All Pain, All Gain: Development of a Primary Care Pain Program

Purpose: To promote patient safety by providing clear guidelines and tools for educating patients, physicians, and advanced practice providers while successfully managing out-patient’s chronic “non-cancer” pain.

Description: A pain management registry was created for an ambulatory care family practice physician group that consists of 8 physicians and two advanced practice providers. The physicians, staff, and nurse leader registered approximately 400 patients within the first year, and successfully executed a multifaceted program that resulted in a 31% reduction of opioid prescriptions. The goal was for patients to visit the clinic on a specialized pain clinic day that was designed to focus on opioid assessment and education. In addition, the patient and provider completed a mandatory pain agreement, drug screen, functional assessment score, calculation of MME’s (morphine milligram equivalent), and scheduling of a return office visit to see the physician every 3 months; the prescriptions are given at these appointments only (including naloxone prescription when indicated). A positive correlation identified with this trial has been that the patients do not call the office for narcotic refill requests, which in turn increases patient compliance and staff perception of increased safety.

The creation of this registry allows ambulatory care nurses to be more proactive and efficient in how patients are managed while enhancing education, collaboration among health care teams, active engagement in clinical workflow development, and support of the development of safe treatment options. Clinical team members quickly check patients’ needs against evidence-based clinical guidelines, including incorporation of the state PMP (prescription monitoring program), to assess for any potential diversion of opioids; preparation includes development of a urine drug screen protocol, and coordination with the psychology department to have LCSWs (licensed clinical social worker) onsite to counsel appropriate patients.

The registry includes the name and MRN (medical record number) of the patient, name and dose of the prescription, last prescription fill date, date of last urine drug screen, status of naloxone prescription, PMP information, chosen pharmacy, date of last office visit, status of pain agreement, functional assessment scores, MME, and diagnosis. PCPs (primary care providers) were provided with education regarding the opioid weaning process as well as education regarding critical conversations with patients related to the risks of opioids and education regarding the use of the functional assessment tool, calculation of MMEs, and documentation requirements.

Evaluation/outcomes: First-year outcomes have shown patient/physician collaboration, which resulted in a 31% reduction in the amount of chronic opioid prescriptions. This includes identified diversions and physician/patient collaboration to wean. Embracing the evidence-based guidelines, the health care team is able to meet the needs of this specialized patient population, which promote positive outcomes, and enhance patient and staff safety.
References
1. Kral, Lee A., (2006). Opioid Tapering Safely Discontinuing Opioid Analgesics. Retrieved from http://paincommunity.org/blog/...