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Expert Advice to Help VA Primary Care Providers Reduce Opioid Prescribing Risks
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.
“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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