1. 1. Pain Points for the Community Health Center: Integration of Addiction-Informed Pain Management Services into Primary Care Jonathan Zellan, MD Vice President Regional Medical Director Carol Murphy, MHA, RNC, NHA Chief Operational Officer Chief Nursing Officer May 7, 2015
2. 2. Patients with a history of substance abuse have increased sensitivity to pain A family history of substance abuse is the main risk factor for developing opioid addiction Physical dependence and tolerance are indicators of opioid addiction Pain Points for the Community Health Center May 07, 20152 True or False?
3. 3. Mission Brightpoint Health drives dramatic improvements in the health of New Yorkers. Vision Brightpoint Health is a recognized leader in the delivery of high-quality, person-centered, integrated care resulting in improved health outcomes for people, families and communities challenged by health disparities caused by poverty, discrimination and lack of access. Using an Integrated Care Team to Improve Treatment Adherence in a Substance Using Population May 7, 2015 3 Mission and Vision
4. 4. Using an Integrated Care Team to Improve Treatment Adherence in a Substance Using Population May 7, 2015 4 Core Values
5. 5. Pain Points for the Community Health Center May 07, 20155 Our Patients Pain Many of our patients have experienced violence, abuse, lack of resources, mental health issues and other societal factors influencing pain
6. 6. Treating patients with chronic pain and substance abuse disorders is a balancing act. Pain Points for the Community Health Center May 07, 20156 Scope Of The Problem: Opioids for Non-Cancer Pain in Patients with Substance Use Disorders
7. 7. Pain Points for the Community Health Center May 07, 20157 Prescription Painkillers In New York City, the abuse of prescription painkillers has developed into a public health and safety threat.
8. 8. Pain Points for the Community Health Center May 07, 20158 The Prescription Drug Abuse Epidemic Unintentional Poisoning Deaths Involving Heroin by NYC Neighborhood Residence, 2011-2012 Source: Bureau of Vital Statistics/Office of the Chief Medical Examiner, New York City; analysis by Health Department's Bureau of Alcohol and Drug Use Prevention, Care and Treatment
9. 9. Brightpoint Healths Solution Development of an Integrated Care Model Pain Points for the Community Health Center May 07, 20159
10. 10. Pain Points for the Community Health Center May 07, 201510 Who Are Our Patients? patients with substance abuse diagnosis patients with substance abuse diagnosis + MH diagnosis patients with substance abuse diagnosis + MH diagnosis + medical diagnosis 75% 73% 28%
11. 11. Juanitas Story Using an Integrated Care Team to Improve Treatment Adherence in a Substance Using Population May 7, 2015 11
12. 12. Outreach (Transportation) Mental Health (Article 31/28) Out Patient Drug Treatment (Article 822) Medical Care Management Primary Care Dental Services Care Coordinator (Health Home) replacement therapy (Buphenoiphinc) Pain Management Pain Points for the Community Health Center May 07, 201512 Brightpoint Healths Homeless FQHC: Our Approach to Treatment Medical Case Manager Office-Based Opioid replacement therapy (Buprenorphine) Outpatient Drug Treatment (Article 822)
13. 13. In the first 6 months Pain Points for the Community Health Center May 07, 201513 Pain Management Service Data Marijuana: 26% 264 new patient encounters 74% of these patients reported history of substance abuse Cocaine: 58% Heroin: 34% Alcohol: 27% Other: 9% Of patients who reported history of substance abuse:
14. 14. Addiction-Informed Pain Management Treatment The Balancing Act Pain Points for the Community Health Center May 07, 201514
15. 15. Pain Points for the Community Health Center May 07, 201515 Syndrome of Pain Facilitation Taken from J Addiction Sci & Clin Pract; June 2008
16. 16. Pain Points for the Community Health Center May 07, 201516 Monitor Aberrant Drug Behaviors J. Pain and Symptom Management 2011; 42(6):893-902 Major High risk to society because of potential for overdose or legal problems Using opioids to get high Exchanging opioids for sex or other drugs Trading street drugs to obtain opioids Selling or stealing opioids Snorting, crushing, sniffing, smoking opioids
17. 17. Pain Points for the Community Health Center May 07, 201517 Monitor Aberrant Drug Behaviors J. Pain and Symptom Management 2011; 42(6):893-902 Minor Pose less risk to societymay even be related to unrelieved pain Saving unused pills Fabricating side effects/allergi es to get a specific drug Borrowing or buying opioids Magnifying the degree of pain in order to get opioids
18. 18. Pain score Level of function Pain Points for the Community Health Center May 07, 201518 Patient Flow and Appropriate Intervention Intensity High intensity Risk Assessment Mental Health Family History Personal History Aberrant Behavior 3. Treatment Agreement 4. Intervention 5. 4 As (monitoring) 2. Psychological Assessment 1. Diagnosis Low intensity Medium intensity
19. 19. Pain Points for the Community Health Center May 07, 201519 Risk Assessment and Stratification
20. 20. Monitoring Tools Pain Points for the Community Health Center May 07, 201520
21. 21. Pain Points for the Community Health Center May 07, 201521 Monitoring Tools Toxicology Screening Pill Counts I-STOP One-on-Ones with Pain Management Specialist Communication
22. 22. Treatment Options Pain Points for the Community Health Center May 07, 201522
23. 23. Pain Points for the Community Health Center May 07, 201523 The Treatment Algorithm Indication Buprenorphine Opioids Non-opioids Can use in active substance use + chronic pain? No No Yes Can use in patients with history of substance use+ chronic pain? Yes Maybe (consider risk factors) Yes Can use in patients with no history of substance use? Yes Yes Yes
24. 24. Encourage participation in on-going addiction treatment (12-step meetings, outpatient treatment, or individual counseling/therapy) and support recovery efforts More frequent office visits Prescribe opioids in smaller quantities Use long-acting formulations if appropriate Involve family member in the treatment plan with patients permission Consistent collaboration with mental health provider Consider cognitive-behavioral interventions Pain Points for the Community Health Center May 07, 201524 Additional Recommendations for Treatment
25. 25. Pain Points for the Community Health Center May 07, 201525 Juanita has been in recovery for 12 years
26. 26. Pain Points for the Community Health Center May 07, 201526 Things to Think About
27. 27. Pain Points for the Community Health Center May 07, 201527 Thank You
28. 28. Addiction Science & Clinical Practice 2013, 8:21 J Pain Symptom Management 2011 December; 42(6): 893-902 Clin J Pain 2010 January; 26(1): 1-8 Pain Physician 2012; 15:ES67-ES92 Addiction Science & Clinical Practice June 2008 J Pain 2009;10:113-130 NEJM 2003; 394: 1943-1953 Pain Medicine 2005; 6(2): 107-112 www.pcss-o.org www.buppractice.com www.doctorssafeguard.com Pain Points for the Community Health Center May 07, 201528 References & Resources