Oregon Pain Management Commission February 21, 2018 - 9:00 AM - 12:00 PM Clackamas Community College - Oregon.gov
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Oregon Pain Management
Commission
February 21, 2018
9:00 AM – 12:00 PM
Clackamas Community College
Wilsonville Training Center
29353 SW Town Center Loop E, Room 111-112
Wilsonville, OR 97070Oregon Pain Management Commission Meeting
Agenda
February 21, 2019, 9:00 AM - 12:00 PM
Clackamas Community College/ Wilsonville Training Center, Room 111-112
29353 SW Town Center Loop E, Wilsonville, Oregon 97070
Item/ Topic Introduced by Action Time Allotted
Welcome & Roll Call Nora Stern None 9:00 - 9:10
Minutes & Agenda Nora Stern Summary, Discussion & Vote 9:10 - 9:15
o Approval of October 2018
minutes. Approval and edits to
agenda.
Public Forum 1 of 3 for 2019 Nora Stern Information Sharing 9:15 - 9:45
Oregon Board of Massage Mark Retzlaff Information Sharing and 9:45 – 10:00
Therapists AMTA Oregon Chapter President Commission Feedback
• Rulemaking Update
Legislation Mark Altenhofen Information Sharing & 10:00 - 10:05
Discussion
o Update on CPTF/VbBS/HERC
o HB 2265 Update
Community Nora Stern Information Sharing & 10:05 - 10:20
o Update on Pt Facing Pain
Kevin Cuccaro Discussion
Module
o Community Forums
Revised 02-14-19Break 10:20 - 10:30
Clinician Education Nora Stern Information Sharing & 10:30 - 11:15
o Update on Pain Module Kevin Cuccaro Discussion
Mark Altenhofen
o OPAT Pain Conference
o Curriculum Review Requirements
& Planning
Commission Internal Business Nora Stern Information Sharing & 11:15 - 11:45
o Mission Statement Draft Kevin Cuccaro Discussion
Rebecca Duffy
o Membership Vacancies &
Michele Koder
Recruiting
Mark Altenhofen
Closing Nora Stern Information Sharing 11:45 – 11:55
Adjournment Nora Stern 11:55 - 12:00
Revised 02-14-19Oregon Pain Management Commission: October 25, 2018
Topic: Presented by: Primary Discussion Points: Actions:
Meeting Roll Call Nora Stern Members in Attendance:
Nora Stern, Ruben Halperin, ReBecca Duffy, Alyssa Franzen, Michele Koder
Members via Teleconference: Kevin Cuccaro, Kim Jones, Amber Rose Dullea, Kera
Murphy
Excused: Sen. Winters, Rep. Sheri Malstrom
Members Absent: David Eisen, Coleen Carlisle, Kevin Wilson, Anthony Marrone and John
Garofalo
Nora asked for the public in attendance to identify themselves: Ryan Fowler, Alan
Chino, Tim Harless, Philip Bowman, Sue Bergman
Mission Statement Nora Stern Nora announced that Rebecca has been working on updating the draft mission
Draft Rebecca Duffy statement to help focus the work of the commission. She went on to say this will be
helpful when addressing complex topics to determine if they are within or out of the
scope of the commissions work. This will also be helpful for ongoing collaborative
efforts between the commission and educational institutions in the development of pain
training.
Rebecca summarized her review of the existing mission statement. She sees the current
wording as being very broad and encompassing aspects that may not be realistic for the
commission to accomplish. She read through the first section of the original mission
statement for the group and pointed out content that seemed to be beyond the scope of
work of the commission. For instance, the development of pain management
recommendations is something that is done on a national and international level. In
addition, the current mission seems to indicate that the commission has the
responsibility to guide curriculum development in our educational facilities, which is a
complex endeavor requiring significant human resources to accomplish.
Rebecca’s draft reads: “The commissions mission is to improve pain management in theOregon Pain Management Commission: October 25, 2018
Topic: Presented by: Primary Discussion Points: Actions:
state of Oregon. The mission is to provide Oregonians with access to the best pain
management options available. The commission will endeavor to improve pain
management through education, development of collaborative endeavors, and
distribution of practice recommendations and research. The commission shall represent
the complex individual and community concerns of pain management to the Governor
and legislative assembly. The commission shall develop a pain management educational
curriculum and will update it biennially. The commission shall work with health
commission regulatory boards, professional educational organizations, other health
boards, committees or task forces to develop compassionate responses for pain
management for Oregonians based upon the best research and guidelines available.”
Rebecca went onto question whether the section below, Principles and Values, was
necessary. To her it seemed to be redundant and restated much of what was already in
the mission statement. Nora recommended that the group focus on the wording of the
mission statement first and then move to the other sections.
Michele Koder suggested removing language that refers to providing access to
treatment. Nora agreed and thinks providing “access” is outside the scope of the
commission. Nora also wondered if removing the second sentence in Rebecca’s draft
would work better. Kevin Cuccaro suggested keeping the word education and removing
the word management. Nora asked if he had an example of language that could be
used. Kevin suggested - provide Oregonians with access to the best pain education
available, instead of pain management might be better. Nora thought this was an
important shift because the commission is working toward facilitating a better
understanding of pain. Ruben also thinks this helps distinguish the commission from
other entities, such as HERC, in that we are not making coverage recommendations or
setting policy. He went on to add that the commission is not making defacto
recommendations as to how physicians should prescribe or treat. Ruben said this helps
clarify that the pain commission is an advisory board and repository for two-way flow of
information. Rebecca suggested using education instead of management in the title of
the commission. Nora agreed and thinks the term management is not helpful. Kevin C.
agreed and shared the content of a recent editorial on the subject. He thinks manyOregon Pain Management Commission: October 25, 2018
Topic: Presented by: Primary Discussion Points: Actions:
assumptions are made when using the word management and pain is thus interpreted
as something that can only be managed rather than improved. Rebecca added that
living with the experience of pain isn’t just pain, there are many other factors that affect
this such as economic factors, etc. She went on to say that while focusing on the term
education is important, there are still many factors outside of the control of the
commission.
Nora suggested having a smaller group work together on clarifying the details and create
a draft document or several versions for the larger membership to review. It would be
good if there were one or two commissioners who would be willing to work with
Rebecca to accomplish this task. Michele believes the intent of the initial legislation was
to create educational content for providers to reference. Nora would like to have
Rebecca and a small group revisit the original piece of legislation in a separate meeting
and then add this back to the agenda for the next meeting. She also recommended
focusing only on the mission statement and leaving the principals and values out of the
evaluation for now. Kevin C. agreed that it is important to focus on what the
commission actually has control over and it would be useful to what is the one key thing
that the pain commission has influence on. With that perspective in mind, Rebecca felt
it would be important to focus more on education for health providers, boards,
committees and individuals in our communities to help bring together a better
understanding of these issues. Ruben supported this proposal and said the commission
is the only coordinating entity that helps to make sure everyone is on the same page in
the use of best practices, philosophy around pain, and headed in the right direction.
Membership Nora Stern Mark shared that there are three professional and one public opening on the
Vacancies and Mark commission. He will be working on posting the opening on the OPMC website and
Recruitment Altenhofen sending out the required public notice. An email will also be sent out to commission
members to pass along to any candidates or professional organizations they are
associated with. Mark pointed out that it will be important to recruit a broad
professional and geographic representation in the candidates. Ruben had a questionOregon Pain Management Commission: October 25, 2018
Topic: Presented by: Primary Discussion Points: Actions:
about who has left and if there are specific professions the commission is seeking to fill.
Mark reported that Eric Davis CADC, Laura Scobie PA, and Catriona Buist, PhD have left
the commission. Colleen Carlisle, public member, has not attended a commission
meeting in quite some time and will be dismissed due to lack of attendance. Ruben
asked if there will be a priority on finding mental health providers or other professionals.
Nora indicated it would be good to have an LCSW on the commission, as that
professional designation has not been represented historically. She also added that
LCSW’s are not required to have continuing education in pain and this leaves a
significant gap because they are typically part of a multi-modal treatment approach.
Rebecca supports finding another chemical dependency professional to replace Eric
Davis and Ruben agreed with this perspective. Ruben thinks there is a significant need
for to include professionals that have both experience in chronic pain and substance
abuse. Amber Rose thinks that it is important that the chemical dependency
professional have experience working with the co-morbidities of addiction, as well as the
management of pain. She went on to emphasize that it is important not to forget about
treating pain in our current environment when discussing addiction.
Nora asked the commission members to keep all of this in mind when reaching out to
colleagues and that a broader representation geographically will be of priority when
filling the open membership positions. Rebecca asked if the commission has ever
considered adding a member with experience treating adolescents and pain. Nora said
this hasn’t been considered historically, but is an excellent call out. Kevin C. thought it
would be important to consider adding a psychologist, as Nora pointed out, but that it
would be also important for them to be experienced in working with trauma or PTSD.
He went on to emphasize that it would be useful for the commission to begin
considering the considerable overlap of addictions and persistent pain. Ruben also thinks
the commission is missing representation from oncology or cancer care, as the
distinction between cancer pain and non-cancer pain is really artificial. He went on to
point out that the risk of persistent pain in cancer survivors is significant in the research
and it is an area that is not receiving much support from a broader perspective. Michele
Koder indicated the commission has not had representation from emergency medicine
also. Alyssa Franzen indicated there is quite a bit happening currently in the acute careOregon Pain Management Commission: October 25, 2018
Topic: Presented by: Primary Discussion Points: Actions:
space right now and wondered if that was appropriate for the work of the commission.
She went on to say that it is conscious decision that the commission should make as
there is much work being done at the state level which includes ED, Surgical, Primary
Care and Dental.
Nora recommended that a summary list be put together and sent out to commission
members for them to forward to those in their network. Ruben asked if there are any
strategies to reach rural communities. Amber Rose said she would distribute to her
contacts on the coast. Alyssa added possibly sending to QHOC, Rural Practice Network,
CCO’s, etc.
Meeting Dates and Mark Meeting dates for 2019 will be distributed to the commission members via electronic
Planning for 2019 Altenhofen calendar invitations. Location, time and day/week of each month will remain the same.
Nora proposed two back to back meeting for either May & June or September &
October. Ruben suggested only scheduling for June and October. Michele pointed out
that the By-Laws state that meetings are to occur bi-monthly. Mark said that the
meetings have in recently been held quarterly. Kevin mentioned that the August
meeting could be more of a work group, sub-group, or conference call. Michele said
Darren Coffman said there was a change to the number of sessions. Amber Rose
thought the change from the By-Laws had to do with the available budget for OHA Staff.
Mark will look into the changes by OHA.
Approval of Nora Stern Kevin C. had a question regarding attendance for the August meeting. He asked if John Michele K. moved to
Minutes Garafolo and J.P. Garafalo are the same. Mark indicated that was an error and will approve.
correct. Ruben – 2nd.
Vote:
Aye: 9
Nay: 0
Legislative Update Mark Mark notified the commission that the next meeting of the Chronic Pain Task Force will
Altenhofen be held on December 5th, 2018 at the Crown Plaza in Lake Oswego. Information is
Nora Stern posted on the HERC web page.Oregon Pain Management Commission: October 25, 2018
Topic: Presented by: Primary Discussion Points: Actions:
Nora provided some background and clarification regarding the work of the Chronic Pain
Task Force. She said this is separate from the Back Pain Guideline work that has been
done previously and will propose moving five diagnoses above the line to be eligible for
reimbursement by the Oregon Health Plan. This will be the last meeting of the CPTF and
their proposal will then be submitted to the Value Based Benefits Subcommittee and
eventually the Health Evidence Review Commission for further deliberations.
Mark also provided a brief update on HB 2265, which would require optometric
physicians to take the 1-hour online pain education module offered by OPMC.
Update on Patient Nora Stern Nora provided information to the members about new work being done to create a
Pain Education patient facing online education tool. It is intended to be a module that will match what
Module is presented in the clinician module. The project is being funded through some
additional grant money available from the CDC via OHA. Lisa Shields, from OHA, is the
project manager and has been working with Nora to establish the scope of work. The
project deliverables will include written education material and a short video segment
on each of the five key domains that are already used in the clinician module. Michele
asked if this will function like an App. Nora said it will be very similar and presented
some slides of the current mock-ups being developed.
Update on Clinician Nora Stern Nora updated the commission on the module poster presentation she and Cat Buist
Pain Education presented to the IASP Conference. Kim Jones presented the module at the National
Module Rheumatology Conference as well. Kim provided a summary of her experience and
noted that the presentation was well attended and received. She mentioned that some
members of the audience asked what was not working or could be improved in the
module, and she did not have enough information to provide an answer. Nora indicated
there has not been much negative feedback around the module. Mark said he has
received some concerns about printing completion certificates by some professionals.
Kevin presented a perspective that he believes underlies the questions regardingOregon Pain Management Commission: October 25, 2018
Topic: Presented by: Primary Discussion Points: Actions:
concerns for some physicians. He thinks many providers are worried about the potential
backlash, misunderstanding of the material and difficulty in managing patient
expectations associated with recommending the module. Kevin and Ruben discussed
this issue further and both agreed that it is belief that is held by many clinicians despite
what the research shows. Kevin said many patients are capable of understanding these
concepts when they have a good relationship with their provider and the language used
is not full of medical jargon. Nora said the module was set up with a video and patient
handout for this reason. All the provider needs to do is initiate the conversation and
then provide the materials to the patient for more information.
Mark reported on the statistics: Between January 1 and October 1st – 5,665 enrolled,
4,684 (83%) completed, 954 (17%) started but did not complete, and 27 enrolled but
never started the course. Michele asked if you can break it down by profession. Mark
indicated that it is possible to allocate the data by licensing board, harder to do by
professional designation. Ruben asked if there was intent to spread outside of Oregon.
Nora thinks this is a complex endeavor and outside of the scope of the commission.
Rebecca asked if the contracting piece was ever figured out within OHA. Mark said that
DOJ reviewed this issue. It is possible for other business or government entities to
purchase the course and use it under their own branding for a donation. Nora said the
module can be utilized by anyone for free in its current format. Alyssa said there is an
opportunity to do another round of communications on the module that can be tied into
the acute prescribing guidelines work that is happening currently. She also said there is
opportunity within the network of dental professionals she is tied in to. Nora would like
to get statistics by professional organization for the next meeting to help inform
communication efforts moving forward. She would also like to make this a part of a
larger conversation at the next meeting.
Kim relayed information on utilization within some of the clinics at OHSU. She said theOregon Pain Management Commission: October 25, 2018
Topic: Presented by: Primary Discussion Points: Actions:
module is being used in the pain and rheumatology clinics. It is not well established in
the primary care clinics, which is where she believes it needs to be. Kim asked how
other organizations were handling the roll out of the model to their primary care clinics.
Nora said that Providence Health System has connected the module to their online
education software (Healthstream) and is making it a requirement within their nursing
department. It has not been loaded into Healthstream as an integrated content module,
however there is a link to take the module externally and then load the CME certificate
back into their software. Nora reports that it has been completed by 10% of the nursing
staff (around 22,000 professionals) in the first month of distribution. She also reported
it has been spread via leadership in the rehab department. Nora and Ruben discussed
how they were exploring making it a part of employee on-boarding, but that has been
met with some challenges. Providence Medical Group has also included reference to the
module in their ongoing email updates for their providers. Kim said OHSU did provide
information on the module in one of their weekly email news updates, saying it was
highly recommended but not required for providers.
Michele indicated she has been distributing to her colleagues at the Multnomah County
Health Department and thought adding it to the employee on-boarding process would
be worth looking into. Rebecca asked about how the module could be spread to other
county health department around the state. Nora wondered if that could be done
through OHA. Alyssa said that many counties in the state operate differently than
Multnomah, which is also and FQHC that employs physicians. Rebecca said she would
do some research on this and report back to the commission.
Curriculum Nora Stern Nora believes this is a very complex topic and should be handled initially by a sub- Need to categorize
Review committee of the commission. Ruben thinks it also needs to be addressed in the mission and structure this
Requirements conversation for
statement revision. Nora agrees and sees this topic as overstepping the scope of the
review by a
commission. Ruben went on to say that all educational institutions have their own
smaller sub-groupOregon Pain Management Commission: October 25, 2018
Topic: Presented by: Primary Discussion Points: Actions:
oversight and accreditation. It is not clear to him what the commission is doing. Kevin of the commission.
thinks this all comes down to control and that the commission should pull back in it’s
expectations. He thinks it would be more reasonable to provide a format or structure
that the commission recommend and the institutions could then adopt to their needs.
Nora wonders if there might be an easier way to do this work. She thinks this could be
simplified and the commission could act as a conduit to existing guidelines, such as those
developed by IASP. Ruben said the best the commission can do is make
recommendations about curriculum and there is very little control over whether an
institution adopts that or not. It is an overwhelming task that the commission does not
have the resources to accomplish.
Member Requests Nora Stern Nora discussed Anthony Marrone’s request to review why there are delays in approval
for non-pharmacological treatment. She said this is an example of an issue that is
outside of the scope of the commission and one that this group is unable to influence.
Michele recommended approaching the CCO medical directors as a possible solution.
Ruben indicated this is a significant issue that providers face and extends well beyond
OHP. Nora agreed and reiterated that this is why it is beyond the scope of the
commission.
Rebecca and Amber had introduced the issue of OUD diagnosis and coding at the last
meeting. They have not had an opportunity to discuss in the interim, but now feel it
may be outside the scope of the work of the commission. Amber Rose felt this started
based on how patients feel stigmatized around OUD and wondered if there are other
ways to educate providers on how not to re-stigmatize individuals. Ruben summarized
the difficulty and complexity of this issue and how OPG was wrestling with it in their
discussions. Kevin said there is a great deal of misconception and understanding of both
addiction and pain which leads to stigmatization. Ruben said the DSM V removed the
word addiction for that very reason and felt OUD was better terminology. Nora said the
commission would look into how to best handle this topic moving forward.Oregon Pain Management Commission: October 25, 2018
Topic: Presented by: Primary Discussion Points: Actions:
Public Comment Nora Stern There were five individuals signed up for public comment. A summary of their testimony
follows. Each individual had three minutes to present comments to the commission.
Nora asked each person to state their name and any conflicts of interest.
Tim Hartless, a resident of Tigard, veteran and chronic pain patient is here today to
share his experience and represent the American Chronic Pain Association. His primary
concern is around access to health care and stigmatization of those who are vulnerable.
He wants the commission members to keep in mind the significant barriers individuals
face. Tim talked about the difficulties many individuals face with regard to
transportation, increase in suicides, and other issues. He applauds the efforts of the
commission and knows this is a complex and difficult area address.
Philip Bowman is also here representing individuals who can not be present today and
the American Chronic Pain Association. He had two comments to make. One is the
issue of mixing individuals with heroine or other drug addictions and chronic pain
patients. He thinks there is a difference between the two. The other is how physicians
are educated. His perspective is that new doctors are being taught a contradiction with
regard to this same issue. That drug addiction and those using opiates for chronic pain
are one in the same.
Alan Chino gave a summary of his professional background and history as a member of
the OPMC. He did not disclose any financial conflicts of interest and stated he was here
representing himself today. His concerns center on the sense that the commission is
moving away from both patient advocacy and advice to the legislature and governor.
Dr. Chino asked to be corrected if he was wrong in that assumption. He also said he
would not be in favor of changing the name of the commission.
Amara Moon said she was at the last meeting and handed out a paper on a pilot
program regarding opiate taper. She left another copy of for the commission. Amara
said she emailed Mark with a request to distribute a copy of this paper. She went on to
say she attended an OPMC meeting in 2016 and provided testimony specifically to Note
60 of the Back and Spine guidelines, in which she objected. Amara says she has backOregon Pain Management Commission: October 25, 2018
Topic: Presented by: Primary Discussion Points: Actions:
pain and utilizes opioids successfully. She believes an important part of the mission
statement is that the commission represents the concerns of patients. Amara believes
there is not enough patient input being considered and the divide is getting bigger. She
went on to state that Denise Taray, the former coordinator replied to confirm receipt of
materials. Amara said she sent Mark three emails and received no replies and left two
voicemails. Mark responded that he didn’t receive any of her email or voicemails.
Amara also suggested that audio of the previous testimony she gave to the commission
in 2016 was not available. Mark indicated that he worked with staff at OHA to respond
to her records request. Amara said she never received a copy of her 2016 testimony.
The meeting concluded with a discussion between an un-named member of the public
and Ruben around the clarification of an OUD diagnosis.
Adjournment Nora Adjourned 11:50 AM. Next meeting: February 21, 2019Oregon Pain Commission Bylaws – Draft 2 Section 2. Mission: The Commission’s mission is to improve pain management in the State of Oregon. The mission is to provide Oregonians access to the best pain management options available. The Commission will endeavor to improve pain management through education and, development of collaborative endeavors, and distribution of practice recommendations and research. The Commission shall represent Commented [KMK1]: I don’t know that we really do the complex individual and community concerns of pain management to the Governor and the either of these. Delete? Legislative Assembly. The Commission shall develop a comprehensive pain management education Commented [KMK2]: Again, I think we are failing in this program curriculum and update it biennially. The Commission shall work with health professional area. Thoughts? regulatory boards, professional education organizations, other health boards, committees and task forces, to develop compassionate responsible pain management for Oregonians based on the best research and guidelines available. Section 3. Principles and Values – Work with national and international bodies contributing to advances in pain management. Work co-operatively with health professional regulatory boards, committees and task forces to improve pain management in the State of Oregon. Serve Oregonians living with pain by understanding, and addressing, their experiences and barriers to treatment.
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