Learn how Bozeman Health established and implemented a standardized approach of care for an influx of new patients, many of whom had used opioid medications and other controlled substances for long periods of time.
One of the long-time practitioners in the area retired, leaving about 1000 patients to establish care with new practitioners. Many of these patients were on chronic opioids and other controlled substances, some with unconventional dosing. Once these patients started establishing care with Bozeman Health, it became quickly clear that an organized strategy was needed to transition them to alternate medication regimens for their pain and anxiety.
Dr Philip Bain took the lead on developing this organized approach. He had been involved in opioid- related projects in the past and was familiar with opioid practice guidelines from the CDC and other organizations. He helped to form an Opioid Task Force at Bozeman Health, and the group developed specific practice guidelines as well as an opioid toolkit for the organization. The task force implemented a broad communication strategy for primary care clinicians and offered to make themselves personally available to discuss challenging cases.
The approach involved the development of several tools, including:
An Opioid Toolkit that included a wide variety of FAQs about chronic pain management
Practice Guidelines regarding the management of patients with chronic pain, based on documents from the CDC and groups such as the Oregon Pain Commission
A dashboard that tracked metrics such as:
Number of patients on a practitioner's panel who were taking opioids
Number of patients on opioids who had a signed an updated controlled substance agreement within the past 3 years
Number of patients on opioids who had a urine drug screen within the past 12 months
Number who were co-prescribed opioids and benzodiazepines
Number of patients on > 90 MME of opioids/day
This dashboard helped to identify care gaps and set action plans.
A mnemonic that helped to summarize the approach:
Pain paradigm shift: recognize that chronic pain is very different from acute pain
PEG functional scale: use to measure progress (as opposed to pain scales)
Physical therapy: enlist to help with improving physical function
Psychological/Behavioral Health: enlist to provide cognitive behavioral therapy
Pharmacists: enlist to help with tapering strategies
There was apprehension on the part of both the care team and physicians about this initiative, as patients on chronic opioids were often thought of as difficult patients. It was true that these patients could be labor intensive, especially at the beginning when transitioning to a different approach for treating pain. Already overwhelmed primary care clinicians were anxious about accepting more than a few of these new patients. Often these patients needed be seen every 1-2 weeks, which presented access issues. Furthermore, many care team members lacked sufficient training on management of chronic pain.
“I haven't felt this good in almost a decade” - Anonymous patient after phenobarbital clonazepam, Adderall slowly tapered off and opioids lowered to a total daily dose of 80% long-acting/20% short-acting after coming to the practice on 8 short-acting oxycodone tabs per day“It feels like I have my dad back again. Thank you” - Daughter of the anonymous patient“I don't need to see him back as he is doing so well. He looks great!” - Pharmacist who assisted with deprescribing
“I haven't felt this good in almost a decade” - Anonymous patient after phenobarbital clonazepam, Adderall slowly tapered off and opioids lowered to a total daily dose of 80% long-acting/20% short-acting after coming to the practice on 8 short-acting oxycodone tabs per day
“It feels like I have my dad back again. Thank you” - Daughter of the anonymous patient
“I don't need to see him back as he is doing so well. He looks great!” - Pharmacist who assisted with deprescribing
Bozeman Health is still early on in this journey. However, practitioners have seen many (but certainly not all) patients buy into the paradigm shift and as a result become much more functional and less sedated on lower doses of opioids and benzodiazepines. PEG scale scores have improved, coinciding with decreases in medication doses. Importantly, as the care team has become more comfortable with this approach, clinicians have expressed less apprehension about managing these patients, and awareness about chronic pain best practices has increased. Having peers whom providers and the care team can consult for difficult situations has been a key factor for improvements as well.
Don't run from these patients; they need your help. While the opioid epidemic is front and center in the news, many of these patients feel abandoned by the medical community. The primary care team is well-equipped to care for these patients if a consistent strategy can be developed.
You cannot do this alone: engage physical therapists, psychologists, social workers, pharmacists, nurses, staff, and patients and their families to help.
Bozeman Health is a multispecialty group that employs 175 practitioners at 3 practice sites in Bozeman, MT.
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