This document summarizes a presentation about an interdisciplinary outpatient pain management program. The program was developed in response to high rates of chronic pain in post-acute populations and new regulations surrounding opioid prescriptions. The program utilizes 10 collaborating disciplines including physicians, psychologists, physical therapists, nurses, and social workers. Key aspects of the program include comprehensive assessments, a pain contract, urine drug screening, and emphasis on non-pharmacological treatments. Initial results after one year include improved capacity for adjunct treatments, integration of new specialists, and fewer demanding patients due to clear guidelines.

1. A Multi-Disciplinary Model Improves
Pain Management in the
Outpatient Setting
Jason Petrishin RN, NEA-BC CCM

2. ANCC Accreditation Statement
The Association of Rehabilitation Nurses (ARN) is accredited as a
provider of continuing nursing education by the American Nurses
Credentialing Center’s Commission on Accreditation (ANCC-COA).

3. Speaker Disclosure Statement
Jason Petrishin is employed by TIRR Memorial Hermann.
Jason Petrishin has no other industry relationships to disclose.

4. TIRR Hospital

5. My background
• Clinical Director of TIRR’s
Outpatient Medical Clinic.
• I’m from Buffalo, New York
• An alumni of the Army Medical
Corp .
• A certified case manager and
nurse executive, with years of
service in outpatient health
services, but new to Rehab.

6. Objectives
• Review the varied presentations and scope of chronic pain
within the post-acute population, specifically those with
diagnosis of Amputation, Post-stroke, and Spinal Cord Injury.
• Describe classification changes affecting controlled substances
and the impact on practice patterns in rehab populations.
• Gain a working knowledge of the objectives, care roles, and
possible outcomes of an Outpatient Pain Program.

7. Incidence of chronic pain
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
TBI Post-stroke Amputation SCI
Annual incidence, # cases NEW
new cases with pain-annually
Are you surprised by these numbers?
Additional high pain-risk population diagnoses: CRPS, Back Pain & Diabetic Neuropathy.

8. Relevance to Rehab Nursing-Practice
“The rehabilitation nurse…
• serves as a coordinator of care and a patient advocate to
facilitate a self-management plan.
• provides pain management information and educates
patients and families to promote wellness, in order to
improve functional abilities.
• has a clinical understanding of the physiology,
pathophysiology, psychosocial factors , and uses
pharmacological and non-pharmacological methods to
prevent, identify, and alleviate pain.” (ARN, 2015)

9. Relevance for Nurse Leaders
Understand that issues of pain can:
• Alter or limit physical/self care goals
• Prolong outcome attainment
• Increase costs of care delivery
• Alter family/interpersonal dynamics
Outpatient pharmacies and provider practices,
have their own legal, business, and regulatory requirements.
There are significant legal concerns unlike other areas of care:
• Law enforcement is actively watching practice patterns
• There is a market for selling medications on the street
• Patients may be augmenting treatment with street drugs
Providers
Legal
Oversight
Patients

10. Medication Interventions
Severe pain, and rare usages
Oxycodone formulations
Morphine, Methadone,
Fentanyl patch
Mild to moderate
Tramadol/Ultram Hydrocodone formulations
Low grade, chronic pain
NSAIDS, Steroid or
Lidocaine injections
Anti-epileptics
Lidocaine patches

11. Federal attention to Hydrocodone
“use only when alternative treatment options are inadequate”

12. Continued federal attention…
On October 6th, 2015, the DEA changed Hydrocodone combination
pain relievers from a schedule III to schedule II medication.
How does this rule impact pain management for outpatients?
• Only method of obtaining these meds is receipt of a written or
e-prescribed RX, from an authorized provider.
• Doctors and nurses cannot call/fax refills to a pharmacy.
• There are strict requirements for office follow-up.
• Writing refills not allowed.
• National suppliers of these medications also face new scrutiny.

13. Houston, we have a problem…
Treating pain became a pain!
Providers of pain services were overwhelmed by follow up needs.
Those new patients not yet established with a specialist
were at risk of being lost to follow up and provision of care,
by their pharmacies and providers who were lost in the mire.
Stress and dissatisfaction for all involved.
It was time for a new approach.

14. Planning a new Pain Program
Leaders at TIRR set the following objectives for a redesign of the
Outpatient Medical Clinic’s pain program:
• Comprehensive pain control is everyone’s goal.
• Move beyond medication management to managing pain holistically
by developing an inter-disciplinary model.
• Improve safety and compliance with regulatory agencies.
• Create a program that deals with all variants of pain; neuropathic,
phantom, traumatic, chronic.
These goals ultimately seek to improve quality of life in the rehab
population, which aligns with the larger mission of the outpatient clinic.

15. Creating the Model
In November of 2015, we completed a gap analysis-What assets
were on hand? What needed to be found/aligned/created?
Key items that needed to be developed:
• A pain contract was needed, in English and Spanish.
• A process for urine drug testing .
• Handouts to support the nurse’s role in patient education
• Assessment and referral tools to support a new collaborative
partnership model, utilizing the expertise of multiple disciplines.
• Create a work group of service leaders to collaborate.

16. Ten key collaborating partners:
• PM&R doc or MSK service
• Psychiatry
• Clinical Psychology
• The Medication-Managing Physician
• Interventional Pain Specialists
• Physical Therapy
• Pharmacy
• Social Work/Case Management
• Dedicated Pain Clinic Nurses
• Patients and their Families

17. PM&R/MSK
The focus of our Outpatient clinic is supporting the PM&R practice
and facilitating the excellent care outcomes of our patients. The
PM&R physician has a central role in our multi-specialty approach.
• Provide central diagnosis of acute and chronic pain.
• Begin first line treatment options: NSAIDS, PT/OT, self-care
education, referrals to adjunct treatments.
• Monitor progress and escalate care if pain medication management
is needed.
• Provide MSK/Joint/Trigger point injections, facilitate continued
Physical Therapy, or refer for interventional care, as needed.
• Provide neurolytic injection to treat chronic headache or mild to
severe spasticity.
• Manage Baclofen Pumps and dose titration to treat moderate to
severe spasticity.

18. Medication Managing Physician
The classic “Pain Doctor”. This physician is tasked with managing the
medication plans, with goal of making sure regimens are safe and
effective.
• Sponsors the Pain Contract and ensures patient is adherent to rules
the organization sets forward for those in this service.
• Coordinates adjunctive referrals.
• The only provider of Schedule II medication prescriptions, this role
is charged with monitoring law enforcement resources and
insurance considerations closely.
• Coordinates with next/prior provider for patients transferring care.

19. Interventional Pain Physician
These physicians play a central role in opioid weaning/cessation, as
they bring surgical techniques to control pain such as:
• Image guided nerve blocks
• Radio Frequency Ablation
• Hypertonic lysis of adhesion
• Surgical implementation of baclofen pump.
• Surgical implementation of spinal stimulator/pain pump
These physicians also frequently order secondary courses of
physical therapy to improve ROM, strength, and balance status post
intervention.

20. Psychiatry
In our program, psychiatry functions to :
• Determine if patient is clinically depressed or has an anxiety spectrum
diagnosis that is influencing pain or adherence.
• Determine if addiction treatment support is indicated.
• Refer to Clinical Psychology for Cognitive Behavioral Therapy (CBT).
• Act as a safety point for any patient who has “failed” the pain contract.
• Monitor if medications like TCAs are impacting pain, even if provided
for a non-pain diagnosis, in select patients.
Psychiatrists can be a key to Prevention!

21. Clinical Psychology
Clinical Psychology offers 3 key services that help mitigate pain:
1. Clinical Interviews- Using Clinical Interviews, assessments of
personality characteristics coping resources, measure of locus of
control, pain experiences, symptoms of depression and anxiety the
clinical psychologist assesses mental states and describes how that
impacts the plan of care.
2. Cognitive Behavioral Therapy- A standard course of 10-12 sessions
of CBT can impact cognitive relations to pain and improve a
patient’s initiation to life affirming activities and behaviors.
3. Specialized care-ex: teaching manual approaches to treat headache
“All chronic pain has a psychological dimension”-Margaret Struchen PhD.

22. Physical Therapy
Therapists provide appropriative activities at an appropriate pace to
improve flexibility, increase strength, improve balance, educate on
the mind/body pain connections.
Some highlights this discipline focuses on:
• Understanding frequent causes of pain
secondary to the diagnoses.
• Understand adjunct treatments and
directing patients to services.
• Providing follow up on home exercises.
• Cheerlead! Along with caregivers, they
serve as chief encouragers.
We also offer after-hours gym access with supervision of an athletic
trainer for patients with a disability who seek a recreational gym.

23. Pharmacy
The Pharmacists have a consultative role, with physicians and patients.
Highlights of their role in our program include:
• Understand, discuss, and educate on formulations of pain-relieving
medication and how those medications interact.
• Understand the challenging payor mix for pain medications and
provide alternate medication suggestions for disapproved drugs.
• Offer guidance and suggested best practices concerning regulatory
requirement/restrictions.

24. Social Work
Social Workers are in a unique position to direct patients in needs
efficiently. Within their scope of practice:
• Needs are discovered during psychosocial assessments and
counseling periods.
• Assistance is offered with locating community resources.
• Help with locating mental health services, or assistance for or with
caregivers.
• Assist with coordination of care between pain care service providers.
Social Workers often serve as a central advocate for patients receiving
care within a closed system, as they sometimes act as Case Manager.

25. Nurses
Patients seen in our pain clinics are supported by a licensed nurse.
Frequently, pain patients are managed by the same nurse and her
role advances the multidisciplinary approach in:
• Assessment of patient needs and understanding of rehab diagnosis.
• Coordinating care holistically, not only between pain providers, but
with other physicians in our wider medical home.
• Introduction of the pain contract, the discussion of how the pain
program functions, and ongoing education, including use of a pain
diary.
• Monitoring drug screen results and notify physicians on findings.
• The nurse also educates on medication side effects. Our primary
Pain Clinic nurse is doing pre-investigation work on different
educational techniques to prevent chronic constipation.

26. A big thank you, for all you do!

27. Highlights of our Pain Contract
• Patient voluntarily enrolls in our Comprehensive Pain Management Program.
• Notified of dangers of opioid use, including side effects.
• No guarantee of results, but we use only evidence-based treatments.
• Patient agrees to initial, annual, and PRN non-legal urine drug screens for check
of adherence with medications, through monitoring of metabolites.
• Patient agrees to rules of program such as
• No phoned-in refills of schedule II medications.
• Agree to seek no other pain provider.
• Agree to be serviced by only 1 retail pharmacy.
• Agree to appropriate adjunct treatments.
• Agree not to share or sell medications.
• Patient agrees to conditions of discharge.

28. Positive first year Trends
• Alignment improved capacity. Successful adjunct treatments have
relieved the medication managers of a backlog of patients.
• The program attracted a new part-time interventionist who quickly
integrated into our program. That practice was ramped to capacity
within 30 days.
• Incidence of patients without, confused about, or presenting
demanding RX for schedule II medication has been vastly reduced
by the clear program guidelines.
• The pain contract empowers providers to give a clear path out of
the program, PRN. To date, we have only needed to manage out 2
patients in 9 months.

29. Quick Tips and Tricks.
I found each discipline has deep information on their role in chronic
pain management.
Keep in mind:
• Psychiatry and Psychology practices have a deep tele-med presence.
• Collaborate on creation of pain contract so the team is accountable.
• Take calls from pharmacies and open mail from insurance companies!
Set goals concerning patient quality of life, provider collaborations, and
narcotic medication weaning and you are on the path to being a great
pain practice.

30. Case Patient #1
• 58 y/o F presented to Interventionalist after d/w with lower back
pain.
• Hx L4-L5-S1 bulge
• B/l Laminectomy 2006 r/t injury.
• Progressed to secondary sciatica 30 years post injury.
Mechanism of initial injury-an assisted pt fall while working as an RN;(
Surgery was temporarily curative, but pain re-presented in 2015.
Pain progression climaxed to 10/10, limiting mobility of back and RLE.
Initial treatment of Toradol ineffective.
Next day, she started on Medrol dose pack and Norco 7.5 Q4hrs.
MRI found scar tissue r/t previous surgery causing nerve root
compression and spinal stenosis.
Pt continued Norco for 30 days without resolution.
It was then determined to do a hypertonic lysis of adhesions and
steroid injections. Norco weaning began immediately.

31. Always open to sharing!
Jason.Petrishin@memorialhermann.org

32. References
ARN (2015). The re of the rehabilitation nurse in pain management. Retrieved from
http://www.rehabnurse.org/uploads/files/uploads/The_Role_of_the_Rehabilitat
ion_Nurse_in_Pain_Management.pdf
CDC (nd). Get the stats on traumatic brain injury in the United States. Retrieved from
https://www.cdc.gov/traumaticbraininjury/pdf/bluebook_factsheet-a.pdf
CNN staff (October 25, 2013). FDA aims to tighten control of hydrocodone. Retrieved from
http://www.cnn.com/2013/10/25/us/fda-painkiller-controls/
Dikers, M., Bryce, T., Zanca, J. (2009). Prevalence of chronic pain after traumatic spinal
cord injury: A systemic review. Retrieved from http://www.ncbi.nlm.nih.gov
/pubmed/19533517
Ephraim, P. (2005). Phantom pain, residual limb pain, and back pain in amputees: Results
of a national survey. Retrieved from http://www. sciencedirect.com
/science/article/pii/S0003999305003588

33. Martin, J., et al. (2013). Chronic pain syndromes after ischemic stroke. Retrieved from
http://stroke.ahajournals.org/content/44/5/1238.short
Nampiaparampil, D. (2008) Prevalence of chronic pain after traumatic brain injury: A
systemic review. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/18698069
NSCISC (2016). Spinal cord injury facts and figures at a glance. Retrieved from
https://www.nscisc.uab.edu/Public/Facts%202016.pdf
Ownings, M., Kozak, L. (1998). National Center for Health S. Ambulatory and Inpatient
Procedures in the United States 1996. Retrieved from: http://www.amputee
coalition.org/limb-loss-resource-center/resources-by-topic/ limb-loss-statistics/
limb-loss-statistics/#2
Patient, blinded (August 8, 2016). Personal Conversation.
Struchen, Margaret (August 8, 2016). Personal Conversation.