Indiana University Health, Indianapolis, IN
Interprofessional ambulatory care pain treatment program
The Indiana University Health Ambulatory Care Pain Treatment protocol is a pharmacy initiative developed in an effort to assist primary care prescribers with best practice standards for chronic pain. These standards aim to improve pain management outcomes while also ensuring appropriate prescribing in accordance with state regulations. It is a team-based approach to patient care for those on chronic pain therapies with the following goals: managing patients on the lowest effective dose of opioids when alternative treatments have been deemed inappropriate or ineffective, providing patient education about the risks of opioids, optimizing non-opioid pain management, safeguarding against diversion, and complying with legal requirements for prescribing of opioid medications.
The program was developed by the pharmacy department and reviewed by a health-system-wide Chronic Opioid Therapy Committee and the IU Health-System P&T Committee. The program is reviewed regularly for updates to the clinical guidelines and recommendations pertaining to opioid prescribing according to the dynamic laws surrounding opioid prescribing. The pharmacy team maintains a clinical presence on the system-wide committees in order to bridge pharmacy services with system policy and legal changes in an effort to maintain alignment of program goals.
Key Elements of Success
Patients are identified as candidates for pharmacy assisted pain management by either the provider at the time of visit or nurses at the time of a request for a refill of narcotic pain medications. A physician sees these patients and outlines goals of therapy with the patient and a patient-prescriber contract is signed. The patients are then referred to the clinical pharmacist to maintain the current opioid regimen, taper the current opioid regimen to a physician-recommended goal, or manage non-opioid medication(s) and adjuvant therapies. At scheduled visits, the patients’ medication regimens are tailored based upon the protocol. Patients receive education about the medications prescribed, and are assessed for physical functionality, depression, objective pain scores, and compliance with the pain contract. Patients are also evaluated for aberrant behaviors through various validated assessment tools and the state prescription drug monitoring program at regular intervals in accordance with the hospital and legal policies. All visit notes, assessments, and data are then recorded in the EMR.
Impact on Patient Outcomes
While the program has been very well received and there are anecdotal successes, the quantifiable outcomes have not yet been assessed. Given the nature of the program, this data will be collected over time and the program is still in its youth. We are currently enrolling patients, conducting education, and making changes to regimens, but the ongoing assessment of patient functionality, tapering down of opioids and optimizing of non-opioid pain management is occurring over periods of months.
Role of the Pharmacy and Pharmacists
Pharmacists provide pain medication prescriptions, as written and approved by the prescriber, if patients meet specified criteria and maintain the requirements of the patient-provider opioid pain contract. Pharmacists monitor patient labs, functional assessment tools, objective pain scoring, urine drug screenings (UDS), and PDMP report for pain contract compliance. Additionally, pharmacists ensure that all assessments are completed at intervals consistent with state law requirements and system policies for prescribing.
These pharmacy efforts were developed to assist with the goals of reduction in opioid doses for chronic users; overall decrease in the number of chronic opioid users; reduced workload for providers and associated improved provider satisfaction due to offloading some assessment review and data collection; compliance with local opioid prescribing laws; and increased patient education around risks of opioids and benefits of alternative treatment modalities.CDTMs were implemented. There was no additional training outside of the CDTM requirements for ambulatory care specialists.
Physician support, validated assessment tools to track patient progress, and patient education on goals and anticipated outcomes were most impactful to ensure success of our program. Obtaining patient acceptance of new initiatives and prescribing laws, influencing change in a provider’s usual workflow, and changing the culture of opioid prescribing proved to be the largest challenge. The importance of additional education and outreach to clinic staff to instruct them on the availability of the pharmacy service and potential benefits of the program was also found to be necessary. Additionally, the inclusion of System Chronic Opioid Therapy Committee chairs that included primary care physicians, and the quality, legal, and compliance departments of our health-system were important to the success of the implementation and success of the program.
Budget & Resource Allocation
The program is budgeted from the standpoint that there are ambulatory care pharmacists in place at multiple clinic sites and they have the capacity to implement this program in addition to current workload. Staffing FTEs and providing CE were key resources that were essential to establishing the program.
Future goals include expansion of the program to a state-wide system, expansion of pharmacy services among additional offices within the region, quantifiable methods to follow successes and track outcomes, continued education for pharmacists and providers, and additional integration of EMR with outcomes tracking.