician in an office or clinic setting diagnoses and societal stigma, but also because of shortcomings in the availability of effective treatments and inadequate patient and clinician knowledge about the best ways to manage pain - IOM report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research (2011) 16 4
6/1/2013 Chronic Pain treatment requires multimodal With multimodal analgesia there is synergistic affect, while side effects are of small degree strategy Multimodal Analgesia: Step therapy STEP 3 Pharmacotherapy Interventional Severe Postoperative Pain Approaches STEP 2 Step I and Step 2 strategies Treatment Moderate Postoperative Pain STEP 1 AND Approaches Local Anesthetic Step I strategy Mild Postoperative Pain Peripheral Neural Lifestyle Psychological Non-opioid analgesic blockade AND (With/Without catheter) Changes Support Acetaminophen, Intermittent doses of NSAIDs/COX2 selective AND Opioid analgesics inhibitors Use of Sustained release AND Opioid analgesics Local Anesthetic infiltration 17 18 Adapted from Crews JC. JAMA 2002; 288: 629 - 632 Pain treatment focuses on minimal invasive Better clinical outcomes, low risk, and reduced therapies initially costs of care compared with standard treatments Level 3 Counseling about the pain, management strategies, Pain therapies lifestyle factors Neuroablation, Patient Level 2 Neurolysis, education Pain therapies Physical micro vascular Surgical, therapy decompression Neuroablation, Physical modalities for Surgery Level 1 Implantable drug rehabilitation reconditioning Pain therapies pumps, Spinal cord stimulation Relaxation training, Opioids, Thermal hypnosis, procedures, Interdisciplinary Neurolysis, biofeedback, Application of heat or Other Nerve blocks Psychological copings skills, approach cold, Diagnosis physical approaches NSAIDS, TENS, behavior approaches TENS, massage, Psychological modification, acupuncture therapy, psychotherapy OTC Pain medicine, Nonopioids, opioids, Exercise programs Occupational Pharmaceuticals therapy antidepressants, Attention to proper Afte antiepileptic drugs, 201 2011 2012 2013 201 body mechanics, Least Invasive Most Invasive Regional stimulants, r resumption of normal 0 4 anesthesia antihistamines 201 daily activities 4 Nerve blocks, Pain treatment Continuum intraspinal analgesia 19 20 Adapted from Beverly Meyer ...On Diet & Health.com TENS: Transcutaneous electrical nerve stimulation 5
6/1/2013 Primary-care physicians are the base of Pain consultation chain Distribution of pain patients among major pain management providers 2% 40% Primary care physicians treat more pain patients when compared to other pain management providers Education, Education, Education. Educate more physicians on proper diagnosis and 52% proper pain management. Educate the person with pain and their family on 7% addiction versus physical dependency and proper storage of medication. Educate the public and press about the realities of pain medication and people living with pain Primary care physicians Pain physicians - A response from a person with chronic pain Chiropractors Acupuncturists � Primary-care physician (PCP) is usually the first source of contact for any patient with pain 21 22 PCPs are well placed to handle Pain problems PCPs have to be trained in Chronic Pain management to improve patient care A Primary care physician with an ongoing relationship % of Highly satisfied patients with practitioner visits with the patient can provide enhanced access to care in the complex healthcare system 59% 55% 53% Primary care physicians 44% have a low patient 34% satisfaction quotient compared to other pain Advantages of a PCP: management providers . • Ease of access Chiropractor Physical Acupuncturist Specialist Primary care therapist physician physician • Exposure to variety of clinical presentations Source: Consumer Reports Health Ratings Center • Long-term relationship with patients � Primary care physicians in US devote 1/3 rd of their • Continuity of care time to patients with a chief symptom of chronic pain � Most PCPs have little education or training in chronic pain management 23 24 6
6/1/2013 Post-operative pain is undermanaged 12% Slight pain 7% 19% 25% Moderate pain 22% 40% 23% 52% Extreme pain Severe pain Pain Before Discharge Pain After Discharge Progress occurs when courageous, skillful leaders seize the opportunity to change Adapted from Apfelbaum JL et al. Anesth Analg. 2003;97:534-540 things for the better A collaborative care, lead by Primary care physician - Harry S Truman in coordination with Pain specialist can close this gap in post-operative pain management 25 26 Regulatory bodies have recommended the In collaboration with Pain specialist, PCP can PCP-Pain specialist collaboration improve care Educate and collaborate Both recommended complete restructuring > care, emphasizing the central role of PCPs Coordination in confirming the PCPs diagnosis June 2009 Meeting PAIN SUMMIT-Nov 2009 > Pain Primary Care Specialist Physician Recommending the use of Recommended supporting narcotics collaborating between pain specialists and PCPs < Relieving Pain in America, June 2011 Collaborative Care Model 27 28 7
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