Prescription medication misuse is a growing problem in the US that causes significant morbidity and mortality. As attention to the importance of pain management has increased so has prescribing of opioid analgesics. Unfortunately, increased use of opioids to treat pain has been paralleled by a large increase in prescription opioid related problems, including non-medical use, overdose, and litigation against physicians. A variety of problematic medication taking behaviors may lead to serious negative medical, social, or functional consequences for the user or another person.
Minimizing misuse is necessary for safe and effective use of prescription medications. Misuse is generally defined by patient behaviors, and substantial research effort has been directed at identifying at-risk or misusing patients for special clinical intervention. While this focus on the patient is useful, provider and systems factors also contribute to medication misuse, and these factors may be more amenable to quality improvement within health care systems. Clinical practice guidelines for chronic opioid therapy provide recommendations regarding health care system and practitioner level practices that are thought to maximize safe and effective use and minimize misuse. For example, the guideline encourages clinicians to conduct on-going assessments of pain and functioning, use urine drug screening protocols to discourage and detect medication misuse and diversion, proactively address side-effects and drug combinations that may increase risk, and use opioid therapy within the context of promoting comprehensive non-pharmacologic pain management. Using recommended care practices should minimize negative consequences of opioid prescribing without reversing gains made in improving pain management.
Consistent with Step 3 of the QUERI process (Defining existing practice patterns and outcomes across the VA and current variation from best practices), a first step towards increasing adherence to guideline-recommended practices is developing methods to systematically measure use of these practices and identify gaps in their current implementation. We proposed examining the extent to which individual clinical practice guideline recommendations are followed at VA facilities and variability in implementation of these guideline recommendations across VA facilities.
Specific Aim 1: To develop and code VA administrative data-based metrics that map onto recommendations to minimize medication misuse in the VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Pain.
Specific Aim 2: To determine gaps in adherence to guideline recommendations for opioid prescribing in VA.
a)To determine domains in which there is poor performance system-wide
b)To determine domains for which there is substantial variability in performance across VA facilities
We analyzed FY10 administrative data from the National Patient Care Database and the Decision Support System files. The project team designed metrics to capture guideline recommended opioid prescribing practices through an iterative process of guideline review, drafting of metrics, expert review and discussion of definitions and concepts, then coding and review of data. In general, definitions of evidence-based care were designed to be broadly inclusive so metrics would provide a "best case" estimate of adherence to guideline recommended practices and avoid false negative assessments of adherence.
Metrics were created to assess adherence to guideline recommendations in the following domains: Side effects (bowel regimen use and serious adverse events), Risky drug combinations (sedative co-prescription and over-prescription of acetaminophen), Misuse risk (treatment and monitoring of patients with active SUD), Appropriate follow-up following initiation, Avoiding sole reliance on opioids (use of psychosocial, other pharmacotherapy, rehabilitation, and CAM services), Safe prescribing (medication reconciliation and absolute contraindicated prescribing), and use of Urine drug screening (UDS). Metrics were calculated from FY10 administrative data at the patient, facility, and VISN level.
Descriptive analysis found substantial non-adherence to guideline-recommended prescribing practices across VA facilities and across measures, but the patterns of non-adherence differ substantially across measures. For example, guideline adherence for risky sedative co-prescribing was lower in patients on long-acting opioids or chronic short-acting formulations than in patients with acute short-acting or tramadol prescriptions. Moreover, rates of risky sedative co-prescribing were normally distributed across facilities within a relatively tight range (e.g. 24-35% of patients on chronic short-acting opioids received an overlapping sedative prescription across facilities), suggesting similar non-optimal practice patterns across medical centers. In contrast, guideline adherent use of recommended UDSs was more common in patients on long-acting or chronic short-acting formulations, and rates of UDSs varied substantially across facilities with leftward skewed distributions. For example, rates of UDSs in patients on chronic short-acting opioids ranged from 0 to 38% with 25% of facilities screening less than 1% of their patients, and 50% of facilities screening less than 7%. This suggests that the majority of facilities have not instituted procedures that successfully encourage UDSs, but a few much more effectively promote this practice. In this case, wider dissemination of practices at high-performing facilities may help improve practices.
These data will be provided to VACO pain and addictions leadership, pharmacy benefits management, and pain and SUD research, evaluation and quality improvement workgroups to guide initiatives to improve opioid safety and efficacy within VA. They will be recalculated and redistributed by the VA Program Evaluation and Resource Center in VACO Mental Health Clinical Operations to track changes in prescribing practices over time. These measures are being considered for official adoption by VA National Pain Management as part of their FY11 Operating Plan.
- Oliva EM, Midboe AM, Lewis ET, Henderson PT, Dalton AL, Im JJ, Seal K, Paik MC, Trafton JA. Sex differences in chronic pain management practices for patients receiving opioids from the Veterans Health Administration. Pain medicine (Malden, Mass.). 2015 Jan 1; 16(1):112-8.
- Trafton JA, Henderson P, Paik M, Tavakoli S, Bowe T, Oliver J, Midboe AM, Lewis ET. VA Opioid Therapy Clinical Practice Guideline Adherence Report: Customizable intranet-based report of facility-level adherence to guideline recommended care practice to improve the safety and efficacy of opioid prescribing for pain. 2015 Oct 1. Available from: http://vssc.med.va.gov/VSSCAgreements/Default.aspx?locn=http%3A//vssc.med.va.gov/uat.asp..