4. Tweak your EHR
To support providers in following the new guidelines, Allina revised its electronic health record system, developing a structured order set and progress note to aid in adherence to the chronic pain management guideline. “In this order set, providers have all the tools needed to guide them in the proper protocol for prescribing opioids, including access to the state’s Prescription Monitoring Program, a link to Allina’s guideline, risk assessment tools, a calculator for confirming appropriate opiate dosage, and a link to the Minnesota Board of Medical Practice pain management guidelines,” Kveton says.
5. Discuss alternatives with patients
Providers and care team members need to have conversations with their patients, setting clear expectations and encouraging shared decision making on the best approach for managing pain, including possible alternative treatments, such as acupuncture, massage, and non-opioid medication, Kveton says. As a result Allina developed education materials to enable providers and care team members to have effective conversations.
As a result of the above Allina initiatives, 980,527 fewer opioid pills were prescribed in the outpatient setting in 2016, a 12% reduction, says Kevton.
6. Pinpoint the pain source
Ira B. Fox, MD, cofounder, Tamarac, Florida-based Anesthesia Pain Care Consultants, says the best way to treat chronic pain is to properly identify the source. At his facility, providers obtain a patient’s medical history, review radiography, conduct a physical exam, and perform a medication reconciliation. Patients also complete a survey about the origin and intensity of their pain. Physical therapy and conservative treatments are initially recommended; new radiography is prescribed as needed.
In addition, Fox uses interventional pain management techniques such as administering injections under fluoroscopy to determine the actual source of pain based on a patient’s response. “This enables us to treat the pain at its origin, making it less necessary to administer pain medications over time,” he says.
For patients with the most serious chronic pain conditions such as late stage metastasized cancers or spinal cord injuries, Anesthesia Pain Care Consultants has had great success with implanting intrathecal pain pumps, which deliver pain medications directly into the spinal canal—often reducing dosages by up to 99%.
7. Provide chiropractic care
Myrtle Hilliard Davis Comprehensive Health Centers in St. Louis, Missouri, which is affiliated with Logan University, in Chesterfield, Missouri, introduced chiropractic care in an effort to curb opioid prescription rates. “The medical doctors at this facility can refer patients in-house for a trial of conservative care before resorting to prescribing opioids,” says chiropractor Ross Mattox, DC. “The chiropractor can identify complicating factors during treatment, such as behavioral health issues or diabetic foot problems, and refer patients to other providers who specialize in those conditions.”
Some patients get better with the trial of conservative care and never need an opioid prescription. Others report that after starting chiropractic care, they no longer feel the need to take the opioids they were previously prescribed. “Because we are working in an integrated setting, it is easy to communicate between doctors and share notes on a patient’s progress or lack thereof,” Mattox says.
8. Use available tools
In an effort to battle the epidemic, the Accreditation Association for Ambulatory Health Care developed and released an opioid stewardship toolkit derived from CDC guidelines.
Naomi Kuznets, PhD, vice president and senior director of quality improvement for the institute, says using standardized pain scales to accurately assess pain pre- and post- prescribing can ensure that if opioids are prescribed, they decrease pain satisfactorily.
But she says most important tool may be communication with the patient. “This includes not only helping patients understand the benefits and dangers of opioid use, but also helping patients set realistic expectations with regard to pain control and teaching them about non-opioid medications or therapies,” Kuznets says.
Sullivan says providers should be re-educated that the goal of “zero pain” for patients is not a realistic one. Pain can be managed adequately without overprescribing, he explains. In addition, tools such as the SOAPP-R and CAGE-AID opioid risk scales can identify patients who may be at risk for opioid addiction so that they can be monitored closely.