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?

erin.krebs@va.gov