A simple screening tool to

reduce unnecessary opioid

exposure in vulnerable

chronic pain populations.

Derek Titus, OSM-III, Emily Marshal, OSM-IV,

Josh Steenstra, MBA, Paul Coelho, MD

DisclosuresWe have no relevant disclosures. We will not be discussing any off-label uses of

medications or devices.

Table of Contents

• Scope of the opioid problem

• Opioid prescribing for FMS

• Pain catastrophizing predicts opioid

misuse

• The Salem Health pain clinic experience

• Evidence-based treatment options for

FMS & elevated pain catastrophizing

US Overdose Deaths 1980-2016

50000

37500

25000

12500

0

Peak Incidence of Prescription ODD Age 45-54*

20161980

Peak Incidence Ages 45-54

6K

64K

1990 FMS

Variation in Opioid Rx’ing for

FMS 2007-2009

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346177/

Opioids in FMS: Once Started

Seldom StoppedN = 100K, 60% Received Opioids.

https://www.ncbi.nlm.nih.gov/pubmed/26443495

Expert Consensus is that FMS is not

Opioid Responsive

Organization

American Pain Society

American Academy of Pain Medicine

American Academy of Neurology

European League Against Rheumatism

Canadian Pain Society

Canadian Rheumatology Association

British Pain Society

https://www.ncbi.nlm.nih.gov/pubmed/26975749

Elevated Pain Catastrophizing Predicts

Opioid Misuse

https://www.infona.pl/resource/bwmeta1.element.wiley-jabr-v-22-i-1-jabr12081

96% Sensitivity, 92% Specificity

2016 ACR Fibromyalgia

Screening Questionnaire

FMS + > 13

1995 Pain Catastrophizing ScaleAbnormal if > 20

FMS & PCS are Trait-like Features

Fibromyalgia & Pain Catastrophizing are

Both ‘trait-like’ measures which tend to emerge

In adolescence & persist through-out life.

SALEM HEALTH PAIN CLINIC

EXPERIENCE

The FSQ & PCS are Deployed

on All Patients with CNP

• Screening is immediately prior to visit.

• Screening time 10min.

• MA’s perform the screening, score the

tests, and enter the data into the EMR

prior to the visit.

Salem Health Pain Clinic

First 840 referrals 500 (59%) Screened

Positive for FMS, ~50% Positive for Pain Catastrophizing.

Salem Health Pain Clinic

Marion County PDMP Data 10/16 Patients on > 120MED

1,624 Patients

Salem Health Pain Clinic

> 120 MED 100 (~6% of County Total)

MED Range 120 - 3200

MED Average 360

Co-prescribed a benzo 40%

Average Age 60

Gender 57% Female

Fibromyalgia 50%

Average PCS 22

# of buprenorphine pts 50

1st 6mo High Dose Referrals

Salem Health Clinic Philosophy

FMS

Opioid Naive

Offer Evidence-based Non-opioid Tx’s.

Opioid Tolerant

Offer a Taper and Rotation to

EB Tx’s.

Salem Health Clinic Philosophy

FMS (M79.7):

#*** FMS: I showed @FNAME@ @HIS@ formal ACR

fibromyalgia screening questionnaire and explained that @HIS@

score of *** is consistent with the diagnosis. Fibromyalgia is a

‘centralized pain’ or ‘central sensitivity syndrome’ that results in a

state of chronic hyperalgesia or pain. Fibromyalgia accentuates

other painful diagnoses by functioning as a pain amplifier.

Consequently, patients with fibromyalgia and other painful

diagnoses - like back pain, or neck pain, or abdominal pain, or

arthritis pain - experience much higher pain levels than their non-

fibromyalgia counterparts. Most experts agree that, when present

among an array of chronic non-cancer pain diagnoses,

fibromyalgia is the primary source of morbidity.

I gave @FNAME@ our 'centralized pain' handout along with a

link to Dr. Dan Clauw you tube video

(https://www.youtube.com/watch?v=pgCfkA9RLrM&t=4s ) on

evidence based treatment for FMS. @CAPHE@ can return to

clinic to discuss evidence-based treatment options after watching

Dr. Clauw's video.

Salem Health Clinic Philosophy

Pain Catastrophizing (F45.1):

#*** Pain Catastrophizing: @FNAME@'s pain catastrophizing

scale today was highly elevated at ***/52. This is a powerful

predictor of pain severity and sensitivity, disability, pain chronicity,

satisfaction with care, and opioid misuse. Moreover, pain

catastrophizing is a target for behavioral interventions aimed at

diminishing rumination, magnification, and helplessness. In the

future @HIS@ may benefit from a referral to behavioral health

for CBT/ACT/MBSR.

Sample High Dose Case

XX

XX X

X

X

X

X

X

X

11

XX

X

X

X

XX

X

X

7

18

PCS = 13

FMS + IF > 13

Sample High Dose Case

Ms. X is a 33y/o woman with Lupus, Crohn’s Ds, & psoriatic arthritis. She

Follows with a rheumatologist at OHSU. Managed with hydroxychloquine

400mg QD. Pain managed by PCP with oxycodone IR 30mg, 72/day, MED

3,200.

We offered a 12wk taper to 800MED, made a diagnosis of opioid use disorder

And rotated the patient to buprenorphine-naloxone 8/2 SL BID.

Evidence-Based Treatments for

FMSTreatment Evidence Level

Patient Education 1A

Graded Exercise 1A

CBT 1A

Tricyclics 1A

SNRI’s 1A

Gabapentenoids 1A

NSAIDS 5D

Opioids 5D

https://www.ncbi.nlm.nih.gov/pubmed/28077978

Evidence-Based Treatments for FMS

https://www.youtube.com/watch?v=pgCfkA9RLrM

Evidence-Based Treatments for FMS

https://fibroguide.med.umich.edu/

Evidence-Based Treatments for Pain

Catastrophizing

Resources

2016 Fibromyalgia Survey Questionnaire & PCS

https://www.slideshare.net/101N/2016-fsq-pcs

Evidence-Based Treatments for FMS, Dr. Clauw JAMA

http://www.slideshare.net/101N/fibromyalgia-clinical-review

Daniel Clauw, MD YouTube Video for patients

https://www.youtube.com/watch?v=pgCfkA9RLrM&t=6s

Sample Centralized Pain Patient Handout

http://www.slideshare.net/101N/central-sensitization-70569194

List of non-opioid alternatives for chronic non-cancer pain

http://www.slideshare.net/101N/nonopioid-alternatives-for-

chronic-noncancer-pain

Thank You!

Derek Titus: dtitus@weternu.edu

Emily Marshall: emarshall@westernu.edu

Josh Steenstra: joshua.steenstra@salemhealth.org

Paul Coelho: paul.coelho@salemhealth.org