Clinicians scrutinize pain treatments to curb opioid use

February 15, 2017


Leaders at four Catholic health care systems — Avera Health, Providence St. Joseph Health, Ascension and Hospital Sisters Health System — say they've stepped up education for clinicians and patients related to pain management and overhauled their procedures related to opioid prescribing even as they are increasingly supporting other forms of pain treatment.

Nora Stern, right, program manager for Providence's Persistent Pain Toolkit, teaches clinicians at a health plan nonprofit called Care-Oregon about changing the language used to discuss pain with patients.

Opioids can give immediate relief from debilitating pain, and some patients who don't respond to other pain treatments find relief with prescription opioids. But the drugs are highly addictive, and addiction to prescription and street opioids is now epidemic in the United States. Drug overdose was the leading cause of accidental death in the United States in 2015, according to the Centers for Disease Control and Prevention. That year more than 52,000 people in the United States died of a drug overdose, and more than 60 percent of those deaths involved an opioid, according to the CDC in a December 2016 report.


Clinicians must weigh the risk of prescription opioids against the need to provide meaningful pain relief to suffering patients. Health care organizations are scrutinizing the prescribing of opioids in their systems and educating clinicians about offering patients alternative pain management treatment when it's appropriate.

"Our charge is to relieve pain and suffering for people. As an organization, we also help provide guidance for our providers to help them make the best choices for their patients that need pain control," said Dr. Tad Jacobs, chief medical officer for Avera Medical Group, which employs 900 physicians, physician assistants and nurse practitioners in South Dakota, North Dakota, Minnesota, Iowa and Nebraska.

Pain management contracts
Jacobs said Avera Medical Group brought together 60 administrators and clinicians from the group's primary care, emergency care and behavioral health service lines to develop guidance related to treatment using opioids. Their work began in late 2015, and continues. One key work product has been a new standardized controlled substance prescribing agreement to be signed by patient and physician.

Professional societies and regulatory organizations have encouraged or mandated such written contracts for at least a decade; some of the documents are getting an overhaul, as many health care providers believe well-written agreements are important tools in chronic pain management, according to a Cleveland Clinic Journal of Medicine article from November 2016, "Breaking the pain contract: A better controlled-substance agreement for patients on chronic opioid therapy."

Health care systems or medical groups working on such agreements have been revising the language so the same contract can be used in multiple care settings, updating the documents to reflect the latest medical guidance related to opioid prescription and use, and clarifying language to make the contracts easy to understand.

Avera Medical Group updated and standardized its agreement to be used when a patient in chronic pain for 90 days or more is prescribed a narcotic painkiller. Patients briefly taking opioids for acute pain and cancer patients taking opioids or other controlled substances to manage pain are not required to sign an agreement.

The agreement states the patient will take the medication as directed and submit to random drug tests, Jacobs said. If the results reveal a patient doesn't have the medication in his system, a provider would become concerned that the patient may be selling the drug illegally. By signing the agreement, the patient commits to keeping the medication out of the reach of children and agrees not to sell or share the drug.
(A copy of Avera Health’s June 2016 controlled substances agreement can be found below.)

Hospital Sisters Health System administrators and clinician leaders also worked together to simplify their standard pain management contract, whittling it down from three pages to one.


Dr. Andrew Bland is chief quality officer for HSHS. In his prior role with the system, he worked on opioid prescribing changes for HSHS Medical Group, which includes 350 primary care physicians and specialists in Illinois. He said clinicians are hungry for the best and latest information about opioid prescriptions and pain management.

HSHS Medical Group offers one-hour continuing education classes for health care providers. The classes are led by an addiction specialist. Bland said attendees regularly pepper the presenter with questions, and the classes routinely stretch to two to three hours. Doctors want to know how to effectively treat chronic pain and how to detect if a patient has an addiction to painkillers, he said.

Persistent pain tool kit
To help its clinicians and patients better understand the risks and options in pain management choices, Providence in Oregon, which is part of Renton, Wash.-based Providence St. Joseph Health, has packaged a variety of new resources in a "Persistent Pain Toolkit" it introduced in November. The tool kit is made up of resources for clinicians and patients including live training sessions, videos and written resources to educate both groups about chronic pain and pain management. Providence is making some components of the tool kit available to other health care organizations through negotiated contracts.

Physical therapist Nora Stern is the program manager for Providence's Persistent Pain Toolkit, which includes resources to help teach new ways of understanding pain. Stern said the brain puts together information it receives from tissue and several systems in the body, determining how threatening that information is, and whether to initiate a pain response.

Pain initially serves a protective purpose, stopping a person from doing further damage to an injured part of the body. Treatments like painkillers can relieve pain in the short term. However, a person with persistent pain may have a system that has gotten too good at protecting them. The person may feel pain that may not be an indication of harm. The person may benefit from taking a more active approach in his or her pain management to retrain the brain and nervous system, Stern wrote in an August blog post on Providence's website.


Clinicians use the Persistent Pain Toolkit's videos, written materials and teaching aids to help people with pain understand it as a multifaceted experience and to set the stage for a change in care plan that is reinforced by primary care, mental health and rehabilitation services, including physical therapy and occupational therapy.

Providers tell Stern they like having pain education materials and relaxation resources to offer patients. "They want to be able to have some things to say 'yes' to," especially in cases where doctors are limiting or eliminating the use of prescription opioids in pain treatment, she explained.

Multimodal tactics
Since the fall of 2014, Ascension nurses, doctors, pharmacists and employees working in emergency medicine, behavioral health, home health care and senior living have met on teams to review the latest medical guidelines related to opioid prescribing and use. They are enhancing Ascension's pain assessment and pain management protocols for inpatient care, said Judy Henderson, who leads the system pain management team for Ascension.

Dr. Roy Guharoy is vice president of clinical integration and chief pharmacy officer for The Resource Group, a business services subsidiary of Ascension. Guharoy is another leader for Ascension's pain management initiative. He said one area of focus is the development of multimodal approaches to pain treatment that combine medications with nondrug therapies. A multimodal approach could be as simple as a medication used in tandem with heat or ice for pain relief. A patient might be referred to a behavioral health specialist to learn stress management techniques, because stress can exacerbate pain.

"It's treating the patient as a whole person," Guharoy said of Ascension's approach to pain management.


Dr. Gregory Teas, AMITA Health behavioral medicine service line chief of psychiatry, co-chaired AMITA Health's pain steering committee and has worked on one of Ascension's pain committees since the fall of 2015. AMITA Health is an integrated health system operated by Alexian Brothers Health System, which is part of Ascension, and Adventist Midwest Health, part of Adventist Health System.

AMITA Health is planning to install a link with its office-based electronic medical record software so that, before prescribing an opioid, primary care physicians can easily check state-run prescription registries of controlled substances to determine if their patient already has a prescription for a narcotic. The medical directors of AMITA's group practices have highly encouraged primary care doctors to conduct urine drug screenings on patients before prescribing opioids and to repeat the test at set intervals. AMITA has directed its primary care physicians to prescribe no more than three to seven days of an opioid to new patients to treat acute pain, he said.

Avera Health’s June 2016 controlled substances agreement.

Copyright © 2017 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3490.