The use of opioids to treat chronic noncancer pain (CNCP) has become increasingly common over the previous 2 decades. The Office of National Drug Control Policy (ONDCP) reported that from 1997 to 2007, there was a 4-fold increase in the mg per person per year sale of prescription opioids, from 74 mg to 369 mg.1 The number of opioid prescriptions dispensed by pharmacies also has increased by 48% from 2000 to 2009.2 Within the VA population, about half of the 1.44 million patients with a diagnosis of pain (excluding cancer pain) received opioids during 2011, and 57% of these patients received chronic opioid therapy (COT), which is at least 90 days of opioid use in a year.3
Despite this increased use of opioids, data regarding the efficacy of long-term opioid use for noncancer pain remain limited.1,4-8 Instead, there is a growing body of evidence describing potential adverse effects (AEs) of long-term opioid use at even relatively modest doses, including sexual dysfunction, hyperalgesia, and altered brain structure.9-11 Additionally, increases in the misuse and abuse of opioids as well as mortality associated with opioid toxicity have been observed.12-14 Opioid pain relievers were involved in nearly 17,000 deaths in the U.S. in 2010, which represents a 3-fold increase since 1999. This number also represents 75% of all deaths that were attributed to prescription drug poisoning in 2010.13 Unfortunately, this alarming trend parallels the aforementioned increases in the utilization of prescription opioids for CNCP.
Given this accumulating data regarding the profound risks and limited benefit of COT, many organizations have advocated a reassessment of the upward trajectory of opioid utilization. In 2009, the American Pain Society (APS) in partnership with the American Academy of Pain Medicine (AAPM) released clinical guidelines for the use of COT in CNCP.6 In this guideline, the authors advocate a balanced approach to opioid use: Clinicians consider both the legitimate medical need for opioids in some patients with CNCP as well as the serious public health problem of abuse, addiction, and diversion.6 In 2011, the FDA, Drug Enforcement Agency (DEA), and ONDCP enacted the Prescription Drug Abuse Prevention Plan, which focused on 4 major areas: education, prescription monitoring, proper medication disposal, and law enforcement.4
In March 2016, the CDC released a new guideline for prescribing opioids for chronic pain that included 12 recommendations based on 3 key principles. First, nonopioids are preferred for chronic pain in all settings except for active cancer, palliative, and end-of-life care. Next, when opioids are used for chronic pain, they always should be prescribed at the lowest possible effective dose to reduce the risk of opioid use disorder and overdose. Finally, clinicians should exercise caution when prescribing opioids and monitor all patients closely for opioid-related risk.15
Recently, an August 2016 FDA review found that the combined use of opioids and benzodiazepines (BZDs) resulted in serious AEs, including respiratory depression and death. Based on these findings, the FDA requires that updated boxed warnings be added to the labeling of prescription opioid and BZDs.16
The VHA also has been at the forefront of this national movement to promote the appropriate use of opioids. In 2009, the VHA released a pain management directive that highlighted the risks of COT and required adoption of a stepped-care approach to opioid prescribing that focused on quality of life as the primary determinant of treatment quality.17 In 2010, the VHA released its guideline on opioid therapy for chronic pain, which also included tools for providers, such as a sample opioid therapy agreement, equivalent potency tables, and a urine drug screening guide.18 In 2014, the VHA released the Opioid Safety Initiative (OSI), which advocates for a team-based approach to reduce the use of opioids for veterans through a focus on alternate methods to alleviate pain.
At the Ralph H. Johnson VAMC (RHJVAMC) in Charleston, South Carolina, a multidisciplinary pain oversight committee (POC) was tasked with assisting in achieving the goals set forth in the VHA OSI. To reach these goals, the POC sought to develop and implement a population-based initiative targeting modifiable factors that are known to increase the risk of opioid-related toxicity and overdose. These factors included patient utilization of multiple prescribers or multiple pharmacies, high-dose COT (defined in the APS/AAPM guidelines as a morphine equivalent daily dose [MEDD] > 200 mg6), and use of concomitant central nervous system-active medications, chiefly BZDs.19-23 The POC consisted of the RHJVAMC chiefs of mental health, primary care, and pharmacy; a physician specializing in pain and addiction medicine; a pharmacist specializing in pain and palliative care; quality management personnel; a patient advocate; and multiple physicians from the mental health and primary care departments.
Previous studies have described the successful implementation of opioid management initiatives in a variety of health care settings.2,21,24-27 However, most of this work focused only on strategies to decrease prescribing of high-dose and long-acting opioid formulations. The study presented here sought to add to the existing body of knowledge through evaluation of an initiative aimed at increasing appropriate monitoring as a tool to decrease opioid-related patient risk. The primary aim of this study was to describe the types of interventions implemented by the POC during the study period. The secondary aim was to evaluate the effect of these interventions on the appropriate monitoring of COT as well as the appropriate management of high-risk COT > 200 mg MEDD.
