Teamwork for positive results

Monday, January 01, 2018 12:18 PM

Kaiser Permanente Colorado: Demonstrating best practices in pain management

by Kate Alfano, CMS Communications Coordinator

In the face of sobering statistics on prescription drug abuse and misuse, particularly concerning certain pain medications, Kaiser Permanente Colorado and Colorado Permanente Medical Group (CPMG) are making proactive changes to how their care teams manage patients who need opioids and, as a result, are achieving high patient and provider satisfaction. CPMG is one of the state’s largest multispecialty medical groups and serves the 680,000 members of Kaiser Permanente Colorado.

These changes require the teamwork of primary care and specialty care physicians throughout CPMG, and other health care professionals who are aided by Kaiser Permanente Colorado’s integrated electronic medical record (EMR). When a patient requires opioids, his or her primary care physician creates a pain management plan that can be easily accessed by other care providers in real time, ensuring all can communicate a consistent message to the patient. Physicians can also “staff message” within the EMR to colleagues who will be seeing the patient to alert them to changes in medication management.

When prescribing, the EMR setting for all narcotics is to dispense 14 tablets as a defaulted standard. Kaiser Permanente Colorado pharmacists have a fully implemented corresponding responsibility for patients who appear to be at higher risk for an adverse event. Pharmacists will alert primary care physicians when an opioid dose is flagged as high, written prior to the expected fill date or includes a high quantity of tablets/capsules. Clinical pharmacy specialists – who are informed about the current research around elective pain management – are available to review medication regimens and provide recommendations for safe prescribing when contacted by primary care physicians.

As an additional safeguard, Kaiser Permanente Colorado built a comprehensive opioid registry to track opioid use for all members who are prescribed chronic opioid therapy. Standard patient/physician opioid agreements and monthly fill calendars are used for any patients receiving a monthly opiate prescription in primary care.

Licensed practical nurses (LPNs) have a color-coded calendar that helps track all monthly opiate fills (28-day prescriptions). They ensure the urine drug screens are completed at the correct intervals, the Prescription Drug Monitoring Program is checked and the prescription is ready for cosign before the patient’s fill day arrives.

“We are learning that improving patient safety when it comes to chronic pain and opioids is most successful when all parties commit to working toward the common goal at the system, provider and patient levels. Our multidisciplinary pain management team works collaboratively with primary care physicians not only on opioid dose changes and care plans, but also on strategies to fully engage patients in the process to help them understand their non-opioid pain management options,” says Michael Evers, DO, CPMG pain medicine physician.

“We know that some patients with chronic pain benefit from opioid prescriptions, but whenever possible, we prefer to use adjuvant agents including over-the-counter creams and medications, as well as non-pharmacological treatments,” says Heidi Clune, MD, CPMG family medicine physician. “Kaiser Permanente Centers for Complementary Medicine provide acupuncture, massage and chiropractic care, and we will often recommend these services as the primary focus of the pain treatment even if opioids are still necessary. We are also strong proponents of cognitive behavioral therapy, which has been shown to improve pain better than opioids.”

In the specialty of anesthesia, there is a movement to use “multi-modal” pain management in the preoperative, intraoperative and postoperative settings. This includes use of NSAIDs, gabapentin and acetaminophen to decrease the use of narcotics in the postoperative setting.

In obstetrics for cesarean deliveries, patients are given preoperative NSAIDs, Celebrex and acetaminophen. Postoperative ibuprofen and acetaminophen are scheduled every six hours. Oxycodone is given on an as-needed basis. Patients are sent home with 20 tablets of oxycodone, if needed. They may have one refill of 10 tablets and must have a follow-up visit if they request a second refill.

In palliative care, physicians often see the complicated side of opioid addiction as it can interfere with optimal pain control at the end of life. Sometimes this means that patients with current or past addiction require very high doses of opioids to manage their pain. Conversely, some patients who have heard about opioid abuse in the media or have personally experienced opioid abuse, overdoses or deaths of their family members are reluctant to use these medications at all. As a result, Kaiser Permanente Colorado has instituted a comprehensive plan to assess, educate and follow patients with serious illness to keep them as comfortable and as safe as possible.

This protocol involves the following:

1. Initial opioid risk assessment as standard practice for all patients for whom CPMG physicians prescribe opioids.
2. Standard education regarding opioid risk for all patients for whom CPMG physicians prescribe opioids.
3. Routine RN follow-up calls within a few days of medication initiation to ensure safety and efficacy.
4. Telephone calls required for patients to request refills and to discuss their plan of care with the RN to maximize the efficacy of medications and ensure that the medications sent home (often in large quantities) are being used according to plan. No automatic refills allowed for patients because their care needs often change as they move through treatment.
5. Routine, face-to-face follow-up visits every three months (at a minimum) to ensure the pain plan is still appropriate.
6. Careful attention to adjuvant agents and non-pharmacologic treatment modalities based on the nature of the pain (e.g. if bone pain, using anti-inflammatories as adjuncts).

Finally, patient education is an important part of the program. One of Kaiser Permanente Colorado’s main locations provides a multidisciplinary pain management program run by CPMG physicians, along with clinical psychologists, clinical pharmacists, physical therapists and social workers. This integrated eight-week course is designed to educate high-risk opioid use patients about pain management and alternatives to opioid use through exercise, meditation, acupuncture and mindfulness.

Robert Kerley, a Kaiser Permanente member since 2015, sustained a serious back injury in 2010 and spent years fighting the pain with medication after medication, rarely leaving his couch, unable to work or participate in family activities.

“It disrupted our lives so much. You feel less than human. Life changed for me when I went to Kaiser Permanente and actually got a doctor that cared,” says Kerley. “Going to the classes and talking to other people there that had been weaned down off of their doses helped me. Life now is great because I’m able to be a father again. I got my life and my family back.”

You can learn more about Kerley’s experience in Kaiser Permanente Colorado’s Integrated Pain Service program at https://kp.qumucloud.com/view/orzN8PAp2Ez.  

The program has shown results in addition to the personal recovery of participants. A 12-month quality improvement cohort study of program effectiveness demonstrated a 25 percent decrease in emergency department visits and a 40 percent decrease in total opioid doses across the 80-patient cohort.

“It boils down to a culture shift for both providers and patients,” Evers says. “Integrating data and analytic capabilities allows us to target opportunities for improvement in a compassionate, patient-centered manner, while simultaneously pursuing a broader prevention-oriented population management model.”