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2012 Compendium
Expert Advice to Help VA Primary Care Providers Reduce Opioid Prescribing Risks
- Categorized in: Addiction, August 2012, Department of Veterans Affairs (VA), Pain Management
Frequent follow-up required
Once an agreement is in place, providers need to see patients on opioid therapy regularly, to evaluate the treatment’s effectiveness and monitor drug use with urine screens, both Krebs and Robeck emphasized.
OPIOD AGREEMENT
- Patients agree to comply fully with all aspects of the treatment program including behavioral medicine and physical therapy if recommended
- A prohibition on use with alcohol, other sedating medications or illegal medications
- Agreement not to drive or operate heavy machinery until medication-related drowsiness is cleared
- Opioid prescriptions are provided by only one provider
- Patients agree not to ask for opioid medications from any other doctor without the knowledge and assent of the provider
- Patients agree to keep all scheduled medical appointments
- Urine drug screens will be obtained as indicated
Source: “Opiate Risk Mitigation in Primary Care,” a PowerPoint presentation by Ilene R. Robeck, MD
“Do not treat patients with opioids if you are unable to follow them adequately. If your practice is unable to see patients at high-risk weekly or monthly, then these patients should be treated with a non-opioid approach in primary care, with possible opioid therapy left to the specialists,” according to Robeck.
For lower-risk patients, follow up between one and six months might be sufficient, depending on the patient, Krebs suggested.
Urine screens may detect non-prescribed drugs or indicate that opioids are not actually being used by the patient, raising the possibility that the medications are being diverted. A suspicious screen result should be confirmed with a more sensitive follow-up test and the results discussed with the patient and/or caregiver, when appropriate.
A negative urine screen also can indicate that the patient is doubling up on medication earlier in the month, perhaps because of insufficient relief. If an addiction problem is suspected, referral to a substance abuse program and rapid tapering of opioids is recommended.
“Patients must elect to enter a substance abuse program; some never do. I stick with them to help manage the pain but taper the opioids as rapidly as possible,” said Krebs. “In some settings, physicians use an algorithm to calculate the taper; within the VA, pharmacists are very helpful with this. The key is to not stop so abruptly that someone goes into withdrawal.”
In cases where Krebs suspects diversion, she does not continue prescribing.
“Sometimes it seems ridiculous to do a urine test, but twice in my career I’ve found consistently negative results in older patients who were, clearly, not intentionally diverting their medications,” she recounted. “In both cases, we found younger family members were taking the medications themselves. In one instance, the patient was moved to another family member’s home and it became clear exactly what the problem was.”
1. .Haskell SG, Heapy A, Reid MC, Papas RK, Kerns RD. The Prevalence and Age-Related Characteristics of Pain in a Sample of Women Veterans Receiving Primary Care. J Women's Health. 2006;15(7):862-869.
2. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, May 2010. http://www.va.gov/PAINMANAGEMENT/docs/CPG_opioidtherapy_summary.pdf
3. Breuer, B, Cruciani, R, Portenoy, RK. Pain Management by Primary Care Physicians, Pain Physicians, Chiropractors, and Acupuncturists: A National Survey. Southern Medical Journal. 2010; 103(8):738-747
4. Improving Access to Opioid Agonist Therapy, QUERI Update, June 2012, http://www.queri.research.va.gov/about/impact_updates/SUD-oat.pdf
5. Bohnert AS, Velenstein M, Bair MJ, Ganoczy D, McCarthy JF, et al. Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths, JAMA, 2011;305(13):1315-1321.
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I've also recently been to a VA sponsored 1 day pain symposium in which Dr. Robek moderated the break-out sessions and she's dedicated, passionate and a wealth of knowledge. After that symposium I put some thoughts down on paper.
I graduated from Medical School in 1985. Like many physicians my age, I had very little formal education on managing pain, especially noncancer pain.
I’ve practiced, as a Primary Care Physician, within the VA since 1998.
Here are some of the reasons I was so accepting of opioid use for the treatment of chronic noncancer pain (CNCP) in the late 1990's and early to mid 2000's.
1. The WHO developed the 3- step ladder for cancer pain relief in 1986 (over time it became widely used for the treatment of all types of pain).
2. A study of 10,000 dying patients published in 1995, in JAMA, in which researchers found that almost half died in severe pain.
3. In 1998, a working group in Congress was established to examine what role the federal government should play in alleviating pain and in other end-of-life issues.
4. Pain becomes the VA’s 5th vital sign in February 1999. One press release stated:
• “Beginning this month, patients receiving health care through the VA will be assessed for something most other patients around the country aren’t: pain”
5. Position statements by various organizations that usually included a summary statement such as: “narcotics are underused and have low addiction potential when used for CNCP.”
6. Numerous CME conferences for catch-up education. No "ceiling dose" for opioids was emphasized. I remember how impressed I was at one particular case study in which an elderly woman was taking over 1000 mg of morphine/day, for severe DJD, and remained functional and independent.
7. Mini-fellowships for the treatment of pain became available. In the early 2000’s, a colleague became our pain specialist after spending 4 days with another facilities pain team.
8. There was little noticeable support for primary care providers in the early days. Our facility was setting records for an outpatient facility at the time, enrolling 25-35 patients a day.
9. Pain was the most frequent presenting complaint (greater than 50%) of returning Operation Enduring Freedom /Operation Iraqi Freedom soldiers (greater than 90% for polytrauma victims).
10. Private pain clinics appeared in abundance around our city. Many patients would seek private sector care and then return to the VA, after seeing a board certified pain specialist a few times, due to the costs of the high dose narcotics.
11. NSAID and acetaminophen scares.
12. Delays in obtaining many complimentary services (PT, pain anesthesia) and the unavailability of many other services (chiropractic, massage, etc.).
So, fast forwarding to now.
A quote by Maya Angelou is very appropriate: “I did then what I knew how to do; now that I know better, I do better.”
The efforts by various authors/educators have been very helpful, including an article this month in American Family Physician: Rational Use of Opioids for Management of Chronic Nonterminal Pain.
Another excellent resource is: Management of Opioid Therapy for Chronic Pain: VA/DoD Evidence Based Practice Guideline. May 2010 (http://www.healthquality.va.gov/COT_312_SUM-er.pdf ).
The efforts by Physicians For Responsible Opioid Prescribing (PROP) are also much appreciated.
One member, Jane Ballantyne MD, a pain specialist from Seattle, WA has stated, “we started on this whole thing because we were on a mission to help people, but the long term outcomes for many patients are appalling, and it’s ending up destroying their lives.”
Our VA now has vastly improved pain management services available (E-consults, Medical Pain consults, MH chronic pain consults).
It's still a work in progress and will be for years to come but as a VA Primary Care Physician, it feels as if the pain cavalry has finally arrived.