Disclosures 6/5/2017. Dr. Franklin has no disclosures Dr. Ngo has no disclosures

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1 Tu Ngo, PhD, MPH Julie Franklin, MD, MPH International Conference on Opioids Boston, MA June 11, Disclosures Dr. Franklin has no disclosures Dr. Ngo has no disclosures 2 Objectives Identify areas for improvement in opioid safety within your practice. Identify barriers to improved opioid safety. Discuss use of EMR to improve and monitor opioid prescribing practices. Name two (2) strategies for promoting cultural change in an organization. 3 1

2 Development of VIPS Veterans Integrated Pain System of Care (VIPS) Impetus for change Leadership Buy-in Year 1 Year 2 Directions for the Future 4 Recognizing the Problem Opioids prescribed in US increased 400% between Opioid-related overdose deaths in US increased 400% between Veteran Specific Data Prescription medications prescribed in the military quadrupled from (NIDA) Prescription drug abuse increased five-fold between (IOM) Veterans are twice as likely to die from an accidental overdose (OD) than non-veterans (Bohnert, 2011) Accidental OD linked to: (Bohnert, 2011) Narcotics 51.4% Benzodiazepines 8% Antidepressants 8% 6 2

3 PTSD increases Risk for Opioid Prescriptions, High-Risk Use and Adverse Events Retrospective cohort study of 141,029 Veterans with non-cancer pain diagnosis Veterans with mental health issues were more likely to receive opioids: Approximately 3 times as likely with PTSD, Approximately 2 times as likely with other mental health issues. Those with co-morbid PTSD were significantly more likely: Highest quintile for dose; more than one opioid prescribed concurrently; concurrent sedative hypnotics; early refills, Opioid related accidents, overdoses, alcohol and non-opioid related accidents and overdoes, self-inflicted injuries and violence related injuries. Seal et al (2012). JAMA, March, 307(9). 7 Opioid Prescribing and Opioid Use Disorder Patients with CNCP prescribed opioids had significantly higher rates of OUDs compared to those not prescribed opioids. Effects varied by average daily dose and days supply: low dose, acute OR=3.03 low dose, chronic OR=14.92 medium dose, acute OR =2.80 medium dose, chronic OR=28.69 high dose, acute OR=3.10 high dose, chronic OR= Among individuals with a new CNCP episode, prescription opioid exposure was a strong risk factor for incident OUDs; magnitudes of effects were large. Duration of opioid therapy was more important than daily dose in determining OUD risk. Edlund et al (2014). Clin J Pain, July 30(7):

4 Dose* (mg/day) Odds of overdose by increasing dose Dunn Gomes Bohnert HR (95% CI) OR (95% CI) HR (95% CI) 1-< (REF) 1.00 (REF) 1.00 (REF) 20-< ( ) 1.3 ( ) 1.9 ( ) 50-< ( ) 1.9 ( ) 4.6 ( ) 100 or ( ) 2.0 ( ) 7.2 ( ) ( ) *morphine equivalent Dunn et al. Annals IM 2010; Gomes et al. Archives IM 2011; Bohnert et al. JAMA 2011 Slide courtesy of JW Frank, MD, MPH 10 Mortality: Opioid-Benzo Overdose Deaths 13% 31% Source: CDC s National Vital Statistics System Mortality File, IOM s vision for multimodal chronic pain care (2011) SELF CARE Behavioral therapies SELF EFFICACY Rational pharmaco therapy Physical activation Promotion of Healthy Behaviors Addressing Co-Morbidities Integrated Health System 12 4

5 VA New England Healthcare System VIPS Evolution VISN 1- PC-MH Integration core team focusing on pain VISN 1 OEF/OIF Trainingconsultative model to address pain VISN 1 Primary Care Strategic Plan on Pain Care Pain Champion and Facility level Primary Care Pain Champion Innovation Grant- Pain Workshops VISN 1 Grand Rounds 4 part series Pain Management Directive published Primary Care Sharing Best Practices- Interdisciplinary meeting on Chronic Pain Management Adoption of VISN 1 Pain Agreement VISN 1 Taskforce CARF Accredited Pain Program National Informed Consent VISN 1 OSI Pilot (2 year) Pain designated as VISN 1 for Chronic Opioid Therapy Strategic Initiative VISN 1 Integrated Pain Initiative funding approved VISN Opioid Pain Report first deployed OSI rolled out Nationally VISN 1 Pain Summit VA Maine earns CARF accreditation Initiative official start (FY16-FY20) 13 VHA Pain Directive 2009 Stepped Care Model Implemented Biopsychosocial Model Of Pain Care Introduced Focus on Quality of Life and Functional Improvement Encouraged Multidisciplinary Pain Management Oversight Committees Mandated 14 VHA Stepped Pain Care RISK Comorbidities Advanced pain medicine diagnostics & interventions; CARF accredited pain rehabilitation STEP 4 Treatment Refractory Multidisciplinary Pain Medicine Specialty Teams; Rehabilitation Medicine; Behavioral Pain Management; Mental Health/SUD Programs STEP 3 Complexity Routine screening for presence & severity of pain; Assessment and management of common pain conditions; Support from MH- PC Integration; OEF/OIF, & Post-Deployment Teams; Expanded care management; Pharmacy Pain Care Clinics; Pain Schools STEP 2 Nutrition/weight management, exercise/conditioning, & sufficient sleep; mindfulness meditation/relaxation techniques; engagement in meaningful activities; family & social support; safe environment/surroundings STEP 1 5

6 VHA Opioid Safety Initiative (OSI) National OSI Pilot (2013): no consensus on standard template and process National OSI Memorandum (2014) Dashboard Reports provided to identify high risk Utilization, MEDD, Urine Drug Screen (UDS), Co-prescription of opioids/benzodiazepines 9 Goals in response to OIG report 16 VHA OSI Goals 1) Educate prescribers on urine drug screen (UDS): each VISN standardized education system 2) Increase use of UDS graded on current performance 3) Facilitate use of state Prescription Drug Monitoring Program (PDMP) 4) Establish safe and effective tapering program for coprescribed opioids and benzodiazepines 5) Develop tools to identify higher risk patients 17 VHA OSI Goals cont d 6) Improve prescribing practices around long-acting opioid formulations 7) Review treatment plans on high dose of opioids: Mandated chart reviews over >200 MEDD 8) Offer Complementary and Integrated Health (CIH) modalities: at least one of CIH and one evidencebased psychotherapy (CBT, ACT) 9) Develop new models of mental health and primary care collaboration to manage prescribing of opioids and benzodiazepines in patients with chronic pain 18 6

7 VHA Informed Consent for Long-term Opioid Therapy Directive (2014) Required that all patients on long-term opioid therapy have signed informed consent in charts by May 6, 2015 Overseen by VHA Integrated Ethics Committee Barriers: Difficult to reach patients in rural areas, How to use the primary care team efficiently, Non-primary care prescribers were not complying, Database was not clean (i.e. included palliative care). 19 VHA Opioid Overdose Education and Naloxone Distribution (OEND) Program (2014) National Implementation of OEND Program to reduce opioid-related deaths (Pharmacy Benefits/ SUD) VA actively engaged in promoting safe and effective practices Recommendations for naloxone education and distribution to high-risk Veteran population Resources provided 20 VHA Academic Detailing Memorandum (2015) Implement system-wide Academic Detailing (AD) and pain program champions Aim to improve evidence-based delivery of health-care and disease management/ preventative services Support frontline providers with specialty trained AD staff, individualized benchmarking data and educational programming Target areas: Psychotropic Drug Safety Initiative Opioid Safety Initiative 21 7

8 VHA Prescription Drug Monitoring Program (PDMP) Memorandum (2016) Required querying state PDMP for all patients prescribed opioids in the VA at initial prescription, at least annually, and more often as clinically indicated Must be documented in records with standard note Exclusion if less than 5 day prescription or patient is receiving hospice care 22 CDC (2016) and VA/DoD Guidelines (2017) Patient selection Medication and dose selection Follow-up and discontinuation Assessment of risks Addressing harms CDC Opioid Guidelines 2016; MMWR / March US Department of Health and Human Services/Centers for Disease Control and Prevention 18, 2016 / Vol. 65 / No Concepts from Guidelines Initiation of Chronic Opioid Therapy Risk stratification Attention to Morphine Equivalent Daily Dose Opioid Conversion Attention to medication interactions 24 8

9 Concepts from Guidelines Need for informed consent and patient education Monitoring and reassessment Need for alternatives to chronic opioid therapy for chronic pain Need for assistance to Primary Care Teams 25 CARA Memorandum (2017) Pain Care Pain Management Teams at each facility Availability of immediate consultation for opioid prescriptions Team reviews Availability of prescribing for high risk patients Expansion of OSI Availability of Complementary and Integrative Health Modalities 26 Struggles from the Start Collateral Duty Lack of shared vision Lack of consensus with leadership about scope and goals Excessive focus on opioids/opioid safety vs. quality pain care Fragmented/ silo-effect / uncoordinated VISN-wide team 27 9

10 Lessons Learned Year 0 Need for consensus among group and with leadership Team development essential Regular F2F meetings Regular phone meetings Protected time for clinicians Administrative support / project management Regular feedback to stakeholders Leadership Frontline 28 VA New England Healthcare System (VISN 1) VIPS (2015) Vision: To create a comprehensive, safe, evidence-based system of pain care that improves the function and quality of life for all Veterans with chronic pain Goal 1: Improve Safety- Improve the safety of care for Veterans with chronic pain in VISN 1 by achieving a VISN 1 Pain Composite Score of 97% by September 30, Goal 2: Enhance Access- Improve access to care for Veterans with chronic pain in VISN 1 by achieving 97% completion of the VIPS Pain Grid by September 30, VA Stepped Pain Care Comorbidities RISK CARF accredited pain rehabilitation program STEP 3 FY17- FY18 Treatment Refractory Chiropractic Care, Interdisciplinary Pain Care Team, Interventional Pain Care, Acupuncture Care, Pain School, Evidence Based Psychotherapy (EBP) programs for chronic care, Complementary Integrative Health (CIH) approaches, Medication Assisted Therapy (MAT) for veterans with chronic pain and substance use disorder STEP 2 FY16-FY17 Complexity Informed Consent Urine Drug Screen State Prescription Drug Monitoring Program Naloxone Safety Tier 1 Review STEP 1 FY15-FY17 10

11 Year 1 Metrics (2016) Safety (Step 1) Informed consent Urine drug screen State PDMP checks Engaged teams (Steps 2 and 3) Interdisciplinary Comprehensive Pain Substance Use Disorder Complementary and Integrative Health Chiropractic Care CARF Pain Rehabilitation % 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% VISN 1 Informed Consent 85.5% 85.9% 86.6% 87.6% 88.4% 89.4% 89.8% 89.8% 81.4% 82.6% 79.5% 77.4% VISN 1 Average Goal = 90% Aspirational Goal = 95% % 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% VISN 1 Urine Drug Screen 89.9% 90.7% 91.0% 88.2% 91.2% 82.0% 84.0% 82.5% 82.4% 83.9% 85.0% 86.3% VISN 1 Average Goal = 90% Aspirational Goal = 95% 33 11

12 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% VISN 1 PDMP 70.9% 73.6% 76.2% 66.5% 56.3% 49.5% 37.5% 21.9% 22.3% 24.5% 28.6% 29.9% VISN 1 Average Goal = 50% Aspirational Goal = 55% 34 Urine Drug Screen Dip Noted decrease in rates from December 2015 to January 2016 Unclear reason for this/ processes variable across and within facilities Taskforce convened to develop and implement standard process Rapid Process Improvement Workshop (RPIW) Standardized refill note Standardized VISN-wide UDS order set Plan for standard UDS confirmation process 35 Lessons Learned Consensus development across 8 facilities and many stakeholders 100% not achievable- What could you live with? Differing resources Differing perspectives Resistance to change Lab Cost concerns Equipment Training New England VERC

13 Project Approach- FY16 Workgroups VIPS Leadership Site Visits Workgroups Review Inventory VIPS Leadership Complete Inventory Facilities Current State, Future State, and Gap Analysis Develop Inventory Criteria Oct Dec 2015 Jan 2016 Submit Recommendations Feb 2016 Revise Recommendations Play Catchball Obtain Approval Receive & Review Recommendations Implement Recommendations Mar Aug 2016 Jun 2016 Sept Year 2 Metrics (2017) Safety Additions (Step 1) Naloxone education and distribution to high risk chronic opioid therapy patients Opioid safety review on all chronic opioid therapy patients Access (Steps 2 and 3) Measure Veteran access to non-opioid pain treatment Chiropractic care, interdisciplinary care, pain school, interventional pain, acupuncture and 2 additional CIH, medication assisted therapy, evidence based psychotherapy, CARF accredited pain rehabilitation

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15 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 35.1% VISN 1 Annual Safety Tier 1 Review Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep Lessons Learned VISN-level approval difficult and time-consuming Approval by 5 separate committees required 4 months Disagreement on how to use the team Concern about use of provider time although they are prescribing Union issues for nurses they are NOT prescribing P4P Call Center staff is this improving safety? IT rollout slow Competing priorities/ demands Limited functionality Limited engagement at facilities

16 Target: Achieve a VISN 1 Pain Access Composite Score (Access to Step 2 Pain Services) of 70% (14 0f 20) by September 30, Education Physicians Nurses Psychologists Physical Therapists Occupational Therapists Recreational Therapists Pharmacists Medical Students, Residents, Pain Fellows Nursing Students, Nurse Practitioner Students, Nurse Practitioner Residents Pre-doctoral Interns, Post-Doctoral Fellows Physical Therapy Doctoral Students Post grad Occupational Therapy Students Undergrad Recreational Therapy Students Pharm D Students, Post Doctoral Residents VA Staff Pain mini residency 100% compliance with mandatory opioid safety training Academic Detailing Research 21 Pain-specific Research projects totally $3.63 million 47 Name the most important area of focus for your practice to improve opioid safety? Universal precautions Consent Timely UDS PDMP Evaluation- Pain history/exam/ assessment of risks and benefits Doses Limits Conversion Co-prescribing (bzo/sedatives) Identifying high risk patients SUD Suicidality/depression/anxiety Aberrant behaviors Evaluation/education re: naloxone 48 16

17 Identify 3 barriers to improving the area named above. Staff time Provider access Time to check PDMP, f/u on labs, panel management Education Not knowing what should be done Not knowing how to do what should be done Ancillary Resources Admin support RN support Logistics (UDS, patient visits) Someone to call on for difficult questions/ patients Competing priorities Buy-in from staff and/or Leadership 49 Identify 2 strategies to change practice patterns/improve care Basic clinical improvement tools (PDSA) Define current process/outcomes Identify areas for improvement/change Monitor Education Taskforce/committee/practice management group P4P Clinical Pharmacy Support- Academic Detailing Clinical tools Templates Reminders Panel management tools 50 What data is important to feed back to prescribers to change practice? How will you measure it? What is measurable? EMR (Panel management) Chart audit What can clinicians / management agree upon? How often can the team meet? How often can data be collected? 51 17

18 Summary Quality pain care is a team-sport Performance measures do improve practice Don t give up too early! Site visits are crucial to know what is really happening at the front lines Relationship building helps: To better understanding the barriers for more effective process improvements To increase buy-in from frontline and leadership 52 Questions? 53 Thank you! Contact information: Tu Ngo - Tu.Ngo@va.gov Julie Franklin - Julie.Franklin2@va.gov 54 18