PAIN MANAGEMENT: THE PAIN PATHWAY PROGRAM

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Tour Clark
Masters in Public Health
University of San Francisco
Pain Management: The Pain Pathway Program
Fieldwork Summary























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Abstract


BACKGROUD: Nearly 15,000 people die every year of overdoses involving
prescription painkillers. In 2010, 1 in 20 people in US (age 12 or older) reported using
prescription painkillers for nonmedical reasons in the past year. Enough painkillers were
prescribed in 2010 to medicate every American adult around the clock for a month.
Opioid use leads to tolerance, and after a period of use to dependence (National Institute
Drug Abuse, 2008). Opioid dependence has been considered a chronic medical illness,
benefiting from the same kind of long-term treatment and supportive care (McLellan,
2000). Untreated patients can have a relapse rate greater than 90 % (McLellan, 1983).
I was able to completed 300 hours of interning at Maxine Hall Health Center
(MHHC). It serves a little over 4,000 patients of these, approximately, 160 are using
opiate painkillers chronically these powerful medications were not being monitored in a
safe and standard way. The purpose of this paper is to discuss how MHHC developed a
multidisciplinary approach for the care of patients who are prescribed opioid painkillers
and the positive and negative outcomes with this approach. Maxine Hall Health Center
has become the leading clinic amongst the consortium clinics under the Department of
Public Health of San Francisco.


OBJECTIVE: To summarize the evidence pertaining to the effects of prescription opiate
misuse, abuse and the efforts to create a registry of patients using these medications at a
Primary Care clinic Maxine Health Center (MHHC).
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Results: The efforts of a multidisciplinary team to improve, including management
team, M.D, Clinical Pharmacist, R.N, Clerk, and Social Worker, and a Intern of the
Public Health school of the University of San Francisco. In 2007 there was no systematic
approach to monitor these patients prescribed opiates. In 2014, there is now standard
approach to tracking and monitoring patients of MHHC. Clinical Social Worker and
Psychologist educates patients on the risks and benefits of opiate medications. Patients
then sign informed consent and medication agreement. Each patient gives a urine sample
for toxicology screening at least once a year and clinical staff runs a pharmacy report on
each patient in the registry once a year through the California prescriptive drug-
monitoring program. Patients are now required to complete a pain agreement contract
with the behavior staff team and the physicians, a toxicology screening, and a use of
prescription opiate use database

Conclusion: The Public Health implications of prescription opiate use and abuse are
tremendous. Millions of people across the United States and abroad are suffering from
prescription opiate dependence and abuse. The current available evidence strongly
supports using a clinical opiate registry combined with psychosocial assistance for
keeping patients in treatment and reducing illicit opioid use, and premature mortality.



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Introduction

Prescription opiate abuse has had a tremendous effect on the Public Health; there
are multiple factors that are driving this high prevalence. Drug overdoses rates in the
United States have more than tripled since 1990 and have never been higher. Just in 2008
alone, more than 36,000 people died from drug overdoses, with the majority of the deaths
being caused by prescription drugs. If you break the statistics down to every day, 100
people die from drug overdoses in the United States everyday (CDC, 2014). Opioid
overdose is both preventable and, if witnessed, treatable (reversible)

Opiates, which can be chemically synthesized from the opium plant, are a group
of compounds that activate that brains opioid receptors. These receptors influence
perceptions of pain and euphoria and are involved in the regulation of breathing. The
more commonly known and used opiates are morphine, methadone, heroin, codeine,
buprenorphine, tramadol, oxycodone and hydrocodone. These are typically used to treat
pain and opioid dependence, suppress cough and recently to execute a death row inmate.
The rate of abuse, misuse and overdose of opioid painkillers rose as the
percentage of the United States population using opioid painkillers for control rose in the
late 70s. Worldwide overdosing is the leading cause of avoidable death among people
who inject drugs, the same as in America. There was a total of 38,329 drug poisoning
deaths in 2010, including 16,651 fatal opioid overdoses related to prescription opioid
analgesics in 2010, the remained of those deaths largely involved heroin and/or cocaine
[13].
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Maxine Hall Health Center (MHHC) was serving a little over 4,000 patients who
were not being monitored in a safe and standard way. The purpose of this paper is to
discuss how MHHC developed a multidisciplinary approach for the care of patients who
are prescribed opioid painkillers and the positive and negative outcomes with this
approach. Maxine Hall Health Center has become the leading clinic amongst the
consortium clinics under the Department of Public Health of San Francisco.


Description of the public health problem

There is a deadly epidemic of prescription opiate medication abuse growing in the
states and worldwide. The availability of large amount of prescription opiates doesnt
help. Just about 3 out of four prescription drug overdoses are caused by prescription
painkillers- also known as opioid pain relievers. The unparalleled rise in overdose deaths
in the United States shows a 300% increase since 1999 in the sale of these very strong
and powerful painkillers. The combined deaths from cocaine and heroin is smaller than
painkillers; painkillers account for 14,800 overdose deaths in 2008 (CDC, 2014) Chronic
pain represents a significant public health issue with potentially deadly outcomes.

This abuse affects the safety of people by increasing the environmental availability.
Prescription for stimulants increased from 5 million to nearly 45 million and for opioid
analgesics from about 75.5 million to 209.5 million [15] There are various motives
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ranging from pain, anxiety, and sleeping problems. Overall, patients with opioid
dependence die at much higher rate than nonusers from various medical complications.
The incidence of hepatitis C has increased due to the sharing of needles, even with the
population that are allegedly clean and recycled.

Individuals raised in environments in which addiction is present have a greater risk
for developing an addition later in life. These environments can include; living courters
that have easily access to prescriptive opiates. Chronic pain and acute pain are two
different types of pain and must be approached differently. Acute pain is a symptom that
arises when the body is injured and resolves with tissue recovery. Acute pain is
transmitted along the intact neural pathways that are effectively controlled by opiates to
decrease pain perception.
Chronic pain however, does not resolve with tissue recovery, has no functional
role, (and can become a primary diagnosis). Chronic pain involves a very complex
central nervous system signaling that can be amplified by stressors. [8,9] Theses stressors
can range from financial problems, relationship problems, or underlying psychiatric
diagnoses. The wide range of stressors can result in the perception of terrible pain, and an
increase in the chance of a negative change in social functioning. [10,11,12]
Consequently, chronic pain is a biopsychosocial condition that necessitates a
comprehensive, multidisciplinary approach to evaluation and management.
People that are abusing prescription painkillers may take larger doses to reach a
euphoric effect and to reduce or avoid withdrawal symptoms. Large doses cause
breathing to slow down so much it may altogether resulting of a fatal overdose. For
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certain individuals, dosages as low as 30mg per day of morphine, or its equivalent can
actually lower pain thresholds by creating an opiate induced hyperalgeisa, which is an
increased. Ironically leading to more pain paradoxically worsens as opiate doses are
increased. (3-7) Although the gravity of the prescription drug abuse problem has been
recognized, the American Academy of Family Physicians recommended that we must
also address the ongoing public health requirement to provide adequate pain management
(AAFP).
In response to the efforts of a variety of advocacy groups to address opioid abuse
over the past two decades, the U.S. Congress declared the Decade of Pain Control and
Research, beginning on January 1, 2001. [1] Several organizations, including the
American Pain Society, the American Academy Pain Medicine, and the American
Headache Society, along with many others, were founded to improve the training of
physicians who manage pain. [2] There has been an enormous amount of research
concentrated the significance increasing in pain levels. Maxine Hall Management team
began to review the current research and best practices for pain registries to improve their
training and management of patients on chronic opiate medication.

There was not a standardized approach to treatment of chronic pain at MHHC
amongst the providers. In addition, there was not a system of gathering information to
identify the population at risk at Maxine Hall Health Center. In 2007, Maxine Hall Health
Clinic Management sat down and discussed the importance of opioid abuse and deaths in
regards to their specific population that they serve and chose to look at the problem from
a multidisciplinary approach to care (M.D, Clinical pharmacist, social worker, and
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psychologist). They named this multidisciplinary approach the Pain Pathway, its goal to
standardize the approach to include the behavioral staff. The reasons were for this
inclusion was noted by is the limited time providers were able to spend with patients
receiving prescriptions for opiates.
Maxine Hall Health Center management team developed a pain contract
agreement based on the Department of Public Health standards to ensure that each patient
with a prescription for opiate prescription drug is fully educated and made aware of the
positive and negative consequences to using the particular prescription drug. The pain
contract agreement is to be reviewed every year from the multidisciplinary approach to
healthcare maintenance. The clinic management all agreed that it would be important to
share responsibility with the patients by informing them of side effects and the difference
between dependence and addiction.
Maxine Hall Health Center providers collaborated with the clinics pharmacist,
Behaviorist team, and several interns/volunteers, including myself to develop and
implement the multidisciplinary approach to care for the patients using prescription
opioid painkillers. Reviewing the data from the CDC, the management team created a
chronic pain registry. The registry included CURES (Controlled substance Utilization
Review and Evaluation System) reporting, a change in workflow for annual contracts
agreements, and adding a urine toxicology (UTOX) to pain registry in clinics population
health management system (i2i).
Initially, the team chose to conduct group sessions with patients diagnosed with
the chronic pain icd 9 Code 338.4 and who was receiving any prescriptive opiate pain
medication. The management team started a systematic checking of Utox, Cures Reports
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and Pain agreement contracts, but there was not a protocol written up that all the
providers would follow. As I started to help manage the data for the chronic pain registry
I began to notice and articulate the need for a systematic process that all the providers
follow when it comes to certain aspects of the registry. Some very important parts to the
registry were the protocols; For example, what is the protocol that all providers follow
when a patient loses his/her prescription script? Or what happens when a patient breaks
the behavioral pain contract that they signed with the behavioral provider or medical
provider? I began to meet with the management team and discuss the importance of
implementing protocols for all the providers so that each provider doesnt feel alone
when it comes to dealing with rogue patients or that they are not prescribing more than
the recommended dose for pain opiates.

My learning objectives for my 300 hours of interning for Maxine Hall Health
Center were all completed by the end of my time. I reviewed literature surrounding
chronic pain management and best looked for practices around the country. I identified
strategies and protocols that I could implement for the program. My final project for the
clinic was to draft a protocol detailing maintained of the chronic pain registry and to
present this to the Medical Director and Assistant Medical Director of the clinic. I was
able to complete this project with much support from volunteers, staff and the
management team. I am humbled and thankful that I was able to help create a protocol
that is useful to staff responsible for the Chronic opiate patient registry at Maxine Hall
Health Center.
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While developing on the Chronic opiate registry I used several of the USF MPH
competencies I learned in class to follow. I used the biostatics and Epidemiology
competencies, as need as, interpreting, monitoring and reporting data. In regards to
epidemiology, I had to research the trends of prescription opiate abuse, protocols from
the CDC and recommendations that could be used at the clinic. Lastly, I was asked to
help lead clinic opiate registry project by the Medical Director. I utilized the skills I
learned from the Public Health Administration and Leadership course and competency. I
had to present a clear vision of the project and then delegate tasks that I had to ensure to
move the project forward.
Maxine Hall Health Center staff identified 209 patients who have a chronic pain
diagnosis and receive an opioid painkiller for more than 3 months. They set the goal of
the number of cures reports, Utoxs and signed agreements over baseline. Subjectively,
there is a more standard approach practice wide of no early refills, no replacement of lost
or stolen medications, less patient and staff tension at the time of pickup for medication.

I can honestly say that the quality of my fieldwork experience was incredible
despite my challenges along the way. From a personal viewpoint, it was difficult to
connect with my first preceptor and get started on the initial project that I was suppose to
complete for the Department of Public Health African American Health Initiative. In
addition, I had to have a major surgery that rendered me unable to walk on complete my
hours of interning in one semester. Yet, as I reflect back on the journey I am thankful for
the experiences and the support I received during that time.
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I was able to empathize with the patients at the clinic who had a chronic pain that
they were taking prescriptive opiates for. Even though my health issue would only allow
me two years on a prescriptive opiate, I was able to relate to the negative and positive
results that the patients were discussing with the providers and me when we had to
tamper them down on some of the medications. I distinctly remember an elderly woman
who had terrible chronic back pain come in for a regular check up and Dr. James had to
express to the patient that she cannot increase her medication due to the deadly side
effects. The patient burst into tears exclaiming that she needs it to survive, especially
since she is having family visit and she doesnt want to lie in the bed all day. I was then
able to see how important it is to have a chronic pain registry and to ensure that each
patient is getting the recommended dose level of prescriptive opiates to ensure no
dependence and addiction to the medication.
On a professional level, I learned a tremendous wealth of knowledge on how to
manage data in a clinical environment and see the importance of having protocols in
place. I was able to see that I was capable and able to take on a huge responsibility and
complete my deliverables that was asked of me at the beginning of the internship. I
learned the importance of having a keen eye for details and a strong work ethic while
being at the clinic. The Medical Director Dr. Catherine James demonstrated these two
qualities at such a high level. I was and still very impressed with her uncanny ability to
delegate tasks, resolves staff complaints and disagreements, manage the entire clinic staff
and budget and moral, while inspiring newly interns that come into the clinic. I can say
that I will never be the same after interning under Dr. James for the completion of the
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Chronic Pain. I was inspired and learned a great deal about management and
implementation of protocols and procedures.








































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Reference:

1. Decade of Pain Control and Research, S 3163, 106
th
Cong, 2
nd
Sess (2000).

2. Public policy statement on the rights and responsibilities of health care professionals in
the use of opioid for the treatment of pain: a consensus document from the American
Academy of Pain Medicine, the American Pain Society, and the American Society of
Addiction Medicine. Pain Med. 2004;5(3):301-302.

3. Chang G, Chen L, Mao J. Opioid tolerance and hyperalgesia. Med Clin North Am.
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4. Gallagher RM, Fishman SM. Pain medicine: history, emergence as a medical
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5. Chu LF, Angst MS, Clark D. Opioid-induced hyperalgesia in humans: molecular
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7. Decade of Pain Control and Research, S 3163, 106
th
Cong, 2
nd
Sess (2000).
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Public policy statement on the rights and responsibilities of health care professionals in
the use of opioids for the treatment of pain: a consensus document from the American
Academy of Pain Medicine, the American Pain Society, and the American Society of
Addiction Medicine. Pain Med. 2004;5(3):301-302.

8. Brookoff D. Chronic pain: 1. A new disease? Hosp Pract (Minneap).
2000;35(7):455259.
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10. Jensen MK, Thomsen AB, Hjsted J. 10-year follow-up of chronic non-malignant
pain patients: opioid use, health related quality of life and health care utilization. Eur
J Pain. 2006;10(5):423433.

11. Brookoff D. Chronic pain: 1. A new disease? Hosp Pract (Minneap).
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12. Clauw DJ. Fibromyalgia: an overview. Am J Med. 2009;122(12 suppl):S3S13.




13 M. Warner, L. H. Chen and D. M. Makuc, Increase in fatal poisonings involving
opioid analgesics in the
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United States, 1999-2006, NCHS Data Brief, No. 22 (Hyattsville, Maryland, National
Center for Health Statistics,

September 2009).

14. National Drug Intelligence Center (2011). The Economic Impact of Il-licit Drug Use
on American Society. Washington D.C.: United States Department of Justice. Available
at: http://www.justice.gov/archive/ndic/pubs44/44731/44731p.pdf(PDF, 2.4MB)


15. Topics in Brief: Prescription Drug Abuse. (2011, December 1). Prescription Drug
Abuse. Retrieved June 15, 2014, from http://www.drugabuse.gov/publications/topics-in-
brief/prescription-drug-abuse


















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Appendices:

1) Project timeline and student/preceptor agreement and learning contract
2) Tables, charts, graphs, surveys, evaluation, forms, educational materials etc.













Figure 1




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Figure 2