MT Pain Initiative White Paper by Montana Connect Magazine

Recommendations for Improving Pain and Symptom Management in Montana A White Paper of the Montana Pain and Symptom Management Task Force

February 2008

Prepared by Lindsay Joss Iudicello

A special thank you goes to the American Cancer Society for its financial and staff support of the Montana Pain and Symptom Management Task Force (MPSMTF) and for the printing and distribution of this paper. The MPSMTF would also like to thank the Alliance of State Pain Initiatives, American Cancer Society National Government Relations Department and the Pain and Policy Studies Group for their resources and technical support.

For additional copies of this paper and for more information on how to get involved with the newly formed Montana Pain Initiative please contact: Montana Pain Initiative c/o American Cancer Society, Great West Division Missoula Office 3550 Mullan Road, Suite 105 Missoula, MT 59808 www.mtpain.org 1.877.488.7723, option 3 or 1.406.728.1004, ext. 208

EXECUTIVE SUMMARY Untreated and under-treated pain is a serious public health problem in Montana and the United States, often resulting in substantial physical, personal and social costs. Though pain and symptom management are fundamental to medical practice, they are complex as they depend upon multiple factors, including patient self-report; provider assessment and practice; availability of treatment options and referral networks; and institutional, state, and federal policies. The Montana Pain and Symptom Management Task Force (MPSMTF) was founded as a result of Senate Joint Resolution 28 passed by Montana Legislature in 2005. This resolution recognized the formation of a task force that would be given the task of assessing pain management practices and policies in Montana and making recommendations aimed at improving pain management throughout the state. This white paper, Recommendations for Improving Pain and Symptom Management in Montana, is the MPSMTFâ&#x20AC;&#x2122;s report of its findings and resulting recommendations. The resolution founding the task force states in part: Be it further resolved, that the American Cancer Society and the leadership of the task force are encouraged to give the task forceâ&#x20AC;&#x2122;s report and recommendations the widest circulation practicable so that implementation of the recommendations made by the task force become a collaborative effort between public and private bodies and organizations with the most influence on privately furnished health care and on public policy. 1 In keeping with this resolution, the MPSMTF submits this report and the following recommendations to the Montana Legislature, the Governor, and the Director of the Department of Public Health and Human Services and to all those who are interested in improving pain management in Montana. The report contains the following recommendations: x Recommendation 1: Integrate pain surveillance into existing statewide health monitoring systems. x Recommendation 2: Support initiatives that will conduct large-scale studies of patients, health care providers, and pain management systems in Montana. x Recommendation 3: Support efforts to create a Montana Pain Initiative x Recommendation 4: Build Institutional Commitments to Improving Pain and Symptom Management x Recommendation 5: Modify existing and adopt new policies that could enhance pain and symptom management in Montana. x Recommendation 6: Require or encourage provider practice improvement education in pain and symptom management. x Recommendation 7: Encourage licensing boards and professional associations to regularly inform licensees and members about pain management policies and guidelines. x Recommendation 8: Encourage development of public education regarding effective pain management. x Recommendation 9: Encourage development of public education regarding patient advocacy. 1

Montana 59th Legislature. Joint Resolution 28. 2005. 13 Mar. 2007 < http://data.opi.state.mt.us/bills/2005/BillPdf/SJ0028.pdf> MPSMTF White Paper February 2008

INTRODUCTION Untreated and under-treated pain is a serious public health problem. The American Pain Foundation estimates that 76.5 million people suffer from persistent pain.2, 3 Pain and other symptoms can be debilitating, causing not only physical strain but serious financial, social, and quality of life issues for many pain sufferers. It is estimated that chronic pain in the United States costs $100 billion annually in lost wages, worker productivity and health care expenses. 4 Pain and symptom management are complex, multi-faceted issues. Social, cultural and psychological factors play significant roles in the experience of pain, the willingness or reluctance to report it, and the way it is managed. 5 Disparities in pain treatment and experience exist between men and women, veteran and non-veteran populations, racial and ethnic groups, and elderly populations. Factors such as racial profiling for diversion, gender-bias in treatment, and higher rates of pain incidence for institutionalized elders all contribute to complexity in pain management. 6 Furthermore, some pain medications have the potential to be abused. Resultant efforts to curb abuse and diversion have created barriers to effective pain management including fear of regulatory scrutiny by some providers, interference with legitimate medical practice through suggestions that opioid analgesics are a last resort in pain treatment, and undue burdens in requirements for prescribing and dispensing of opioids. Effective pain management cuts across professional disciplines and may include a variety of providers and modalities of treatment. Health care systems, however, are generally compartmentalized and do not necessarily facilitate easy communications among providers. Insurance coverage, similarly, is not comprehensive: reimbursement for pain treatment may be limited and may tend to over-emphasize certain modalities. The Montana Pain and Symptom Management Task Force (MPSMTF) is a multidisciplinary coalition made up of health care professionals, health care organizations, elected officials, medical consumers, and other interested persons, dedicated to promoting pain and symptom management in Montana. 7 MPSMTF is dedicated to supporting the public, patients, health care providers, and legislators with educational, consulting, and research activities that work to improve the quality of life for people experiencing acute and chronic unremitting pain in Montana. The task force provides balanced and expert information and recommendations to

American Pain Foundation: Pain Facts and Figures. Jan. 2007. American Pain Foundation. 13 Mar. 2007 <http://www.painfoundation.org/page.asp?file=Newsroom/PainFacts.htm>. 3 Special Feature: Pain Introduction: Prevalence and Duration of Pain among Adults in the Month Prior to Interview in â&#x20AC;&#x153;Health, United States, 2006: With Chart Book on Trends in Health in Americans;â&#x20AC;? Centers for Disease Control, National Center for Health Statistics; Hyattsville, MD: 2006 <http://www.cdc.gov/nchs/data/hus/hus06.pdf> 4 United States. National Institutes of Health. NIH Guide: New Directions in Pain Research I. 4 Sept. 1998. 13 Mar. 2007 < http://grants.nih.gov/grants/guide/pa-files/PA-98-102.html>. 5 United States. National Center for Health Statistics. Health, United States, 2006: With Chartbook on Trends in the Health of Americans. 2006. Hyattsville, MD: 68-71. 13 Mar. 2007. < http://www.cdc.gov/nchs/data/hus/hus06.pdf>. 6 American Pain Foundation: Pain Facts and Figures. Jan. 2007. American Pain Foundation. 13 Mar. 2007 <http://www.painfoundation.org/page.asp?file=Newsroom/PainFacts.htm>. 7 A list of MPSMTF members can be found in Appendix A. MPSMTF White Paper February 2008

appropriate governing boards, which may include but should not be limited to the state legislature and state agencies on topics related to pain and symptom management. Founded by the 2005 Montana Legislative Sessionâ&#x20AC;&#x2122;s Joint Resolution, SJ 28, the MPSMTF was charged with assessing the state of pain and symptom management practices and policies in Montana, and making recommendations to improve pain and symptom management throughout the state. Accordingly, the MPSMTF planning committee convened in May, 2005 to begin recruitment for task force membership. American Cancer Society Great West Division acted as the recruiting partner in formation of the MPSMTF and has been the main financial contributor to the task force as it was founded without a legislative appropriation. Task force members were recruited with a wide variety of expertise and interests. In total the task force has 30 members, representing public and private entities, health care institutions and professional associations, with representatives from a variety of professions including physical therapists, dentists, chiropractors, consumer advocates, physicians, nurses, pharmacists, and legislators. Through its founding mandate, MPSMTF was charged first with assessing the state of pain and symptom management practices and policies in Montana and secondly with making recommendations aimed at improving pain and symptom management to appropriate public and private organizations as directed by the outcome of the assessments. Upon convening, the MPSMTF drafted and adopted the Montana Pain and Symptom Management Standard of Care 8 in order to have a mutually recognized definition of what constitutes quality pain and symptom management practice. The Montana Pain and Symptom Management Standard of Care consists of the following principles: x Reports of pain and symptoms are taken seriously and are treated with dignity and respect by all health care professionals. x Pain and symptoms are thoroughly assessed and promptly treated. x Patients are informed by the health care provider about what may be causing the pain and/or symptom(s), possible treatments, and the benefits, risks and costs of each. x Patients participate actively in decisions about how to manage their pain and symptoms. x Pain and symptom control is reassessed regularly and the treatment adjusted if the pain or symptom has not been eased. x Patients are referred to a pain specialist if the pain persists. x Patients obtain clear and prompt answers to their questions, are allowed time to make decisions, and are allowed to refuse a particular type of treatment if they choose. x Health care professionals utilize nationally recognized Pain and Symptom Treatment Guidelines 9 to identify and optimize individual treatment plans. Upon adoption of the Montana Pain and Symptom Management Standard of Care, the MPSMTF circulated it to health care and health care related organizations and associations throughout the 8

The Montana Pain and Symptom Management Standard of Care is adapted from the Pain Care Bill of Rights created by the American Pain Foundation. See http://www.painfoundation.org for more information. 9 Pain and Symptom Treatment Guidelines are specific to different disciplines. For a list of some treatment guidelines see Appendix B. MPSMTF White Paper February 2008

state. The standard of care was sent with a letter explaining the purpose of the MPSMTF, introducing the standard of care, and asking recipient organizations to sign-on in support of the standard. The MPSMTF received a positive response to the introduction of the standard of care. Twenty-five organizations signed on in support of the standard of care. For a complete list of supporting organizations see Appendix F. Based upon the standards put forth in the Montana Pain and Symptom Management Standard of Care, the MPSMTF developed three instruments designed to assess attitudes and experiences regarding pain and symptom management practice in Montana from three distinct perspectives: x Health care providers; x Health care consumers; and, x Health policy and insurance providers. Due to the limited financial resources of the task force, the MPSMTF was able only to administer the health care consumer survey. The methodology and results of this survey are discussed below. The MPSMTF recommends that assessments of health care providers and health policy/insurance providers are undertaken when finances allow. Though the task force was able to draw on its diverse expertise, literature review, and anecdotal evidence to frame its recommendations, assessment of health care providers and health policies would offer a more detailed picture of pain and symptom management practices and barriers in Montana.

HEALTH CARE CONSUMER SURVEY Methods and Findings The Joint Resolution, SJ 28, which founded the Montana Pain and Symptom Management Task Force, reads in part: it is the intention of those who will participate on the task force to hold public hearings to gather information from the public on issues pertaining to pain and symptom management and to then provide advice and recommendations to appropriate public and private entities. 10 The MPSMTF developed two methods to gather information from the public, as directed by SJ 28. A survey instrument was created to collect information about peopleâ&#x20AC;&#x2122;s perceptions about pain, their experience of pain, and how their health care providers have addressed their pain. 11 Secondly, the MPSMTF held eight public forums around the state, giving people an opportunity to discuss pain issues and to fill out the survey. Despite efforts to publicize the forums, there was poor turn-out, necessitating the distribution of additional surveys through other methods. MSU-Bozeman School of Nursing students took the surveys to flu clinics in Missoula and the Flathead and asked people attending the clinics to complete them. Additionally, the task force contacted several health care providersâ&#x20AC;&#x2122; offices and asked them to circulate the survey among their patients. Two chiropractors, two family practitioners, and two pain specialists participated. 10

Montana 59th Legislature. Joint Resolution 28. 2005. 13 Mar. 2007 < http://data.opi.state.mt.us/bills/2005/BillPdf/SJ0028.pdf> 11 An annotated version of the MPSMTF consumer survey can be found in Appendix D. MPSMTF White Paper February 2008

Finally, task force members were asked to circulate surveys as well. The task force received 329 completed surveys. Admittedly, convenience sampling of this sort does not provide information generalizable to all Montanans. However, the survey results still tell a story that is important to hear as they do provide insight into some Montanans’ perceptions of pain, experience with pain, and thoughts about the pain management they have received. Experience with Pain Almost 70 percent (69.9%) of survey respondents reported that a member of their household has had chronic pain. Of those, 9 94% report that pain is impacting their household through limiting activities, 9 68.5% indicate that the household member’s pain is causing extra expenses in medicine and other care, and 9 30.6% report lost wages as the pain caused the household member to miss work. Sixty-four percent (64.2%) of survey respondents replied “yes” when asked if they had ever had chronic pain. Of the survey respondents who have experienced chronic pain, 9 86.2% report having experienced pain in the last month, 9 80.1% report moderate to severe pain, 9 56.6% say they have experienced chronic pain for more than three years, 9 95.9% say that their pain limits their activities, 9 61.7% indicate that they have incurred extra expenses for medicine and other care, 9 24.4% have lost wages for missing time at work due to pain. Experience with Pain Management Roughly 60 percent of total respondents (59%) agreed or strongly agreed that their doctor believes them when they report having pain. However, 38.9 percent of respondents opposed or strongly opposed the statement “whenever I’ve had pain, it’s been well controlled.” And 26 percent admit to some ambivalence over this statement, choosing to neither support nor oppose it. Of the 64 percent of respondents who report having experienced chronic pain, 87 percent have told their health care provider that they are having pain. While most (70.8%) feel that their health care provider treats them with respect and dignity, over one-third of respondents who have experienced chronic pain (36.3%) do not feel that their health care professionals ask good questions to learn about their pain and how their pain impacts their daily life. Additionally, only around half of those experiencing chronic pain (53.5%) feel that their health care providers regularly monitor their progress by asking about their pain and ability to function at every visit. Similarly, only half (52.6%) report that their treatment is adjusted if their pain has not been eased or their ability to function has not significantly improved. A full third of respondents who have experienced continuing pain (33.5%) report having never been referred to any other provider for their pain, while 9 9 9 9

45% have been referred to a physical therapist, 20.9% to a chiropractor, 17.3% to a pain specialist, and 7.9% to a naturopath.

MPSMTF White Paper February 2008

Attitudes about Pain and Pain Management Pain did not seem to be a taboo subject with most respondents, as almost 60 percent (57.6%) strongly opposed the statement that “’good patients avoid talking about pain.” Generally, respondents were optimistic about pain relief with the majority (59.3%) supporting or strongly supporting the statement that pain can be effectively relieved. While more than one quarter of respondents (27%) neither opposed nor supported the statement “it is easier to put up with pain than with the side effect of the pain medicines,” almost half (48.7%) either opposed or strongly opposed that statement. Correspondingly, most seem to think that pain medicines are effective as 57.9 percent did not agree with the statement “pain medicine cannot really control pain.” Respondents also seem to have some openness to non-pharmacological methods of pain control. More than three-quarters of respondents (76.2%) believe that pain medicines (prescriptions and ‘over-the-counter’ drugs) are not the only effective way to relieve pain. Despite the general optimism regarding pain relief, some respondents also evidenced adherence to common myths about pain and pain management. Almost three in ten respondents (29.5%) believe that most people taking pain medicines will become addicted over time and one-third (33%) believe that people get addicted to pain medicine easily. More than one-quarter of respondents (27.4%) believe that pain medicine should only be taken when pain is severe. A sizeable minority (41.5%) agreed that it is important to take the lowest amount of medicine possible and save larger doses for later.

RECOMMENDATIONS Central to the founding mandate of the Montana Pain and Symptom Management Task Force is the task of providing: advice and recommendations to appropriate public and private entities on pain and symptom management, including advice and recommendations concerning acute and chronic pain and symptom management treatment practices, state statutes and rules regarding pain and symptom management, and use of alternative therapies for pain and symptom management. 12 Accordingly, the MPSMTF has developed several key recommendations aimed at improving pain and symptom management in Montana through surveillance and assessment, institutional and policy changes, and education and outreach. The following sections address each of these recommendations.

Montana 59th Legislature. Joint Resolution 28. 2005. 13 Mar. 2007 < http://data.opi.state.mt.us/bills/2005/BillPdf/SJ0028.pdf> MPSMTF White Paper February 2008

EVALUATIVE RECOMMENDATIONS Recommendation 1: Integrate pain surveillance into existing statewide health monitoring systems. In order to establish a high-definition picture of the incidence of pain in Montana and the impact of pain on the health of Montanans, the MPSMTF recommends that the Montana Department of Public Health and Human Services (DPHHS) explore current measures of pain and incorporate pain surveillance measures into the health surveillance schedule regularly conducted by DPHHS. Regular inclusion of pain measures in DPHHS’ administration of the Behavioral Risk Factor Surveillance System (BRFSS) would provide important baseline information regarding pain incidence in Montana and the impact of pain on Montanan’s health and quality of life. Continued monitoring of pain’s impact in Montana through regular repetition of these measures would provide scientifically rigorous information which could inform program planning and evaluation. Recommendation 2: Support initiatives that will conduct large-scale studies of patients, health care providers, and pain management systems in Montana. The MPSMTF recommends that continued evaluation and assessment of pain and symptom management practices in Montana be undertaken. Due to limited resources, the task force was unable to conduct as many assessments as are needed for a thorough review of the systems influencing pain management in Montana. In particular, the task force recommends further evaluation of the following: x Insurance – Nearly three-quarters of respondents (74.5%) to the MPSMTF’s health care consumer survey cited health insurance coverage issues as one of the barriers to pain management in Montana. As with worker’s compensation, pain is not treated by most insurance companies as a disease system. Thus coverage for pain care is often limited in scope and may not cover the range of treatment that may be indicated for comprehensive pain management. The MPSMTF recommends that the Montana Pain Initiative work with representatives from Montana’s Health Insurance providers to assess pain treatment coverage. x Health care providers– The MPSMTF recommends the administration of an assessment across the spectrum of care of health care providers’ knowledge, practice, and attitudes toward pain and symptom management. In 1997, an assessment of Missoula health care providers was conducted that revealed inconsistencies in pain assessment, perceptions that regular pain assessment would further burden already heavy workloads, and misperceptions about the relationship between pain and other vital signs. 13 This evaluation was part of a baseline assessment for a community-wide Pain as the Fifth Vital Sign Project, a project which successfully integrated regular pain assessment into the practices of several Missoula-area health care organizations and began to raise community expectations for pain management. Administering an assessment of health care providers, similar to what was done in Missoula a decade ago, would assist in identifying barriers to good pain management and help direct programming. x Workers’ Compensation – The Workers’ Compensation system is essentially injurydriven. As workers receive benefits on claims directly related to a workplace injury, the 13

D. Mayer, L. Torma, I. Byock, K. Norris. “Speaking the Language of Pain” AJN. 101 (2) 44-49. Feb. 2001.

MPSMTF White Paper February 2008

treatment focus is directed toward the physical. Though pain is a physical sensation it is also a subjective experience and can continue even after its physical cause has healed. As one author notes, “all disease and injury are disruptions not only on a physical or cellular level, but also on a personal and social one.” 14 Evidence suggests that roughly 10 percent of Workers’ Compensation cases account for 90 percent of the cost. Many of these costly cases are claimants who are experiencing on-going pain issues.15 While there are suggestions that claimants’ rehabilitation can be increased while costs to employers and the Workers’ Compensation system can be decreased through a model of disease management that addresses psychosocial issues throughout the course of care, the MPSMTF recognizes that further study of the current system needs to be undertaken. The MPSMTF recommends that the following questions be investigated: How are workers’ complaints of pain and other symptoms treated under the Workers’ Compensation system? What would comprehensive pain management under Workers’ Compensation look like and what are the barriers to achieving this? The task force recommends that the Montana Pain Initiative work with representatives of the Workers’ Compensation system to investigate these questions and, as appropriate, make recommendations to the legislature for revision of the state Workers’ Compensation Act. Though administering large-scale scientifically rigorous studies regarding Montanans’ experience with pain and pain management is outside the scope of the MPSMTF, the task force encourages researchers at Montana’s health care institutions and institutions of higher education to look for opportunities to undertake such research.

ORGANIZATIONAL RECOMMENDATIONS Recommendation 3: Support efforts to create a Montana Pain Initiative MPSMTF recommends the creation of a Montana Pain Initiative. Unlike a task force created essentially for evaluation and recommendation, a free-standing Pain Initiative would have the ability to educate and advocate as well as continue to evaluate and recommend. The Montana Pain Initiative will build upon the foundation laid by the MPSMTF, working to enact the recommendations put forth by the MPSMTF and to design and undertake on-going public and professional outreach and education. The creation of a Montana Pain Initiative is a key component to developing a culture within Montana which supports, and actively seeks to provide care in compliance with, the Montana Pain and Symptom Management Standard of Care. Like the MPSMTF, the Montana Pain Initiative will draw its membership from across the spectrum of care, from stake holder organizations, and throughout Montana. Membership may consist of individual and organizational members. In addition to education and outreach, the Montana Pain Initiative will advocate for balanced pain policy in Montana. The Montana Pain Initiative will monitor the legislature for proposals 14

Jurisic, M. “Workers’ Compensation: The difficult ten percent.” JSOnline. 11 Oct. 2005. 13 Mar. 2007 <http://www.jsonline.com/story/index.aspx?id=362264> 15 Ibid. MPSMTF White Paper February 2008

that could influence pain and symptom management in the state, and will seek to make sure that proposals create conditions which facilitate rather than compromise quality pain and symptom management practice. The Montana Pain Initiative will also monitor the state’s public and private insurance formulary committees and be ready to respond to proposals that could restrict access or limit reimbursement for pain therapies. Recommendation 4: Build Institutional Commitments to Improving Pain and Symptom Management Adoption and dissemination of the MPSMTF’s Montana Pain and Symptom Management Standard of Care marked the initial steps in a process the task force recommends continue throughout the state. In order to reduce the number of Montanans experiencing unrelieved acute or chronic pain and other distressing symptoms, Montana’s health care related organizations must develop overarching institutional commitments to improving pain and symptom management. Individual organizations’ support of the Montana Pain and Symptom Management Standard of Care is an important first step toward building such institutional commitment, further steps could include: x Drafting policies and procedures regarding pain care; x Providing mandatory pain information training for all employees involved with patient care; x Building interdisciplinary pain teams; x Monitoring pain management services through the use of continuous-quality improvement teams; x Tying pain management to patient satisfaction; x Building inter-organizational partnerships for pain referrals and advice.

POLICY RECOMMENDATIONS Montana’s professional licensing boards have an important role in directing pain and symptom management practice and policy throughout Montana. The University of Wisconsin Pain & Policy Studies Group (PPSG), a World Health Organization Collaborating Center, whose mission “is to ‘balance’ international, national and state policies to ensure adequate availability of pain medications for patient care while minimizing diversion and abuse, and to support a global communications program to improve access to information about pain relief, palliative care, and policy,” 16 recently released a state by state report card evaluating each state’s statutes, regulations and other governmental policies that influence pain management. Released in September 2006, this report, Achieving Balance in State Pain Policy: A Progress Report Card (Second Edition) 17 , gave Montana a C+ for its state pain policies. Montana’s grade was based upon the following policies: x Controlled Substances Act: Montana Code Annotated § 50-32-101 x Medical Board Guideline: Montana Board of Medical Examiners. Statement on the Use of Controlled Substances in the Treatment of Intractable Pain, Guidelines for Prescribing 16

Pain & Policy Studies Group: About the PPSG Page. 27 Feb. 2007. Pain and Policy Studies Group. 13 Mar. 2007 < http://www.painpolicy.wisc.edu/about.htm>. 17 The full report is available at: < http://www.painpolicy.wisc.edu/Achieving_Balance/PRC2006.pdf>. MPSMTF White Paper February 2008

Opioid Analgesics for Chronic Pain. Montana Medical Association Bulletin. Vol. 51. pp. 3-4. June 1996. Adopted: March 15, 1996. Joint Policy Board Statement: Montana Board of Medical Examiners, Board of Nursing, and Board of Pharmacy. Statement of the Prescribing and Filing of Controlled Substances in the Treatment of Chronic Pain. Adopted: July 27, 2002.

Montana received a grade of C+ from the PPSG evaluation based upon “positive” and “negative” provisions in these policies identified by the PPSG. PPSG classified provisions in the policies as positive and negative upon a review of language that could potentially enhance or impede pain management. Montana received points toward its grade for provisions that had the potential to enhance pain management including provisions that: x Affirm that opioids are part of professional practice; x Encourage pain management; x Address fear of regulatory scrutiny; x Represent the idea that efforts to reduce misuse of controlled substances should not interfere with appropriate medical practice; x Recognize robust treatment goals including quality of life and patient functioning. Montana received points which detracted from its overall grade for provisions that had the potential to impede pain management, including provisions that: x Suggest the prescription of opioids is a last resort; x Restrict medical decisions. Recommendation 5: Modify existing and adopt new policies that could enhance pain and symptom management in Montana. Montana has an opportunity to improve its policies that influence pain and symptom management throughout the state. The MPSMTF recommends that: x

The Montana’s Board of Medical Examiners consider adopting the Federation of State Medical Boards’ (FSMB) Model Policy for the Use of Controlled Substances for the Treatment of Pain. This model policy explicitly affirms that pain management is “integral to the practice of medicine; that opioid analgesics may be necessary for the relief of pain; that the use of opioids for other than legitimate medical purposes poses a threat to the individual and society; that physicians have a responsibility to minimize the potential for the abuse and diversion of controlled substances; and that physicians will not be sanctioned solely for prescribing opioid analgesics for legitimate medical purposes.” 18 The Controlled Substances Act is amended to state that controlled substances are necessary for public health as is stated in the Federal Controlled Substances Act. 19

Federation of State Medical Boards of the United States, Inc. Model Policy for the Use of Controlled Substances for the Treatment of Pain. May 2004. 13 Mar. 2007 < http://www.painpolicy.wisc.edu/domestic/model04.pdf>. 19 The Federal Controlled Substances Act reads in part: “Many of the drugs included within this subchapter have a useful and legitimate medical purpose and are necessary to maintain the health and general welfare of the American people” (Title 21 Controlled Substances Act §801(1)). MPSMTF White Paper February 2008

In addition to adoption of the FSMB Model Policy, Montana’s professional licensing boards should consider guidelines for symptom management, communicating the message to their licensees that 1) pain and symptom management are integral to professional practice and that 2) communication between professional disciplines is essential for optimal pain and symptom management.

Recommendation 6: Require or encourage provider practice improvement education in pain and symptom management. The MPSMTF recommends that decision making bodies in Montana such as the Montana Legislature, Montana’s professional licensing boards, hospital systems, and professional associations require or encourage health care professionals to participate in provider practice improvement seminars in pain and symptom management. Results from the task force’s health care consumer survey suggest respondents consider lack of health care provider training in pain management to be a considerable barrier to effective pain control in Montana. Eighty-one percent of respondents who feel there are barriers to pain management, identified lack of health care provider training as one such barrier. As of 2005, ten states have adopted provisions that either require or encourage medical board licensees to complete continuing medical education programs in pain treatment in an effort to provide physicians with current clinical information and practice strategies. The MPSMTF recognizes that traditional lecture-style CMEs may not be the most effective educational strategy for improving providers’ knowledge and skill base in pain and symptom management. Thus, the task force recommends that the Montana Pain Initiative consider other educational strategies such as interactive CMEs, provider practice improvement seminars, and the development of community-based guidelines that are championed by locally respected providers. 20, 21 Such interactive and community-based approaches have shown promising results for changing provider practice and improving patient outcomes. 22 Further research of these various types of continuing education strategies is recommended.

Davis, Dave, et. al., “Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA, September 1, 1999;282(9):867-74 21 Calkins, Evan, et. al., “The small group consensus process for changing physician practices,” HMO Practice, September 1995, 9(3):107-110. 22 Centers for Occupational Health and Education. White Paper Physician Mentoring and Training. 16 Nov. 1999, http://www.lni.wa.gov/ClaimsIns/Files/Providers/ohs/WhitePaper/MentoringTraining.pdf MPSMTF White Paper February 2008

EDUCATION RECOMMENDATIONS Professional Education As was stated earlier, the MPSMTF recommends an assessment of Montana providers’ knowledge and practices regarding pain and symptom management. Upon completion and analysis of the provider assessments, the task force recommends that the Montana Pain Initiative develop materials about pain management topics which can be used in in-services and workshops throughout the state. Such sessions could include topics such as: x Pain assessment: rating, function, impact on daily life; x Building a referral network; x Pharmacological and non-pharmacological methods of treating pain; x Pain and depression; Recommendation 7: Encourage licensing boards and professional associations to regularly inform licensees and members about pain management policies and guidelines. The Montana professional licensing boards and professional health care associations have great potential to influence pain and symptom management in the state. Through communicating their policies and guidelines to their licensees and members, the licensing boards and professional associations can reinforce the message that pain and symptom assessment, treatment, and continued management are critical components of standard care. The MPSMTF recommends that the Montana Pain Initiative work with each of Montana’s licensing boards for health care professionals and professional associations to communicate with their licensees and members that pain management is an important and integral part of care, and to communicate their policies and guidelines. Health Care Consumer/ Public Education Recommendation 8: Encourage development of public education regarding effective pain management. Results from the MPSMTF’s health care consumer survey point to the importance of public education aimed at dispelling the myths surrounding pain control methods. Only 31.5 percent of respondents disagreed or strongly disagreed with the statement “when you take pain medicine your body becomes used to its effects and pretty soon it won’t work anymore.” Clearly many believe that tolerance is a significant and concerning problem with pain medications. Similarly, 29.5 percent of respondents believe that most people taking pain medicines will become addicted over time and 33 percent believe that people get addicted to pain medicine easily. Fears about tolerance and addiction may contribute to other misconceptions commonly held regarding pain treatment. More than four in ten respondents (41.5%) to the task force’s health care consumer survey, agreed or strongly agreed that it is important to take the lowest amount of medicine possible and save larger doses for later when the pain is worse. Twenty-seven percent of respondents agreed or strongly agreed that pain medicines should only be taken when pain is severe. These attitudes regarding pain management and the myths which reinforce such attitudes likely contribute to inadequate pain care and disrupted treatment.

MPSMTF White Paper February 2008

The MPSMTF recommends public outreach focusing specifically on dispelling addiction myths and communicating appropriate pain treatment practices such as treating pain before it becomes severe. Recommendation 9: Encourage development of public education regarding patient advocacy. In addition to public outreach focused on dispelling commonly held misconceptions about pain treatment, the MPSMTF also recommends public education encouraging pain treatment advocacy and individualsâ&#x20AC;&#x2122; active participation in taking control of pain. Almost one quarter of respondents (23%) to the task forceâ&#x20AC;&#x2122;s health care consumer survey who reported experiencing chronic pain, said they did not feel like they were active participants in decision making about their pain treatment plan. Almost one-third of respondents (31.7%) were not able to respond affirmatively when asked if they felt they had an adequate amount of time to think about the treatment plan their health care provider recommended. Almost one-quarter (23.9%) were not able to respond affirmatively when asked if they felt they were able to refuse recommendations or ask for alternative treatment options. Forty-nine percent of respondents said they are unaware of their rights regarding referral for health care in Montana, and an additional 16.7 percent didnâ&#x20AC;&#x2122;t know whether or not they were aware of these rights. Additionally, of those respondents who reported experiencing chronic pain, 70.4 percent said they do not monitor their pain and how their treatment affects their pain such as through keeping a daily log. This information suggests that those experiencing pain and their caregivers could benefit from education focused on the following: x Information about integrated care, which offers a full range of treatment options including alternative pain management therapies; x Strategies for monitoring and reporting pain; x Strategies for communicating with a health care provider about setting treatment goals; x Information about pain specialists and referral rights. NEXT STEPS The MPSMTF recognizes the sizeable number of recommendations put forward in this white paper. In order to begin work enacting this agenda, the MPSMTF has formed the Montana Pain Initiative (MTPI). To move the Initiative forward, a transition team was developed. One of the first activities of the MTPI was to conduct a pain management conference on April 27-28, 2007. In addition to conducting the April conference, in July 2007, the MTPI received a $20,000 Pain Improvement Partnership grant from the Alliance of State Pain Initiatives funded by the Lance Armstrong Foundation. This 10-month program has recruited, and will provide training and support for 13 long-term care facilities, home health agencies, and rural community hospitals in Central and Eastern Montana to assist them in making policy and structural changes for the purpose of improving their assessment and management of pain.

MPSMTF White Paper February 2008

In September 2007, the Montana Pain Initiative began its work by holding a strategic planning session to: x Create a governance structure; x Strategize how to accomplish the work outlined in the recommendations of this white paper; x Create plans for evaluating the impact of implementation as the work goes forward; and, x Create a concrete plan to guide resource attainment. Following the Strategic Planning Retreat, the transition team of the Montana Pain Initiative, as instructed by the Retreat participants, reviewed the five-year strategic plan and the governance and membership structure. After final approval of the Retreat participants, recruitment of leadership and membership began. Sections of the Montana Pain Initiative’s 2007 – 2012 Strategic Plan: A Roadmap for Success can be found in Appendix D. For a full copy of the strategic plan, contact the Montana Pain Initiative housed in the American Cancer Society Missoula Office at 406.728.1004, ext. 208.

The following Appendices are included: APPENDIX A: QUESTIONS ASKED FOR PUBLIC COMMENT APPENDIX B: PUBLIC COMMENT APPENDIX C: 2007 MONTANA PAIN AND SYMPTOM MANAGEMENT TASK FORCE LIST APPENDIX D: MONTANA PAIN INITIATIVE OBJECTIVES AND ACTIVITIES AND GOVERNANCE AND MEMBERSHIP STRUCTURE 2007 – 2012 APPENDIX E: RESULTS FROM THE MPSMTF COMMUNITY SURVEY APPENDIX F: MONTANA PAIN AND SYMPTOM MANAGEMENT INITIATIVE STANDARD OF CARE STATEMENT APPENDIX G: PAIN AND SYMPTOM TREATMENT GUIDELINES

MPSMTF White Paper February 2008

APPENDIX A QUESTIONS ASKED FOR PUBLIC COMMENT

1. Do you have any general comments or suggestions about the White Paper? 2. What do you like best about the White Paper? 3. Is there anything in the White Paper that would be potentially counterproductive to its implementation and usefulness? 4. In your opinion, what is missing from the White Paper? 5. How do you see the White Paper benefiting either you as an individual, your practice and patients, your community, the State of Montana?

MPSMTF White Paper February 2008

APPENDIX B PUBLIC COMMENT At the Montana Pain Initiative Conference in April of 2007, The Montana Pain and Symptom Management Task Force released a draft version of this white paper. The release of the paper initiated a period of public comment during which time conference participants and the general public were invited to comment on the recommendations put forward by the MPSMTF. The public comment period closed in October 2007. The MPSMTF thanks all those who took the time to comment on the white paper. Public comments received on the white paper fell into the following general categories: x Provider education concerns: particularly regarding over-medication and the need to highlight outreach to primary care providers; x The MPSMTF’s lack of specific attention to medical marijuana; x Privacy concerns regarding the MPSMTF’s public survey tool; x Suggestions to emphasize an integrative approach to pain and symptom management. Provider Education Concerns Several public comments highlighted some concerns regarding provider training in pain management. One commenter suggested the MPSMTF specifically address problems of over medication. Several others pointed out the importance of providing pain management outreach and training to Montana’s primary care providers. Due to the large rural nature of the state many Montanans living with chronic pain will depend upon their primary care providers to manage their pain. The MPSMTF acknowledges that incidences of over medication for pain can occur and can have devastating results. The potential for over medication adds to the complexity of addressing pain and symptom management from a public health standpoint. The Montana Pain Initiative will work to include awareness of the risks of over medication in provider trainings that will be developed under Recommendation Six. Similarly, the suggested emphasis on targeted trainings for Montana’s primary care providers is noted and will also be developed by the Montana Pain Initiative under Recommendation Six. Medical Marijuana The majority of public comments the task force received were in regards to medical marijuana. In general, these comments asked the MPSMTF to specifically discuss medical marijuana as an appropriate pain treatment option and to analyze the education and policy barriers which continue to inhibit its use. The MPSMTF recognizes that medical marijuana is a legal treatment option for Montanans living with chronic pain. The task force supports efforts which improve patient access to MPSMTF White Paper February 2008

effective evidence-based pain treatment and that provide Montana providers with more pain management options. However, given the wide number of pain treatment modalities (e.g. pharmacological treatment, physical therapy, acupuncture, chiropractic services, to name a few) it is not within the scope of this paper to single out particular pain treatment regimens for special discussion. Privacy concerns Through the public comment period, the task force received a comment of concern about the public survey tool used by the task force. The comment voiced privacy concerns over pieces of demographic data collected in the survey tool such as race, income, and gender. As this information does not, on its face, have to do with pain and symptom management, the commenter was confused as to why the task force would collect such personal information. The MPSMTF appreciates the privacy of all those who participated in the public survey. The information gathered by the survey was entirely anonymous, thus no information received leads back to any one individual. The task force gathered demographic information such as race, income, education level, and gender in order to be able to speak about the surveyâ&#x20AC;&#x2122;s participants collectively. Public health research often uses such demographic inquiries to make analyses between groups. For example, a survey tool which asks participants to classify their income allows researchers to see if certain income groups are more likely to experience living with pain. Such survey techniques not only allow researchers to speak more precisely about survey results, but this information can also be used to guide the development of targeted outreach. Integrative Approach Several public comments mentioned the importance of an integrated multi-disciplinary approach to pain and symptom management. Comments ranged from suggesting that patients are given better information about how to use many methods for pain care, to suggesting that special clinics are created to provide comprehensive, interdisciplinary pain care. The MPSMTF strongly supports all efforts which improve patient access to pain care and improve communication and collaboration between providers of different disciplines and modalities. Through the active participation of members from different disciplines across the spectrum of pain care and through a values commitment to integrative pain care, the task force has consistently emphasized a multi-disciplinary approach to pain care options. As the Montana Pain Initiative moves forward it will keep a multi-disciplinary, integrative approach as a central value as it implements the recommendations put forward in this white paper.

MPSMTF White Paper February 2008

APPENDIX C 2007 MONTANA PAIN AND SYMPTOM MANAGEMENT TASK FORCE LIST First Name Michael

Last Name Bergkamp, ND

Company Montana Association of Naturopathic Physicians Montana Senior Citizens Association Montana Board of Pharmacy Montana Medical Association and American Association of Hospice and Palliative Care Montana Pharmacy Association and University of Montana School of Pharmacy Bozeman Deaconess Hospital Palliative Care Consultants St. Vincent Hospital Mountain-Pacific Quality Health Foundation Department of Public Health and Human Services

City Helena

Betty Starla Kathryn

Beverly Blank, PharmD Borgenicht, MD

Lee Ann

Bradley, PharmD, BCPS

Deanna

Brame, MSN, RN, C, CHPN

Jeannine Gayla

Brant, RN, MS, AOCN Brown, BSN, RN, LNHA

Roger

Citron, R.Ph.

Kristina Becky Joan

Davis, RN Deschamps, R.Ph. Eliel

American Cancer Society - Volunteer Kalispell Regional Hospital Montana Department of Justice Attorney General's Office Office of Consumer Protection and Victim Services Big Sky Hospice Yellowstone City-County Health Department Montana Chiropractic Association Montana Nurses Association St. Peter's Hospital Montana Physical Therapy Association Montana Dental Association Department of Public Health and Human Services State Department of Corrections Montana Spine and Pain Center New West Montana State Senate Montana Board of Medical Examiners Montana State University-College of Nursing Carroll College Parish Nurse Center Hospital Palliative Care Programs

Great Falls Kalispell Helena

Jean

Forseth, MN, RN, CHPN

Scott Teresa Jan Linda Mary Sue

Hansing, DC Henry, MS, RN Jahner Fike-Looser, PT, CLT-LANA, CES McCue Miller, RN, BSN

Liz Randale Robert Carolyn Dwight Linda

Rantz, MD Sechrest, MD Shepard, MD Squires Thompson, PA Torma, MSN, APRN, BC

Deric Staff

Weiss, MD, FACP

Kristin

Nei

Connie

Sage

Missoula

MPSMTF White Paper February 2008

American Cancer Society Montana Government Relations

Helena Helena Bozeman

Missoula

Bozeman Billings Helena Helena

Billings

Helena Missoula Helena Hamilton Helena Helena Missoula Missoula Clancy Missoula Harlowton Missoula

Billings

Missoula

APPENDIX D MONTANA PAIN INITIATIVE OBJECTIVES AND ACTIVITIES AND GOVERNANCE AND MEMBERSHIP STRUCTURE 2007 â&#x20AC;&#x201C; 2012 Using the MPSMTF white paper recommendations, particiants attending the Montana Pain Initiative Strategic Planning Retreat, with the assitance of a facilitation consultant, developed the following objectives and activities to use as guides over the next several years. The governance and membership structure were also determined. Following is an exerpt from the Montana Pain Initiative 5-year Stategic Plan. Objectives Objectives refer to specific measurable results for the initiative's broad goals as articulated by its vision and mission statement. Objectives generally lay out how much of what will be accomplished by when. White Paper Recommendations & Strategies Translated into

Objectives (big picture measurable outcomes)

Support efforts to create a Montana Pain Initiative

By March 2008, create a governance and membership structure for the Montana Pain Initiative and recruit leadership. By August 31, 2008, the Montana Pain Initiative will raise $20,000 in funds to support the Initiativeâ&#x20AC;&#x2122;s mission, projects, and operating costs. By the end of 2010, integrate pain surveillance into existing statewide health monitoring systems for purposes of establishing a baseline measurement of pain incidence and its impact; review and repeat regularly. By the end of 2009, create a process to support existing large-scale studies of patients, health care providers, and pain management systems and/or conduct new studies. By the end of 2009, 50% of hospitals and longterm care facilities in Montana will sign onto the Standard of Care as defined by the Montana Pain Initiative.

Address sustainability

Integrate pain surveillance into existing statewide health monitoring systems.

Support initiatives that will conduct largescale studies of patients, health care providers, and pain management systems in Montana. Build institutional commitments to improving pain and symptom management.

Modify existing and adopt new policies that could enhance pain and symptom management in Montana. MPSMTF White Paper February 2008

By year-end 2012, Montana will achieve an A on the Pain & Policies Studies Group Progress Report Card.

White Paper Recommendations & Strategies Translated into

Objectives (big picture measurable outcomes)

Require or encourage provider practice improvement education in pain and symptom management.

By the end of 2010, the governing boards of medical professionals will each or jointly sign onto a statement recognizing pain as an important clinical issue that necessitates provider practice improvement education. Encourage licensing boards and professional By the end of 2009, encourage Montana associations to regularly inform licensees licensing boards to adopt a practice of making and members about pain management evidence-based annual policy modifications to policies and guidelines. current pain management guidelines and notify members of modifications. Encourage development of public education By the end of 2010, improve public awareness regarding effective pain management. of evidence based pain treatment options and access through the development and implementation of a coordinated multimedia public education campaign. Encourage development of public education By the end of 2009, provide persons with tools regarding patient advocacy. to improve their communication with health care providers regarding pain. Activities and Projects Activities and projects are the vehicles through which the newly formed Montana Pain Initiative will reach its objectives. These strategies range from very broad projects and activities that encompass many of the stakeholder groups previously identified, to very specific projects with a much narrower focus. Using the objectives and the MPSMTF white paper recommendations as a launching point, the retreat participants brainstormed a list of possible projects and activities. The group then analyzed each project to determine whether a sufficient resource infrastructure exists to support their successful implementation. To meet the threshold for continued consideration, each project had to have at least two of the following characteristics in place: x The Initiative leadership has the relevant expertise and/or experience to take on the project x There are willing partners within the Initiative leadership eager to support the activity x There is funding available to complete the project or the project will generate enough resources to pay for itself. x There is a track record of success, within Initiative leadership, or within other state pain initiativeâ&#x20AC;&#x2122;s for the activity x Constituents (pain sufferers, providers, policymakers, etc.) are asking for or involved in a tangible way x It builds or maintains the Initiativeâ&#x20AC;&#x2122;s infrastructure

MPSMTF White Paper February 2008

It is worth noting that all of the projects and activities identified during the brainstorming exercise met the resource infrastructure criteria threshold, providing validation the retreat participants were on track and the recommendations in the white paper are on the mark. The retreat participants recommend to the Montana Pain Initiative that the following projects and activities be undertaken: 1. Develop and implement a capacity building action plan for the Montana Pain Initiative 2. Develop and implement a fundraising action plan for the Montana Pain Initiative 3. Get baseline data on pain and symptom management practices in the state of Montana by: x assisting Montana Department of Public Health and Human Services in developing a pain survey to include in their 2010 Behavioral Risk Factor Surveillance Survey x identifying existing provider, insurance, and workmenâ&#x20AC;&#x2122;s compensation studies x identifying gaps in studies, prioritizing study needs, and developing survey action plans 4. Review and develop guidelines and policies to improve Montanaâ&#x20AC;&#x2122;s grade on the Pain & Policies Studies Group Progress Report Card 5. Review pain sufferers access to care challenges and develop a strategy to address identified gaps 6. Evaluate the success/failure of mandated continuing medical education, research the connection/disconnection between education and behavior change, and develop an action plan based on the findings. 7. Develop and identify advocacy group to build support for the annual review of pain management policies and guidelines. 8. Develop a reporting tool for tracking the receipt of pain management policies and guidelines 9. Develop, distribute, and track distribution of an institutional pain management education tool kit for hospitals and long-term care facilities using existing tools and developing new tools, where needed 10. Form a partnership plan with interested pharmaceutical companies to educate providers on safe prescribing and risk management 11. Form a partnership with the Federation of State Medical Boards and Montana Board of Medical Examiners to distribute to all practicing physicians in Montana, the Federation of State Medical Boardâ&#x20AC;&#x2122;s sponsored book "Responsible Opioid Prescribing: A Physician's Guide." authored by Scott Fishman, MD 12. Finalize and distribute the final MPSMTF white paper 13. Develop and implement a coordinated multimedia community education campaign that addresses pain education and self-advocacy. On the following page is the proposed organizational chart of the Montana Pain Initiative governance and membership structure.

MPSMTF White Paper February 2008

Sustainability

2007- 08 Program Director: Kristin Nei (.25 FTE) Linda Lang (.05 FTE) ACS Admin staff (. 05 FTE)

Contracted Staff

Public Policy

Leadership Development

Provider Practice Improvement

Standing Committees

Executive Committee Chair Vice-Chair Program Director (ex officio) Medical Director ACS Liaison

Finance

x x x x x

Committees

Terms: Staggered 2 year terms - Â˝ of initial Council members will be asked to serve a 3-year term in order to accommodate the staggering.

Comprised of one member of each state association, plus a representative from each of the hospitals and pain centers.

Advisory Council

Public Engagement and Advocacy

Montana Pain Initiative Proposed Organizational Chart

Ad-Hoc Committees â&#x20AC;&#x201C; sub committees, work groups formed as needed, may report to committee(s) or directly to Advisory Council

Membership Open to everyone who supports our mission. Annual membership fee is $35, with a $15 Living Lightly option for those who cannot afford the $35.

APPENDIX E RESULTS FROM COMMUNITY SURVEY

MPSMTF Annotated Health Care Consumer Survey Dear Montanan: Thank you for taking a few moments to fill out the following survey. As the newly formed Montana Pain and Symptom Management Task Force, we are trying to determine how pain is addressed by your health care providers and to try to eliminate any obstacles there may be in providing that care. Your answers will help propose new ways for information to be distributed to the general public, health care providers, and insurers in order to ensure your voices are heard and your concerns are being earnestly addressed. For each survey item below, 9 check the box that best represents your opinion or experience.

1. What do you think is the percentage of the general population in Montana have moderate to severe chronic (persistent) pain?

Less than 25%

2650%

5175%

15.4%

39.2%

23.5%

2. How strongly do you agree with the following statements?

My doctor always believes me when I tell him/her I have pain

“Good patients” avoid talking about pain.

Pain medicines should only be taken when pain is severe.

Whenever I’ve had pain, it’s been well controlled.

Pain medicine cannot really control pain.

Pain can be effectively relieved.

It is easier to put up with pain than with the side effects of the pain medicines.

More than 76% 4.5%

Don’t Know

17.4%

Strongly Support

Strongly Oppose

34.5

25.3

22.5

13.3

4.4

7.0

10.1

8.2

17.1

57.6

14.5

12.9

23.3

20.8

28.4

17.7

17.1

26.3

25.0

13.9

7.8

12.3

22.0

28.8

29.1

32.4

26.9

23.7

10.6

6.4

7.5

16.7

27.0

22.6

26.1

7.8

16.6

20.4

21.0

34.2

8.9

19.1

29.9

25.8

16.2

Pain is just a normal part of aging.

If I have pain it means that my illness has gotten worse.

Pain medicines (prescriptions and ‘over-the-counter’ drugs) are the only effective way to relieve pain.

6.9

5.3

11.6

30.0

46.2

When pain is well controlled, your body heals better.

57.9

21.5

9.7

5.6

5.3

MPSMTF White Paper February 2008

When you take pain medicine your body becomes used to its effects and pretty soon it wonâ&#x20AC;&#x2122;t work anymore.

12.6

23.3

32.7

21.1

10.4

Pain from a broken leg (acute pain) is easier to deal with than chronic pain (like chronic back pain or cancer pain).

30.8

27.2

16.7

13.1

12.2

Most people taking pain medicines will become addicted to the medicines over time.

14.6

14.9

21.9

27.9

20.6

It is important to take the lowest amount of medicine possible to save larger doses for later when the pain is worse.

17.1

24.4

18.4

19.4

20.6

14.7

18.3

29.5

22.8

14.7

People get addicted to pain medicine easily.

3. Are you currently covered by any health care insurance or program including insurance through work/retirement, the military, Medicare, Medicaid, or some other government program?

92.1% 7.6% 0.3%

Yes No Not sure

4. Have any members of your household had chronic pain? 69.9% Yes If yes, how is it impacting your household? Check ALL that apply. 94.0% Limits activities 68.5% Extra expenses for medicine and other care 30.6% Lost wages for missing time at his or her work 30.1% No 5. Have you ever had chronic pain? 64.2% Yes If yes, how is it impacting your household? Check ALL that apply. 95.9% Limits activities 61.7% Extra expenses for medicine and other care 24.4% Lost wages for missing time at your work 36.2% No

STOP HERE IF YOU SAID NO TO QUESTION 5. THANK YOU FOR FILLING OUT THIS SURVEY. INCIDENCE, FREQUENCY & CAUSE OF PAIN 6. Have you experienced mild to severe pain in the last month?

7. Which of the following best describes the frequency of your pain?

MPSMTF White Paper February 2008

Yes 86.2%

No 13.8%

Not sure 0.5%

Every Day Almost Every Day

Several Times a Week

Several Times a Month

Donâ&#x20AC;&#x2122;t Know

44.3%

11.9%

13.8%

8.1%

21.9%

8. Which of the following best describes the severity of your pain?

9. How long have you been experiencing this type of pain?

More than 3 years 56.6%

Severe

Moderate

Mild

24.3%

55.8%

22.8%

1-3 Years 22.9%

Don’t Know 4.9%

6-12 Months 6.3%

1-5 Months 7.8%

Don’t Know

QUESTIONS RELATING TO STANDARDS OF CARE 10. Do you feel there are barriers to pain management in Montana?

Yes 58.6%

No 14.4%

Don’t Know 28.4%

11. If yes to Question 10, check all that you believe to be barriers: a. Health Insurance Coverage issues

Yes 74.5%

No 15.6%

Don’t Know 9.9%

b. Lack of healthcare provider trained in pain management

81.0%

11.7%

7.3%

c. Fear of addiction or other side effects

72.1%

20.7%

7.1%

d. Distance from pain care

58.5%

31.3%

10.4%

Yes 87.0%

No 10.6%

Don’t Know 2.4%

70.8%

18.2%

10.9%

Yes 65.2%

No 27.0%

Don’t Know 7.8%

57.8%

36.3%

5.9%

32.5%

10.2%

6.3%

e. Other barriers you experience: (Please list)

12. Have you told your healthcare provider that you are having pain? 13. If so, do you feel that you are treated with respect and dignity?

14. Do you feel your healthcare professional listens to what you have to say and takes you seriously concerning pain? 15. Do you feel that your healthcare professional asks good questions to learn about your pain and how it impacts your daily life? 16. Once your healthcare professional has learned about how pain is impacting your life, have they provided you with a treatment plan within an amount of time that is acceptable to you?

MPSMTF White Paper February 2008

57.4%

17. Does your healthcare provider(s) explain in a way you understand? a. The cause of your pain?

Yes

Don’t Know

69.1%

22.9%

8.0%

b. Possible treatment options?

68.0%

25.0%

7.0%

c. The benefits, risks, and costs of each option?

54.0%

38.1%

7.9%

Yes 73.0%

No 23.0%

Don’t Know 4.0%

19. Do you monitor your pain and how the treatment plan affects your pain? For example, do you keep a daily diary or log sheet?

27.1%

70.4%

2.5%

a. If yes, do you share this information with your healthcare professional?

57.3%

34.5%

8.2%

18. Do you feel you are an active participant in decision making about your pain treatment plan?

Regarding your pain control… 20. Do you feel your healthcare provider(s) monitors your progress by asking about your pain and ability to function on each visit?

Yes 53.5%

No 40.4%

Don’t Know 6.1%

21. Is your treatment adjusted if the pain has not been eased 52.6% or your ability to function has not significantly improved?

32.6%

14.7%

22. Have you been referred to any of the following if your pain continues? 17.3% Pain Specialist; 20.9% Chiropractor; 45.0% Physical Therapist; 7.9% Naturopath 20.9% Other: _______________________________________________________________ 33.5% My physician has not referred me to any other provider.

23. Do you feel that your healthcare professional provides clear and prompt answers to your questions and concerns? 24. Do you feel you have an adequate amount of time to think about the treatment plan your healthcare professional recommends? 25. Do you feel that you are able to refuse recommendations for treatment or ask for alternative options? 26. Do you know your rights regarding referral for healthcare in Montana?

MPSMTF White Paper February 2008

Yes

Don’t Know

66.8%

23.8%

9.4%

68.3%

21.3%

10.4%

76.1%

17.6%

6.3%

34.3%

49.0%

16.7%

PLEASE FILL OUT THE FOLLOWING DEMOGRAPHIC QUESTIONS TO HELP US FURTHER IN OUR ASSESSMENT OF PAIN MANAGEMENT IN MONTANA. 27. What is your current marital status? 10.9

Single, never married Married Living with a partner

64.0 2.9

1.3 10.9 12.1

Separated Divorced Widowed

28. What is the highest level of education that you completed? Less than high school High school graduate or equivalent Some college or technical training beyond high school

1.3 16.6 31.1

28.9 23.0

College graduate (4 years) Post-graduate or professional degree

29. Which of the following best describes your current employment status? 41.9 16.1 34.3

Employed or self-employed full-time Employed or self-employed part-time Retired and not working

4.7 5.1

Homemaker Unemployed and looking for work

30. What is your race/ethnicity? Check ALL that apply. 0.4 0 0.4

5.1

Asian Black or African American Hispanic or Latino

96.6 0

Native American or Alaskan Native White or Caucasian Other

31. What was your annual household income before taxes in 2005? 9.3 15.9 13.1 14.0

Less than $10,000 $10,000 to under $20,000 $20,000 to under $30,000 $30,000 to under $40,000

14.5 7.0 8.9 19.6

$40,000 to under $50,000 $50,000 to under $60,000 $60,000 to under $75,000 $75,000 or more

32. What is your age? _______________________ 33. What is your 5-digit zip code? (write in your zip code) ____ ____ ____ ____ ____ Thank you for your time and participation in this valuable survey THE MONTANA PAIN AND SYMPTOM MANAGEMENT TASK FORCE WAS CREATED BY THE MONTANA STATE LEGISLATURE IN OCTOBER, 2005 BY SENATE JOINT RESOLUTION 28. IT IS STAFFED BY PROFESSIONALS IN THE MEDICAL, EDUCATIONAL, AND LEGISLATIVE FIELDS WHO DEVOTE THEIR TIME AND ENERGY TO SERVE THE PEOPLE OF MONTANA THIS SURVEY TOOL WAS CREATED IN COLLABORATION BETWEEN THE MONTANA PAIN TASK FORCE, AMERICAN CANCER SOCIETY AND THE AMERICAN ALLIANCE OF CANCER PAIN INITIATIVES. THANKS ALSO TO BARBARA SPRING, PhD FOR HER CREATIVE CONTRIBUTIONS TO THIS SURVEY TOOL. Please return this completed survey to American Cancer Society, Montana Pain and Symptom Management Task Force, 3550 Mullan Road, Suite 105, Missoula, MT 59808. MPSMTF White Paper 27 February 2008

APPENDIX F APPENDIX APPENDIXFF MONTANA PAIN AND SYMPTOM MANAGEMENT INITIATIVE MONTANA MONTANAPAIN PAINAND AND SYMPTOM SYMPTOM MANAGEMENT INITIATIVE INITIATIVE STANDARD OFMANAGEMENT CARE STATEMENT STANDARD STANDARDOF OFCARE CARESTATEMENT STATEMENT Reports of pain and symptoms are taken seriously and are treated with dignity and respect by all Reports Reports ofofpain painand and symptoms symptomsare aretaken takenseriously seriouslyand andare aretreated treatedwith withdignity dignityand andrespect respectby byall all healthcare professionals. healthcare healthcareprofessionals. professionals. x Pain and symptoms are thoroughly assessed and promptly treated. xx Pain Painand andsymptoms symptomsare arethoroughly thoroughlyassessed assessedand andpromptly promptlytreated. treated. x Patients are informed by the healthcare provider about what may be causing the pain xx Patients Patients are areinformed informed by bythe the healthcare healthcare provider provider about about whatmay may be becausing causing the theof pain pain and/or symptom(s), possible treatments, and the what benefits, risks and costs each. and/or and/orsymptom(s), symptom(s),possible possibletreatments, treatments,and andthe thebenefits, benefits,risks risksand andcosts costsofofeach. each. x Patients participate actively in decisions about how to manage their pain and symptoms. xx Patients Patientsparticipate participateactively activelyinindecisions decisionsabout abouthow howtotomanage managetheir theirpain painand andsymptoms. symptoms. x Pain and symptom control is reassessed regularly and the treatment adjusted if the pain or xx Pain Painand and symptom symptom control isisreassessed reassessedregularly regularlyand andthe thetreatment treatmentadjusted adjustedififthe thepain painoror symptom hascontrol not been eased. symptom symptomhas hasnot notbeen beeneased. eased. x Patients are referred to a pain specialist if the pain persists. xx Patients Patientsare arereferred referredtotoaapain painspecialist specialistififthe thepain painpersists. persists. x Patients obtain clear and prompt answers to their questions, are allowed time to make xx Patients Patients obtain obtainclear clear andallowed prompt promptanswers answers theirquestions, questions, are are allowed allowedtime totochoose. make make decisions, andand are to refusetoto a their particular type of treatment iftime they decisions, decisions,and andare areallowed allowedtotorefuse refuseaaparticular particulartype typeofoftreatment treatmentififthey theychoose. choose. x Healthcare professionals utilize nationally recognized Pain and Symptom Treatment xx Healthcare Healthcare professionals professionals utilize utilize nationally recognized recognized Pain Painand andplans. Symptom SymptomTreatment Treatment Guidelines to identify andnationally optimize individual treatment Guidelines Guidelinestotoidentify identifyand andoptimize optimizeindividual individualtreatment treatmentplans. plans. Adapted from the Pain Care Bill of Rights by the American Pain Foundation Adapted Adaptedfrom fromthe thePain PainCare CareBill BillofofRights Rightsby bythe theAmerican AmericanPain PainFoundation Foundation

ORGANIZATIONS SUPPORTING THE MONTANA PAIN AND SYMPTOM ORGANIZATIONS ORGANIZATIONSSUPPORTING SUPPORTING THE THEMONTANA MONTANA PAIN PAIN AND ANDSYMPTOM SYMPTOM MANAGEMENT STANDARD OF CARE MANAGEMENT MANAGEMENT STANDARD STANDARD OF OF CARE CARE ENDORSEMENTS RECEIVED AS OF JANUARY 15, 2007 ENDORSEMENTS ENDORSEMENTSRECEIVED RECEIVEDAS ASOF OFJANUARY JANUARY15, 15,2007 2007 Action for Eastern Montana Action ActionAmerican for forEastern Eastern Montana Montana Cancer Society American American Cancer Cancer Society Society Area V Agency on Aging Area AreaVV Agency Agencyon onAging Aging of Hospice and Palliative Care American Association American American Association Association ofofHospice Hospice and andPalliative PalliativeCare Care Bozeman Deaconess Hospital Bozeman Bozeman Deaconess Deaconess Hospital Hospital Carroll College Parish Nurse Center (representing parish nurses statewide) Carroll Carroll College CollegeParish Parish Nurse NurseCenter Center (representing (representing parishnurses nursesstatewide) statewide) Montana Area Agency on Aging Associationparish Montana Montana Area Area Agency Agency on on Aging Aging Association Association Montana Attorney Generals Office of Consumer Protection & Victim Services Montana Montana Attorney Attorney Generals Generals Office OfficeofofConsumer ConsumerProtection Protection&&Victim VictimServices Services Montana Board of Pharmacy Montana Montana Board BoardCancer ofofPharmacy Pharmacy Montana Control Coalition Montana Montana Cancer Cancer Control Control Coalition Coalition Montana Chiropractic Association Montana Montana Chiropractic Chiropractic Association Association Montana Medical Association Montana Montana Medical Medical Association Association Montana Nurses Association Montana MontanaNurses NursesAssociation Association MPSMTF White Paper MPSMTF MPSMTF White White Paper Paper February 2008 February February2008 2008

28 28

Montana Senior Citizens Association APPENDIX F Senior Montana Citizens Association Montana Spine and Pain Center â&#x20AC;&#x201C; Missoula Montana Spine and Pain Center â&#x20AC;&#x201C; Missoula Montana State University-Bozeman College of Nursing MONTANA PAIN AND SYMPTOM MANAGEMENT INITIATIVE Montana State University-Bozeman Nursing N Central Area III Agency on AgingCollege of CARE STATEMENT N III Agency onSciences AgingOF Center, St.Central PatrickArea Hospital &STANDARD Health Missoula St. Patrick Hospital & Health Sciences Center, Missoula St. Peters Hospital Helena ReportsSt. of pain and symptoms are taken seriously and are treated with dignity and respect by all Peters Hospital Helena St. Vincent Hospital Billings healthcare professionals. St. Vincent Hospital Billings State of Montana Department of Corrections State State of of Montana Montana Department Department of of Corrections Public Health and Human Services x State Pain and symptoms are thoroughly assessed and promptly treated. of Montana Department of Therapy Public Health and Human Services University of Montana Physical Department and Rehabilitative Services University of Montana Physical Therapy Department and Rehabilitative Services Yellowstone City County Health Department City County Health Department x Yellowstone Patients are informed by the healthcare provider about what may be causing the pain and/or symptom(s), possible treatments, and the benefits, risks and costs of each. x

Patients participate actively in decisions about how to manage their pain and symptoms.

Pain and symptom control is reassessed regularly and the treatment adjusted if the pain or symptom has not been eased.

Patients are referred to a pain specialist if the pain persists.

Patients obtain clear and prompt answers to their questions, are allowed time to make decisions, and are allowed to refuse a particular type of treatment if they choose.

Healthcare professionals utilize nationally recognized Pain and Symptom Treatment Guidelines to identify and optimize individual treatment plans.

Adapted from the Pain Care Bill of Rights by the American Pain Foundation

ORGANIZATIONS SUPPORTING THE MONTANA PAIN AND SYMPTOM MANAGEMENT STANDARD OF CARE ENDORSEMENTS RECEIVED AS OF JANUARY 15, 2007

Action for Eastern Montana American Cancer Society Area V Agency on Aging American Association of Hospice and Palliative Care Bozeman Deaconess Hospital Carroll College Parish Nurse Center (representing parish nurses statewide) Montana Area Agency on Aging Association Montana Attorney Generals Office of Consumer Protection & Victim Services Montana Board of Pharmacy Montana Cancer Control Coalition Montana Chiropractic Association Montana Medical Association Montana Nurses Association MPSMTF White Paper MPSMTF White2008 Paper MPSMTF White Paper February February 2008 2008 February

29 29

APPENDIX G APPENDIX F APPENDIX G

PAIN AND SYMPTOM TREATMENT GUIDELINES PAIN AND SYMPTOM TREATMENT GUIDELINES MONTANA PAIN AND Assessment and Management of SYMPTOM Acute Pain MANAGEMENT INITIATIVE STANDARD OF Pain CARE STATEMENT Assessment and Management of Acute Institute for Clinical Systems Improvement (ICSI); 2004 Mar Institute for Clinical Systems Improvement (ICSI); 2004 Mar http://www.guidelines.gov/summary/summary.aspx?doc_id=4930&nbr=003517&string=assessm Reports of pain and symptoms are taken seriously and are treated with dignity and respect by all http://www.guidelines.gov/summary/summary.aspx?doc_id=4930&nbr=003517&string=assessm ent+and+%22 healthcare professionals. ent+and+%22 Guidelines for the assessment and management of chronic pain x Guidelines Pain and symptoms are thoroughly assessed andofpromptly treated. for the assessment and management chronic pain WMJ 2004;103(3):13-42 WMJ 2004;103(3):13-42 http://www.guidelines.gov/summary/summary.aspx?doc_id=6303&nbr=004040&string=pain+A x http://www.guidelines.gov/summary/summary.aspx?doc_id=6303&nbr=004040&string=pain+A Patients are informed by the healthcare provider about what may be causing the pain ND+management and/or symptom(s), possible treatments, and the benefits, risks and costs of each. ND+management x Guideline Patients participate actively inof decisions about to and manage their pain and symptoms. for the management cancer pain in how adults children. Guideline for the management of cancer pain in adults and children. American Pain Society (APS); 2005. (Clinical practice guideline; no. 3 Pain Society (APS); 2005. (Clinical practice guideline; no.adjusted 3 x American Pain and symptom control is reassessed regularly and the treatment if the pain or http://www.guidelines.gov/summary/summary.aspx?doc_id=7297&nbr=004341&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=7297&nbr=004341&string=pain+A symptom has not been eased. ND+management ND+management x Symptom Patients are referred toin a pain specialist if the painand persists. management cancer: pain, depression fatigue Symptom management in cancer: and fatigue NIH Consensus Statement Online pain, 2002 depression Jul 15-17;19(4):1-29. Consensus Online answers 2002 Julto15-17;19(4):1-29. http://www.guidelines.gov/summary/summary.aspx?doc_id=6108&nbr=003963&string=paIN+ x NIH Patients obtain Statement clear and prompt their questions, are allowed time to make http://www.guidelines.gov/summary/summary.aspx?doc_id=6108&nbr=003963&string=paIN+ AND+MANAGEMENT decisions, and are allowed to refuse a particular type of treatment if they choose. AND+MANAGEMENT practice guidelinesutilize for quality palliative care. Pain and Symptom Treatment x Clinical Healthcare professionals nationally recognized Clinical practice guidelines for quality palliative care. National Consensus Project for Quality Palliative Care; 2004 Guidelines to identify and optimize individual treatment plans. National Consensus Project for Quality Palliative Care; 2004 http://www.guidelines.gov/summary/summary.aspx?doc_id=5058&nbr=003542&string=paIN+ Adaptedhttp://www.guidelines.gov/summary/summary.aspx?doc_id=5058&nbr=003542&string=paIN+ from the Pain Care Bill of Rights by the American Pain Foundation AND+MANAGEMENT AND+MANAGEMENT ORGANIZATIONS SUPPORTING Management of fibromyalgia syndromeTHE MONTANA PAIN AND SYMPTOM Management of fibromyalgia syndrome MANAGEMENT STANDARD OF Nov CARE Goldenberg DL, Burckhardt C, Crofford L. JAMA 2004 17;292(19):2388-95 Goldenberg DL, Burckhardt C, Crofford L. JAMA 2004 Nov 17;292(19):2388-95 ENDORSEMENTS RECEIVED AS OF JANUARY 15, 2007 http://www.guidelines.gov/summary/summary.aspx?doc_id=6426&nbr=004057&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=6426&nbr=004057&string=pain+A ND+management ND+management ActionGuideline for Eastern forMontana the management of fibromyalgia syndrome pain in adults and children Guideline for the management fibromyalgia syndrome pain in adults American CancerPain Society American Society (APS); of 2005. (Clinical practice guideline; no. 4)and children Pain Society (APS); 2005. (Clinical practice guideline; no. 4) Area VAmerican Agency on Aging http://www.guidelines.gov/summary/summary.aspx?doc_id=7298&nbr=004342&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=7298&nbr=004342&string=pain+A American Association of Hospice and Palliative Care ND+management ND+management Bozeman Deaconess Hospital CarrollThe College Parish Nurse Center (representing parish nurses statewide) management of persistent pain in older persons The management of persistent pain in older persons Montana Area Agency Aging Association J Am Geriatr Socon 2002 Jun;50(6 Suppl):S205-24 Jhttp://www.guidelines.gov/summary/summary.aspx?doc_id=3365&nbr=002591&string=pain+A Am GeriatrGenerals Soc 2002Office Jun;50(6 Suppl):S205-24 Montana Attorney of Consumer Protection & Victim Services http://www.guidelines.gov/summary/summary.aspx?doc_id=3365&nbr=002591&string=pain+A Montana Board of Pharmacy ND+management ND+management Montana Cancer Control Coalition Montana Chiropractic Association Pain in osteoarthritis, rheumatoid arthritis and juvenile chronic arthritis. 2nd ed. American Pain Pain in osteoarthritis, arthritis and juvenile Montana Medical Association Society (APS); 2002. rheumatoid (Clinical practice guideline; no. 2)chronic arthritis. 2nd ed. American Pain Society (APS); 2002. (Clinical practice guideline; no. 2) Montana Nurses Association MPSMTF White Paper MPSMTF White2008 Paper Paper MPSMTF White February February 2008 February 2008

30 30

http://www.guidelines.gov/summary/summary.aspx?doc_id=3691&nbr=2917 http://www.guidelines.gov/summary/summary.aspx?doc_id=3691&nbr=2917 http://www.guidelines.gov/summary/summary.aspx?doc_id=3691&nbr=2917 Pain in care Pain management Pain management management in the long-term in the the long-term long-term care setting. care setting. setting. American Medical Directors Association (AMDA); American American Medical Medical Directors Directors Association Association (AMDA); (AMDA); 2003 2003 2003 http://www.guidelines.gov/summary/summary.aspx?doc_id=4954&nbr=003522&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=4954&nbr=003522&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=4954&nbr=003522&string=pain+A ND+management ND+management ND+management The initial of The initial The management initial management management of chronic of chronic chronic pelvic pelvic pelvic pain. pain. pain. Royal of and (RCOG); 2005 Royal College Royal College College of Obstetricians of Obstetricians Obstetricians and Gynaecologists and Gynaecologists Gynaecologists (RCOG); (RCOG); 2005 Apr 2005 Apr Apr http://www.guidelines.gov/summary/summary.aspx?doc_id=7672&nbr=004471&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=7672&nbr=004471&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=7672&nbr=004471&string=pain+A ND+management ND+management ND+management treatment situations: behavioral interventions for of head SpecialSpecial Special treatment treatment situations: situations: behavioral behavioral interventions interventions for management for management management of primary of primary primary head pain. head pain. pain. Standards of care for headache diagnosis and treatment: National Headache Foundation; Standards Standards of careof forcare headache for headache diagnosis diagnosis and treatment: and treatment: National National Headache Headache Foundation; Foundation; 2004 2004 2004 http://www.guidelines.gov/summary/summary.aspx?doc_id=6584&nbr=004144&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=6584&nbr=004144&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=6584&nbr=004144&string=pain+A ND+management ND+management ND+management Adult low back Adult low Adult back lowpain back pain pain Institute for Clinical Systems Improvement 2005 Institute Institute for Clinical for Clinical Systems Systems Improvement Improvement (ICSI);(ICSI); (ICSI); 2005 Sep 2005 Sep Sep http://www.guidelines.gov/summary/summary.aspx?doc_id=8150&nbr=004543&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=8150&nbr=004543&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=8150&nbr=004543&string=pain+A ND+management ND+management ND+management guidelines the treatment, and of ClinicalClinical Clinical practicepractice practice guidelines guidelines (second(second (second edition)edition) edition) for the for for diagnosis, the diagnosis, diagnosis, treatment, treatment, and management and management management of of reflex dystrophy/complex regional pain (RSD/CRPS). reflex sympathetic reflex sympathetic sympathetic dystrophy/complex dystrophy/complex regional regional pain syndrome pain syndrome syndrome (RSD/CRPS). (RSD/CRPS). Sympathetic Dystrophy Syndrome Association (RSDSA); 2002 ReflexReflex Reflex Sympathetic Sympathetic Dystrophy Dystrophy Syndrome Syndrome Association Association (RSDSA); (RSDSA); 2002 Feb 2002 Feb Feb http://www.guidelines.gov/summary/summary.aspx?doc_id=3204&nbr=002430&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=3204&nbr=002430&string=pain+A http://www.guidelines.gov/summary/summary.aspx?doc_id=3204&nbr=002430&string=pain+A ND+management ND+management ND+management

MPSMTF MPSMTF MPSMTF White White White Paper Paper Paper February February February 2008 2008 2008

31 31

Montana Pain Initiative In care of: American Cancer Society 3559 Mullan Rd., Ste. 105 Missoula, MT 59808

Non-Profit Org. US Postage PAID Missoula, MT 59808 Permit No. 526