Addressing the Opioid Crisis: A Comprehensive Approach to Pain Management
Firefighters/EMT Begin to
Carry Narcan
Mike Brown
Doug Call
Clinical Perspective
“
Handling 5,000 patients,
one patient at a time”
Daniel C. Roth, DO, MBA, MS
Summit Pain Management
Fort Wayne, Indiana
The Problem
Over 5, 000 patients were being seen by
clinicians/providers (MD/NP/PA/RN) who
had very little to no advanced training or
collaboration in pain medicine
Patients were not being appropriately
assessed for risk, comorbid psychological
diseases, and appropriate interventional
care
Generic/Sham interventional procedures
were being performed
The Problem (continued)
When the patient got no real benefit, the provider
seeing the patient in follow-up would act to “try to
alleviate” the patients pain. This resulted in a
very clear and obvious trend of dose-escalation
of opioid medications and other concomitant
medications.
Patient would unknowingly become more and
more “dependent and tolerant” of their opioid
medications (not necessarily addicted)
The Problem (continued)
Many patients had no imaging (MRI/CT, etc)
and no real plan of care for short, moderate
and long term, safe and effective pain
management.
Thus, when the practice was closed
abruptly, thousands of opioid
dependent/tolerant and some addicted
patients were turned loose to “fend for
themselves” (PCP, friends, the street)
The Solution
The team of the Allen County Health
Department, community ERs, some PCPs, and
(surprisingly) few Pain Management
Practices……. All stepped up to try and care for
these patients
Full assessment of these patients included their
complete history and physical, current
medications, proper pain generator diagnosis
and closely working with a mental health
professional.
The Solution
Once a full assessment had been completed, the
patient was then started on an evidence-based
treatment plan
Approximately 1/3 of all patients seen were
weaned or immediately discontinued from opiate
medication
Approximately 1/3 had drastic changes to dosages
Approximately 1/3 stayed at their current dosage
while a functional treatment plan was established.
Outcomes
Most of the patients referred to us by PCP,
ER, Allen County Department of Health,
self-referral, stayed in our practice.
Many of them are on significantly lower or
no opioid medications
Some of the patients who had severe
aberrant behaviors or addictions got into
appropriate mental health treatment, albeit
with significant issue (insurance, etc)
Outcomes
Many patients were treated with the
appropriate interventional procedures
including;
Transforaminal Epidural Steroid Injections
Facet Joint Rhizotomies
Kyphoplasty
Spinal Cord Stimulation
TFESI
Facet Joint Rhizotomy
Kyphoplasty
Spinal Cord Stimulator
Key Points
Crisis required collaboration
Careful assessment of these patients
revealed many therapeutic
opportunities that had not previously
been utilized.
Mental Health Response
– Facilitating Providers
Referrals for Addiction
Kristian Johnson
Connie Kerrigan
Marcia Haaff
Clinical Response
•
Care Navigators
•
800 Number
•
Partial Hospitalization for Addiction
•
Faith Based Intensive Outpatient Program
•
Pain Management Program (Cleveland
Clinic Model)
•
Partial Hospitalization for Pain
Management (in development)
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Improving resource and referral networks;
Sustaining care until positive therapeutic
outcomes can be realized;
Balancing personal cost and investment
with realities
Expanded and accessible services beyond
case management and intake assessments
in non-urban counties’
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Address needs of families with mental
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Seeding a systemic approach;
Supporting schools to become reliable
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resources;
Addressing stigmatization
Reducing the Risk of HIV
and Hepatitis C
Needle Exchange Program
Deborah A. McMahan, MD
Why Needle Exchange Program
Well if things weren’t bad enough …
In Scott County (pop 4,500) over 180 cases
of HIV (most co-infected with Hepatitis C)
identified
Largest IVDU related HIV outbreak in
decades – IN THE COUNTRY
Now what?
Needle Exchange Program
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Principles of Harm Reduction
"Harm reduction” aims to keep people
safe and minimize death, disease, and
injury from high risk behavior.
Harm reduction involves a range of
support services and strategies to
enhance the knowledge, skills, resources,
and supports for individuals, families and
communities to be safer and healthier.
The Process to Open in Indiana
Senate Bill 461 outlines process
Outbreak established
County government approves
State Health Commissioner approves
Engage local law enforcement and public
officials and community to ensure all on
same page with respect to evidence.
Community Concerns
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Community Concerns
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No. A study presented in the Journal
of Public Health found a lack of
association of overall and type-
specific arrest data with NEP
implementation and argues against
the role of needle exchange programs
in increasing crime rates.
Community Concerns
D
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Studies since 1997 have
demonstrated that individuals in areas
with needle exchange programs have
an increased likelihood of entering
drug treatment programs. -
Community Concerns
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According to the Centers for Disease
Control, the one-time use of sterile
syringes remains the most effective way to
limit HIV transmission associated with
injection drug use
Supported by AMA, Surgeon General,
HHS, WHO, CDC, etc.)
Components of NEP
Provision of NEP Kits
Collection of used needles
Screening for HIV, Hepatitis B and C
Education about safe practices and HIV and
Hepatitis
Provision of Immunizations for those with
Hep C or B
Referrals for other services including
Mental health and addiction
HIP
Other services
Kits
30 syringes.
Filter needles- 1 cc 28 gauge ½ inch
(http://catalog.bd.com/nexus-
ecat/getProductDetail?productId=329410)
Alcohol swab-30
Tourniquets-3
Sterile water-2ml
Cookers-2
Condoms-5
Band-Aids-10
Anti Biotic Ointment-5
Kits
Include sharps box for used needle
return
Entire kit costs about $5
Remember to educate that it is not
just the needle that spreads HIV and
Hep C
Key Points
Engage stakeholders and community to
provide current evidence about NEPs
Provide screening and mental health and
addiction services
Include both needle/syringe and other
necessary materials to reduce risk of Hep
C
Questions for Any of Us?
Firefighters and EMTs now carry Narcan to combat opioid overdose, while a clinical perspective reveals challenges in pain management for over 5,000 patients. Issues include inadequate training in pain medicine, leading to unnecessary opioid prescriptions and lack of proper care plans. A solution involves collaboration among healthcare providers, thorough patient assessments, evidence-based treatment plans, and weaning off opioids where possible.
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Presentation Transcript
Firefighters/EMT Begin to Carry Narcan Mike Brown Doug Call
Clinical Perspective Handling 5,000 patients, one patient at a time Daniel C. Roth, DO, MBA, MS Summit Pain Management Fort Wayne, Indiana
The Problem Over 5, 000 patients were being seen by clinicians/providers (MD/NP/PA/RN) who had very little to no advanced training or collaboration in pain medicine Patients were not being appropriately assessed for risk, comorbid psychological diseases, and appropriate interventional care Generic/Sham interventional procedures were being performed
The Problem (continued) When the patient got no real benefit, the provider seeing the patient in follow-up would act to try to alleviate the patients pain. This resulted in a very clear and obvious trend of dose-escalation of opioid medications and other concomitant medications. Patient would unknowingly become more and more dependent and tolerant of their opioid medications (not necessarily addicted)
The Problem (continued) Many patients had no imaging (MRI/CT, etc) and no real plan of care for short, moderate and long term, safe and effective pain management. Thus, when the practice was closed abruptly, thousands of opioid dependent/tolerant and some addicted patients were turned loose to fend for themselves (PCP, friends, the street)
The Solution The team of the Allen County Health Department, community ERs, some PCPs, and (surprisingly) few Pain Management Practices . All stepped up to try and care for these patients Full assessment of these patients included their complete history and physical, current medications, proper pain generator diagnosis and closely working with a mental health professional.
The Solution Once a full assessment had been completed, the patient was then started on an evidence-based treatment plan Approximately 1/3 of all patients seen were weaned or immediately discontinued from opiate medication Approximately 1/3 had drastic changes to dosages Approximately 1/3 stayed at their current dosage while a functional treatment plan was established.
Outcomes Most of the patients referred to us by PCP, ER, Allen County Department of Health, self-referral, stayed in our practice. Many of them are on significantly lower or no opioid medications Some of the patients who had severe aberrant behaviors or addictions got into appropriate mental health treatment, albeit with significant issue (insurance, etc)
Outcomes Many patients were treated with the appropriate interventional procedures including; Transforaminal Epidural Steroid Injections Facet Joint Rhizotomies Kyphoplasty Spinal Cord Stimulation
TFESI http://www.aptcmd.com/wp-content/uploads/TF%20injection.jpg
Key Points Crisis required collaboration Careful assessment of these patients revealed many therapeutic opportunities that had not previously been utilized.
Mental Health Response Facilitating Providers Referrals for Addiction Kristian Johnson Connie Kerrigan Marcia Haaff
Clinical Response Care Navigators 800 Number Partial Hospitalization for Addiction Faith Based Intensive Outpatient Program Pain Management Program (Cleveland Clinic Model) Partial Hospitalization for Pain Management (in development)
Mental and Behavioral Health Needs Assessment Recommendations Address issues of access, including: Improving resource and referral networks; Sustaining care until positive therapeutic outcomes can be realized; Balancing personal cost and investment with realities Expanded and accessible services beyond case management and intake assessments in non-urban counties
Mental and Behavioral Health Needs Assessment Recommendations Address issues of access, including: Address needs of families with mental illness amongst family members; Seeding a systemic approach; Supporting schools to become reliable referral resources; Addressing stigmatization
Reducing the Risk of HIV and Hepatitis C Needle Exchange Program Deborah A. McMahan, MD
Why Needle Exchange Program Well if things weren t bad enough In Scott County (pop 4,500) over 180 cases of HIV (most co-infected with Hepatitis C) identified Largest IVDU related HIV outbreak in decades IN THE COUNTRY Now what?
Needle Exchange Program A needle exchange program (NEP) is a harm reduction strategy that allows injecting drug users (IDUs) to obtain hypodermic needles and associated paraphernalia at little or no cost.
Principles of Harm Reduction "Harm reduction aims to keep people safe and minimize death, disease, and injury from high risk behavior. Harm reduction involves a range of support services and strategies to enhance the knowledge, skills, resources, and supports for individuals, families and communities to be safer and healthier.
The Process to Open in Indiana Senate Bill 461 outlines process Outbreak established County government approves State Health Commissioner approves Engage local law enforcement and public officials and community to ensure all on same page with respect to evidence.
Community Concerns Do needle exchange programs encourage IVDU in a community? No. According to Surgeon General Dr. David Satcher: "After reviewing all of the research to date, the senior scientists of the Department and I have unanimously agreed that there is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs."
Community Concerns Do needle exchange programs increase crime? No. A study presented in the Journal of Public Health found a lack of association of overall and type- specific arrest data with NEP implementation and argues against the role of needle exchange programs in increasing crime rates.
Community Concerns Do needle exchange programs encourage addicts to seek care? Studies since 1997 have demonstrated that individuals in areas with needle exchange programs have an increased likelihood of entering drug treatment programs. -
Community Concerns Are needle exchange programs effective? According to the Centers for Disease Control, the one-time use of sterile syringes remains the most effective way to limit HIV transmission associated with injection drug use Supported by AMA, Surgeon General, HHS, WHO, CDC, etc.)
Components of NEP Provision of NEP Kits Collection of used needles Screening for HIV, Hepatitis B and C Education about safe practices and HIV and Hepatitis Provision of Immunizations for those with Hep C or B Referrals for other services including Mental health and addiction HIP Other services
Kits 30 syringes. Filter needles- 1 cc 28 gauge inch (http://catalog.bd.com/nexus- ecat/getProductDetail?productId=329410) Alcohol swab-30 Tourniquets-3 Sterile water-2ml Cookers-2 Condoms-5 Band-Aids-10 Anti Biotic Ointment-5
Kits Include sharps box for used needle return Entire kit costs about $5 Remember to educate that it is not just the needle that spreads HIV and Hep C
Key Points Engage stakeholders and community to provide current evidence about NEPs Provide screening and mental health and addiction services Include both needle/syringe and other necessary materials to reduce risk of Hep C
