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CDA 08-276 – HSR&D Study

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CDA 08-276
Identifying Indications for Opioid Reassessment in Primary Care
William C Becker MD
VA Connecticut Healthcare System West Haven Campus, West Haven, CT
West Haven, CT
Funding Period: April 2012 - March 2016

BACKGROUND/RATIONALE:
In the face of limited data on long-term safety and efficacy of opioids for chronic pain, expert consensus has arrived at the following broad paradigm: clinicians should conduct frequent re-assessments to weigh benefit and harm of ongoing opioid treatment and continue therapy only if benefit is outweighing harm. This general approach has been promoted by the VA since 2003's "VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain;" 2010-updated guidelines do not diverge from this main principle. However, specific guidance on assessing harm and benefit are lacking. The specific aims outlined in this project are designed to improve assessment, specifically, PCPs' ability to identify patients on opioids who may need a change in medication regimen either because the current regimen is unsafe, ineffective or because of medication misuse.

OBJECTIVE(S):
This project fills an important void in the clinical armamentarium by creating a brief instrument that fulfills the need for patient reassessment advocated in current guidelines on the use of opioids in patients with chronic pain.

METHODS:
Objectives/Methods -
Specific Aim #1: To perform a systematic review of the published literature describing clinical features and validated patient-reportable items related to opioid safety, efficacy and misuse during opioid treatment and to create an item pool to be subject to expert consensus review in Aim #2.

Specific Aim #2: To use the Delphi method to achieve expert consensus on the patient-reportable items from Aim #1 that are indications for opioid reassessment (IOR) in primary care patients with chronic pain.

Specific Aim #3: To develop and assess preliminary validity and reliability of an instrument to screen patients for IORs using items identified in Aim #2: the Patient-Reported Indications for Opioid Reassessment (PRIOR).

Specific Aim #4a: To design a Computerized Patient Record System (CPRS) progress note to transmit results of the PRIOR to the treating clinician and assess the feasibility of implementing it in primary care.

Specific Aim #4b: To conduct a pilot trial of the PRIOR to obtain data required to design a randomized clinical trial

FINDINGS/RESULTS:
Not yet available.

IMPACT:
We have made step-wise progress in developing a brief instrument (the PRIOR) that will identify patient-reported indications for opioid reassessment in primary care. We hypothesize that once developed and incorporated into CPRS, this instrument will address a key clinician gap and improve clinical outcomes related to opioid safety, one of the most pressing Veteran health issues.

PUBLICATIONS:

Journal Articles

  1. Becker WC. Commentary on Ilgen et al. (2016): Integrating chronic pain programs into addiction treatment-full steam ahead. Addiction (Abingdon, England). 2016 Aug 1; 111(8):1394-5.
  2. Tobin DG, Andrews R, Becker WC. In Reply: Prescribing opioids. Cleveland Clinic journal of medicine. 2016 Aug 1; 83(8):554-5.
  3. Becker WC. Rigorous Epidemiologic Work Shows Positive Impact of VHA's Efforts to Rein in Opioid Prescribing. Pain medicine (Malden, Mass.). 2016 Jul 1; 17(7):1209-1210.
  4. Becker WC, Tetrault JM. Medical Marijuana in Patients Prescribed Opioids: A Cloud of Uncertainty. Mayo Clinic proceedings. 2016 Jul 1; 91(7):830-2.
  5. Merlin JS, Young SR, Azari S, Becker WC, Liebschutz JM, Pomeranz J, Roy P, Saini S, Starrels JL, Edelman EJ. Management of problematic behaviours among individuals on long-term opioid therapy: protocol for a Delphi study. BMJ open. 2016 May 6; 6(5):e011619.
  6. Tobin DG, Andrews R, Becker WC. Prescribing opioids in primary care: Safely starting, monitoring, and stopping. Cleveland Clinic journal of medicine. 2016 Mar 1; 83(3):207-15.
  7. Becker WC, Fiellin DA, Black AC, Kostovich CT, Kerns RD, Fraenkel L. Initial development of patient-reported instrument assessing harm, efficacy, and misuse of long-term opioid therapy. Journal of rehabilitation research and development. 2016 Feb 1; 53(1):127-36.
  8. Becker WC, Merlin JS, Manhapra A, Edens EL. Management of patients with issues related to opioid safety, efficacy and/or misuse: a case series from an integrated, interdisciplinary clinic. Addiction science & clinical practice. 2016 Jan 28; 11(1):3.
  9. Wright AP, Becker WC, Schiff GD. Strategies for Flipping the Script on Opioid Overprescribing. JAMA internal medicine. 2016 Jan 1; 176(1):7-8.
  10. Becker WC, Ganoczy D, Fiellin DA, Bohnert AS. Buprenorphine/Naloxone dose and pain intensity among individuals initiating treatment for opioid use disorder. Journal of substance abuse treatment. 2015 Jan 1; 48(1):128-31.
  11. Dorflinger LM, Ruser C, Sellinger J, Edens EL, Kerns RD, Becker WC. Integrating interdisciplinary pain management into primary care: development and implementation of a novel clinical program. Pain medicine (Malden, Mass.). 2014 Dec 1; 15(12):2046-54.
  12. Gaither JR, Goulet JL, Becker WC, Crystal S, Edelman EJ, Gordon K, Kerns RD, Rimland D, Skanderson M, Weisberg DF, Justice AC, Fiellin DA. Guideline-concordant management of opioid therapy among human immunodeficiency virus (HIV)-infected and uninfected veterans. The journal of pain : official journal of the American Pain Society. 2014 Nov 1; 15(11):1130-40.
  13. Frank JW, Linder JA, Becker WC, Fiellin DA, Wang EA. Increased hospital and emergency department utilization by individuals with recent criminal justice involvement: results of a national survey. Journal of general internal medicine. 2014 Sep 1; 29(9):1226-33.
  14. Becker WC, Meghani S, Tetrault JM, Fiellin DA. Racial/ethnic differences in report of drug testing practices at the workplace level in the U.S. The American journal on addictions. 2014 Jul 1; 23(4):357-62.
  15. Wang KH, Fiellin DA, Becker WC. Source of prescription drugs used nonmedically in rural and urban populations. The American journal of drug and alcohol abuse. 2014 Jul 1; 40(4):292-303.
  16. Frank JW, Bair MJ, Becker WC, Krebs EE, Liebschutz JM, Alford DP. Update in pain medicine for primary care providers: a narrative review, 2010-2012. Pain medicine (Malden, Mass.). 2014 Mar 1; 15(3):425-31.
  17. Becker WC, Fraenkel L, Kerns RD, Fiellin DA. A research agenda for enhancing appropriate opioid prescribing in primary care. Journal of general internal medicine. 2013 Oct 1; 28(10):1364-7.
  18. Becker WC, Fraenkel L, Edelman EJ, Holt SR, Glover J, Kerns RD, Fiellin DA. Instruments to assess patient-reported safety, efficacy, or misuse of current opioid therapy for chronic pain: a systematic review. Pain. 2013 Jun 1; 154(6):905-16.
  19. Fiellin LE, Tetrault JM, Becker WC, Fiellin DA, Hoff RA. Previous use of alcohol, cigarettes, and marijuana and subsequent abuse of prescription opioids in young adults. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2013 Feb 1; 52(2):158-63.
  20. Edelman EJ, Gordon K, Becker WC, Goulet JL, Skanderson M, Gaither JR, Brennan Braden J, Gordon AJ, Kerns RD, Justice AC, Fiellin DA. Receipt of opioid analgesics by HIV-infected and uninfected patients. Journal of general internal medicine. 2013 Jan 1; 28(1):82-90.
  21. Wang KH, Becker WC, Fiellin DA. Prevalence and correlates for nonmedical use of prescription opioids among urban and rural residents. Drug and Alcohol Dependence. 2013 Jan 1; 127(1-3):156-62.
Journal Other

  1. Edelman EJ, Gordon KS, Goulet J, Tate J, Becker W, Bryant K, Crothers K, Gaither J, Gibert C, Gordon AJ, Rodriguez-Barradas M, Samet JH, Justice AC, Fiellin DA. Is unhealthy alcohol use associated with CD4 cell count among HIV-infected patients on and off combination antiretroviral therapy? [Abstract]. Alcoholism, clinical and experimental research. 2014 May 30; 38(S1):196A.
Book Chapters

  1. Becker WC, Kerns RD. Pain after trauma (including PTSD). In: Expert Decision Making on Opioid Treatment. New York, NY: Oxford University Press; 2013. Chapter 8. 81-88 p.
Conference Presentations

  1. Becker W, Tate JP, Edelman EJ, Gaither J, Akgun K, Barry D, Crystal S, Gordon A, Merlin JS, Kerns RD, Justice AC, Fiellin DA. The Relationship Among Opioid Use, HIV, and Accidental Death: Is It In the Eye of the Beholder? Poster session presented at: Society of General Internal Medicine Annual Meeting; 2015 Apr 24; Toronto, Canada.
  2. Edelman EJ, Gordon K, Goulet J, Tate J, Becker W, Bryant K, Crothers C, Gaither J, Gibert C, Gordon AJ, Rodriguez-Barradas M, Samet JH, Justice AC, Fiellin DA. Is unhealthy alcohol use associated with CD4 cell count among HIV-infected patients on and off combination antiretroviral therapy. Poster session presented at: Research Society on Alcoholism Annual Scientific Meeting; 2014 Jun 22; Bellevue, WA.
  3. Becker WC, Ganoczy D, Fiellin DA, Bohnert AS. Buprenorphine/naloxone dose and pain intensity among individuals initiating treatment for opioid use disorder. Poster session presented at: College on Problems of Drug Dependence Annual Meeting; 2014 Jun 19; San Juan, Puerto Rico.
  4. Becker WC. Recent trends and regional variation in opioid analgesic exposure in the Veterans Health Administration. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 26; San Diego, CA.
  5. Becker WC. Trends in and correlates of opioid receipt among Veterans with and without HIV. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 26; Denver, CO.


DRA: Health Systems
DRE: Prevention
Keywords: none
MeSH Terms: none

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