improving opioid prescribing in va primary care by erin e. krebs, md, mph
TRANSCRIPT
Improving opioid prescribing in VA primary care
Erin E. Krebs, MD, MPHMinneapolis VA Health Care System
University of Minnesota
Disclosures• I have no commercial financial relationships• I have received research funding from VA, NIH, FDA, and DOD• Views expressed are mine and do not reflect the position or
policy of the VA or US government
“My first doctor… I trusted him all the time… and didn’t ask him a question at all, and I [was] on almost 600 mg of the OxyContin and that other drug together and I mean I was just in la-la land all the time.
I never should’ve let him do that to me, but his, his—I’m at a loss for words. He wanted to relieve my pain… He really did care for me, but he was overly taking care of me and didn’t think about the side effects of what he was doing.”
Outline
• Barriers to improving pain management practice• VA Opioid Safety Initiative• Minneapolis VA Opioid Safety Initiative experience
Opioid prescribing in VA
• VA patients have ~2x rate of accidental poisoning compared with the general population– Opioid medications ~1/3 of deaths
• 50% of 1.4 million Veterans with chronic pain* received ≥ 1 opioid prescription in 2011– Median days’ supply: 120– Median daily dose: 21 ME mg
Bohnert AS et al., Med Care 2011; Edlund MJ et al., Pain 2014
*Back pain, neck pain, arthritis, headache, neuropathic pain
Opioid prescribing in VA
Edlund MJ et al., Pain 2014
VA Opioid Safety Initiative
• OSI dashboard: national, regional, & facility-level reporting of opioid prescribing metrics
• Opioid panel report: Primary care team-level reporting of patient risk and treatment characteristics
• Nationwide targets for all VA facilities/health systems– Issued April 2014– Revised December 2014
National VA OSI goals
1. Educate prescribers on use of UDT
2. Increase use of UDT3. Facilitate use of PDMP4. Establish tapering
programs for patients on benzodiazepines & opioids
5. Develop tools to identify high-risk patients
6. Improve prescribing of long-acting opioids
7. Review treatment plans of patients on high-dose opioids
8. Offer behavioral & CAM therapies at all facilities
9. Develop collaborative PC and MH models to manage benzodiazepine & opioid prescribing
Minneapolis VA OSI
• Primary care population-level QI initiative (2011-)• Objectives– Reduce dose to <200 ME mg/d for chronic non-cancer pain– Phase out use of oxycodone SA
Westanmo A et al., Pain Med 2014
Minneapolis VA Health Care System
• 1 urban tertiary care hospital + 11 suburban and rural clinics
• 68,000 patients enrolled in primary care
Mpls OSI implementation
• Preparation phase (April 2011-January 2012)– Leadership/stakeholder meetings– Primary care pain/opioid seminars (6 sessions)– Clinical pharmacist meetings/training
Westanmo A et al., Pain Med 2014
Mpls OSI implementation
• Implementation (February 2012)– Chief of Staff letter to PCPs– Patient lists and OSI action plans to PCPs• Develop taper/conversion plan with pharmacist• Schedule patient visit for pain medication review• Work with pharmacist to implement plan
– OSI performance measures– Patient pain education classes
• Phase 2 (2013): Opioid review committee
Westanmo A et al., Pain Med 2014
Pre-OSI PCP attitudes & beliefsAgree
I’m satisfied with care provided for pts with chronic pain 9%I have adequate training to care for my pts with chronic pain 32%It is important to have a consistent standard of care for opioid rx 97%It is reasonable to set a dose limit of 200 ME mg/day 76%
There are no good alternatives to high dose opioids 35%If I decrease doses, my pts may be threatening or violent 62%If I decrease doses, I will be pressured by pt representatives 59%
Keeping doses <200 will improve pt safety/reduce risk of death 85%Keeping doses <200 will improve pts’ quality of life 59%Keeping doses <200 will protect me as a prescriber 65%
Westanmo A et al., Pain Med 2014
Pre-OSI PCP concerns and hopes• What if treatment options
have been exhausted?• Some veterans may be left
less functional• Suicide threats/attempts • Long waits for specialty
referrals, etc.• Physician burnout, stress,
extra time and extra work• Security, especially at CBOCs
• Back-up to help us do what we all want to do anyway—use fewer opioids
• Hope at least some patients will wind up better off
• Patients may become more engaged in their own care and healing
Panel-specific patient data
Adapted from slide by Peter Marshall, MD
PC performance measures
• Performance measure data distributed to all PCPs
• Number of patients on ≥ 200 ME mg/d and receiving oxycodone SA
Adapted from slide by Peter Marshall, MD
Change in opioid daily doses
>50 >100 >200 >4000
200
400
600
800
1000
1200
14001256
712
342
126
811
303
65 11
Pre OSI Post OSI
Number of patients receiving daily dose above threshold
Westanmo A et al., Pain Med 2014
Change in long-acting opioids
Morphine SA Methadone Fentanyl TD Oxycodone SA0
100
200
300
400
500
600
700
800
900 831
286
94
292
770
16494
3
Pre OSI Post OSI
Number of patients receiving drug
Westanmo A et al., Pain Med 2014
Post-OSI PCP attitudes & beliefsPre Post
I’m satisfied with care provided for pts with chronic pain 9% 26%I have adequate training to care for my pts with chronic pain 32% 29%It is important to have a consistent standard of care for opioids 97% 100%It is reasonable to set a dose limit of 200 ME mg/day 76% 87%
There are no good alternatives to high dose opioids 35% 23%If I decrease doses, my pts may be threatening or violent 62% 64%If I decrease doses, I will be pressured by pt representatives 59% 22%
Keeping doses <200 will improve pt safety/reduce risk of death 85% 87%Keeping doses <200 will improve pts’ quality of life 59% 55%Keeping doses <200 will protect me as a prescriber 65% 65%
Westanmo A et al., Pain Med 2014
“…the VA system swung too suddenly in the other direction after the national spotlight on overprescribing… Veterans should not be imprisoned by pain because doctors are unwilling or unable to prescribe the medications they need.”
Mpls OSI summary
• Accomplishments– Altered primary care prescribing practices lower dose,
lower risk opioid regimens– Change in system-wide standard of pain care more
conservative expectations for opioids• Persistent challenges– PCP perceptions of quality of care & adequacy of training– Availability of non-pharm pain management options– Patient/public perceptions
• Unknowns– Patient outcomes
“99% of the conversations we ever have… is my weight, blood pressures, what number of pain I’m in, but there is no conversation about pain. See my personal belief—and [my doctor] is the best I’ve seen over these four decades—is they’re at a loss at this.”
Implications
• Systematic efforts can reverse opioid prescribing patterns
• The main challenge is to transform our understanding of chronic pain and how it should be prevented, assessed, and managed
IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press
Questions?