Chronic non-cancer pain (CNCP) is widely prevalent among Veterans and one of the most common reasons for their engagement with primary care in the VA health system.Increasingly, potent opioids are prescribed in the long-term management of CNCP, predominantly by primary care providers (PCPs), despite growing safety concerns and scant evidence for efficacy. PCPs indicate they often feel unprepared to assess the harms and benefits of prescription opioids, yet may prescribe them anyway. We term ongoing opioid prescribing without assessment of harm or benefit or after adverse effects, low efficacy or misuse have been identified "low quality opioid prescribing (L-QuOP)." L-QuOP exposes patients to excess risk of harm and may cause or facilitate poor outcomes such as overdose, addiction and death.
Objectives: We established an inter-disciplinary clinic--the opioid reassessment clinic (ORC), staffed by a general internist, addiction psychiatrist, and behavioral health nurse practitioner, in which patients with evidence of adverse effects, low efficacy or misuse of opioids were enrolled. The clinic, embedded within primary care, performed assessments and designed and initiated an individualized, multi-modal treatment plan for chronic pain. Patients were followed in the clinic longitudinally until safety, efficacy or misuse issues were stabilized.
The specific objective of this application were to use the RE-AIM framework to systematically evaluate strengths and weaknesses of the clinic to improve its uptake and effectiveness.
This study was approved by the West Haven VA human subjects subcommittee of the Investigational Review Board. We recruited a convenience sample of 28 patients enrolled in the clinic. We evaluated REACH by determining the no-show rate for the initial clinic appointment. Patients were interviewed at 0, 3 and 6 months to assess pain level, pain-related functional interference, and treatment satisfaction. Selected PCPs completed a brief survey pertaining to their satisfaction with the clinic, including impact on patient-provider relationships. ADOPTION was assessed as the proportion of PCPs who reported willingness to adopt the intervention - both the clinic's management but also the subsequent recommendations to be carried out in primary care. We evaluated IMPLEMENTATION through assessment of the no-show rate for follow-up appointments with the clinic as well as the frequency and type of contact with the clinic. To gain a more in-depth understanding of factors associated with implementation, semi-structured individual interviews will be conducted with purposively selected patients and PCPs. We evaluated MAINTENANCE at the system level, by meeting with PCPs and administrators near the end of the study to gauge their willingness to maintain the intervention as part of usual care, identify potential barriers to maintenance, and necessary areas for additional assistance.
The no-show rate for the first evaluation appointment was low at 7% likely owing to the fact that many patients were expecting to have opioid therapy continued. Four out of 28 enrolled patients said they did not know or were not sure why they were referred to the clinic. The 28 enrolled patients were seen for a total of 137 visits for an average of 4.9 visits in the ORC. On a 5-point scale, with 5 being very satisfied, patients' average satisfaction was 3.82 (SD 1.31), or between neutral and satisfied. Patients seen for multiple visits were undergoing opioid rotations, including switches to buprenorphine/naloxone treatment, downward dose tapers or, in some cases, simply additional monitoring. In each case, opioid treatment agreements were initiated and standard monitoring (urine drug testing, pill counts, caregiver information and prescription drug monitoring program queries) was implemented. Qualitative data from patients revealed a wide variety of opinions regarding the clinic and its staff, ranging from comments reflecting anger and frustration to others expressing gratitude and satisfaction. In general, patients who were not in agreement with decisions to taper opioids were the most dissatisfied. PCPs, on the whole, were satisfied with ORC services, particularly with support managing complex pain and misuse issues and offering patients easier pathways to alternative treatment options. Providers did note that ORC's limited availability (one half-day clinic/week) meant that issues arising between clinic visits often fell to the primary care team.
The study revealed several barriers and facilitators to implementation of a co-management clinic focused on chronic pain and safe opioid prescribing. Qualitative and quantitative data have driven modifications to the clinic structure and ideas for expansion. For example, data from this study were included in a now-funded Office of Specialty Care Transformation grant application that will pay for a Nurse Care Coordinator to help provide continuity of care between ORC clinic visits. Expanded implementation models studying patient outcomes are underway.
- Oldfield BJ, Edens EL, Agnoli A, Bone CW, Cervone DJ, Edmond SN, Manhapra A, Sellinger JJ, Becker WC. Multimodal Treatment Options, Including Rotating to Buprenorphine, Within a Multidisciplinary Pain Clinic for Patients on Risky Opioid Regimens: A Quality Improvement Study. Pain medicine (Malden, Mass.). 2018 Sep 1; 19(suppl_1):S38-S45.
- Dorflinger L, Moore B, Goulet J, Becker W, Heapy AA, Sellinger JJ, Kerns RD. A partnered approach to opioid management, guideline concordant care and the stepped care model of pain management. Journal of general internal medicine. 2014 Dec 1; 29 Suppl 4:870-6.