6/5/2017 1 Tu Ngo, PhD, MPH Julie Franklin, MD, MPH International Conference on Opioids Boston, MA June 11, 2017 1 2 Disclosures • Dr. Franklin has no disclosures • Dr. Ngo has no disclosures Objectives • Identify areas for improvement in opioid safety within your practice. • Identify barriers to improved opioid safety. • Discuss use of EMR to improve and monitor opioid prescribing practices. • Name two (2) strategies for promoting cultural change in an organization. 3
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Goal V: Excellence in Service to Our Communities # 2 - … · 2018-06-10 · address pain Pain Management Directive published Agreement Adoption of VISN 1 Pain VISN 1 Primary Care
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6/5/2017
1
Tu Ngo, PhD, MPH Julie Franklin, MD, MPH
International Conference on Opioids Boston, MA
June 11, 2017
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Disclosures
• Dr. Franklin has no disclosures
• Dr. Ngo has no disclosures
Objectives • Identify areas for improvement in opioid safety
within your practice.
• Identify barriers to improved opioid safety.
• Discuss use of EMR to improve and monitor opioid prescribing practices.
• Name two (2) strategies for promoting cultural change in an organization.
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Development of VIPS
• Veterans Integrated Pain System of Care (VIPS)
• Impetus for change
• Leadership Buy-in
• Year 1
• Year 2
• Directions for the Future
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Recognizing the Problem
• Opioids prescribed in US increased 400% between 1999-2010
• Opioid-related overdose deaths in US increased 400% between 1999-2010
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Veteran Specific Data
• Prescription medications prescribed in the military quadrupled from 2001-2009 (NIDA)
• Prescription drug abuse increased five-fold between 2002-2008 (IOM)
• Veterans are twice as likely to die from an accidental overdose (OD) than non-Veterans (Bohnert, 2011)
• Accidental OD linked to: (Bohnert, 2011) – Narcotics 51.4%
– Benzodiazepines 8%
– Antidepressants 8%
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• Retrospective cohort study of 141,029 Veterans with non-cancer pain diagnosis
• Veterans with mental health issues were more likely to receive opioids:
– Approximately 3 times as likely with PTSD,
– Approximately 2 times as likely with other mental health issues.
• Those with co-morbid PTSD were significantly more likely: – Highest quintile for dose; more than one opioid prescribed
concurrently; concurrent sedative hypnotics; early refills,
– Opioid related accidents, overdoses, alcohol and non-opioid related accidents and overdoes, self-inflicted injuries and violence related injuries.
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Seal et al (2012). JAMA, March, 307(9).
PTSD increases Risk for Opioid Prescriptions, High-Risk Use and Adverse Events
Opioid Prescribing and Opioid Use Disorder
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• Patients with CNCP prescribed opioids had significantly higher rates of OUDs compared to those not prescribed opioids. Effects varied by average daily dose and days supply:
– low dose, acute OR=3.03
– low dose, chronic OR=14.92
– medium dose, acute OR =2.80
– medium dose, chronic OR=28.69
– high dose, acute OR=3.10
– high dose, chronic OR=122.45
• Among individuals with a new CNCP episode, prescription opioid exposure was a strong risk factor for incident OUDs; magnitudes of effects were large. Duration of opioid therapy was more important than daily dose in determining OUD risk.
Edlund et al (2014). Clin J Pain, July 30(7): 557-64.
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Dunn Gomes Bohnert
Dose* (mg/day)
HR (95% CI) OR (95% CI) HR (95% CI)
1-<20 1.00 (REF) 1.00 (REF) 1.00 (REF)
20-<50 1.2 (0.4-3.6) 1.3 (0.9-1.8) 1.9 (1.3-2.7)
50-<100 3.1 (1.0-9.5) 1.9 (1.3-2.9) 4.6 (3.2-6.7)
≥100 or 100-199
11.2 (4.8-26.0) 2.0 (1.3-3.2) 7.2 (4.9-10.7)
≥200 2.9 (1.8-4.6)
*morphine equivalent Dunn et al. Annals IM 2010; Gomes et al. Archives IM 2011; Bohnert et al. JAMA 2011
Slide courtesy of JW Frank, MD, MPH
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Odds of overdose by increasing dose
Mortality: Opioid-Benzo Overdose Deaths
Source: CDC’s National Vital Statistics System Mortality File, 2014
31% 13%
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SELF CARE SELF EFFICACY
Promotion of Healthy Behaviors Addressing Co-Morbidities
Integrated Health System
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Behavioral therapies
Physical activation
Rational pharmaco therapy
IOM’s vision for multimodal chronic pain care (2011)
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VA New England Healthcare System VIPS Evolution
VISN 1- PC-MH Integration core team focusing on pain
VISN 1 OEF/OIF Training- consultative model to
address pain
Pain Management Directive published
Adoption of VISN 1 Pain Agreement
VISN 1 Primary Care Strategic Plan on Pain
Care Pain Champion and Facility level Primary Care
Pain Champion
Primary Care Sharing Best Practices-
Interdisciplinary meeting on Chronic Pain Management
Innovation Grant- Pain Workshops
VISN 1 Grand Rounds –
4 part series
VISN 1 Taskforce CARF Accredited Pain Program
National Informed Consent for Chronic Opioid Therapy
VISN Opioid Pain Report first deployed
VISN 1 OSI Pilot (2 year) Pain designated as VISN 1 Strategic Initiative
mindfulness meditation/relaxation techniques; engagement in meaningful
activities; family & social support; safe environment/surroundings
STEP 1
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VHA Opioid Safety Initiative (OSI)
• National OSI Pilot (2013): no consensus on standard template and process
• National OSI Memorandum (2014)
– Dashboard Reports provided to identify high risk • Utilization,
• MEDD,
• Urine Drug Screen (UDS),
• Co-prescription of opioids/benzodiazepines
– 9 Goals in response to OIG report
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VHA OSI Goals
1) Educate prescribers on urine drug screen (UDS): each VISN standardized education system
2) Increase use of UDS graded on current performance
3) Facilitate use of state Prescription Drug Monitoring Program (PDMP)
4) Establish safe and effective tapering program for co-prescribed opioids and benzodiazepines
5) Develop tools to identify higher risk patients
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VHA OSI Goals cont’d
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6) Improve prescribing practices around long-acting opioid formulations
7) Review treatment plans on high dose of opioids: Mandated chart reviews over >200 MEDD
8) Offer Complementary and Integrated Health (CIH) modalities: at least one of CIH and one evidence-based psychotherapy (CBT, ACT)
9) Develop new models of mental health and primary care collaboration to manage prescribing of opioids and benzodiazepines in patients with chronic pain
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VHA Informed Consent for Long-term Opioid Therapy Directive (2014)
• Required that all patients on long-term opioid therapy have signed informed consent in charts by May 6, 2015
• Overseen by VHA Integrated Ethics Committee
• Barriers:
– Difficult to reach patients in rural areas,
– How to use the primary care team efficiently,
– Non-primary care prescribers were not complying,
– Database was not clean (i.e. included palliative care).
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VHA Opioid Overdose Education and Naloxone Distribution (OEND) Program (2014)
• National Implementation of OEND Program to reduce opioid-related deaths (Pharmacy Benefits/ SUD)
• VA actively engaged in promoting safe and effective practices
• Recommendations for naloxone education and distribution to high-risk Veteran population
• Resources provided
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VHA Academic Detailing Memorandum (2015)
• Implement system-wide Academic Detailing (AD) and pain program champions
• Aim to improve evidence-based delivery of health-care and disease management/ preventative services
• Support frontline providers with specialty trained AD staff, individualized benchmarking data and educational programming
• Target areas:
– Psychotropic Drug Safety Initiative
– Opioid Safety Initiative
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VHA Prescription Drug Monitoring Program (PDMP) Memorandum (2016)
• Required querying state PDMP for all patients prescribed opioids in the VA at initial prescription, at least annually, and more often as clinically indicated
– Must be documented in records with standard note
– Exclusion if less than 5 day prescription or patient is receiving hospice care
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CDC (2016) and VA/DoD Guidelines (2017)
• Patient selection
• Medication and dose selection
• Follow-up and discontinuation
• Assessment of risks
• Addressing harms
CDC Opioid Guidelines 2016; MMWR / March US Department of Health and Human Services/Centers for Disease Control and Prevention 18, 2016 / Vol. 65 / No. 1
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Concepts from Guidelines
• Initiation of Chronic Opioid Therapy
• Risk stratification
• Attention to Morphine Equivalent Daily Dose
– Opioid Conversion
• Attention to medication interactions
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Concepts from Guidelines
• Need for informed consent and patient education
• Monitoring and reassessment
• Need for alternatives to chronic opioid therapy for chronic pain
• Need for assistance to Primary Care Teams
CARA Memorandum (2017)
• Pain Care
– Pain Management Teams at each facility
– Availability of immediate consultation for opioid prescriptions
– Team reviews
– Availability of prescribing for high risk patients
• Expansion of OSI
• Availability of Complementary and Integrative Health Modalities
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Struggles from the Start
• Collateral Duty
• Lack of shared vision
• Lack of consensus with leadership about scope and goals
• Excessive focus on opioids/opioid safety vs. quality pain care
• Fragmented/ silo-effect / uncoordinated VISN-wide team
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Lessons Learned Year 0
• Need for consensus among group and with leadership
• Team development essential – Regular F2F meetings
– Regular phone meetings
• Protected time for clinicians
• Administrative support / project management
• Regular feedback to stakeholders – Leadership
– Frontline
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VA New England Healthcare System (VISN 1) VIPS (2015)
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Vision: To create a comprehensive, safe, evidence-based system of pain care that improves the function and quality of life for all Veterans with chronic pain Goal 1: Improve Safety- Improve the safety of care for Veterans with chronic pain in VISN 1 by achieving a VISN 1 Pain Composite Score of 97% by September 30, 2019. Goal 2: Enhance Access- Improve access to care for Veterans with chronic pain in VISN 1 by achieving 97% completion of the VIPS Pain Grid by September 30, 2019.
Informed Consent
Urine Drug Screen
State Prescription Drug Monitoring Program
Naloxone
Safety Tier 1 Review
Complexity
Chiropractic Care, Interdisciplinary Pain Care Team,