Responsible Prescribing Practices

April 10-12, 2012 Walt Disney World Swan Resort

Learning Objectives: 1. Describe how cautious, evidence-based prescribing practices can lower opioid-related overdose deaths while maintaining appropriate access for medically needed treatment of chronic pain. 2. Identify “best practice” strategies that can be used by clinicians for pain management treatment. 3. Explain evidence-based practice and policies for provider education and patient education programs being utilized across the US.

Disclosure Statement

•  All presenters for this session, Dr. Rollin M. Gallagher, Dr. Andrew Kolodny, and Robert Sproul, have disclosed no relevant, real or apparent personal or professional financial relationships.

Opioid-High Alert Appropriate Treatment / Risk Mitigation

Robert Sproul PharmD Program Director, OVAMC Pain Management

Program Manager, Pharmacy PM, Palliative Care Project Director, OVAMC E-Consult Pain Management

Co-Chair, VA National Pain Management Pharmacy Work Group Co-Chair, VA National Clinical Pharmacy Training Work Group Pain Management

Member, VA National Pain Management Strategy Coordinating Committee

National RX Drug Abuse Summit 2012

Orlando VA Medical Center

FOLKS I KNOW WHAT YOU ARE THINKIN

•  UNCANNY RESEMBLANCE

? Where Do We Start How Do We Get There ?

Patient Aligned Clinical Team (PACT) Routine screening for presence & intensity of pain

Comprehensive pain assessment Management of common pain conditions

MH-PC Integration, OEF/OIF, & Post-Deployment Teams Expanded care management

Opioid Renewal Clinics

Complexity

Treatment Refractory

Co morbidities

RISK  

Tertiary Interdisciplinary Pain Centers

Advanced diagnostics & interventions

CARF accredited pain rehabilitation

Abridged VA Quality Monitors Going Beyond DEA Regulations

•  PBM High Dose Opioid (HDO) Monitor –  Multi-Site review identify patients receiving opioids from

more than one site within a VISN –  Multi-VISN review identify patients receiving opioids from

sites in more than one VISN •  Formulary Management

–  Evidence Based Drug class and molecular reviews –  Criteria for use that address safety concerns

•  MAP (Medical Advisory Panel) –  Field input and review from subject matter experts,

clinical alerts –  PBM site (Public Link) http://www.pbm.va.gov/

Abridged VA Quality Monitors Provider Education Support Programs

•  VA MedSafe –  Pharmacovigilance/PostmarketingSurveillance and VA ADERS program

•  National ADE reporting program for all VA –  Active surveillance

•  Proactive tracking of all patients exposed to a medication and identifying adverse events using diagnostic codes or symptom

•  Provider Education: It’s not just about Monitors –  VA Web Programs for Providers (Example: Opioid Web Course) –  INTRANET Department of Veteran Affairs

•  VHA Pain Management –  VA Methadone, Fentanyl Dosing, Safety –  Collaborative Intervention for Pain and Depression –  VA/DoD CPG: Management of Opioid Therapy

for Chronic Pain –  Stepped Integrated Pain Care in the VHA

Managing Chronic Opioid Therapy VHA Innovations In Clinical Services

Support of our Veterans and their Providers

Gollie

Helping the Bewildered “Survive the Storm”

National Clinical Pharmacy Training “BOOT CAMP / Mentoring Program”

•  Boot Camp –  Designed

•  Empower the attendees with the most fundamental knowledge •  Necessary to develop competence and confidence •  To address every day pain issues

–  In the AMB Care or PACT setting

•  VA Pain Management Mentoring (VAPPMM) –  Mentoring Outlook Exchange Service

•  Continue this theme by providing continued support •  Solidify the skills learned in the boot camp •  Broaden the horizons of those participating in this exchange •  Safety Net (NOT SURE THEN ASK)

BOOT CAMP / VAPPM Mentoring Abridged Topics of Emphasis

•  Opioids –  Check the "math" –  Conversions, Rotation, Titration, Taper etc. –  Choice of Opioids /Drug to Drug interactions –  Pharmacokinetic/dynamic implications –  Adjuvant or Alternatives

•  Urine Drug Tests (UDT) –  Results, Implications, Caveats –  Follow up procedures

•  Appropriate documentation •  Patient Safety Issues/Moderate to High Risk Patients •  Provider Coverage

•  Referral Considerations –  Substance Abuse, Mental Health, Physical Therapy, Other

E-Consult Pain Management HELP! DIRECTIONS PLEASE-NOW?

PCP PATIENT

Labs

?

UD

S

Bridging The Gap OVAMC E-Consult Pain Management

Primary Care Daily PM Issues, Support

Specialty Care Pain Clinics Management Services

OVAMC E-Consult PM

OVAMC E-Consult PM Fundamental Goals

•  To address everyday pain management questions and patient safety issues

•  To provide “easy access” to the service for the consulting provider –  “Easy Access” equates with “Timely Support” –  Paramount for addressing patient safety issues

•  Typical concerns addressed by the E-Consult Pain –  Opioid related

•  Titration, rotation, conversions, tapering •  Alternative treatment modalities

–  Urine Drug Screen •  Interpretation, policy, provider recourse •  Associate opioid tapering and

ethical considerations

VHAORL E-Consult Pain Management Outlook

Provider Non-CPRS Follow up Contact Option

CPRS Clinical Review

Pain Pharmacist 1.0 FTE

Pain Psychologist % FTE

Pain Physician % FTE

E-Consult CPRS Review/Documented Recommendations

Outcomes Quarterly/Annual Data

Pain Psychologist

Triage Chart Review

Pain Pharmacist: Initial Responder Triage Based on Level of Complexity (LOC) L1 Pharmcotherapy concerns L2 Pharmcotherapy /MH Comorbitity Concerns

a. Multidisciplinary L3 Complex Comorbitity/High Risk Patients: Teleconferencing a. Interdisciplinary

Project Coordinator Pain Pharmacist

Progress Notes Primary Responder-Pharmacist

MH Screen Pain Psychologist +Screen-Comorbitity L2

Provider Education Week Teleconference

Recommendations / Documentation What’s In A Name

•  Intent –  Is not to “paint a provider into a corner” –  Is to provide guidance for / with options to the provider

•  Wording –  How a recommendation is “worded” is crucial

•  Stipulates the recourse the Pain Service would take •  Offers alternative to the Clinic’s stance (opinion)

– Acknowledges provider's discretion

•  Example –  For the following patient safety issues detailed above a.b.c.,

the Pain Clinic would no longer prescribe opioids for this pt at this time

–  However, should the provider determine opioids will be continued, then the Pain Clinic would recommend the following

•  Frequent UDS •  No more than a seven day supply, etc

OVAMC E-Consult PM Provider Education

•  OVAMC/VISN 8 E-Consult –  Chronic Pain Audio Conference

•  Weekly Case-Base Provider Education (CME) –  Moderate to High Risk Patients –  Complex patients with Comorbitity

•  Supporting didactics

•  Provides an Interdisciplinary Forum –  Explore alternatives –  Discuss controversies –  Provider recommendations

Hidden Treasures Transcending the Routine E-Response

•  Typical consults –  Often directly address important daily issues, such as urine

drug screens, opioids, and associated concerns

•  However, provider support is not limited to "treatment modalities" alone –  May directly assist the provider in resolving difficult

scenarios •  Patient treatment and or ethically related issues •  Assist in coordination of care

E-Case Study Ethical Considerations

•  Reason for Consult –  Terminally ill cancer patient –  In the ambulatory care setting –  Non-End of Life Scenario –  On significant amount of opioids –  Test positive for cocaine/alcohol

•  Provider's Comments ..."I'm concerned that the patient is going to overdose or hurt

someone else” …“Is a second chance reasonable, or must I discontinue the opioids” …“I don’t want to cut the opioids” …“I know he’s in a lot of pain” ...“What should I do”

E-Hidden Treasures PCP Doesn’t Have to Walk the Walk Alone

•  Ultimately it will be the provider's discretion that determines the recourse which will be taken

•  However, the provider can reach out to a "team" for support and or advice –  Options with the supporting details –  To address a controversial pain / ethical issue

•  Means to avoid the unilateral decision process –  An uncomfortable situation for many providers –  Due to perceived scrutiny

•  From oneself or from others •  Laced in the form of legal, ethical, moral

considerations/implications

Balancing the Benefits and Risks Personal Perspective

•  Opioids CNMP: The Approach and Contingency •  Exhaust “other options” prior to prescribing opioids for “chronic” use •  Utilize all resources / tools available to ensure success •  Discuss with patient expectations, limitations, shared responsibility •  Set goals prior to implementing opioid therapy •  Monitor for success and or failure to protect our Veterans who may

have an abuse problem who may not be able to help themselves •  However, we respect the rights of our Veterans to the use of these medications,

•  When other options have failed •  When these medications prove affective

–  Safety comes first, function is at minimum preserved •  When used responsibly

•  We Do Not Sacrifice or Label our Veterans who are in need for those who would abuse, when being treated with opioids

VHA Pain Management Support of and Care for our Veterans

To All of Our Veterans -Who Have Sacrificed-