2. Learning Objectives:
1. Describe how cautious, evidence-based
prescribing practices can lower opioid-related
overdose deaths while maintaining appropriate
access for medically needed treatment of chronic
pain.
2. Identify “best practice” strategies that can be
used by clinicians for pain management treatment.
3. Explain evidence-based practice and policies for
provider education and patient education
programs being utilized across the US.
3. Disclosure Statement
• All presenters for this session, Dr. Rollin
M. Gallagher, Dr. Andrew Kolodny, and
Robert Sproul, have disclosed no
relevant, real or apparent personal or
professional financial relationships.
4. Opioid-High Alert
Appropriate Treatment / Risk Mitigation
Robert Sproul PharmD
Program Director, OVAMC Pain Management
Program Manager, Pharmacy PM, Palliative Care
Project Director, OVAMC E-Consult Pain Management
Co-Chair, VA National Pain Management Pharmacy Work Group
Co-Chair, VA National Clinical Pharmacy Training Work Group Pain Management
Member, VA National Pain Management Strategy Coordinating Committee
National RX Drug Abuse Summit 2012
Orlando VA Medical Center
6. ? Where Do We Start
How Do We Get There ?
Tertiary Interdisciplinary Pain
Centers
RISK
Advanced diagnostics &
interventions
CARF accredited pain rehabilitation
Co morbidities
Treatment
Refractory
Patient Aligned Clinical Team (PACT)
Routine screening for presence & intensity of pain
Comprehensive pain assessment
Complexity Management of common pain conditions
MH-PC Integration, OEF/OIF, & Post-Deployment Teams
Expanded care management
Opioid Renewal Clinics
7. Abridged VA Quality Monitors
Going Beyond DEA Regulations
• PBM High Dose Opioid (HDO) Monitor
– Multi-Site review identify patients receiving opioids from
more than one site within a VISN
– Multi-VISN review identify patients receiving opioids from
sites in more than one VISN
• Formulary Management
– Evidence Based Drug class and molecular reviews
– Criteria for use that address safety concerns
• MAP (Medical Advisory Panel)
– Field input and review from subject matter experts,
clinical alerts
– PBM site (Public Link) http://www.pbm.va.gov/
8. Abridged VA Quality Monitors
Provider Education Support Programs
• VA MedSafe
– Pharmacovigilance/PostmarketingSurveillance and VA ADERS program
• National ADE reporting program for all VA
– Active surveillance
• Proactive tracking of all patients exposed to a medication and
identifying adverse events using diagnostic codes or symptom
• Provider Education: It s not just about Monitors
– VA Web Programs for Providers (Example: Opioid Web Course)
– INTRANET Department of Veteran Affairs
• VHA Pain Management
– VA Methadone, Fentanyl Dosing, Safety
– Collaborative Intervention for Pain and Depression
– VA/DoD CPG: Management of Opioid Therapy
for Chronic Pain
– Stepped Integrated Pain Care in the VHA
9. Managing Chronic Opioid Therapy
VHA Innovations In Clinical Services
Support of our Veterans and their Providers
11. National Clinical Pharmacy Training
BOOT CAMP / Mentoring Program
• Boot Camp
– Designed
• Empower the attendees with the most fundamental knowledge
• Necessary to develop competence and confidence
• To address every day pain issues
– In the AMB Care or PACT setting
• VA Pain Management Mentoring (VAPPMM)
– Mentoring Outlook Exchange Service
• Continue this theme by providing continued support
• Solidify the skills learned in the boot camp
• Broaden the horizons of those participating in this exchange
• Safety Net (NOT SURE THEN ASK)
12. BOOT CAMP / VAPPM Mentoring
Abridged Topics of Emphasis
• Opioids
– Check the "math"
– Conversions, Rotation, Titration, Taper etc.
– Choice of Opioids /Drug to Drug interactions
– Pharmacokinetic/dynamic implications
– Adjuvant or Alternatives
• Urine Drug Tests (UDT)
– Results, Implications, Caveats
– Follow up procedures
• Appropriate documentation
• Patient Safety Issues/Moderate to High Risk Patients
• Provider Coverage
• Referral Considerations
– Substance Abuse, Mental Health, Physical Therapy, Other
16. OVAMC E-Consult PM
Fundamental Goals
• To address everyday pain management questions and
patient safety issues
• To provide easy access to the service for the consulting
provider
– Easy Access equates with Timely Support
– Paramount for addressing patient safety issues
• Typical concerns addressed by the E-Consult Pain
– Opioid related
• Titration, rotation, conversions, tapering
• Alternative treatment modalities
– Urine Drug Screen
• Interpretation, policy, provider recourse
• Associate opioid tapering and
ethical considerations
18. Recommendations / Documentation
What s In A Name
• Intent
– Is not to paint a provider into a corner
– Is to provide guidance for / with options to the provider
• Wording
– How a recommendation is worded is crucial
• Stipulates the recourse the Pain Service would take
• Offers alternative to the Clinic s stance (opinion)
– Acknowledges provider's discretion
• Example
– For the following patient safety issues detailed above a.b.c.,
the Pain Clinic would no longer prescribe opioids for this pt at
this time
– However, should the provider determine opioids will be
continued, then the Pain Clinic would recommend the following
• Frequent UDS
• No more than a seven day supply, etc
19. OVAMC E-Consult PM
Provider Education
• OVAMC/VISN 8 E-Consult
– Chronic Pain Audio Conference
• Weekly Case-Base Provider Education (CME)
– Moderate to High Risk Patients
– Complex patients with Comorbitity
• Supporting didactics
• Provides an Interdisciplinary Forum
– Explore alternatives
– Discuss controversies
– Provider recommendations
20. Hidden Treasures
Transcending the Routine E-Response
• Typical consults
– Often directly address important daily issues, such as urine
drug screens, opioids, and associated concerns
• However, provider support is not limited to "treatment
modalities" alone
– May directly assist the provider in resolving difficult
scenarios
• Patient treatment and or ethically related issues
• Assist in coordination of care
21. E-Case Study
Ethical Considerations
• Reason for Consult
– Terminally ill cancer patient
– In the ambulatory care setting
– Non-End of Life Scenario
– On significant amount of opioids
– Test positive for cocaine/alcohol
• Provider's Comments
..."I'm concerned that the patient is going to overdose or hurt
someone else
… Is a second chance reasonable, or must I discontinue the opioids
… I don t want to cut the opioids
… I know he s in a lot of pain
... What should I do
22. E-Hidden Treasures
PCP Doesn t Have to Walk the Walk Alone
• Ultimately it will be the provider's discretion that
determines the recourse which will be taken
• However, the provider can reach out to a "team" for
support and or advice
– Options with the supporting details
– To address a controversial pain / ethical issue
• Means to avoid the unilateral decision process
– An uncomfortable situation for many providers
– Due to perceived scrutiny
• From oneself or from others
• Laced in the form of legal, ethical, moral
considerations/implications
23. Balancing the Benefits and Risks
Personal Perspective
• Opioids CNMP: The Approach and Contingency
• Exhaust other options prior to prescribing opioids for chronic use
• Utilize all resources / tools available to ensure success
• Discuss with patient expectations, limitations, shared responsibility
• Set goals prior to implementing opioid therapy
• Monitor for success and or failure to protect our Veterans who may
have an abuse problem who may not be able to help themselves
• However, we respect the rights of our Veterans to the use of these medications,
• When other options have failed
• When these medications prove affective
– Safety comes first, function is at minimum preserved
• When used responsibly
• We Do Not Sacrifice or Label our Veterans who are in need for those who
would abuse, when being treated with opioids