Current opiate prescription treatment has led to increased deaths, patients with marginal improvement in pain with minimal improvement in quality of life and high system utilization. The integrated high-risk patient pain management clinics have been established to increase quality of pain care, stabilize high-risk patients and reduce impact of on primary care physicians and clinic utilization. These clinics are one aspect of a comprehensive plan to increase high quality pain care and reduce opiate deaths. Mental Health – In this current period of data collection rates of depression in all groups were reduced number of patients with mild MDD < 10%, number of patients with moderate < 7%, number of patients with severe depression < 7% and # of patients with all levels of MDD by 23%. The change in sample depression was significant with p =.01. 37% of patients had a score that indicates a likely full diagnosis of PTSD.

1. Current, opiate prescription
treatment has led to increased
deaths, patients with marginal
improvement in pain with
minimal improvement in
quality of life and high system
utilization.
The integrated high-risk
patient pain management
clinics have been established
to increase quality of pain
care, stabilize high-risk
patients and reduce impact of
on primary care physicians
and clinic utilization. These
clinics are one aspect of a
comprehensive plan to
increase high quality pain
care and reduce opiate
deaths.
Integrated High-Risk Pain Management Clinic: Addressing comorbid pain
and depression in high risk chronic opiate use patients
Natasha Choudri, MA, Doctoral Candidate1,2; Morley Hoffman, MA, Doctoral Candidate 1,2; Michael Changaris, PsyD1,2
1The Wright Institute, 2Contra Costa Medical Center
Clinic Utilization: On average each patient had attended
8.44 clinic visits (range 3-17), there was a mean 5.63
health psychology appointments with a (range 1-31
appointments *note 31 appointments included other mental health
services not pain focused) and 3.37 physical therapy
appointments (range of 0 to 15).
Key Pain Quality Outcomes – Current risk of opiate
misuse as measured by COMM was found to be reduced
below clinical significance (>9) at first and second
measure and these findings were significant with
p = .000. Other quality metrics include 100% of patients
received u-tox screening, 100% of patients had a cures
report completed in appropriate timing.
Clinic Measures of Outcomes
COMM Current Opiate Misuse Measure
PHQ-9 Depression Measure
GAD-7 Anxiety Measure
PC-PTSD Primary Care PTSD Screener
FAQ-5 Physical Functioning Questionnaire
PCS Pain Catastrophizing Scale
Mental Health – In this current period of data collection rates of
depression in all groups were reduced number of patients with mild
MDD < 10%, number of patients with moderate < 7%, number of
patients with severe depression < 7% and # of patients with all levels
of MDD by 23%. The change in sample depression was significant
with p =.01. 37% of patients had a score that indicates a likely full
diagnosis of PTSD.
Morphine Equivalent Dose and Opiate Safety – Morphine equivalent dose
(MED) was reduced by 57% indicating a safer dose range. The pain scale
Pain, Enjoyment and General Activity (PEG) was largely stable across the
group between initial (M = 23) and post testing (M = 22.07) despite
significant changes in opiate prescription levels. Narcan nasal opiate rescue
was prescribed to 40% of this cohort.
MAT – Buprenorphine 40% of patients were taking at chart review, (* Note
some patients received methadone and buprenorphine for pain treatment), 3% of this cohort
was receiving methadone for addiction treatment in offsite center.
Integrated multidisciplinary high risk pain management clinics as one
part of a system of care have had a meaningful impact on increased
safety, reduced opiate dose and improved symptoms of depression.
Along with significant opiate dose reductions patients report high
levels of satisfaction with all aspects of the treatment team.
Clinic Treatment Model
Opiate Epidemic
Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary
care for patients with chronic illness: the chronic care model, Part
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Krause, K. M., Pollak, K. I., Gradison, M., & Michener, J. L. (2009). Family
physicians as team leaders:“time” to share the care.
Lambeek, L. C., van Mechelen, W., Knol, D. L., Loisel, P., & Anema, J. R.
(2010). Randomised controlled trial of integrated care to reduce disability
from chronic low back pain in working and private life. Bmj, 340, c1035.
Sherman, K. J., Cherkin, D. C., Erro, J., Miglioretti, D. L., & Deyo, R. A.
(2005). Comparing yoga, exercise, and a self-care book for chronic low back
pain: a randomized, controlled trial. Annals of Internal Medicine, 143(12),
849-856.
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CONCLUSIONS
Mental Health and Opiate SafetyClinic Utilization and Pain Tx Quality
REFERENCES
Chart 2. Current Opiate Misuse Risk
> 9 is Low Risk of Misuse,
Sig. t-test P = .000
Chart 3. Morphine Equivalent Dose >60%
Clinical Impact sig t-test P = .02
Chart 1. Patient satisfaction with treatment provided (40 data points)
ABSTRACT
Upon arrival in the clinic the patient meets
with the health psychologist for assessment
and development of 5 part care plan.
Patients with behavioral risks, high-dose
opiates or challenges with pain
management are referred to the clinic.
Patient is assessed by physical therapy,
given pain education, referred for services
and offered access to TENS device.
Medical provider meets with the patient and
develops a medication, functional goals and
biopsychosocial plan.
4.83 4.75
4.90 4.80 4.89
4.70 4.65
4.90 4.95 4.92
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
Wait time? Your needs
met?
Physician
Care?
Physical
Therapist
Care?
Health
Psychology
Care?
Information
about
condition?
Pain
management
program?
How did staff
treat you?
Nursing staff? Your
appointment
today?
Patient Satisfaction
99.80
42.22
MORPHINE
EQUIVILANT DOSE 1
MORPHINE
EQUIVILANT DOSE 2
Morphine Equivalent
Dose
10.96
6.50
0.00
2.00
4.00
6.00
8.00
10.00
12.00
1 2
Current Opiate Misuse
Risk: COMM Score“Managing pain requires more then medications it requires an
integrative approach. Medications are one tool in the tool kit.
Learning skills, understanding pain and building a plan can help
you take your power and life back from pain.”
Level 2 Collaborative Care
Collaborative care approach
that reduces provider burden
and increases care
System of Care
Patients are seen in the clinic until stable and then they return to
primary care provider for medication management.
Level 3 Multidisciplinary
High Risk Team
Integrated pain management
using share the care model for
highest risk patients
Level I - Coordinated
Pain Care
Increased support and
effective care for pain patients
Acute Pain Track
Early treatment planning
reduces the number of patients
on risky doses
1
2
3
4
MDD All PHQ-9 > 10 MDD Mild (10-15) MDD Moderate (15-20)
MDD Severe
(20+)
PHQ-9 Pre 60% 40% 20% 7%
PHQ-9 Post 37% 30% 13% 0%
60%
40%
20%
7%
37%
30%
13% 0%
PercentofPatientswithMDD
Change in MDD Pre/Post PHQ-9