Utility of a Sole Provider Program in the Treatment of

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Utility of a Sole Provider Program in the
Treatment of Chronic Non-Cancer Pain 

• Anthony A.D. Noya, MD
• CPT (P), MC
• NHMA 14th Annual Conference

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• The opinions and assertions expressed herein are
  my private views and are not to be construed as
  official or as reflecting the views of the U.S.
  Army Medical Corps or the U.S. Army at large.
• I do not have any conflicts of interest. Sources
  of funding None.

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My Background

• Born and raised in New England parents came to
  U.S. from Cuba in the 1960s.
• College and Medical School in New England ROTC
  and HPSP Scholarships.
• Family Medicine Residency in Augusta, GA
  Eisenhower Army Medical Center.
• Little to no training in/exposure to Chronic Pain
  during medical school and residency training.
• Moved to Fort Polk, LA Bayne-Jones Army
  Community Hospital (BJACH) in 2007.

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Presentation Outline 

• Increase Awareness of the complexity of treating
  chronic non-cancer pain.
• Familiarization with the Clinical Guidelines for
  the Use of Chronic Opioid Therapy in Chronic
  Non-Cancer Pain.
• Bayne-Jones Army Community Hospital Sole Provider
  Program Case Example.

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Backdrop

• Pain is 1 reason why Americans visit the office
  and the number one reason why they come away
  disappointed
• Pains burden on society - 100 billion/yr
• 5th Vital Sign late 1990s
• Prescriptions for NSAIDs and Opiates for chronic
  musculoskeletal pain increased 4-fold between
  1980 and 2000
• Prescription opioids are fastest growing form of
  drug abuse

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Chronic Noncancer Pain

• Pain unrelated to cancer that persists beyond the
  usual course of disease or injury (3 to 6 or more
  months of pain)
• It may or may not be associated with a pathologic
  process
• Psychosocial comorbidities
• Rarely cure patients
• What is the best treatment approach?

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More Definitions

• Physical Dependence Withdrawal symptoms
• Addiction maladaptive behavior to satisfy a
  craving for the drug
• Chronic, neurobiological disease
• Genetic, psychosocial, and environmental factors

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More Definitions

• Pseudoaddiction Relief-seeking behaviors that
  resolve upon institution of effective analgesic
  therapy
• Substance Abuse Use for purposes that are not
  those for which prescribed (e.g. getting high)
• Tolerance Adaptation resulting in a gradual
  need to increase the dose to obtain the same
  effect

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More Definitions

• Misuse Use of a medication other than as
  directed
• Aberrant drug-related behavior A behavior
  outside the boundaries of the agreed upon
  treatment plan
• Hyperalgesia An increased response to a
  stimulus which is normally painful

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Clinical Guidelines for the Use of Chronic Opioid
Therapy(COT) in Chronic Non-Cancer Pain(CNCP)

• The Journal of Pain, Vol 10, No 2 (February)
  2009 pp 113-130.
• The American Pain Society and the American
  Academy of Pain Medicine multidisciplinary panel
  of 21 experts
• Literature through November 2007
• 8,034 abstracts, 14 systematic reviews, and 57
  primary studies reviewed

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Patient Selection and Risk Stratification

• History, physical examination and appropriate
  testing, including an assessment of risk of
  substance abuse, misuse, or addiction
• COT is an option if CNCP is moderate or severe,
  pain is having adverse impact on function or
  quality of life, and potential therapeutic
  benefits outweigh or are likely to outweigh harms
• Benefit-to-harm evaluation documented before and
  during COT

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Use of Psychotherapeutic Interventions

• CNCP is a complex biopsychosocial condition
• Routinely integrate psychotherapeutic
  interventions, functional restoration,
  interdisciplinary therapy, and other adjunctive
  nonopioid therapies

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Identifying a Medical Home and When to Obtain
Consultation

• Patients on COT should identify a clinician who
  accepts primary responsibility for their overall
  medical care
• This clinician may or may not prescribe COT, but
  should coordinate communication among all
  clinicians involved in the patients care
• Clinicians should pursue consultation, including
  multidisciplinary pain management, when patients
  with CNCP may benefit from additional skills or
  resources that they cannot provide

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Bayne-Jones Army Community Hospital Fort Polk,
LA

• Fort Polk is a Combat Training Center that
  trains and deploys combat units
• About 9,000 active duty soldiers and a total of
  about 23,000 healthcare beneficiaries including
  family members and retirees
• Demographics play a role
• Rural vs Metropolitan, Age (young), Psychosocial
  Stressors

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Medical Home Model

• Improved provider to patient ratios by utilizing
  multiple sole providers
• Key Partnerships Managed Care/Case Management,
  Department of Behavioral Health, BJACH Pharmacy,
  and local Pain Specialists
• Nurse case management provides patient education,
  coordination and continuity of care for more
  complex patients
• Behavioral Health offers Complimentary
  Alternative Management Approach (CAMA) Group
  Therapy sessions weekly

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Conclusion

• Safe and effective therapy requires clinical
  skills and knowledge in both the principles of
  opioid prescribing and on the assessment and
  management of risks associated with opioid abuse,
  addiction, and diversion
• Target psychosocial factors
• Identify a medical home for all chronic pain
  patients

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References

• Chou, R, et al. Clinical Guidelines for the Use
  of Chronic Opiod Therapy in Chronic Noncancer
  Pain. J Pain. February 2009 10(2)113-130.
• http//www.painmed.org/pdf/noncancer_opioid_g
  uidelines.pdf
• Disorbio JM, Bruns D, Barolat G. Assessment and
  Treatment of Chronic Pain A physicians guide to
  a biopsychosocial approach. PPM. March 20061-10.
• Bonakdar RA. Non-pharmacolgic Pain Management.
  Lecture notes from presentation given at 2009
  AAFP Scientific Assembly.
• Sullivan MD. The quest for rational chronic pain
  pharmacotherapy. General Hospital Psychiatry.
  200931203-205. Editorial.
• Caudill-Slosberg MA, et al. Office visits and
  analgesic prescriptions for musculoskeletal pain
  in US 1980 vs. 2000. JIASP. June
  2004109(3)514-519.
• Jackman RP, Purvis JM. Chronic Nonmalignant Pain
  in Primary Care. Am Fam Physician.
  200878(10)1155-1162, 1164. http//www.aafp.org/a
  fp/20081115/1155.html
• Benedict DG. Walking the Tightrope Chronic Pain
  and Substance Abuse. JNP. September
  20084(8)604-609.
• Gelfand SG. Medscape Commentary The Pitfalls of
  Opioids for Chronic Nonmalignant Pain of Central
  Origin. Posted 02/25/2002. http//www.medscape.com
  /viewarticle/425468
• Memorandum. OTSG/MEDCOM Policy Memo 09-064, 04
  AUG 2009, subject Use of Opioid Medications in
  Pain Management.
• MEDDAC Regulation. MEDDAC Reg 40-99, 27 SEP 2009,
  subject Medical Services Sole Prescriber Program.