Spotlight on Pain Management- 30 -Department of Veterans Affairs

**Department of Veterans Affairs**

**Spotlight on Pain Management Cyberseminar**

**Barriers to Opioid Monitoring in Primary Care**

**Presenter: Erin Krebs**

**April 3, 2012**

Moderator Bob Kerns:   It is my great pleasure today to introduce a colleague Erin Krebs. She will be presenting on Barriers to Opioid Monitoring in Primary Care. Erin Krebs is a co-investigator at the Minneapolis VA for the center for chronic disease outcome research or CCDOR and associate professor at the University of Minnesota. She completed medical schooling in primary care residency training at the University of Minnesota and is the president at the Minneapolis VA Medical Center. She then completed research for training with the Robert Wood Johnson Clinical Scholars Program at the University of North Carolina. Dr. Krebs is a general internment with an active VA primary care practice. She was the recipient of a five year VA Health Services Research and development research career development award dealing with the quality and safety of VA prescribing with primary care. Her research focuses on pain management in primary care, particularly the effectiveness of prescriptions used for chronic pain. Her additional interests are areas of research include women’s health and co-morbidity of mental health conditions or chronic pain. It is my pleasure to introduce Erin Krebs who will be speaking on Barriers to Opioid Monitoring in Primary Care. Erin? Take it away.

Erin Krebs:  Thank you, Bob. Good morning. It’s nice to talk to you all today even though I can’t see you out there. I’m just going to go ahead and start with a couple of slides that I pretty much include in all of my talks these days. This one is pretty self-explanatory. It shows the increase in prescription opioid sales in the United States. On this slide, it is from 1997 to 2007. The increase started probably a little bit before that and has really continued since 2007. I was in training at the very beginning when this trend took off, and that explains my interest in opioid management. 

Opioid sales are up ten fold since 1990 overall. I think an item of trivia that really says it all is that hydrocodone and acetametaphin, also known as Vicadin as one of the brand names, is currently the number one most prescribed medication in the US and has been for a number of years. This is why the topic is so relevant to a number of us.

This slide shows some of the unintended consequences of the increase in opioid prescribing. That top line there – the dotted one, is the same as the red line on the prior slide. It is the trend on opioid sales. The other two lines – the middle one, shows the trend of prescription opioid deaths per 100,000 Americans. Accidental poisoning, now, is the top cause of injury or death in the twenty-five to sixty-four age group. That means that many of us on this call are more likely to die of an opioid related unintended poisoning than we are of a motor vehicle accident.

The bottom slide there, or the bottom line just shows admissions to – opioid related admissions to addiction treatment for 10,000 Americans. Non-medical prescription drug use is secondary only to marijuana in the US. Just to get us all on the same page today, a couple of definitions for this talk – when I’m talking about Opioid analgesics, which is the focus of this talk, I’m talking about natural and synthetic relatives of morphine that are regulated by the DEA as controlled substances. I am talking about analgesics that are used for pain management. 

I will be focusing on chronic pain today and an important definition of chronic pain is pain that persists, usually at least for three to six months and importantly interferes with function. It’s not just defined by duration but also the effects on the life. Chronic pain is really a life-altering problem. I’m not mostly speaking today about acute pain such as acute injury or illness related pain or post-operative pain. And I’m not talking about palliative care or pain associated with terminal illness. So, those – pain management with opioids in those situations really have different issues than pain management of chronic pain. And then a specific topic of course is opioid monitoring. I’ll define briefly now as the ongoing assessment of the effectiveness, harms of therapies and adherence to therapy. 

This is the outline of today’s talk, briefly. First I will give an overview of the goals of opioid monitoring and also relative guidelines of opioid monitoring practice. I’ll then present some data briefly about primary care adherence to guidelines both in and without the VA. I will then present study results from my VA funded career development award – looking at barriers to monitoring in primary care. Then I’ll give a couple brief implication slides and leave some time, I think, for questions at the end.

So, the goals of opioid monitoring – I think the most important thing here is to keep in mind that the primary goal of opioid monitoring is a patient-centered goal. And that is to maximize benefit and minimize harm. For the individual patient who is receiving opioid therapy for chronic pain, when considering that primary goal, we should know that the evidence for benefits of opioids in chronic pain is limited. I think this is surprising to a lot of patients, so it is important information to get to them. The overall evidence is weak for long-term opioid therapy in chronic pain. It’s weak both in terms of quantity and quality of existing evidence. The few trials that we do have on this topic do not show large benefits. In generally, they show modest or no benefits in some conditions.

So a statement that may sound controversial but I actually think is probably the best summary that we have right now for long-term opioid therapy and chronic pain is that for most patients with chronic pain, the harms of long-term opioid therapy may outweigh the benefits. And that really brings us back to that patient-centered goal of maximizing the benefit and minimizing the harm of the individual.

Of course there is a secondary goal of opioid monitoring and that is to minimize the possibility of collateral harm for community and the population from opioid therapy. That initial slide that I showed you of unintended consequences gets that. We know from the national survey on drug use and health that most non-medical prescription drug users report that they got their prescription drugs from someone they knew. Seventy percent of all self-reported non-medical prescription drug users got them from someone they knew. Sixty five percent reported getting them for free. Nine percent reported paying for them and five percent stole them from a friend or relative. So, most of the prescription drugs that are used non-medically are coming from patients of ours, not from Internet pharmacies or large scale drug diverters.

So opioid monitoring is about balancing benefits and harms. A simplified view that I have seen often is that it is pain relief versus abuse and addiction. I think that is an oversimplified view. A more reality-based view for our patients is that we are talking about uncertain benefits of opioids and uncertain risks. We just don’t know a lot of the things that we would like to counsel our patients about. Patients are interested in pain relief and getting back to work and remaining physically active, keeping their social roles. They’re interested in their mood and symptoms overall, not just pain but the big picture. Of course, we’re all concerned about the tolerance and dependence abuse of addiction. Some of the under recognized risks that can occur with patients, also. 

In a little more detail, opioid monitoring addresses effectiveness, which is more than a reduction of pain intensity. For patients with long-term chronic pain, this includes improved overall function and quality of life and progress towards individual goals or whatever is important for that patient. We’re also monitoring for harms. The common symptoms we all know about are constipation, nausea, somnolence and also some long term harms that may be recognized such as contributions to sleep disordered breathing with central sleep apnea and hypogonadism. In the VA, we usually think of impotence when it comes to hypogonadism from opioids, but it’s also important to remember that this does include women. Women can have early menopause or sensation of mensies. Both men and women can have motor symptoms that can be very bothersome.

Psychosocial harms are possibly the most concerning to patients. That includes interference with their roles in family and at work as well as concerns about physical dependence and tolerance and finally addiction. Of course, we’re looking at adherence. That’s the appropriate medication taking and safe storage and disposal to prevent unintentional sharing with family members. And this includes no intentional sharing, borrowing or selling. Many people think of these as relatively harmless activities.

This slide just shows some of the recommended opioid monitoring practices presented in the VA Department of Defense Opioid Monitoring Guidelines. Many of you may be familiar with those guidelines, which were released in 2010. They are available on the website in the references section at the end of this talk has a link. At the top, opioid monitoring starts with informed consent at the beginning. That includes written and verbal education about the risks and benefits of opioids and about the purpose of opioid monitoring, discussing specific goals of treatments with patients, and reviewing an opioid agreement. Sometimes these are referred to as narcotics contracts, but opioid agreement is the terminology recommended by the guidelines. Really, because it’s not a legal contract, this is a clinical contract that is not legally enforceable. The guidelines do not say that this has to be a signed agreement, but the signature can be considered to document the discussion.

Part of informed consent is also obtaining consent for urine drug testing. That’s UDT – urine drug testing. This consent could be verbal and it doesn’t have to be a written consent, but it is making sure the patient understands what we are doing and why. Although the guidelines recommend that these conversations should be occurring before opioid therapy should start, I think most of us recognize how often patients come to us who are already on opioid therapy. This is a conversation that could be had at any point. It could certainly be started by – we have new guidelines so I want to review what we are currently doing and make sure we are on the right track and these are the things that I want to discuss with you. That could occur at any time.

The guidelines recommend, also, visit frequency of at least every one to six months in person and every six months is just for those low risk and stable maintenance patients. Other patients should be seen more frequently. That’s a tough one for many of us. Finally, the guidelines review the effectiveness, harms and adherence tasks that we previously mentioned.

So, who needs opioid monitoring? Really, everyone does. Everyone may not need the same exact intensity, but the goals of opioid monitoring apply to all patients on opioid therapy. Recommendations from both the VA and the American Team Society Guidelines are that monitoring should be more intensive if needed based on a number of factors including a recent dose increase or medication changes, the presents of aberrant behaviors. These are things that many of us are familiar with – problems with lost or stolen medications, early refill requests, evidence of borrowing or sharing of medications, obtaining medications from other providers and there are many other examples of aberrant behaviors that I won’t go into in great detail today.

Finally, monitoring should be based in part on the risk for misuse, abuse or addiction based on the patient’s characteristics. This table is pretty much taken from the VA and DoD guidelines with a little adaptation. What I think is most notable about this table, really, is how few of my patients fall into that low-risk category at the top. According to the guidelines, who is low risk? This is someone who has no history of substance abuse or mental health disorders. I think we often think of no history of substance abuse, but mental health disorders are strongly associated with opioid misuse and poor opioid treatment outcomes from therapy. But, no mental health disorder history is part of being low risk. Good social situation with social support and also good history of adherence to other treatments both pain related and other medical therapies. So, really, in terms of my patients who are on chronic opioid therapy, very few fall into that low risk group. More of my patients fall into a moderate risk group, which includes a history of substance abuse or a history or current mental health disorder. Any positive urine drug test or any past legal problems and then young age. 

And finally, the high-risk group is characterized by unstable or untreated substance abuse disorder or mental health conditions or repeated or persistent aberrant behaviors such as the behaviors I listed before. Those asterisks right there indicate that high risk patients should be managed in a structured specialty setting or very actively co-managed with specialized mental health or addiction services or other services as appropriate for the patient. That’s a really important one. I think in primary care, many of the difficulties we have with opioid therapy are because we have high-risk patients who are not appropriate for primary care based treatment. But that is where we are taking care of them by default.

Before I move on to talk about adherence to guidelines, I want to mention some limitations to opioid monitoring. Opioid monitoring is not the answer to all of the concerns and questions about opioid therapy in chronic pain. First of all, it really does not address appropriate issues. I am not talking about appropriateness in this talk, either. There are a number of situations where opioid prescribing is probably inappropriate from the get go. These are prescribing for chronic pain when benefit is actually very unlikely. There are a number of conditions for which opioid therapy is unlikely to be successful. Some examples are back pain and headaches but there are others. The data is not perfect, but if the likelihood of benefit is very low to start, then that’s a different problem in and of itself.

Another area of appropriateness – likely inappropriate proscribing is chronic pain in urgent settings. This happens all too often. Prescribing for chronic pain should be occurring in a structured setting with one primary provider regardless of whom that person is. And then overprescribing for minor ailments is another problem with opioid therapy. We’ve all seen this situation where problems like minor sprains or strains or even sore throats or symptoms from viral illnesses that once would have merited no prescription now result in prescription for an opioid like hydrocodone. 

Opioid monitoring, it is important to note, does not address underlying deficiencies in pain management training and services. I mentioned how so many of our high risk patients are being managed in primary care. That’s something that opioid monitoring cannot solve as a bigger issue. And another limitation worth mentioning is that there is limited evidence that opioid monitoring improves outcome. A systematic review by Speros in 2010 found weak support for a couple of recommended practices such as urine drug test opioid agreements. Some of these practices are very well supported by indirect evidence. So, for example, the urine drug testing – there’s plenty of evidence that urine drug testing does turn up unexpected information and also that physicians are terrible at guessing which of their patients are going to have a positive drug screen or have some kind of underlying substance abuse. There is indirect evidence for some of these practices and some of them are just common sense. If you prescribe a therapy, you follow-up to see if it is effective. That is just good clinical care and does not require clinical trials to demonstrate its value.

And finally, opioid monitoring has not been widely implemented in primary care. That’s going to be the subject of the rest of the talk. I’m briefly going to review three studies that have been published in the past year or two that have looked at primary care adherence to opioid monitoring guidelines. The first one is a small study or a pilot study that I did with some colleagues at the Indianapolis VA. We included patients who filled at least six opioid prescriptions in six months. These are all people who were getting long-term opioid therapy. We eliminated those who we deemed where not treated primarily in primary care and we reviewed a random sample of those getting their opioid management in primary care.

We assessed for recommended opioid monitoring practice and we also assessed for evidence of opioid misuse, which in this case was defined as evidence of aberrant behaviors such as early refills and some of those things I mentioned previously or evidence of substance abuse anywhere on the chart. The patients in this sample, most of them were receiving more than one opioid medication. Seventy percent were getting a short acting opioid and fifty seven percent were getting a long acting. They were overall getting a pretty high dose. The mean daily dose was ninety-seven morphine equivalent milligrams per day. That’s a pretty good dose on the order of high dose. The indication for the opioids was back pain in fifty-three percent. That was the most common identification. Arthritis or joint pain at thirteen percent and then unfortunately, the second most common indication was that we couldn’t find one. So, nineteen percent we could not find any pain diagnosis anywhere on the chart. We only had one patient on the sample who was being treated for cancer related pain. 

Briefly, our results we found evidence of misuse in thirty-three percent. So, about a third of the patients had some evidence of either aberrant behavior or possible substance abuse. These are not diagnosis of addiction, by any means. This number is probably fairly consistent with other studies from primary care. A quarter or a third of patients have some evidence of misuse somewhere on the scale.

We also found that the use of opioid monitoring practices overall was low and abuse was associate with misuse evidence so that those patients who have some evidence of misuse on their chart were more likely to get things like urine drug screenings. This table just shows the percent of patients who received a recommended practice. It’s a zero to one hundred scale so all the bars are very short because these practices were used in less than thirty percent of patients in each case. Across the bottom, those are assessment of function, assessment of adherence history, assessment of drug or alcohol use, a urine drug screen and presence of an opioid agreement anywhere on the chart. Here are the most commonly used practices, which was assessment of adherence documented on the chart.

The second study I’ll talk about today was a retrospective cohort study done by Joanna Sorrels and colleagues, which were published in 2011. She used administrative data from eight university affiliated primary care clinics, so not VA. Their patient population was different from the prior study. Patients were required to have a non-cancer pain diagnosis for inclusion. So, the nineteen percent that we found who had no diagnosis with that were included in this group. They were required to have at least three opioid prescriptions within six months. They assessed five risk factors for misuse: drug disorder, alcohol disorder, smoking, mental health diagnosis, age less than forty-five and patients counted the number of risk factors that they had.

The outcome they looked at were the presence of a urine drug test on the chart – only eight percent of patients in their sample had a urine drug test. They also looked at whether patients had regular visits defined as every six months and within one month of a dose change. About half of the patients received that recommended practice. They looked for restricted early refills meaning one or less – one or no early refills in twelve months. So, seventy-seven percent of the patients in this sample had restricted early refill. The converse being that almost a quarter received at least one early refill in twelve months.

This is a slide from their paper and it just shows that the receipts of these services was associated with risk of misuse so that the bars there from left to right are the light color one is no risk factors, then one risk factor then two and three or more risk factors for misuse. So, for urine drug testing, people with more risk factors for misuse were more likely to get a urine drug test. On the other end here, people with more risk factors for misuse were less likely to have restricted early refills or it might be easier to say that people with higher risk were more likely to get early refills.

The third study was done by Ben Morasco at the Portland VA. This is a retrospective cohort study using administrative and clinical databases, in this case at VISN 20, so the northwest corporate VA region. They included patients with non-cancer chronic pain and at least 90 days of opioid prescriptions. They, in particular, looked at those patients who had a substance use diagnosis and compared services over twelve months for those with a substance use diagnosis versus those without a substance abuse diagnosis. They found that patients with a substance use diagnosis were more likely to receive a urine drug test consistent with the other study. They were also more likely to get a mental health visit and have a concurrent benzodiazepine prescription.

They found no different between people with and without substance abuse and the number of primary care visits or physical therapy visits. So, just to summarize real quick, from these three studies looking at adherence to opioid monitoring guidelines, all three studies found low use of opioid monitoring practices overall. The study found that some recommended practices are more common among high-risk patients. Those are drug testing, mental health visits and documentation of adherence assessment. But unfortunately, some high-risk practices are more common among high-risk patients such as providing early refills and prescribing concurrent benzodiazepines. 

So now I’m going to shift gears here and talk about why it may be that we are not doing a fabulous job of opioid monitoring in primary care. I’m going to present a few preliminary results from my career award which is entitled Improving the Safety and Quality of Opioid Prescribing in Primary Care. These results are from a qualitative study that is part of this career award. Briefly, the project rationale is that primary care providers prescribe most of the long-term opioid therapy for chronic pain and are concerned about harms of opioid therapy. Yet, they rarely follow guideline recommendations for monitoring opioid effectiveness harms and adherence to opioid therapy.

The aims of the project were to identify barriers and facilitators to opioid monitoring in primary care and to understand primary care physician and patient perspectives on opioid monitoring. We have semi-structured in depth interviews with physicians and patients that included general questions about opioid management and questions about specific topics related to recommended opioid monitoring tasks. Those included assessing effectiveness, the decision to change therapy, taking substance abuse history, urine drug testing, and opioid agreement and discussing ground rules for opioid therapy. Our analysis was informed by grounded theory.

The study was done at six primary care clinics affiliated with the Indianapolis VA. We included fourteen primary care physicians who were recruited through maximum variation sampling, meaning we were really trying to get a diverse set of perspectives on these questions. The physician sample was diverse. The mean age was forty-seven. Fifty percent was female. And the mean time at VA was ten years with a wide range of VA experience. We also interviewed twenty-six patients. To be eligible, patients had to have at least six opioid prescriptions filled within the year prior to participation. Patients were randomly selected from participating physician’s panels. 

I’m going to talk today about two categories to barriers to opioid monitoring. I think the first category is probably the most common sense. Institutional barriers or lack of system support for opioid monitoring – the big issues here that came up again and again in physician and patient interviews were lack of time, limited appointment availability and lack of support for monitoring tasks. Short and infrequent appointments were mentioned as barriers at each step of the prescribing and monitoring process. This quote comes from a physician who is very concerned about addiction based on some personal experience. She said typically these are complex people with multiple problems. You really need to sit down and go through a person’s record and really try to make a rational decision. I take it very seriously. It’s serious business. What if you do create an opioid problem for someone because you’re not being careful enough about it? 

Limited follow-up was closely related to the lack of time. This response was – in this physician’s response was in response to a question about how effectiveness was assessed. In an in patient setting, if someone has pain, you can give something and the nurse can go back and assess the pain. In an out patient setting, they are gone unless they call back. We do not have a system in place where my nurse can call and say how are you doing? Is it working? We just hope they don’t call back and be happy with what they got. You know it’s not a good system. We actually did hear this answer from several physicians about the best sign whether the medication was working was that patients didn’t complain that it wasn’t working.

Patients also complain about limited follow-up. In particular, difficulty in getting follow-up appointments, infrequent follow-ups and difficulty reaching physicians on the telephone. I feel that if I explained to my doctor that this medication is really not helping my pain, then they should be willing to try something else or just say okay, we’re going to prescribe you this for thirty days then come back and see me to make sure this medication is working for you instead of saying well, that’s all I’m going to do. And in this case the patient was complaining that the next appointment wasn’t for six months so he wasn’t going to get any adjustment of his therapy in that time.

Other concerns were about support for specific monitoring tasks. Periodic urine drug testing was considered to be unrealistic by many of the people interviewed for the study. As one physician said, especially people who live like two hours away, it’s really hard to bring them in just for a urine drug screen when they won’t even go for a stress test or this and that. 

Patients often expect to get their medications refilled by mail and so there were few opportunities for assessment between regularly scheduled appointments. Other physicians commented on the process for collecting urine drug screens, since it was done just like regular urine analysis collection, there was no ability to be totally certain that the urine hadn’t been tampered with. One physician said sometimes I wonder if they have someone else’s urine.

Perhaps more interesting scenes that we uncovered in this study were those barriers that could best be described as related to attitudes or beliefs about opioid therapy or opioid monitoring. I’m going to talk about three categories of beliefs or attitudes today. The first one is beliefs about patient selection for opioid monitoring. Most physicians indicated that they used monitoring practices selectively based on their clinical intuition or their relationship with the patients. We currently heard terms like intuition or just felt when referring to why a test would be ordered. I do not at all routinely check patients, but I probably have a pretty good hit rate when I do because you get a sense as to them not being honest with you.

Physicians, some of them anyway, thought it would be difficult or inappropriate to do adherence monitoring for patients who were a long time and low risk patient. For those patients that have a legitimate reason for wanting to take it and if I can trust them that they are not selling and are not abusing and most of these are older patients of mine, I don’t have them sign a contract because they never request early refills and they never go to the ER to get them and so there’s no need for me to do periodic drug screenings.

The small minority of physicians reported that they use drug screening and opioid agreements for all patients. There’s no way you can just who’s going to be a problem and who’s not. You just treat everybody fairly. A strong theme in interviews was seeing opioid monitoring as a law enforcement activity or primarily from a seemingly legalistic perspective and I really think this is a barrier because often physicians express discomfort with this role. It seems to be an unintended role and one that doesn’t fit very well with their medical practice and so some physicians actively avoided activities like drug testing because of the difficulties they felt it created in the relationship. 

I think drug screening is destructive to the basic patient doctor relationship. You are there to help them and they can tell you their deepest and darkest secrets, but yet you are policing them. From this law enforcement perspective, opioid agreements can be seen as a form of punishment or a mechanism of control. One patient I had on a narcotic contract came to me and he was like why am I on this? Why am I being singled out? I’ve never had any problems with abuse. It made me think that unless you are going to do it consistently and have a reason other than just looking at the person and thinking maybe I should put him on a contract, maybe it’s not fair to do that.

Both physicians and patients that are interviewed sometimes refer to the opioid agreement as a legal document. As I mentioned earlier, this is mistaken because these are not contracts that are legally enforceable. They’re just clinical tools. As one patient said, I don’t see the purpose of it. It’s like finding a legal agreement with a doctor that is clearing him of responsibility. Many of the patients indicated that they thought the opioid agreement was primarily to cover the doctor and not for their benefit.

My initial reaction to it is we are living in a police state. You have no recourse or something. It tells you exactly what you have to do and it is hard to follow that. I could sign that and if you followed me around every minute, you could get something on me. But not all clinicians and patients had the opioid monitoring. The few that reported using urine drug tests and opioid agreements on all patients viewed it as primarily educational and consistent with the usual clinical care. It’s a tool. It’s one tool to help education the patient what proper pain management is and what their role is as a patient. Some patients were also expecting these practices, especially when physicians that explained it to them in patient-centered terms had previously introduced them to them. 

The doctor has only a few moments. He’s trying to think of everything that he can think of and the hospital can think of in areas to protect not just them but you also. The third and final theme I’m going to mention today is an important and consistent theme that appeared only in the patient interviews and that was the theme of poor physician listening. Both positive and negative comments about physicians referred to their perceived listening skills and how understanding and interested they seemed to be in their patient’s condition. 

Patients sometimes reported that when they wanted to talk about their pain and wanted their physician to understand them, that it was seen as drug seeking behavior. He could have more of a sympathetic ear towards how I feel. I’ll tell him what is wrong with me and he’ll say I want you to give a urine sample. Interestingly, although some of the patients in the interviews said that they wished their doctors would give them stronger medicines, many patients actually described their physicians of pushing medications and being unwilling to listen to patient’s concerns about the medications.

I won’t take them like they want me to. They want me to take like five or six of them a day and I don’t want to take that many because I can’t function. I mentioned it to him what I don’t like and he said you net hem in your system. It goes along with the other medicine. They will help you. Dr. So and So, I don’t know what his deal was but he said in the appointment that you need to go at a higher level of medication. Well, in my world, staying at the same level to me is critical to my lifestyle. Since I’ve finally accepted the fact that there is no cure, my opinion is that it’s going to come to – I’ll be at a point where I take too many drugs and I won’t have a life.

So, we are nearing the end. I have a couple more slides and I’m just going to talk about what I think are some implications for practice from this work. First implications on the system level – I think our study really shows that the barriers to opioid monitoring are very complex. They’re not just things that can be done in a clinic system, but they are also beliefs and attitudes barriers these complex barriers really do call for multi-faceted solutions. I think if we try a simplified solution, it could have some unintended consequences. Opioid monitoring is on that list as well.

I think support is really needed for high quality management of opioid therapy including monitoring. This includes systems for regular follow-up, allowing more frequent visits, which is a challenge everywhere in primary care. We need a system for interim phone visits, and in the VA, I think tag team involvement might be key to making this work. Also, I think clinical and facility level protocols are important here. I didn’t talk about it today, but a common concern between both patients and physicians were how different physicians were and how that created conflicts sometimes and varying expectations that really make therapy difficult.

I think it’s really important that better education for our patients and training for the entire care team make this happen. And then on the provider level, there are additional implications. I think for most of us who actually care for patients or who teach learners, it is important that we maintain focus on the balance of benefits and harms of opioid medications when we are talking about opioid monitoring rather than focusing on trustworthiness of the patient. I think that’s avoiding the law enforcement role or the legalistic role that I discussed earlier and working the decision making of goals of therapy and listening to patient perspectives on whether it is working or not as well as considering a wide diagnosis when faced with aberrant behaviors.

Another topic I didn’t really address too much today – but it’s easy to fall into a situation that feels accusatory between patients and physicians. Time spent listening may be a very good investment. Some of the problems according to patients may have been avoided if physicians had been more willing to just talk it out. Like I tell my residents sometimes, don’t just do something. Just stand there. And then finally, I’m going to make a specific recommendation of a perspective piece that was published by Kristina Nicolitus from Oregon Science and Health University in the last year. It’s just a very helpful, I think, piece and review article that focuses on how to have a patient centered perspective on chronic opioid management. Thank you all for listening and I would be happy to talk about your questions.

Moderator:  Thank you, Erin. We have several questions and for our audience, please take this opportunity. Use your Q and A screen on the right hand side to submit your questions. We are ten minutes from the top of the hour. Just to let your audience know, we are expecting to run over time today because we have a very large audience. We are expecting to get a lot of questions. For those of you who are unable to stay, we will be recording and we are recording the session and we will make that available to everyone after the session if you need to leave early. We will have that available to you. I was going to give the first question to Bob. Bob, do you want to ask your question?

Bob:  Yes. Can you hear me?

Erin Krebs:  Yes. 

Bob:  Yes. I have a question for you. You asserted that you think everybody – all people should be candidates for close monitoring. Some have asserted that patients with cancer or patients in cognitive care settings should be excluded from some of these practices. Would you state your view on that matter?

Erin Krebs:  Well, I guess – in the very beginning of the talk I did want to make it clear that when I’m talking about chronic pain in this talk, I’m not talking about paleocare settings because I do think that they are so different there. And I certainly wouldn’t want to be too directive. I don’t practice peleocare and I think their needs to be individualized care. I think the basic goal of balancing risks and benefits – in paleocare; the goals of therapy are different. They are more about comfort overall than about improving function and getting back to your regular life. But the idea of really having clear goals for therapy and monitoring effectiveness and harms of therapy and both apply to paleocare whether or not the actual adherence monitoring does. I think that needs to be individualized in that setting.

Bill:  Thank you.

Moderator:  Okay. Just a second to find the first question here. Okay. For audience, I just want to apologize to start with. I am not a subject expert and I know I am going to butcher a lot of words on these questions. The first question we have here – role for buepernorphine in VA by primary care clinicians and especially in the new VA homelist tact team?

Erin Krebs:  Okay. Bupernorphine is a treatment that is primarily used for management of addiction. It is used for management of addiction to prescription opioids as well as heroin. It does require special training and clinic setup to do. This is not my area of expertise. I’m not a bupernorphine provider and I know that the evidence bases are growing for how this can be done in primary care, but I think I probably have to defer that question. It’s currently not available in too many VA primary care settings.

Moderator:  Okay, that’s fine. The next question we received – while we might want to have structured specialties in cohort or co-management, how can we manage a high-risk patient who declines to work with a pain specialist? Are there any policies that prohibit PPCs from providing opioid therapies to high-risk patients who refuse pain specialty care?

Erin Krebs:  Now, I do not believe there are any policies here. The guidelines recommend that high-risk patients should either be managed in a specialty setting or co-managed and I don’t know what the appropriate comment is. It depends on why the person is high risk, whether there are mental health or addiction issues. I think it always comes down to that basic issue. We are, as physicians, required to use our best judgment regarding balance of judgments and harms. Ultimately, we are responsible to our patients and ourselves to do that. I’ve been in situations like this that have caused me to do a lot of personal soul searching. It is really hard to do intensive monitoring in primary care. It’s not necessarily impossible depending on your setup, but you have to feel that your setup is safe enough to do it and that you can get the follow-up you need and the patient is cooperative with the follow-up. I’ve done this and I’ve actually done it successfully, but it so much depends on your setup and the patient and you and why they are high-risk. Whether you want to take that on, but I think you want to be very careful about documenting the reasons for your decisions and really being clear with the patient that the balance of benefits and harms is the big thing and if the balance comes out on the harms side and it is not safe to continue that, you may have to taper the medications off if that is indicated.

Moderator:  Thank you. The next question is – is the assumption that greater than six opioid prescriptions in twelve months would indicate that these patients had chronic pain?

Erin Krebs:  Yes. That was one of the criteria that we used for the study that the chart reviewed and yes, that is the assumption. There’s really only one indication for long-term opioid therapy and that’s chronic pain. I should say that those are six thirty-day prescriptions. And so, at the facility that we did this review, those can’t come from the ER. They were not coming from an urgent setting, they were coming from primary care and even though there was no documented indication, I can’t imagine what the indication would have been otherwise. Obviously it does raise some concerns about the quality of care when the quality of documentation is so poor, but that’s what we had.

Moderator:  Thank you. The next question – was there data related to how many patients in the study signed an opioid agreement as part of the monitoring process?

Erin Krebs:  I’m guessing that that’s maybe referring to that first study about adherence to guidelines. One of the outcomes that we looked at was whether an opioid agreement was present on that chart and we looked at any point in time. The thing could be eight years old, if there was any evidence of an opioid agreement on the chart, we counted it as present. They were present on nine percent of the patients. I do not believe that either of the other two adherence studies I reviewed looked at opioid agreements probably because they were both using a large database for their study and depending on what system you are in, often those would be hard to identify using that kind of administrative data. So use was pretty low in our setting.

Moderator:  Okay, thank you. What qualifies as misuse in your study?

Erin Krebs:  So, actually each of the three studies that I reviewed that looked at adherence guidelines used slightly different criteria. In the one that we did, we had a list of – I’ll have to refer you to the publication for the full list, but we had a list of aberrant behaviors that we listed as either minor or major and the evidence of substance use. So, those were the things that we called evidence of potential misuse. Again, staying away from diagnostic sounding terms like abuse or addiction from chart review, you have a hard time saying those things clearly. So, it was really behaviors and aberrant behaviors were things like early refills.

Moderator:  Okay, thank you. The next question – what tools do you use to determine morphine equivalent dose per day for individual patients?

Erin Krebs:  There are a number of different tools out there. And Bob, correct me if I am wrong, but I think the VA guidelines actually include it as an appendix. I can’t – some information about that – otherwise; I know Washington State has a nice online calculator that you can get. It should be noted, though that this is not an exact science, actually. There have been – there are a lot of different ways to do these calculations. They are not perfect. But there are a bunch of calculators out there and when in doubt, I think clinical pharmacists can be very helpful in a clinic setting working at a morphine equivalent dose. Bob, can you comment on that at all? Okay, maybe he can’t hear me. We can move to the next question.

Moderator:  Okay. Next question – regarding occasional negative drug screens and patients filling opiates monthly, if repeated again negative, with patients swearing they are taking daily, I’ve been discontinuing their opiate because I believe they are diverting meds into public for profit. Is this proper management or am I just being mean?

Erin Krebs:  I think if the drug screens are true negatives, that this is proper practice. If I have a setup like that, that is what I do. There are some caveats. One is that it can be complicated to interpret a negative drug screening result. It depends on which medication the patient is on because some of the synthetic opiates like oxymoron and phentinol do not turn up in some of the drug screens in many of the drug screens. So, you want to talk with your lab and find out what – how reliable your test is for what drugs and make sure that you are not making a mistake based on a false negative here. So, first you have got to do that investigation. 

Usually you are going to have to order a drug confirmation to be clear that it is not there on some low level because those screening tests have a cutoff. It could be present above zero but below whatever the cutoff is and not shows up as a positive test. That’s the big warning there. But, I do this when I have done the confirmation and often I’ll call someone in for a pill count right away and see if they can produce the medications. Sometimes instead what they produce is a story that’s not right and that I can’t make sense of. 

I’ve had long-term patients actually, that out of nowhere have ended up in this situation where both the drug screen and the confirmation is negative and the pills were missing. And the story was unconvincing and at that point, what I have done is stop prescribing and just explain that although I can’t be one hundred percent sure what’s going on, a pattern like this is really suggestive that the medications might be going elsewhere and because that is so dangerous to the community and to the other people that I just can’t continue to prescribe with that doubt there. I apologize in case I’m incorrect and try to be as patient centered as I can in that situation. I’ve had some success in patients of being accepting of that explanation and being willing to try other things for the pain and doing okay and sticking with me. So, usually when that happens, I think I was probably doing the right thing. I don’t think it’s mean.

Moderator:  That will be a hard conversation to have, I’m sure though.

Erin Krebs:  These are painful conversations.

Moderator:  Thank you. Next question – we received this from someone who works in an in-patient acute psych unit. We find that a very large percentage of our veterans report chronic back and other pain and most are prescribed opioids. We encounter a couple of common situations – number one; they request an increase of opioids or resolution of their pain in this setting. Or number two; patients have overdosed on their medications often in a suicide attempt. Providers are commonly not willing to prescribe that medication. Any suggestions?

Erin Krebs:  These are clearly high-risk patients according to the risk stratification that we talked about earlier. We know that risk is higher than average. In terms of how to manage that person in the acute setting, in the situation where a patient is requesting increase in doses of long term medications while they’re in an in-patient setting, I think probably the best way to respond to that is not to increase the dose but to defer that to the long term care provider since again, it is an acute setting and the chronic back pain is unlikely to be resolved in the in patient hospital setting. It may be that the worsening of the chronic pain is related to the severe underlying emotional distress that the patient is clearly undergoing. Getting that mental health focus in better position is probably the first act before you would even consider a dose change.

In terms of the overdose issues, that is a clear safety issue that is a major hazard. These are – so, that’s a big harm. I think tapering the medication would be a reasonable thing to consider in that circumstance, depending on the individual situation. You might decide the long term out patient provider should continue, but I do think in many cases like that, especially if there is good evidence of efficacy, tapering is probably the right thing to do. It’s not the right thing to do to stop the medication abruptly. We talked about stopping when a patient is not taking the medication, but if the patient is taking the medication, the best way to address it is a taper and even if there is an acute safety issue on an in patient basis you could do a quicker taper, but you wouldn’t want to put somebody into withdrawal in that scenario.

Moderator:  Thank you. The next question – the studies show higher risk for younger patients. I see many substance issues in patients fifty five to sixty five years old. I am wondering if this is nationwide or specific to our area.

Erin Krebs:  I think it’s true that being younger is a risk factor in many studies, but it’s not a very strong risk factor and it certainly does not rule out the possibility that older people have problems. I think sometimes we are too quick to assume that older people cannot have problems. I’ve certainly seen a lot of addiction and substance abuse in people over the age of fifty-five. In my patient population, I do not think that this is regional. I think that substance abuse occurs at all ages. Maybe the version may be more common at younger ages, but you know, I don’t think that we can assume that older people are lower risk. And I’m not sure if it’s been published or not, but I have seen data from an uncontrolled pharmaceutical sponsor study where they did urine drug screens which specifically involved a lot of older people and they had a very high prevalence of positive drug tests and positive for illicit drugs and for street drugs. This was actually a poster presentation at a meeting I saw and the woman at the poster said that the company was not thrilled about her presenting the data. I think we don’t know everything out there and that we should be cautious with older people as well.

Moderator:  Thank you, the next question – how do you feel about actively involving the pharmacy staff in opioid monitoring? For example, extending the medical staff involvement past the opioid agreement to pharmacist awareness of conditions being treated and the physician documenting or questioning true medical sciences and reiterating opioid use specific cases?

Erin Krebs:  I think the best care for this is team based care and so I’ve really found that it’s been very helpful the more other people can get involved in primary care is often working with clinical pharmacy and clinical psychologist as well as nursing. That’s where it works best in my mind, to have everyone on the same page. I think sometimes when there is a communication between pharmacists and physicians or other members of the care team that patients get mixed messages about the therapy or about the goals of monitoring and those mixed messages can be really frustrating and destructive, I think. So, if it works in your situation, I think it’s great to get people really involved as a team to do this in the best possible way.

Moderator:  Okay, thank you. The next we received a request for a – they’re looking for the difference between opioid agreement and contract

Erin Krebs:  The difference is terminology, but the reason I think the preferred terminology is agreement is because these are not contracts. Even when people call them contracts, they are not legally enforceable in any way. We really find in our qualitative work that this is very confusing both for physicians and for patients and especially for patients. It was seen as something people would be held to or could be legally enforced and that is not true and it is very – I think it’s challenging and detracts from the idea behind the agreement, which is informed consent. It’s a structured way to provide information about benefits and harms and responsibilities of everyone including people in the care team and the patients. Those are kind of the most – those are the ideas behind them but when you call it a contract, it just confuses the situation, I think.

Moderator:  Okay. Thank you. The next question – we have someone who is wondering what you do when you see a patient for a first time who has just been discharged from the PCP and they are on three hundred milligrams of methadone a day.

Erin Krebs:  Well, I think the first thing I do is a chart review. I really spend a lot of time with the chart when I have a tough situation like that. For those of you who are not clinicians, that is a high dose of methadone and methadone is a medication that, if taken incorrectly, can really be very hazardous in terms of overdose. Now, I would do a lot of chart review and just see what it looks like in terms of the patient’s follow-up and if they’ve been doing well on the medication or not. The questioner mentioned that the primary care physician, which makes me concerned that maybe it was a patient firing situation, had discharged the patient. If that happened because of evidence of misuse of abuse, or incorrect use, that – I think methadone is very dangerous if people don’t use it correctly and so that’s a high risk situation and I would want to enter into a treatment plan very deliberately. What I wall often do is take the best history I possibly can from the patient and tell them I’m sorry, but I cannot make any clinical decisions today. I really need to spend some time with your chart and come up with a plan. I’m going to get back with you tomorrow and we’ll go from there. A decision that can be pretty high stakes, I don’t think we should be forced to make right this second.

Moderator:  Okay. Thank you. The next question – are there any clinically validated and or simple tools for monitoring benefits for example short surveys of functional status or pain measures that can be used at each visit?

Erin Krebs:  There are a number of different measures that can be used and I will refer you at this point back to that opioid monitoring guideline because that provides some examples of specific questions and validated measures, so yes, there are definitely options out there. And I’ll just be very self-serving and say that I have worked with a brief pain inventory, which is an eleven-item measure over time, so with some colleagues in the VA; we’ve developed a very shortened version of that. It’s just three items and we call it the peg. It was published in J Gem a couple of years ago. It should be online. The reason we developed it was to shorten that brief pain inventory down to an ultra-brief measure but you could remember in your head and do real quickly with patients. That is not the end all be all, but there are plenty of different options out there.

Moderator:  okay. Thank you. The next question – do you think implementation of the pain vital sign has led to a greater number of opioid prescriptions?

Erin Krebs:  I think that’s a great question that there’s no good answer for. Often, people ask if there isn’t a lot of great new evidence for opioid evidence for chronic pain, why is it so much more common now? I think there are a number of factors. One of them is that we have had a lot more attention to pain and vital sign is part of that. Now, the idea behind the focus on pain was not to increase opioid prescribing, necessarily. It was to focus on pain in general, but I think there’s been an increase in focus on pain not necessarily an increase on training of pain management or an increase of pain therapies like activating – exercise therapy, physical therapy, cognitive behavioral therapies – there are a lot of ways to manage pain that are more evidence based than opioids but less available and less accessible. 

So, we didn’t get increased access to those treatments. And at the very same time, we had a lot of pharmaceutical advertising that just dovetailed very neatly with the clinical activism to improve our attention to pain. So, it’s a perfect storm in a way. I don’t know that the vital sign is directly responsible for increasing opioid prescribing, but I do think it was part of an increased focus on pain that combined with a lot of new pharmaceutical products and advertising has resulted in a big change in practice. There is my non-answer to that question.

Moderator:  Thank you. The next question, do you recommend narcotics contracts and drug screens for all patients and how often do you recommend drug screens?

Erin Krebs:  So, I would say that I agree with – I’ll take those two issues separately. I agree with the VA guidelines that recommend doing a urine drug screen at the first visit for all patients and periodically thereafter. So, in my own personal practice, whenever I see a patient at the first visit if they are a new patient coming to me, I’ll get a drug screen on that first visit. If I’m starting long-term opioids or there is some transition from acute to chronic pain that is where the opioids are being continued longer than I thought they would be, I’ll order a drug screen then. I explain to patients that it is my standard practice and I do it because I cannot tell who might have trouble with these medications and that it is really a safety thing for their benefit primarily. I really never actually had anyone refuse at that point. Plenty of people come back with positive cocaine urine, which didn’t complain at all about me testing, so it’s pretty well accepted the way I deliver that message. 

Now, the VA guidelines recommend going over a written opioid agreement and then consider having it signed as a method of documenting or documenting in your chart note that you reviewed the agreement. I think that is a reasonable recommendation, though personally I’ve not – I don’t use an opioid agreement have not had people sign them. That’s just my personal practice. I have a speech that I give that includes the information in the opioid agreement. It includes my understanding of the risks and benefits to opioid therapy and the fact that we don’t know a lot of stuff about it. It includes the fact that I do have a monitoring approach that I use with all of my patients and that is – those are what make me feel like it’s an okay thing to do this. There are risks and potential harms and that it’s the patient – I hope the patient will let me know if they have any concerns and I always promise that I will let them know if I have any concerns in turn about developing problems. I have my own text that I will document in the note that we discussed these things and the patient agrees to periodic drug screens and other things that we’ve discussed. That’s how I handle it. I think for a lot of people that going through that opioid agreement that’s provided; it just streamlines the process more than anything. For me it is the educational content and understanding the purpose of monitoring that is the most important part, not exactly how you do it, whether it is on paper or whether there is a signature or not. I try to be clear that it is not a contract, but an educational tool.

Moderator:  The next question – we received a comment here. I work in a pact team. We work with a patient on establishing an agreed treatment plan. I think pact could definitely help with opioid management. It would be nice to have a template create so our end care managers can assist the provider and follow-up with patients.

Erin Krebs:  I agree totally. If Bob is still on the call, he might be able to comment on this, but there is, I believe some work going on right now to develop some tools like that for pact teams because really there is not a lot. Go for it Bob.

Bob:  Hello, this is Bob. I couldn’t agree more and I emphasize what she just said. I think we are working with very strong nursing leadership groups in VHA with pain management nurses who are providing their expertise regarding the role of nurses specifically within the pact and what Erin is talking about are a growing number of initiatives within VHA in which we are involved and some of them are initiatives in developing these kinds of tools or resources that would be used by our ends or nurse care managers in the pact or other settings in the way that I think the person from the field was suggesting in their comment.

Moderator:  Okay. Thank you. The next question – is it possible to get a negative opioid on a urine drug screen on a patient that is taking five milligrams of hydroquinone daily?

Erin Krebs:  I’m no toxicologist, and I don’t know specifically what the – I do think that the lab tests differ from VA to VA so I do not believe they are entirely consistent. It is always very helpful to have a history of medication taking prior to getting the urine drug test to understand how people actually take the pills because in truth some people don’t take any for a week and then take many more than the recommended for several days in a row or whatever. There are plenty of possibilities here. I would expect if someone was actually taking five hydroquinone at regular intervals everyday, at least on my local urine drug screen, that would come up positive, so in my mind, that would raise a concern that there might be something amiss, but I do think it needs more investigation, both at your lab to understand whether the test is for hydroquinone and with the patient. I would be pretty inclined to call the patient back for a pill count or a repeat drug test on short order. Probably one drug screen is not enough here unless you have other reason to be concerned. I would be starting the diagnostic process at this point.

Moderator:  Okay, thank you. Erin, I just wanted to check in with you. We have gone twenty-five minutes over at this point and right now we have fourteen pending questions. I wanted to check on your time and I don’t know if you are able to stay longer if you wanted to go through more of these on the call or if you wanted to take these offline?

Erin Krebs:  I could probably spend another ten minutes here and then I’ll have to head out. 

Moderator:  Okay. That’s fine. We do have a list of everyone who asked a question and for the ones we don’t get to, we can deal with those offline. I apologize and I know we have a lot of our audience that has hung with us and we will try to get you answers to all of your questions. The next question we have here – what do you do for the patient that says his narcotic is not working and wants to escalate the dose when we know that our narcotics do help in different ways? The patient gets upset when you do not change dose.

Erin Krebs:  For many patients, opioids are not going to be effective so the trials that have been done seem to show that in some conditions, I’ll say again, the trials are inadequate. We don’t have enough data, but in the trials that have been positive, it’s tended to be a minority of patients that have responded and that group that did respond, usually they had a small to moderate benefit. So, really important to think about is to make sure that the patient’s expectations are realistic. If you have already gotten to a reasonable dose and there is no benefit, you know, I’m speaking away from the evidence right now, but it’s likely that there will be no benefit with higher dose. If it has never worked at all, it is not likely to work in the future if you keep going up on the dose. So it really does depend but perhaps the patient’s expectations are unrealistic. In our interviews with patients, we found that many, when we asked what they expected from the medications; many had very high expectations for these drugs as we talk about as painkillers. The truth is that many of them were experience much less than what they wanted from the medicine and I think many patients just do not benefit and the right thing to do at that point if you have gotten to a decent dose and there is no benefit is probably to taper the medication off and try a different approach. That really has to be individualized so it’s hard to get specific about it.

Moderator:  Thank you. The next question – how do you address when you see cocaine and or marijuana in a urine sample?

Erin Krebs:  Well, this is a question about what I do and I think everyone develops a personal style. I think the guidelines are right on here. Those are problematic and if people are using other substances other than opiates this makes them high risk for harms to opioid therapy and your balance is tilting towards harm. I would try to assess what this positive drug test indicates and it can be difficult to tell, but trying to take some sort of substance abuse history and understand what’s going on or get that patient to specialty substance settings so they can have an evaluation is probably the best approach. If the patient has an addiction, likely the harm of opioid therapy outweighs the benefits. 

If it is something less than addiction, treatment has to be individualized, but I would really seek help from my specialty addiction colleagues. I would talk to the patient about my concerns and here, again, avoiding that law enforcement perspective. My concern is not whether they are using an illegal drug. My concern is about their health and the risk to them of combined opioid with illicit drug use. And so that’s why I need more evaluation and need to determine if those are appropriate for therapy or not. That’s the approach I would use.

Moderator:  Okay. Thank you. The next question – how do you balance the need to sit and listen with the reality of having fifteen minutes to see a patient and address all of their issues? Should all chronic opioid patients be in specialty clinics regardless of risk level?

Erin Krebs:  I would say no to the second question. I do not believe all chronic opioid patients should be in specialty clinics regardless of risk. I think we really are in the best position in primary care to have a longitudinal relationship with a patient and really understand their care over time and do the best job for them. That’s just my primary care pride speaking right there. It depends on your particular VA what kind of care system you have set up. It’s kind of a big issue. I think actually listening to the patient is an investment and it is an investment I choose to make upfront so long conversations up front where this is primarily all we talk about. If I have a new patient with a complex chronic pain thing, I will have them come back pretty darned soon for a visit where all we do is talk about the pain. I actually think as a clinician over time that saves you time, having really understanding where they’re coming from and having a plan upfront. It often clarifies issues so in the future those conversations are not as long.

Now, I have no always found that the clinics I have been in have been particularly supportive of this practice. I have had people in the past settings trying to reduce my in person visits with these people and I pushed back on that. I thought it was inappropriate. I think we have to do some adjusting of expectations. This is a condition that requires close follow-up so personally; all my chronic opioid patients I see back every three months at a minimum. I don’t feel comfortable going to six months. That’s my practice. I sort of sit firm on that. I think there’s only so many of these patients you can handle in one panel for that reason. It’s really tough but my practice is if I see you today, I’m having you come back in four weeks or whenever the next available is where we are just going to talk about this and air it out so that it does reduce problems. It reduces phone calls in the future and it’s good clinical care. It gives you a chance to develop a sense of trust right away and the patient knows you are interested in their concern. Long answer, sorry.

Moderator:  Thank you. I know we are riding up on the time that you wanted to leave. Do we have time for one more question or should we just wrap it here?

Erin Krebs:  One more. Let’s do it.

Moderator:  Okay. This is the last question for the live session. Do VA physicians input or check state prescription drug monitoring registries as required by civilian physicians?

Erin Krebs:  This is another complicated one and Bob might want to weigh in on the policy side of this, which is rapidly evolving. Currently, VA pharmacies do not report VA prescriptions to VA pharmacies to the state based prescription monitor programs. My understanding is that there is legislation that that will change in the future. In terms of whether VA physicians can check those state-based prescription-monitoring programs, currently that is somewhat facility or region specific, as I understand it. We are supposed to obtain patient permission to do that. I have recently moved from one VA medical center to another and my prior VA medical center had prolonged the pain committee over months with conversation over our legal representation with a VA of what was an okay way to do this. 

Eventually we developed a facility-specific written and informed consent like HYPA for our state prescription program. Then I started to use that with my patients and it worked okay, though it was a barrier to using those prescription-monitoring sites. I actually think those programs are incredibly important for patient care and I think that people are really working to make this work in the VA, but there are a lot of issues that have not been worked out. Bob, do you want to comment on that? I hope that I haven’t totally screwed up the answer.

Bob:  Yes. I would be happy to comment and your answer was right on target. I can add that they cleared this – President Obama did find legislation that provides the VA with these programs and a group is very actively working on a quite rapid timeline to develop regulations for VA participation in both of the ways you have described in contributing information to the databases and providers being allowed to query the databases. There will soon be a very brief update announcement to the field about this. Erin is exactly right that there is already permission with informed consent from veterans that would allow VA providers to query the databases and there are centralized models or approaches that we want to encourage but I also, in the mean time, would encourage you to check with your local facility leadership and regional council about your facility’s policies and strategies for participation. I can say that even though it is on a very short timeline, there are obstacles to be a full participation including issues related to privacy and protection of veteran information and IT or information technology challenges to contributing data to the databases in particular. Stay tuned. Our office among others will continue to communicate, as new information is developed and publicly available.

Moderator:  Okay. Thank you.

Erin Krebs:  This is Erin. I just put up the first of three reference pages and this one just shows the clinical practice guideline that I’ve been referring to and the link to get to it if you would like to –

Bob:  This is Bob again. I might emphasize these kinds of resources are readily available via our national pain management website which is quite straightforward. www.va.gov/painmanagement if you go to that website, you are likely to find additional clinical resources that you might use. The link to the opioid therapy guideline is there and I also highlight a web-based coursed in the management system on opiate therapy. This is a course that is quite important and has received really good feedback from clinicians and others in the field about its content. It is updated every year. Last year it was specifically updated for thorough review and revision. It is largely quite up to date and I strongly encourage providers, nurses, and clinicians to consider taking that course.

Moderator:  Okay. Fantastic. That should wrap up everything for today. Erin, Bob, do either of you have any final remarks before we sign off?

Bob:  I would like to thank Erin for an extraordinary job today and handling so many important questions for the field. I want to thank all of the participants for your interest. Please remember this is a monthly series and we would like you to consider enrolling or registering for future presentations and also please take a shared responsibility in spreading the word if you found this presentation valuable. Thanks, everybody and thanks for the support for this as well.

Moderator:  We are more than happy to do it.

Erin Krebs:  Thanks.

Bob:  Bye, everyone.

Moderator:  Thank you so much, both to Erin and Bob. We really appreciate your time. We’ll see you next time.

**[End of Recording]**