Promoting Self-Efficacy in a PillPopping Culture
Marianne Cloeren, MD, MPH, FACOEM
Medical Director, MCA
Objectives
Lay out the scope of the problem of opioids in workers
compensation and general health
Discuss factors that support the status quo
Report on efforts and resources for promoting change
Propose a novel idea whose time has come
Provide some tools you can use now
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http://www.supportprop.org/news/SupportPROP_PDA_PhPerspective_508.pdf
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http://www.supportprop.org/news/SupportPROP_PDA_PhPerspective_508.pdf
Rates of Opioid Pain Reliever (OPR) Overdose
Death, OPR Treatment Admissions, and Kilograms
of OPR Sold --- United States, 1999--2010
5
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm
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https://www.ncci.com/documents/narcotics-wc.pdf
Subacute -> Chronic Risk
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2011 study of 30,000 patients prescribed opioids > 90
days over 6 months
66% of those followed for 5 years were still on opioids
5 year follow-up after 90+
day prescription
Still on
opioids
Off opioids
7 Martin BC, et al. Long-Term Chronic Opioid Therapy Discontinuation Rates from the TROUP Study. J
Gen Intern Med. 2011.26(12): 1450–1457. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235603/
Dose and Mortality Risk
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Canadian study of opioid-related death in patients
prescribed opioids for nonmalignant pain 19972006
498 opioid-related deaths in 607,156 people on
opioids
Strong correlation between dose and risk
>200 MED 3X death risk of < 20 MED
Gomes T, Opioid Dose and Drug-Related Mortality in Patients With Nonmalignant Pain,
Arch Intern Med. 2011;171(7):686-691.
Average Claim Cost by Opioid Prescription
Involvement, Michigan
Prescription
# Claims
% of
Claims
Medical
Costs
Indemnity
Costs
Total
Costs
None
Other
SA
Opioids
LA
Opioids
4,794
4,156
3,063
39
34
25
6,212
7,759
19,006
7,050
9,119
28,511
13,295
16,918
47,742
213
2
60,898
95,139
156,748
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White JA, et al. The Effect of Opioid Use on Workers' Compensation Claim Cost in the State of Michigan
Journal of Occupational & Environmental Medicine: August 2012 - Volume 54 - Issue 8 - p 948–953
Chronic Opioids and Lost Work Days
Odds of chronic work loss were 6X > for
claimants with schedule II
Odds of chronic work loss were 11-14X if
any opioid > 90 days
Cost at 3 years $20,000 more for schedule
II vs. none
Opioid therapy for nonspecific low back pain and the outcome of chronic work
loss
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Volinn E, et al. Opioid therapy for nonspecific low back pain and the outcome of chronic work loss.
Pain. 2009 Apr;142(3):194-201.
Chronic Opioids Impact on Function
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Study of 1843 workers’ compensation claimants - 111
(6%) received opioids for 1 yr
Daily opioid dose increased significantly over the year
Small minorities improved by ≥30% in pain (26%) and
function (16%) – Majority did not have improvements
in pain or function!
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Franklin et al, Natural History of Chronic Opioid Use Among Injured Workers w Low Back Pain, Clin J
Pain, Dec, 2009
Opioids in WC
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Trends summary:
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Increasing early prescription
Increasing doses in early prescription
Higher the early dose, more likely long term use
Opioid prescription associated with more lost time and higher
overall claim costs
Why Is This Happening?
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No requirement to follow guidelines
Physician dispensing (repackaging companies)
Lack of incentives for better outcomes
Much pressure on physicians to prescribe opioids for any
pain
The system makes it easier to do things wrong than do
things right
Biopsychosocial issues complicating recovery
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Lots of Published Guidelines
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Pretty similar recommendations from a variety of
organizations
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Washington State Agency Medical Directors:
http://www.agencymeddirectors.wa.gov/opioiddosing.asp
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American Pain Society/American Academy of Pain Medicine:
http://www.jpain.org/article/S1526-5900(08)00831-6/fulltext
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VA/DoD: http://www.healthquality.va.gov/guidelines/Pain/cot/
ACOEM:
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Free but dated:
http://www.acoem.org/uploadedFiles/Knowledge_Centers/Practice_Guidelines/Ch
ronic%20Pain%20Opioid%202011.pdf
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Current with subscription: http://www.prnewswire.com/news-
releases/acoem-chronic-pain-guidelines-now-available-online-64919947.html
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Can Guidelines Make a Difference?
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Franklin GM. Bending the prescription opioid dosing and mortality curves: impact of the Washington State opioid
dosing guideline. Am J Ind Med. 2012 Apr;55(4):325-31.
Chronic Opioid Management Guidelines
Commonalities:
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Screening for appropriateness
Try other treatments first
Use with other approaches (esp. psychological)
Continue if improving function (measure function)
Monitor urine drug screening
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ACOEM Opioids for Chronic Pain:
Recommendation 1
Routine use of opioids for treatment
of chronic non-malignant pain
conditions is not recommended
What do
you see in
practice?
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Recommendation 2
Opioid trial is recommended for select
patients with chronic persistent pain,
neuropathic pain, or CRPS
Not well-controlled with non-opioid treatment
approaches
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Physical restorative approaches
Behavioral interventions
Self-applied modalities
Non-opioid medications
Functional restoration
What do
you see in
practice?
Treatment Options for Persistent Pain
Which
Which
Which
are
are
effective
pay
easiest
?
long
most?
term?
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Recommendation 2 cont’d
Ongoing visits to monitor:
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Efficacy
Adverse effects
Compliance
Surreptitious medication use
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What do
you see in
practice?
Recommendation 2 cont’d
Indications for Discontinuation:
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Failure of initial trial to result in objective
functional improvement
Medication no longer needed
Intolerable adverse effects
Non-compliance
What do
you see in
practice?
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Examples of Functional Improvement
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Physical output or performance (with focus on
job specific activities)
Increased active range of motion, strength or
aerobic capacity
Increased social engagement accompanied by
decreased emotional distress
Sheehan Disability Scale
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Sheehan Disability Scale, cont’d
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The ACPA Quality of Life Scale
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The ACPA Quality of Life Scale, cont’d
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Recommendation 3
Screen patients
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Psych, addiction, ACE
Standardized screening tools are
available free online
Positive screening warrants
psychological evaluation prior to
chronic opioid prescription
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What do
you see in
practice?
Recommendation 4
Opioid contract
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Written and signed treatment
agreement
Understanding and agreement with the
expectations and consequences
One source
PDMP
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What do
you see in
practice?
Recommendation 5
Routine use of urine drug screening for all patients on
chronic opioids is recommended
 Can identify aberrant opioid use and other substance use
that otherwise is not apparent to the treating physician
 Baseline, randomly at least twice and up to 4 times a year
and at termination.
 “For cause”
 Abnormal results should lead to change in treatment plan
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What do
you see in
practice?
Treatment Goals
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Should not be measured solely on the basis of pain
reduction
Also health-related quality of life
Role functioning (vocational)
Interpersonal functioning
Health care utilization
What do you see
in practice?
Are Doctors Following
Chronic Opioid
Management Guidelines?
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Are Doctors Using Opioid
Guidelines?
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In a study of practices in 17 states:
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Psychological evaluations – Only median 4% of long
term user cases evaluated
Drug screening – Only median 7% of long term
user cases screened
Wang, Workers’ Compensation Research Institute, 2011:
ttp://www.oregon.gov/oha/pharmacy/DocumentsArticlesPublications/LongerTerm%20Use%20of%20Opioids%20%E2%80%93%20WCRI.pdf
Have you incorporated screening for Adverse
Childhood Experiences into your practice?
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http://my.quantiamd.com/player/ydwfsxndr?r=1&u=wyqyjcmfu
Which of the following do you routinely do
in cases in which you prescribe opioids – for
noncancer pain – for 90+ days?
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http://my.quantiamd.com/player/ydwfsxndr?r=1&u=wyqyjcmfu
How Do Doctors Make Decisions?
Evidence based guidelines
Patient’s wishes
Medical factors
Pushback
Reimbursement
Insurer/employer wishes
Measurements of work capacity
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Reimbursement
Patient’s wishes
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Two Approaches
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Influence the doctor to make the right decisions (often
not what the patient wishes)
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Imposed controls (e.g. legislation)
Payment for following guideline steps (e.g. checking the
prescription drug monitoring program, writing an opioid
management plan)
Education (REMS)
Provide tools to make it easier (PDMP, screening)
Improve access to alternatives
Influence the patient to ask for more appropriate things
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Influencing the Doctor
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Example: Washington State Labor and Industry
http://www.lni.wa.gov/claimsins/providers/treatingpatients/
ByCondition/Opioids/default.asp
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Resources handout has lots of tools to help the
treating doctor
Get to know tools, figure out whether/how you can
use them in your clinical setting
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GOOD
LUCK!
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Influencing the Patient
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How can we help the patient (employee/injured worker)
make better decisions?
How can we help the patient ask the doctor for more
appropriate things?
How can we make the patient a more informed
consumer of health care?
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Shared Decision Making:
A Definition
Integrative process between patient and
clinician that:
Engages the patient in decision-making
 Provides patient with information about alternative
treatments
 Facilitates the incorporation of patient preferences and
values into the medical plan
www.informedmedicaldecisions.org
(Many decision aids – none for opioids yet)
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Forces Sustaining Poor Quality
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Courtesy
of Ben Moulton from the Informed Medical Decisions Foundation
Shared Decisions
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Does the injured worker know there is a decision to
be made?
Did the provider elicit the injured worker’s
preferences?
Does the decision reflect the injured worker’s goals
and concerns?
Does the injured worker know what he or she needs
to know?
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Three Key Decision Points in Opioid
Treatment
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Before using in acute pain
At subacute to chronic transition point (30-90 days)
During chronic treatment
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Acute: What I Want Patients to Understand
about Opioids
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They don’t work any better than non-opioids for
musculoskeletal injuries like low back strains
Lots of side effects
Worse long-term outcomes in patients who start
them
There should be a plan for stopping them if not
helping function
Some people have trouble getting off them once
started (some studies -> 1/3 become addicted)
Arm Patient with the Right Questions to Ask
Doctor
 Why do you think I need this medicine?
 How will opioid medicine help me function better as I
recover from this injury?
 What are the alternatives to taking this medicine?
 How long will I need this medicine?
 What can I do to manage my pain so I don’t need as much of
this medicine?
 Given my personal health history, what is the risk that I will
become addicted?
 What side effects should I expect in the short run? What
about in the long run?
 How will this medicine affect my ability to work or drive
safely?
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Patient Education – Turn this Advice to
Doctors into Patient Information
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http://www.supportprop.org/index_9_2167612031.pdf
Do I
understand the
alternatives?
Do I know
the potential
benefits –
and harms?
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Do I know the
likelihood of
various
outcomes?
Do I know the
potential
consequences
of my decision?
Subacute to Chronic: What I Want
Patient to Understand
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Subacute to Chronic: What I Want Patient
to Understand
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http://www.supportprop.org/index_9_2167612031.pdf
Subacute to Chronic: What I Want Patients
to Understand
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At the 30-90 day point, there should be an informed
decision-making process about continuing opioids, with:
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Assessment of the clinical value of opioids vs. alternatives
Assessment of the risk of dependence, addiction and side
effects
Discussion with the patient about what long-term opioid use
will mean in his or her life
If decision is made to continue, there should be written
materials, a signed agreement, and a plan for
discontinuation if there is not improvement in function
and symptoms
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Chronic Opioid Management: What I Want
Patients to Understand
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It should be stopped if it has not improved their life and
function.
Long-term side effects include sexual dysfunction,
depression, sleep disorders and increased pain.
Professional help is needed to stop.
They will need to trigger getting such help in most cases.
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A Few Good Tools
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http://www.webility.md/pdfs/Patient%20Education%20on%20Extended%20Opioid%20Use%20%20Webility%202012-10-09a.pdf
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http://www.prium.net/assets/Uploads/Patient-Education-Infograph.pdf
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http://www.psychologytoday.com/blog/day-without-pain
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http://www.unlearnyourpain.com/
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http://www.back-in-control.com/
How Can We Get This
Information to the Patient?
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How Might We Offer This Information to
Injured Workers?
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Handouts
Websites
Videos
Doctor panels and networks
Case managers
Employee health visits
Other ideas?
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Influencing Patients Not Doing Well on
Chronic Opioids
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Understand the patient’s perspective – how does the patient
think things are going?
Understand the motivation for maintaining the status quo –
and for changing.
Use motivational interviewing techniques to understand and
help patients who are ambivalent about making a change.
Resources:
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I-Tunes book Changing the Conversation:
https://itunes.apple.com/us/book/changing-conversationinteractive/id627539414?mt=11
Online training in MI: http://www.center4si.com/training/index.cfm
Quick overview of principles of MI:
http://www.motivationalinterview.org/Documents/1%20A%20MI%20
Definition%20Principles%20&%20Approach%20V4%20012911.pdf
Readiness to Change
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Some people don’t want to change
Some people want to change but don’t know how
Some people are ambivalent about change
Some people don’t want to change – yet
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Stages of Behavior Change
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Change Talk – DARN CAT
Ability
Commitment
Behavior
Change
Activation &
Taking Steps
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Sharing Information
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There is a strategy used in motivational interviewing that
can help you recognize when a patient is open to
information, and let you share it successfully:
Elicit/Provide/Elicit
http://prezi.com/mal7bnineip/?utm_campaign=share&utm_medium=copy
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Summary
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Powerful forces maintaining the status quo
In our role, we have little control over medical treatment
decisions
Providing patients with the information they need to
make better decisions is an idea whose time has come
[email protected]
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