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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 ?
                                Tertiary Interdisciplinary Pain
                                            Centers
                   RISK	
         Advanced diagnostics &
                                        interventions
                              CARF accredited pain rehabilitation
  Co morbidities



Treatment
Refractory

                    Patient Aligned Clinical Team (PACT)
               Routine screening for presence & intensity of pain
                        Comprehensive pain assessment
Complexity         Management of common pain conditions
              MH-PC Integration, OEF/OIF, & Post-Deployment Teams
                         Expanded care management
                             Opioid Renewal Clinics
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
Helping the Bewildered
  Survive the Storm
                         Gollie
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?




 PATIENT                 PCP

              ? UDS
              Labs
Bridging The Gap
  OVAMC E-Consult Pain Management



      Primary Care         Specialty Care Pain Clinics
Daily PM Issues, Support     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
Project Coordinator
                                                                                                     Pain Pharmacist




                                                     E-Consult
                                   CPRS Review/Documented Recommendations

Provider Education
Week                           Pain Pharmacist: Initial Responder
                               Triage Based on Level of Complexity (LOC)
Teleconference                 L1 Pharmcotherapy concerns
                               L2 Pharmcotherapy /MH Comorbitity Concerns
                                    a. Multidisciplinary
                               L3 Complex Comorbitity/High Risk Patients: Teleconferencing
                                          a. Interdisciplinary


VHAORL E-Consult Pain Management
             Outlook                           Triage                                MH Screen
   Provider Non-CPRS Follow up                                          Pain Psychologist +Screen-Comorbitity L2

          Contact Option
                                            Chart Review



                                           CPRS Clinical Review

                                        Pain Pharmacist 1.0 FTE
   Progress Notes
                                                                                                 Outcomes
Primary Responder-Pharmacist
                                         Pain Psychologist % FTE
                                                                                            Quarterly/Annual Data
                                                                                             Pain Psychologist
                                          Pain Physician % FTE
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-

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Robert Sproul

  • 1. Responsible Prescribing Practices April 10-12, 2012 Walt Disney World Swan Resort
  • 2. 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.
  • 3. 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.
  • 4. 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
  • 5. FOLKS I KNOW WHAT YOU ARE THINKIN •  UNCANNY RESEMBLANCE
  • 6. ? Where Do We Start How Do We Get There ? Tertiary Interdisciplinary Pain Centers RISK   Advanced diagnostics & interventions CARF accredited pain rehabilitation Co morbidities Treatment Refractory Patient Aligned Clinical Team (PACT) Routine screening for presence & intensity of pain Comprehensive pain assessment Complexity Management of common pain conditions MH-PC Integration, OEF/OIF, & Post-Deployment Teams Expanded care management Opioid Renewal Clinics
  • 7. 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/
  • 8. 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
  • 9. Managing Chronic Opioid Therapy VHA Innovations In Clinical Services Support of our Veterans and their Providers
  • 10. Helping the Bewildered Survive the Storm Gollie
  • 11. 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)
  • 12. 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
  • 13. E-Consult Pain Management HELP! DIRECTIONS PLEASE-NOW? PATIENT PCP ? UDS Labs
  • 14. Bridging The Gap OVAMC E-Consult Pain Management Primary Care Specialty Care Pain Clinics Daily PM Issues, Support Management Services
  • 16. 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
  • 17. Project Coordinator Pain Pharmacist E-Consult CPRS Review/Documented Recommendations Provider Education Week Pain Pharmacist: Initial Responder Triage Based on Level of Complexity (LOC) Teleconference L1 Pharmcotherapy concerns L2 Pharmcotherapy /MH Comorbitity Concerns a. Multidisciplinary L3 Complex Comorbitity/High Risk Patients: Teleconferencing a. Interdisciplinary VHAORL E-Consult Pain Management Outlook Triage MH Screen Provider Non-CPRS Follow up Pain Psychologist +Screen-Comorbitity L2 Contact Option Chart Review CPRS Clinical Review Pain Pharmacist 1.0 FTE Progress Notes Outcomes Primary Responder-Pharmacist Pain Psychologist % FTE Quarterly/Annual Data Pain Psychologist Pain Physician % FTE
  • 18. 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
  • 19. 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
  • 20. 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
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. VHA Pain Management Support of and Care for our Veterans
  • 25. To All of Our Veterans -Who Have Sacrificed-