Presenter Conflicts of Interest Disclosure

Transcription

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2 Presenter Conflicts of Interest Disclosure Faculty: Ruth Dubin, Paul Taenzer : NONE

3 Jesse: 21 y.o. male, requesting hydromorphone for pain from a left ulnar nerve injury due to a childhood compound fracture. Practice taken over from a retired physician Your nurse tells you that your predecessor, stopped prescribing opioids to this patient because he had been repeatedly running out of medications early. Jesse has ADHD and anxiety, previously treated with ritalin and clonazepam. He was raised in foster care, now lives alone in a rooming house, he has limited family support and spends a lot of time gaming on the internet. His income is Social Assistance Jesse is now buying opioids, ritalin and benzos on the street and making multiple visits to the ED and after hours clinics for Rx s He says I can t take this pain any more

4 What s your automatic unspoken response? I have too may of these patients This is way out of my scope I don t get paid enough enough for this Darn, that Dr.. HELP!!!

5 HOW DID WE GET HERE? Start with a sedentary junk-food eating population and remove gym class from the school curricula Be unable to prevent/intervene early in childhood trauma/ abuse Ensure that dogs and cats get better pain management than do humans. (veterinarians get 5 times more pain management education than medical students) Teach Family MD s less than 4 hours about chronic pain and less than 1 hour about addiction + NO pain mgt.? on the LMCC or CFPC exams No funded access to physiotherapy, mental health counselling or exercise programs, unless you are wealthy Pay for opiates and benzodiazepines ad libitum Health Canada ignores the advice of the CFPC president and allows non-tamper-resistant oxycodone and disallows tamper resistant opiates

6 Long Wait Times Pain Care gaps Identified by PCP s in the SELHIN No Physio or Rehab Addiction/ Diversion Inadequate Mental Health or Psychiatry/ Psychology MDs lack knowledge in pain management Distance to pain clinics No multidisciplinary pain clinics Wait times in Canada 6 months to 5 years and waits > 6 months result in reduced function and increased health care utilization Lynch et al Pain 136:97

7 Ontario has high rates of Opioid prescriptions and overdose deaths and our region is one of the worst Some First Nations Communities: Addiction rates: 50% Gomes et al 2011 Healthcare Quarterly 14: 22 (used with permission)

8 TREATING CHRONIC PAIN MOVEMENT Physical / Rehabilitative SELF MANAGEMENT MIND Psychological And Sleep MEDICINE Medications & Interventions *(R Jovey, Canadian Pain Society,2009-with input from R.Dubin) Also see: Action Plan for the organization and delivery of chronic pain services in Nova Scotia, 2006

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10 MOHLTC supports the Stanford Based Self Management Programs* Multiple chronic disease self management programs (License fee paid by MOHLTC) : Diabetes, COPD, HIV, Chronic Pain They also support the Mindfulness for chronic pain program.

11 Multidisciplinary Tertiary Care Pain Clinics: Funded by MOHLTC in ONTARIO s academic Centers For the most complex patients

12 Burden on Family MD s I would say that my chronic pain patients, I don t have a huge number. They are my most challenging patients and I ve got their faces in my brain. And my top three probably take more brain and mental energy than the next 500 most challenging people. I often feel helpless They have seen all the specialists and the specialists had sent them all back to me with not a lot of help.

13 SOLVING A HEALTHCARE DILEMMA Sioux Lookout Meno Ya Win Health Centre How can specialty care reach underserved populations (low income, rural, 1 st Nations) with complex conditions, living a long way from specialist clinics? How can this be accomplished with existing infrastructure?

14 ECHO Mission ECHO is a movement to demonopolize knowledge and amplify the capacity to provide best practice care for underserved people all over the world.

15 How TELEMEDICINE differs from the ECHO model Using Technology to Bridge Distance Patient Specialist CHC FHT Case Presenter Patient Dictated report Inter- Spoke Site Learning Multidisciplinary Team Solo MD MD TELEMEDICINE improves ACCESS FHO Remote RN Outpost ECHO improves ACCESS and increases CAPACITY

16 ECHO (Extension for Community Healthcare Outcomes) USES: Video conference technology to leverage scarce healthcare resources The disease management model to improve outcomes by sharing Best Practices Case-based learning to help community practitioners Learn by Doing. Cases are managed by community practitioners with support from university specialists Databases to monitor outcomes

17 SUPPORTING PCP S MANAGING COMPLEX CONDITIONS.?

18 New ECHO s: Jamaica, Namibia Interest from: Egypt, Peru, Argentina, The UK Australia Copyright 2013 Project ECHO

19 ECHO ONTARIO CHRONIC PAIN/OPIOID STEWARDSHIP MOHLTC FUNDED SINCE APRIL hour, weekly sessions Didactic Presentations 20 week curriculum Case presentations by PCP s +Additional Hands-on Skills Boot camps Rapid access to an expert interprofessional team

20 ECHO CURRICULUM OVERVIEW CYCLE 4 # Sessions Module 1 Chronic Pain Fundamentals 4 Module 2 Opioids and Addictions 5 Module 3 Module 4 Module 5 Special Topics: Diet and Pain, Interventional Treatments, Mindfulness, Chiropractic and Physical Modalities, Core Back Tool Special Populations & Managing Pain in the Community: Suicide Risk Assessment, Community Services, Cannabis, Pediatric Pain Participant Selected Topics: Myofascial Pain Syndrome and Trigger Point Injections, Psychological Trauma and Pain, Post Surgical Pain 5 4 3

21 Status Update: ECHO Ontario Chronic Pain Highlights 105 ECHO Sessions completed (as of Oct ) 139 new cases, 30 follow ups presented hours of accredited CMEs to PCPs 196 Individuals from 73 community provider sites have attended ECHO 3 In-person, 2 day skills sessions: Toronto, Thunder Bay, Kingston 15 member Hub Team represents 12 professions. 26

22 ECHO ACROSS ONTARIO Marathon FHT Spoke sites from 13/14 LHINs 73 sites, 175+ individuals Marathon FHT developed pain/addiction pathway + hired pain educator Smith Falls CHC pharmacistled fentanyl de-prescribing clinic Smith Falls CHC

23 ECHO PARTICIPANTS BY PROFESSION 11% 6% 6% 37% Physicians Nurse Practitioners (NPs) and Registered Nurses (RNs) Pharmacists 12% 28% (n = 175) Mental Health: Psychologist, Social Workers, etc. Rehabilitation: PT, OT, Chiropractor, etc. Other

24 ECHO CASE AND FOLLOW UP First ECHO Case Presentation Follow up 5 months later The patient prescribed The patient opioids by his previous successfully rotated HCP: onto suboxone and -hydromorphone 10 mg then tapered off to self inject up to 10 suboxone times daily, completely. -oral hydromorphone He had significant 8mg bid improvement -oxycontin used a few functionally, walking times per month. about a mile daily. -Despite this very high For the first time in morphine equivalent 20 years he was off dose he still suffered of all opioids. unrelenting pain.

25 ECHO Ontario Chronic Pain & Opioid Stewardship: Participant Feedback I ve taken other courses, you ve probably taken lots of other courses on pain management and those sorts of things, and ECHO, by far and away, was the most practical in terms of what they were bringing to the table Family Physician My chronic pain patients, I don t have a huge number, are my most challenging patients my top three probably take more brain and mental energy than the next 500 most challenging people. I often feel helpless Family Physician Through ECHO I have become an advocate of safe and judicious use of opioids within our community Primary Care Pharmacist We now share this common language [interprofessional] communication is a lot easier because we re on the same page xxxx We tapered (a patient) down from 200mg of morphine a day to 10mg a day. Through this taper she found she was much more alert. This patient got a dog, lost over 50 pounds, and went back to work part-time! I would never have had the confidence to facilitate this taper without the support of ECHO. Primary Care Pharmacist 31

26 For more information: For more information on ECHO Ontario: To Register for ECHO Ontario: Complete the registration form at Or contact Rhonda Mostyn, Project Manager Join via OTN or sit in on a session in Kingston as a visitor: Thursdays PM Queens CPD office 68 Barrie St.

27 ECHO Ontario Mental Health at CAMH and the University of Toronto ECHO Ontario Mental Health provides capacity building and case-based learning in the areas of mental health and addictions for primary care providers in Ontario. For more information visit our website or contact: Brittany Watson Eva Serhal Project Coordinator Manager x x echo_ontariomentalhealth@camh.ca

28 ECHO Ontario Pain Partners

29 Online accredited self-assessment program

30 OTHER RESOURCES mmap.machealth.ca Online forum anyone can post questions/de-identified case discussions and get feedback from a Canada-wide community of pain/addiction experts. Pluses: available any time/virtual/ free Mainpro C credits*.

31 Thank You Contact me at for: More information on ECHO / MMAP Telephone consults re complex patients Anything else.

32 Resources: When a structured program isn t an option...digital Gentle chair yoga routine Progressive Muscle Relaxation CPS Meditation YouTube channel on Chronic Pain self-management meditations and exercise by Cara Kircher, OT with TRI-RC s chronic pain program (google: YouTube Cara Kircher) CPS Body Scan Relaxation

33 ...or books! A Mindfulness-Based Stress Reduction Workbook Bob Stahl & Elisha Goldstein Living a Healthy Life with Chronic Conditions, 3rd Edition: Kate Lorig, et al. Living Beyond Your Pain: Using Acceptance & Commitment Therapy To Ease Chronic Pain The Chronic Pain Care Workbook Michael J. Lewandowski JoAnne Dahl & T. Lundgren Get Out of Your Mind and Into Your Life The New Acceptance and Commitment Therapy Steven C. Hayes, Spencer Smith