Safe and confident opioid management
Howard Bland, MD, FAAFP
OptumCare Medical Group
OptumCare® Medical Group, based in Southern California, was formed through the merger of two well-established and respected primary care provider groups. It serves patients of all ages using a unique care model that stresses proactive, preventative and coordinated care.
The entire spectrum of care is offered in partnership with AppleCare, Monarch HealthCare® and NAMM. OptumCare Medical Group was formed in 2012.
Over the last several years, news coverage and public health initiatives addressing America’s opioid epidemic have disrupted the care of our patients who suffer from chronic pain.
The root cause of the opioid crisis can be traced to multiple factors including false representation of the safety profile of opiates by pharmaceutical companies, coupled with recommendations by various pain societies for aggressive pain control.
These pain societies and new recommendations were strongly supported by state medical boards and primary care physicians were left to manage the bulk of these patients.
As the pendulum of pain management culture now swings to a more conservative approach, how should a primary care physician (PCP) best manage a patient in pain?
Adding to the complexity of this crisis, PCPs are challenged by a larger health care system trying to adapt, inharmoniously, to protect patients from complications of opioid use disorder.
The multiplicity of regulatory agencies attempting to control opioids (local, state, federal), and their shifting policies disrupt the physician-patient relationship and create a climate of anxiety as physicians struggle to maintain compliance.
For these reasons, PCPs may feel uncomfortable prescribing opiates or managing pain, and instead are referring patients to specialty care unnecessarily.
Top reasons for patients requesting opiates may include: acute or chronic pain, untreated psychiatric conditions, unmanaged social situations, and/or current or past addiction.
This new climate around opioid use for pain control has created reluctance by physicians to even attempt pain management, or address patients in need. Our very limited resource of pain management specialists are being inundated with referrals.
Patients who need opioids feel persecuted by regulatory scrutiny at the pharmacy and abandoned when clinics insist on strict non-opioid prescribing policies.
These PCPs benefit from frequent follow-up and have earned the trust of their patients, allowing greater opportunity to guide, educate and manage.
To augment and endorse the care provided by PCPs, OptumCare Medical Group has collaborated with Dr. Scott Ferer, ambulatory medical director at Monarch HealthCare, and Drs. Afshin Girayli and Keyvan Zaverei, practicing pain management specialists.
Together, we have created an evidence-based, four-cohort approach to managing pain in primary care. By determining a patient’s placement into one of the following four cohorts, a clinician is able to make the best possible decision for treatment.
1. New patients with acute or chronic pain:
- Reference CDC guidelines
- Use additional tools (PDMP/CURES, patient contracts, smart phone apps/MME calculators, IPA databases)
- Assess and diagnose condition as appropriate
- Apply appropriate medication and non-medication modalities
- Use opioid medication as last resort
- Thorough documentation
2. Established patient with controlled chronic pain
- Established diagnosis with supporting evaluation and documentation
- Failed other medications and modalities
- Compliant and well-controlled on current opioid treatment
- Okay for PCP to continue treatment
- Thorough documentation of informed consent, treatment plan, goals of treatment and measures of compliance and effectiveness"
3. Established patient with uncontrolled chronic pain
- PCP evaluation: appropriate history, exam, labs and imaging with diagnosis
- Failed treatment trial of medication (with or without opioid treatment and/or other modalities as appropriate)
- Okay to refer to pain management specialist
- Send along appropriate documentation and records to specialist
- Require communication back from specialist"
4. Patients who desire reduction in opioid therapy
- Okay for PCP to wean medication with patient cooperation
- Referral to inpatient or outpatient detox program
- Referral to medication assisted therapy program (MAT)
- Referral to Pain Management specialist
Leadership at OptumCare Medical Group created these guidelines to support the work of our clinicians who improve the quality and safety of patient care. Guidelines are only effective if understood and integrated into practice.
To ensure the guidelines were employed by clinicians, we called upon our Clinical Leadership Council, a group of our senior physicians responsible for overseeing the office site they represent.
After educating our clinical leaders, they were encouraged to bring the pain management strategy back to their practices to be shared as education in their monthly meetings.
In addition, the four-cohort approach was sent directly to each clinician as a PowerPoint presentation to read at their discretion. Finally, our pain management specialists and medical directors made visits to each office to dialogue with clinicians, face to face.
They answered questions about the new guidelines and recommendations, filling in detail, but more importantly, they showed their support of the work done at the bedside by our PCPs.
As a final measure, OptumCare Medical Group, in collaboration with Monarch HealthCare IPA, has engaged clinicians with a new field on their EHR dashboard.
The field provides data regarding the clinician’s opioid prescribing numbers over time and in comparison to other PCPs in the group.
The ultimate goal is to empower clinicians to continue to provide excellent care by safely engaging their patients around the topic of opioid medication and treatment of pain.
We look forward to reducing pain for our patients, continued partnership with our specialists, and lowering the overall use and abuse of opioid pain medication.
This publication is informational and for educational purposes for practitioners only. The views and opinions expressed herein are those of the authors and do not necessarily represent the views of OptumCare®. The views and opinions expressed may change without notice.