Podcast: Risk and Pain Management

Listen to this podcast with Clifford Moy, MD, the behavioral health medical director at TMF Health Quality Institute, and Lindsay Botsford, MD, the market medical director for Iora Health in Houston, a clinical associate professor of the Department of Clinical Science at the University of Houston College of Medicine, as they discuss risk and pain management.


Hello, and welcome to another episode of the TMF Quality Innovation Network’s podcast series on evidence-based pain management alternatives. I’m Dr. Clifford Moy, the behavioral health medical director at TMF Health Quality Institute, a leading non-profit health care consulting organization based in Austin, Texas. I'm joined by Dr. Lindsay Botsford, who is the market medical director for Iora Health in Houston, a clinical associate professor of the Department of Clinical Science at the University of Houston College of Medicine. Today we are speaking about risk management.

We've spoken about many, many clinical issues and where we resources to get information. But I was curious about how we manage our risk and how we do risk management evaluation . We've talked about the rims before. But where do we go from here? There's been a lot of discussion. And now we're going to have everyone across the country is using a PDMP, prescription drug monitoring program, that's configured in different ways. How are you using that in your practice? How does that fit into your patient workflow?

Yeah. A PMP or prescription monitoring program can be a pretty powerful to help identify drug taking behavior that differs from what you expect or the presence of dangerous drug combinations, whether it's intentional or unintentional. Our older adults often will see multiple providers and sometimes unintentionally get put on medications that interact and can lead to increased risks. So I think it's a tool to help us take better care of our patients. So in Texas, starting March 1st of 2020, it's going to become a requirement that at prescribing one of those dangerous drugs, so opioids, benzodiazepines or the sedative hypnotics, that we check that PMP before we prescribe a medication. So there are ways to make that simpler. You can work with your EMR vendor to see if you can get it integrated so that you can see that data directly from your EMR. But short of that, you can do things like making people in your practice a delegate for your prescription monitoring program so that they can look in on your behalf and part of the care of the patient. So it helps streamline, making it an easier part of that prescribing moment.

Do you pull that information before, during or after a patient encounter?

You know, in an ideal world, when you've done your pre-visit planning and prepared for your patient, you know they're coming in to either discuss pain or to renew a medication, that would be a great thing to delegate staff to do before the patient even comes into the office. But we can always predict when we need to consider using these medications. So doing it at the prescribing moment is the other way we can do it.

Have you heard of any EMRs populating the medication list portion with information from the PDMP, you know, to help with medication reconciliation issues? Yeah. So different EMR vendors are going to have different ways it pulls in. Sometimes, it's a button that you click within your EMR that brings you to the external side. And sometimes, doing that search would bring it to you. And I think it just depends on what your interface looks for. But there are definitely ways to bring that data, that query from a [inaudible] or a pharmacy vendor to that point of prescribing on your medication list, which is helpful.

Has it been a hair-pulling experience in the past?

You know, it adds time. So one to two minutes, at least, in terms of the time it takes to query. I do think there's value in it. There's certain times when we have picked up on patients who are getting prescriptions from multiple prescribers and not always with bad intent.

Sure.Patients who have used mail order pharmacies, for example, and get refills sent from a previous physician, changed practices, but that mail order keeps dispensing. And we will pick up on those fills by looking in the prescription monitoring program and be able to help the patient deprescribe and figure out, you know, what's that lowest common denominator of medications they need to help treat their pain. So there is benefit. It adds time. And sometimes, it does seem like just one more thing, which is why strategies that either pull it at the point of care in your electronic medical record or have your staff really helping out as part of that process are key to not just add as one more thing for the physician to do during an otherwise short visit. You tell patients about this database and you're looking at it, or do they just figure it out somehow? You know, I don't see any reason why we shouldn't be transparent about it. When we're building that relationship with a patient, we really are trying to cause the patient relief from pain without harm. And this is one tool that we use as part of that. I think it's always better to be transparent about using it. This is something we are assuming there's bad intent. We just are using it as a way to make sure we're safely caring for our patients. And I think that's the way we frame it with patients. Since this is a pharmacy-based database or a database of filled prescriptions, we should know if prescriptions come from other disciplines like the dental community. That's right. This is any fill at a pharmacy. So the pharmacist is required to report this. So it's regardless of whether the patient is using insurance to help pay for the medication or whether they're doing cash pay. That same information goes into that database. Recently, in Texas and in other states, they have upgraded the prescription monitoring program with a tool called NarxCare. And so this is an additional analytic tool that's added to the data we already had about prescriptions, who's prescribing and what pharmacy they're using. And it provides information that helps to prevent misuse, diversion and overdose. So when you log into the PMP now, you see a dashboard. And it includes risk scores and visualizations of usage patterns to help physicians be able to make more informed decisions when prescribing.

Same, better or worse than a health information exchange? So I would better in that it's more complete. So the PMP, although it sometimes can lag for a few days, is a pretty complete picture of what that patient is receiving in terms of controlled substances. The Narx Score in particular looks at narcotics, sedatives and stimulants, narcotics being opioids and really the more medical term. It gives an overdose risk score and also points out additional risk indicators for the patient.

So are these scores like my credit score or my SAT score or MCAT score? Well, they do have a range like those scores. So they range anywhere from 000 to 999. That last digit indicates the number of active prescriptions of each drug type. So it's not a completely continuous range from 0 to 999. But really, each of those digits helps give you information about the patient. So you'll also see in that last column other risk indicators. And those are things like getting more than three -- getting prescriptions from more than three pharmacies in a 30-day period, which would indicate patient may be using different pharmacies to avoid detection. Having more than five prescribers of controlled substances. And again, whether that's intentional or not, sometimes we just don't know --

Sure. -- what other people are doing. And then any time that a benzodiazepine or anxiety medication and an opioid overlap, we know risks are much greater when we combine those medications. So this helps point that out for you. Sure. Very high risk of respiratory depression, loss of consciousness and death from combinations of those medications frequently seen in overdoses. So we've asked for information like this in the past. We've said we need to address the prescribing issues and we've asked for this. And now we have it. Should we have been more careful about what we ask for?

Well, I think it's not the information that's bad. It's the burden of how long it takes to get it. So again, using your staff to help get this information for you and not happening to be something the physician does, as well as really finding ways to put it at the point of care on your medication list through integration with your EMR. But it is good information. I know that NarxCare is a relatively new product, source of information that we have out there. What are your thoughts about how transparent we should be with our patients about their score and their risk factors? You know, as physicians, we never want to cause harm. And I think that's the stance we take. We don't talk about guidelines or rules. And I think that's the way we would frame talking about NarxCare or other scores. This is a way to prevent harm by making it transparent as to who is prescribing what. There is a small subset of patients where they are intentionally using multiple prescriptions or trying to get medications from multiple providers. But I do think that's the minority. And a lot of times, this is picking up from years of misinformation about opioids and patients starting on these for very good reasons and for whatever reason, continuing on them for longer periods of time and having other medications added.

Since this is a novel or new piece of information, do you think that prescribers will say, "I'm setting a limit on the Narx Score for patients that I'll have in my practice or that I'll treat."? Do you think there could be a side effect or unintended consequence of this? I do think that's a real risk. The point is to use this as a tool and a way to inform your care, not as a cutoff, kind of when we talked about the guidelines being a way to inform your care of patients, and they shouldn't translate into legal rules or laws. The same thing can be said for this. Strict cutoffs or saying that we won't treat patients over a certain risk really leads to us not treating the patients who need it most. Now there are certain flags that should be raised if you do have a patient with a high score. So for example, we know that if patients are greater -- on greater that 50 morphine equivalents a day, so that's the equivalent of 5, 10 milligram hydrocodone tabs, we know we can decrease harm and decrease side effects by offering a prescription for naloxone along with prescribing an opioid. So naloxone is one of the ways we can reverse the effects of opioids and prevent deaths from opioid overdoses. So that translates to a Narx Score of 450 or higher.

Okay. So if you see a score of 450 or higher, it doesn't mean don't prescribe. But you shouldn't be thinking differently. You should ask yourself, "Do I need to be involving a specialist? Do I need to be seeing this patient more frequently? Do they have other substance use issues I need to be concerned about? Do they have other mental health issues that are untreated that's leading to this high dose of pain medicine? And then how can I reduce harm by prescribing naloxone?" We know that this can cut ER visits in almost half when patients are prescribed naloxone along with their opioid, especially at these high doses. Well, again, since this is a new piece of information, I'm not sure how it's going to be utilized in the future. But one of the things over my career that I've always heard is that if it's not documented, it wasn't done. How would you recommend prescribers document this particular piece of information? Yeah. I think, you know, your summary of what you concluded from looking at it is certainly helpful to be in your note to show that conversation happened with the patient. You know, it gets to what we think about in terms of management of pain in general. There's been a lot of talk around pain contracts. I think controlled substance agreement is a better term, a little bit more friendly than talking about a contract, which sounds very legal. But aside from the agreement, really, it's the conversation that's the important part of that informed consent process. So you can have a controlled substance agreement on the chart and not have had any conversation with the patient. And that's really pretty meaningless in terms of reducing harm or having the intended consequences you want. So whatever you do in terms of documentation, really, it's the process and the conversation that's important as well.

Sure. We've seen that in the psychiatric world with a term that I really dislike, which is the suicide contract. What's mostly important -- what's most important is having done a very rigorous and thorough assessment of the patient, talking with the patient about the results of that evaluation and what their treatment options could be and how far they're willing to go to be in a treatment plan with you, with the psychiatrist. So yes, so I think that's a very good analogy and thinking about how to do this. Are there other scoring systems for pain medications, for opioid medications? You mentioned morphine equivalence, morphine milligram equivalence or MMEs. How widespread is that thinking among prescribers?

No, there's a variety of other ways to score or analyze risks as well as results. So some people will use a Dire score, a D-I-R-E score, that looks about helping to predict compliance with a treatment regimen. That's one that's completed by a physician, has some studies showing it can be helpful. Other people will use the COMM or current opioid misuse measure tool. And that can help with monitoring. I think this gets a little bit down to the practice style of the physician and what they're finding helpful. Whatever tool you use, use something and document it and track it over time, showing that you're putting the thought into comprehensively evaluating that patient's pain.

Sure.Let's just close the loop a little bit on the risk management practices. And it also crosses into the comprehensive or a thorough assessment. One thing we haven't really talked much about is the idea or the practice of a substance use evaluation or screen tool and the use of urine drug screens or other types of drug screening since we know that there are many, many, many drugs of abuse out there. How does that work with your practice and with Medicare patients? Yeah. I think the opioid risk tool and urine drug screens have an important role to play in the management of using opioids. So the opioid risk tool, we talked a little bit about earlier, but it's a self-administered tool that gets at those three main categories that is going to put a patient at higher risk from having problems with opioid use. So those are going to be substance use, psychiatric disorders and then polypharmacy. This is one of those ones where there isn't a cutoff where you don't prescribe. There are risk categories that talk about what risk is conferred, should a patient go and start to use opioids. So it can be a signal that you might want to consider involving a specialist colleague treating a behavioral health condition, or if you do choose to prescribe, that you want to be following this patient more regularly in your office. So it's not a cutoff. It's a continuum. And that's a tool that helps you know what your management plan for a patient should be. So the other one is a point of care urine drug screen, and I do say point of care somewhat intentionally because I think that's the most friendly starting point for monitoring our patients who are taking opioids. So the idea is that you help identify prescribed medications but that you also would pick up on undisclosed drugs. So it's both of those things. But it's confirming use and preventing misuse. If a patient is running out early and a drug doesn't appear in a urine drug screen, that's helpful information. It doesn't mean you stop prescribing, but it does inform your management plan as to what you need to do next.

Sure. May even need to increase the dosage if -- That's right. -- you're not getting the adequate pain relief. It could be. I think that's a common thing. If you have committed that a patient needs to be on an opioid type medication, we do often undertreat pain, and this is due to the normal physiology of our bodies. As someone is on an opioid for a longer period of time, they develop what we know as tolerance, meaning the same dose of medication doesn't have the same effect anymore. That doesn't mean the patient is using it wrong or using it in an inappropriate fashion. It's just the way the body responds. Now we need to make a choice whether it's appropriate to continue. But to get that same effect, that patient will need higher doses.

Sure. And you won't know if you don't ask.

That's right. Asking is important. So really, that urine drug screen is part of that conversation that you would use for monitoring anyone who's on an opioid. And the way we talk about it is preventing harm, recommended to do it in everyone and not just because we suspect something. It's part of routine care, just like we looked at an A1C for a patient with diabetes or we monitor someone's kidney function when they're on medications with side effects. So it's really part of the conversation of routine monitoring to treat a chronic condition, not looking for a drug seeker or anything like that.

Sure . Sure. That's great

Dr. Botsford, thank you for your time today and all of your great knowledge.

All right. Thanks for the time. Bye bye.

The TMF Quality Innovation Network’s consultant staff are available to help you and your team assess evidence-based pain management alternatives. Our consultants can work with you and your team to identify and address your goals, and assist you in making progress towards those objectives. For more information, or to request assistance, please visit our Contact Us page at TMFNetworks.org. Thank you for joining me for this podcast.