Patient Care

Outcomes Associated With a Multidisciplinary Pain Oversight Committee to Facilitate Appropriate Management of Chronic Opioid Therapy

Fed Pract. 2017 June;34(6):18-26

References

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Informatics Tool

In September 2014, an e-consult tool was created to enable PCPs to efficiently consult the RHJVAMC pain clinic for advice on opioid-related issues in patients who require specialized attention. On activation of this EMR-based tool, the following patient data autopopulated in the consult: recent and active opioid prescription(s), UDS data from the previous 365 days, and PDMP review data from the previous 365 days. The consulting provider was then required to enter data on concomitant mental health disorders that were deemed pertinent to opioid safety as well as obstructive sleep apnea (OSA) status (OSA diagnosis and continuous positive airway pressure machine receipt and adherence).

The consulting provider was required to indicate whether the patient had an active BZD prescription. If yes, a text field allowed the provider to enter the specific agent(s) prescribed and dose(s). Data were required in all fields for the e-consult to be considered ready for pain clinic review. Common pain clinic recommendations included orders for additional laboratory tests to assess adherence and potential toxicity, drug tapers, and consideration for complementary and alternative medicine (CAM). If a drug taper was recommended (either opioid or BZD), specific taper schedules would be provided by a pharmacist specializing in pain management.

Targeted Patient Intervention

In April 2014, the POC and Mental Health service began a targeted review of all outpatients receiving combination opioid and BZD therapy. First, the POC distributed to each mental health provider a list of patients who were receiving combination opioid and BZD therapy. An opioid/BZD combination risk assessment tool (Table 2) was developed by the POC and made available to assist with these patient reviews. This tool prompted a provider to assess a patient’s stability on the current regimen as well as the presence of any absolute or relative contraindications to concomitant BZD and opioid use. Providers documented whether a discussion regarding the risks and benefits of opioids and BZDs had occurred with the patient. The tool encouraged providers to document a continued indication for combined BZD and opioid therapy use and whether the lowest effective BZD dose was being prescribed. A standardized BZD taper protocol also was developed by the POC to assist providers if a BZD taper was indicated. A total of 222 patients were reviewed over 7 months from April 2014 to October 2015.

Following completion of this targeted review in October 2015, the POC required that starting any patients on opioid and BZD combination therapy would require a specialist consult. For existing COT patients, a mental health consult would be required to initiate BZD therapy. For stable patients on BZD therapy, a pain clinic consult was required before initiating an opioid prescription. The Pharmacy service acted as a gatekeeper for these agents and refused to dispense either new agent until the proper consults had been submitted unless clinical necessity of an agent was apparent (ie, opioid prescription following invasive surgery).

The final targeted patient intervention occurred following deployment of the opioid safety review e-consult tool in September 2015. To review the highest risk COT patients, each PCP was given a list of their patients who were taking ≥ 200 mg MEDD. With support from the primary care service chief, PCPs were required to submit an e-consult for every patient who did not meet the e-consult exclusion criteria. In the fourth quarter of fiscal year (FY) 2014, and first quarter of FY 2015, 116 RHJVAMC patients received ≥ 200 mg MEDD with 49 meeting the exclusion criteria. Of the 67 patients eligible for pain clinic review, e-consults were placed for 58 patients over a 7-month period. The remaining 9 patients did not receive an e-consult because taper was initiated by the patient’s PCP without pain clinic assistance (6), aberrant patient behavior was identified during data collection (2), and patient was transitioned to palliative care (1).

Provider Education

A primary goal of the POC was to educate PCPs on opioid safety, to ensure that each provider was able to use evidence-based medicine and identify potential high-risk situations during patient encounters. Provider education was delivered by physician and pharmacist pain specialists and took place from September 2013 to January 2015 at existing primary care meetings. Topics included UDS interpretation, opioid/BZD combination risks, the goals and requirements of the VA OSI, and legal requirements of the South Carolina Reporting and Identification Prescription Tracking System (SCRIPTS) PDMP.

Patient Education

Patient education was delivered through informational brochures either mailed or given out during clinic visits. The first brochure was mailed to patients and described the VA OSI goals and its potential impact on patients. A second handout described the risks associated with opioid/BZD combination therapy and encouraged patients to discuss these risks and alternate options with their providers. It was made available to primary care and mental health teams for distribution to patients.