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  • Measure Summary
  • NQMC:009370
  • Nov 2013

Assessment and management of chronic pain: percentage of patients diagnosed with chronic pain who are prescribed an opioid at a dose less than 100 mg per day of morphine.

Hooten WM, Timming R, Belgrade M, Gaul J, Goertz M, Haake B, Myers C, Noonan MP, Owens J, Saeger L, Schweim K, Shteyman G, Walker N. Assessment and management of chronic pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Nov. 105 p. [168 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of patients age 18 years and older diagnosed with chronic pain who are prescribed an opioid at a dose less than 100 mg per day of morphine.

Rationale

The priority aim addressed by this measure is to improve the effective use of opioid medications in the treatment of patients age 18 years and older with chronic pain.

Medications are not the sole focus of treatment in managing pain. They should be used when needed to meet overall goals of therapy in conjunction with other treatment modalities: psychosocial and spiritual management, rehab and functional management, non-pharmacologic and complementary medicine, and intervention management. Pharmacotherapy may include agents to treat specific types of pain, such as neuropathic pain, or adjunctive therapies to treat other comorbidities such as depression and anxiety. Use of medications, therefore, should be directed not just toward pain relief, but for increasing function and restoring overall quality of life.

Although most opioids are not known to work through antineuropathic mechanisms, they are nevertheless potent analgesics. They have a role in reliable patients when other measures fail. Careful patient selection is critical to success with long-term opioid therapy.

Opioid doses should be titrated up until there is adequate pain relief, but generally not exceeding doses equivalent to morphine 100 mg/day. Rapid escalation of dose or use of higher doses may be a marker for a substance abuse disorder, and high doses are more likely to induce hyperalgesia and possibly immunosuppression (Chou et al., 2009).

Evidence for Rationale

Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, OConnor PG, Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C, American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009 Feb;10(2):113-30. PubMed External Web Site Policy

Hooten WM, Timming R, Belgrade M, Gaul J, Goertz M, Haake B, Myers C, Noonan MP, Owens J, Saeger L, Schweim K, Shteyman G, Walker N. Assessment and management of chronic pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Nov. 105 p. [168 references]

Primary Health Components

Chronic pain; opioids; morphine

Denominator Description

Number of patients age 18 years and older diagnosed with chronic pain and prescribed an opioid (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patients diagnosed with chronic pain who are prescribed an opioid at a dose less than 100 mg per day of morphine

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence

Additional Information Supporting Need for the Measure

Chronic pain affects at least 50 million adults a year. Prevalence in primary care settings range from 5% to 33% and often imposes upon clinicians the responsibility of managing a substantial disability that can be exacerbated by a patient's distress. Due to its prevalence, the cost of chronic pain is substantial; it has been estimated at $70 billion per year. Chronic pain has the ability to disable and significantly decrease the quality of life for the individual and his or her support systems; the financial and personal cost to those who are affected by chronic pain is significant (Reid et al., 2002; Olsen & Daumit, 2002).

Evidence for Additional Information Supporting Need for the Measure

Hooten WM, Timming R, Belgrade M, Gaul J, Goertz M, Haake B, Myers C, Noonan MP, Owens J, Saeger L, Schweim K, Shteyman G, Walker N. Assessment and management of chronic pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Nov. 105 p. [168 references]

Olsen Y, Daumit GL. Chronic pain and narcotics: a dilemma for primary care. J Gen Intern Med. 2002 Mar;17(3):238-40. PubMed External Web Site Policy

Reid MC, Engles-Horton LL, Weber MB, Kerns RD, Rogers EL, O'Connor PG. Use of opioid medications for chronic noncancer pain syndromes in primary care. J Gen Intern Med. 2002 Mar;17(3):173-9. PubMed External Web Site Policy

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Clinical Practice or Public Health Sites

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Case Finding Period

The time frame pertaining to data collection is monthly.

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Patient/Individual (Consumer) Characteristic

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of patients age 18 years and older diagnosed with chronic pain and prescribed an opioid

Note: Diagnoses that may be related to chronic pain include cervical and lumbar pain, headache, myalgia and myositis, low back pain, neck pain and fibromyalgia. Refer to the original measure documentation for suggestions on identifying other International Classification of Diseases, Ninth Revision or Tenth Revision (ICD-9/ICD-10) codes.

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of patients diagnosed with chronic pain who are prescribed an opioid at a dose less than 100 mg per day of morphine

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Electronic health/medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Percentage of patients diagnosed with chronic pain who are prescribed an opioid at a dose less than 100 mg per day of morphine.

Measure Collection Name

Assessment and Management of Chronic Pain

Submitter

Institute for Clinical Systems Improvement - Nonprofit Organization

Developer

Institute for Clinical Systems Improvement - Nonprofit Organization

Funding Source(s)

The Institute for Clinical Systems Improvement's (ICSI's) work is funded by the annual dues of the member medical groups and five sponsoring health plans in Minnesota and Wisconsin.

Composition of the Group that Developed the Measure

Work Group Members: W. Michael Hooten, MD (Work Group Co-Leader) (Mayo Clinic) (Anesthesiology); Richard Timming, MD (Work Group Co-Leader) (HealthPartners Medical Group and Regions Hospital) (Physical Medicine and Rehabilitation); Miles Belgrade, MD (Fairview Health Services) (Neurology); James Gaul, MD (Fairview Health Services) (Internal Medicine); Kelly Schweim, PharmD (Fairview Health Services) (Pharmacy); Neal Walker, RPh (Fairview Range Regional Health Services) (Pharmacy); Michael Goertz, MD, MPH (HealthPartners Medical Group and Regions Hospital) (Occupational Medicine); Bret Haake, MD (HealthPartners Medical Group and Regions Hospital) (Neurology); Mary Pat Noonan, PhD, ABPD (HealthPartners Medical Group and Regions Hospital) (Psychology); Louis Saeger, MD, FACPM (Midwest Spine Institute) (Anesthesiology); Galina Shteyman, PharmD (Park Nicollet Health Services) (Pharmacy); Cassie Myers (Institute for Clinical Systems Improvement [ICSI]) (Clinical Systems Improvement Facilitator); Jacob Owens, MPH (ICSI) (Project Manager)

Financial Disclosures/Other Potential Conflicts of Interest

The Institute for Clinical Systems Improvement (ICSI) has long had a policy of transparency in declaring potential conflicting and competing interests of all individuals who participate in the development, revision and approval of ICSI guidelines and protocols.

In 2010, the ICSI Conflict of Interest Review Committee was established by the Board of Directors to review all disclosures and make recommendations to the board when steps should be taken to mitigate potential conflicts of interest, including recommendations regarding removal of work group members. This committee has adopted the Institute of Medicine Conflict of Interest standards as outlined in the report Clinical Practice Guidelines We Can Trust (2011).

Where there are work group members with identified potential conflicts, these are disclosed and discussed at the initial work group meeting. These members are expected to recuse themselves from related discussions or authorship of related recommendations, as directed by the Conflict of Interest committee or requested by the work group.

The complete ICSI policy regarding Conflicts of Interest is available at the ICSI Web site External Web Site Policy.

Disclosure of Potential Conflicts of Interest

Miles Belgrade, MD (Work Group Member)
Medical Director, Neurology, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: Mayo Clinic Diabetic Neuropathy Pain guideline
Research Grants: Money paid directly to institution from Rummler Foundation
Financial/Non-Financial Conflicts of Interest: Money paid previously by Purdue Pharma directly to work group member

James Gaul, MD (Work Group Member)
Physician, Internal Medicine/Pediatrics, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Michael Goertz, MD, MPH (Work Group Member)
Physician, Occupational Medicine, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: ICSI Low Back Pain guideline work group member, Mayo Clinic Diabetic Neuropathy Pain guideline work group member
Research Grants: Rummler Hope Foundation money paid to institution for opioid addiction awareness
Financial/Non-Financial Conflicts of Interest: Purdue Pharma money paid to work group member and institution

Bret Haake, MD (Work Group Member)
Assistant Medical Director, Neurology, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: ICSI Low Back Pain guideline work group member, ICSI Acute Pain Assessment and Opioid Prescribing protocol work group member
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

W. Michael Hooten, MD (Work Group Co-Leader)
Anesthesiology, Mayo Clinic
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: ICSI Opiod Protocol work group member
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Mary Pat Noonan, PhD, ABPD (Work Group Member)
Clinical Psychologist, Clinical Psychology, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: ICSI Acute Pain Assessment and Opioid Prescribing protocol work group member
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Louis Saeger, MD, FACPM (Work Group Member)
Interventional Pain Management, Midwest Spine Institute
National, Regional, Local Committee Affiliations: Minnesota Society of Interventional Pain Physicians board member
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Kelly Schweim, PharmD (Work Group Member)
Medical Therapy Provider, Medical Therapy Management, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Galina Shteyman, PharmD (Work Group Member)
Pharmacist, Pharmacy, Park Nicollet Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Richard Timming, MD (Work Group Co-Leader)
Physical Medicine and Rehabilitation, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: ICSI Low Back Pain guideline work group member
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Neal Walker, RPh (Work Group Member)
Pharmacy Manager, Pharmacy, Fairview Range Regional Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2013 Nov

Measure Maintenance

Scientific documents are revised every 12 to 24 months as indicated by changes in clinical practice and literature.

Date of Next Anticipated Revision

The next scheduled revision will occur within 24 months.

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

Source(s)

Hooten WM, Timming R, Belgrade M, Gaul J, Goertz M, Haake B, Myers C, Noonan MP, Owens J, Saeger L, Schweim K, Shteyman G, Walker N. Assessment and management of chronic pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Nov. 105 p. [168 references]

Measure Availability

Source available from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy.

For more information, contact ICSI at 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; Phone: 952-814-7060; Fax: 952-858-9675; Web site: www.icsi.org External Web Site Policy; E-mail: icsi.info@icsi.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on May 28, 2014.

The information was reaffirmed by the measure developer on January 13, 2016.

Copyright Statement

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Measures are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Measures are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Measures are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Measures.

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