Safe, effective opioid therapy: How one urban clinic turned the corner
Tuesday, November 10, 2015 - 13:58
By Rachel Solotaroff, MD, Chief Medical Director for Central City Concern, a nonprofit agency serving single adults and families in the Portland metro area who are impacted by homelessness, poverty and addictions. Dr. Solotaroff, who still spends 18 to 20 hours a week seeing patients, is credited with transforming CCC’s Old Town Clinic into a patient-centered primary care home model. When I joined Central City Concern in 2006, we faced a common scenario: widespread opioid use disorder, poorly managed chronic pain, and rising opioid overdose deaths. Like so many in primary care, we knew we had to find a way to respond to this epidemic. We’ve turned things around by taking a standard disease management approach to pain management and opioid therapy. I’m here to tell you, step by step, what we did. A quick glance at our clinic: we had huge variability in how patients were being prescribed high-risk substances, significant overdose rates, poor chronic pain outcomes, and burned-out providers. Our goal was to establish safety, efficacy, and consistency around opioid therapy, and to improve our quality of chronic pain care. Meeting patients where they are: Our three-tiered approach Our program is best described as a pyramid with three escalating levels. In tier 1 are primary care-only chronic pain patients who have a verifiable medical diagnosis for which opioids are reasonable. They’ve demonstrated improved function on opioids, have good self-management skills, good community support and are on a relatively low dose with few concurrent risk factors. The approach to treating these is similar to caring for well-controlled patients with diabetes. They’re seen by primary care only every three months or so with routine universal precautions around urine drug screens and reviewing our prescription monitoring database. In tier two are people who meet criteria for and need chronic opioid therapy but believe medication is the only answer to the problem. They’re socially isolated, have few strategies for managing pain, and they universally have behavioral health conditions. These people go into our Renew program, where they’re offered monthly group visits with a provider, and our occupational therapist or one of our behaviorists provide a 12-month pain management curriculum. The course goes over body mechanics and energy conservation, mindfulness and relaxation, and emphasizes the role of triggers (i.e., fear or anxiety) that cause people to use more opioids. Renew is where these patients get their prescriptions so our group show rate is close to 100%. At the top of the pyramid in tier three are the high-risk folks. They may be in early recovery from addiction but also have chronic pain for which they use opioids. They may have been doing well on opioids, but had a relapse on some substance. We realized early on that if we ignore addiction or chronic pain in the same individual, one of those things is going to show itself—with force. And if you kick somebody out for one slip, the problem is never addressed; it’s only passed on. We developed a weekly program that’s a certified alcohol and drug treatment program also offering pain management skills. This combined group is facilitated by a certified alcohol and drug counselor who also has integrative or complementary medicine skills. Over time, we’ve seen that sometimes the risk of chronic opioids in these patients is just too high, even in a controlled setting. In those cases, we transition the patient to buprenorphine. Getting to know new patients helps us evaluate their risk We do significant data collection with new patients so that our controlled substances review committee can do risk stratification. New patients have an initial visit with a patient intake coordinator who’s doing the regular release-of-information paperwork , along with administering screening tools for opiate risk, PTSD , and anxiety. We also administer the PHQ for a behavioral health picture. At the first visit, the primary care provider compiles an initial history and physical, reviews outside records and the prescription drug monitoring database, and obtains a urine drug screen. We do an initial visit with our occupational therapist to gauge pain and functioning levels, while asking about meaningful activity in their lives and goals. If the patient screens positive on any of these tools they undergo a behavioral health assessment. All of this information goes to our controlled substances review committee. The committee looks at the data for every patient who may start on chronic opioid therapy to assign them to a tier in that pyramid—or determine if they’re even a candidate for chronic opioid therapy at all. Most importantly, the committee makes recommendations for an overall treatment program designed to increase function and mitigate risk. Those recommendations go back to the primary care provider who sees that patient four weeks after the initial visit and discusses the care plan with them. We’ve been asked about agreements with new patients around opioid prescribing. We do have an agreement that patients sign at intake, before they even see their primary care provider. It describes our chronic pain program, and explains that we reserve about four weeks after an initial visit to prescribe opioids. We clarify that patient may not get opioids, but that their pain will be addressed in a comprehensive way. We defined ceiling limits on opioid dose a few years ago, so we make clear what our ceiling limit is. If a patient is on a higher dose, we’ll meet them at our ceiling limit, not above it. Neither providers nor patients have to ‘go it alone’ Our providers have expressed high satisfaction with this approach. They have enjoyed “not having to go at it alone,” “feeling supported,” and “appreciate the population health approach.” We’ve also found that our patients have become highly reliant on their pain management groups, so much so that it’s hard to “graduate” them. It’s far from perfect, believe me. But we haven’t let perfect be the enemy of pretty good. See more of Dr. Solotaroff and Old Town Clinic’s good work in the Improving Primary Care Team Guide. A question for our readers: What challenges do you face related to chronic opioid therapy in your practice? Please let us know by logging in and leaving a comment.