**Cyberseminar Transcript**

**VIReC Clinical Informatics Series**

**The Prescription Opioid Documentation and Surveillance (PODS) System**

**Barth Wilsey, MD**

**June 19, 2012**

Interviewer:At this time, I would like to introduce our speaker Barth Wilsey M.D. Dr. Wilsey is director of the Sacramento’s VA Medical Center Pain Clinic and a research physician in the department of Physical Medicine and Rehabilitation at the University of California Davis Medical Center. Without further ado may I present Dr. Wilsey.

Dr. Wilsey:Thank you very much Margaret. I am going to talk about a system that we have had at the Sacramento VA Medical Center for about seven years. It is a computer assisted survey instrument. We call it the Prescription Opioid Documentation and Surveillance System. As an outline to this talk, I will be talking about the survey instrument itself and the fact that it uses validated medical and health questionnaires, the use of this questionnaire by the patient prior to the face-to-face meeting with a clinician, and how the information is incorporated into progress notes.

I will start with the fact that this is a computer assisted survey instrument and by way of reference present information on the lack of documentation of opioid prescribing that has been noted by several investigators including Dr. Clark at Palo Alto VA. He did a random chart review of 300 records and found that 50% of Veterans have suffered from at least one type of chronic pain and 44% or almost half of those who suffered from pain are receiving opioids. Therefore, about 25% of patients receive an opioid.

What was interesting about his survey of these 300 charts was that there was infrequent documentation of a physical examination concerning the pain complaint and very seldom was there a comment on the specific opioid treatment plan or followup of that plan. About the same time that that was, written Steve Passik  at Cornell was describing paper and pencil tools to document opioid prescribing. His instrument became known as the 4 A’s where he looked analgesia, activities of daily living, adverse side effects, and aberrant drug taking behaviors.

On the next screen I show Dr. Passik’s 4 A’s or at least two of them. The patient completed the analgesia portion, but then the clinician would talk about activities of daily living or would fill that in after discussing that with the patient. Likewise, the clinician completed the adverse events and then aberrant drug behaviors were completed by the clinician who witnessed those completed behaviors. This was a very interesting start with documenting prescription opioid abuse and it lead me to investigate the use of previous type of questionnaire on a computer. 

Back in 2005 and 2006 we sort of jerry-rigged some computers and started to put a computer-assisted instruments in an access database. We have used the same access database now for seven years and it has performed flawlessly. It was devised by the young man in this photo who is now a surgical intern at the University of Utah devised it. At that time, he was very interested in writing computer programs and it was very gratuitous for me to have him write the prescription opioid documentation system. His name is Carlos Casamalhuapa. 

I am going to talk now about the instruments that we chose to put into this computer assisted survey instrument. I will start by talking about our initial evaluation, which we formulated first. This is the first screen that a patient sees when PODS is opened up in front of them on a computer when they come into our pain clinic. In general, we fill out this information and show the patient that they can just press the next button here and start to complete the survey. Many patients do fill this out themselves and seem to do so without a problem. By the way, we have had over 2,000 patients complete this survey.

These are the validated scales that we are looking at, we are looking at the Brief Pain Inventory which is what Steve Passik emulated in his 4 A’s where you get the worst, the best, the least, and the average pain or recurrent pain over the last 24 hours. Also, the Brief Pain Inventory Interference Scores with seven activities of daily living such as mood, general activity, walking, work, household chores, relations with other people, sleep, and enjoyment of life. We then average those and present those in the progress note as indicated on the left portion of your screen in a summary of these health scales.

We are also looking at the PHQ-15, which is a summarization scale of the patient health questionnaire. We look at the Patient Health Questionnaire-9, which is depression and we look at the anxiety portion of the Hospital Anxiety and Depression Scale. We have reports on every patient on their initial visit on these five scales, so we have some idea of how their mood and anxiety are affecting their chronic pain.

This is a depiction of one of the screens that a patient sees when completing the Brief Pain Inventory. This one depicts the worst and the least pain in the past week and they will just press one of these buttons and they have to complete both questions or all questions on any given screen or if they press the next button and if something is not completed they are not allowed to proceed. 

This is the general activity or the Pain Interference screen that appears. The patient just lists general mood, activity, and walking ability and there will be some other screens that they will complete and that will get the report on the activity level from the Brief Pain Inventory. This is the report summarized from the Brief Pain Inventory. The pain measures are on top, the worst, lowest, average, and current pain levels and then the seven Pain Interference Scales. 

Therefore, we get a good picture of the patient by querying this validated instrument. On the initial visit, we also do the Patient Health Questionnaire-2 where we administer the Patient Health Questinnaire-2 and we ask questions about their interest or pleasure in doing things and whether they feel down, depressed, or hopeless. We chose the Patient Health Questionnaire-2 here because we could save time and effort on the part of the patient, but if the Patient Health Questionnaire-2 was positive, that is if the Likert scales were greater than or equal to 3, then we branched into the PHQ-9 of the complete study.

This is the Patient Health Questionnaire-15. Part of the Patient Health Questionnaire-15 obviously has 12 other questions. We use the Patient Health Questionnaire-15 to not only give us a summary score for somatization, but we also use it as a review of systems on the initial evaluation. A clinician will augment this in the face-to-face interview, but we start with this. This is the depiction of some of the questions presented to subjects in terms of the Hospital Anxiety Depression Scale anxiety component that is, and the report is given to us at the time that we see the patient in the face-to-face interview.

In addition to doing the aforementioned, we also have put in components of the Addiction Severity Index whereby we learn if a patient has used alcohol or a substance in the past 30 days and we learn the lifetime use of substances. When we see the patient in the clinic, we see a printout that is incorporated into CPERS [sic] the VA medical record where the alcohol, heroin, methadone, barbiturates, tranquilizers, cocaine, amphetamines, marijuana, hallucinogens, inhalants, alcohol DTS, alcohol abuse, and drug abuse is enumerated for us the first time we see the patient. Therefore, we have a way of asking these questions without spending the clinician’s time to ask them, but rather having the computer do it before the face-to-face meeting.

When we looked at this, we looked at whether the Addiction Severity Index was compatible with what had been done previously with paper and pencil. We found there was a great deal of similarity between what was found in the computerized version, which are representative of the X that is the frequency in which this was reported in a Veterans Administration population and the O and the frequency with which it was reported in using paper or pencil. They were all very similar. 

We also ask some non-validated questions when patients come for their initial evaluation. We ask them about what they received as far as treatment is concerned. That is presented to the clinician in the form of written information to which the clinician will add the specific opioids that are being used or other types of medications and add other information as well. Another validated question that we ask during the initial evaluation is, what type of ailments people have. We use this to write a past medical history. Now, obviously, this histories and add information. Another thing that we ask is about the treatments that a patient would like to try. This often saves us a lot of time during the face-to-face interview in that we go right to what they want to try.

I am going to now talk about the use of PODS during the prior face-to-face visit and in doing that I am going to show the audience our new pain clinic computer room where we have three of these computers set up next to each other with spaces designed to prevent people from seeing the answers provided by different patients. This is a depiction of the time that it takes that initial evaluation. You can see that the mean is about 20 minutes and some people take a lot longer obviously, but some people complete it sooner. Now, again, we ask people to complete this and it is voluntary, but most people do it. As I said, we have had over 2,000 Veterans complete this questionnaire and there is very little opposition to doing this. In fact, Veterans will come into our office and relate things that they had not thought of that were prompted by the computer.

We published our little documentary of what had transpired in our first few years of implementing the Prescription Opioid Documentation System in the *General Pain Medicine* in 2009 and referenced the aforementioned surveys. The benefit of using PODS is that one can incorporate the information as I have shown before under progress notes and we do this at followup evaluations. In other words, the patient comes in for initial evaluation and completes 56 items. Then, when they come in for followup evaluation, we use the items very often that they completed previously to present specific information or specific questions to them that rely on the initial evaluation and I will show you this.

At every visit, we get the Brief Pain Inventory, but we also get this percentage of pain relief of 10%. I try to use this in such a manner that I try to get patients to 50% overall improvement, but very often I am satisfied with 30 or 40% overall improvement. That comes from the work of John Ferarr at the University of Pennsylvania who showed that 30% overall improvement was correlated with very much improved in a regression analysis. Although I try to get people to 50%, I am satisfied with 30 or 40%. That tells me when I stop increasing an opioid.

We also get the side effects at the visit. This is akin to what Dr. Passik was doing in his 4 A’s and then this will alert us to ask the question during the face-to-face interview concerning the side effects. The interference with activities is also repeated every visit. Again, this is the component of the Brief Pain Inventory that we do at every visit. The advantage of having a computer is that we can accumulate information on a patient at different visits. For instance, this slide is part of the information we put into the progress note as to the progression of their overall pain relief. We see here that this patient started to improve, we kept them in the clinic, and then for some reason his overall pain relief dissipated. I find it very useful to have a trend of pain relief scores and a trend of other scores, as I will show you. 

At the first visit in followup, we administer the Screening for Opioid Assessment for Patients with Pain and we present this at every visit to give us an indication of whether this patient has a propensity for a prescription opioid abuse. We also administer the Current Opioid Misuse Measure at every followup visit and this tells us whether this patient needs to be seen on a more frequent basis depending on the results of this test. In addition, whether or not they scored greater than or equal to 9 telling us if that is affirmative that they have scored greater or equal to 9, then we will see them on a more frequent basis.

In addition to looking at the COMM, we also devised a way of looking at aberrant behaviors and recording them at every visit. The clinician is presented with a question as to whether or not that patient has come in early for a refill or made a phone call for a refill and we document this every time they have one of these requests that Dr. Chabal I believe Seattle VA listed as prescription opioid abuse. We document that so that we can have a record that we can present to the patient that they have been running out early or if need be that we present that to the patient advocate to whom they may go if we reduce their opioids or tapper them from what the opioids were. 

This has been very useful in documenting this rather than having to go through the Electronic Medical Record after we get a gut feeling that they are abusing opioids, rather we have this documented. At one time, I queried the number of times that these aberrant behaviors were documented and it averaged about 15 times a month in our clinic.        

We use the followup visit to inquire about issues from the initial evaluation where we learned that a patient may have had a history of alcohol abuse for instance and so that patient will be presented with a question about alcohol use in the past 30 days. This again is something that a computer can do for one and it can remember what type of substances somebody has endorsed as having abused and ask them before the face-to-face meeting whether they used that before we saw them.

This is again the PHQ-9, which we present at every visit, but we serialize these scores. You can see the serialized scores at the bottom, so we can see if somebody’s PHQ-9s score is improving, remaining the same, or worsening. Therefore, naturally in a pain clinic we want to look into a patients level of depression and this is an apt wayof doing this. In fact, I think there is a movement of foot and various states to mandate that people start using screening instruments for depression. I am aware of this in Minnesota from having heard about this in Opioid and Psychiatry, so I was glad to see that we have already been doing this.

We also have the presentation every visit of whether there has been any suicidal ideation and this patient was endorsing having this nearly every day. Obviously, the commission would then be incumbent upon a commission to inquire as to whether or not the patient should be referred to mental health because of this. As I mentioned, we get the Hospital Anxiety and Depression Scale at the initial visit and we post that at every return visit, but we are also looking at other specific anxiety disorders during subsequent follow-ups and we serialize the presentation of these questions so that it does not take too much time at any given visit. We ask about post-traumatic stress disorder, using the PTSD checklist. We ask about the panic disorders (inaudible)  the report. We inquire as to whether or not they have GAD by looking at the Generalized Anxiety Disorder Questionnaire. We also look at obsessive-compulsive disease as well as having a scale have for borderline personality disorder and bipolar disorder. Therefore, we have six scales that measure both anxiety, borderline personality disorder, and bipolar disorder that we present over six visits and then we post these as they accumulate in the computer database for the clinician to see.

We also let the computer determine whether somebody is going to go for a Random Toxicology Screen. I often tell patients that they should blame the computer and take a mallet to the computer rather than blaming me. The patients are actually presented with a screen that says you have been selected to have a Random Toxicology Screen today. Therefore, they are aware of that, but they often remind me if I forget to bring that up. The clinician has the ability to not do that screening if in fact the patient has had a recent screening or for any other reason, there being time constraints, or another reason the patient does not have to be screened just because the computer says they have to.

This is the graphing of how long it takes to do a followup evaluation. Its average is somewhat shorter than in the initial evaluation. There are again people that take longer periods, but for the most part or at least the average is somewhere between 7 and 11 minutes. It is not too much time on the part of the patient. We published our results of our followup visits again in *Pain Medicine*in 2010 if any of you are interested in looking at that.

The advantage of using a computer survey instrument is that all relevant information is requested. The physician readily has access to this information during the visit, we can enter this information into the patient’s medical record, and it is readily available for other types of use. For instance, for aggregating data about patients who use the Prescription Opioid Documentation and Surveillance System. There are other advantages for instance, where we are administering multidimensional pain and functio scores or instruments to obtain these scores. There is consistent tracking of key outcome targets at each visit where we have surveillance of behaviors or symptoms that we document and we use branched questionnaires to reduce the time spent by patients.

This documentation of opioid prescribing has become all the more important in the last few years where inadvertent overdosing from opioids has become noted. The White House, FDA, and the DEA have all tried to stem this epidemic and it has become very important in the Department of Veterans Affairs, because Veterans have nearly twice the rate of fata accidental poisoning compared with adults in the general US population. PODS are very useful for the second screening that is accidental overdose is strongly associated with substance abuse disorders, depressive disorders, and anxiety disorders. Most of this work was done at the Ann Arbor VA by Dr. Bohnert and some colleagues. 

We are currently looking into expanding PODS. Right now we have a desktop system, but we are looking at smartphones and capitalizing on the “always on, always worn” feature of smartphones to repeatedly sample these health outcomes. We are not necessarily going to use everything that was in PODS, we are actually thinking of using what is in the National Institutes of Health promise screening to get an idea of what is happening, get more frequent measurements so called “ecological momentary assessment” and present that to patients either on the smartphone or at visits. 

We are also interested in looking at patients in between visits with regard to their suicide ideation. The other thing that we are thinking of doing with the smartphone is using the accelerometer and the microphone to track physical movement and sound and make inferences about physical activity and social interaction. The use of the microphone to track sound is an avant gard measurement that we are looking at working with colleagues at UC Davis, UCLA, and UCSF in devising smartphones that will make these measurements. We think that passive assessment will reduce the patient burden in completing self-questionnaires and so we are trying to see whether or not we can use that.

With that, I will answer any questions that might be presented by the audience.

Interviewer:Thank you very much. There are quite a few questions and probably more will be typed in as we go along.

The first comment and question, thank you for citing D. Clark’s paper from PA VAMC. Does PODS help document either informed consent compliance with Oregon law or OPCA documentation?

Dr. Wilsey:We have patients sign an opioid use agreement. In CPRS, we do not use PODS to formally sign that agreement. I think the reference to Oregon is interesting, because Oregon had another paper that was written by a family practice clinician there many years ago that also showed a lack of documentation. 

I think what we are concentrating on with PODS at least is trying to document the prescribing...   It is interesting that in our use of smartphones we are thinking of having videos to present to patients concerning the tenets of the opioid agreement to explain to patients that they need to safeguard their opioids and to not use multiple providers for instance. If we receive funding, we are applying for a Department of Defense grant for this, and if we receive funding for the smartphones we will cover the opioid contract using videos.     

Interviewer:Cool. Okay next question, I am interested in assessing our young Veterans for opiads, so maybe that is not a misspelling. Does PODS help assess for this?

Dr. Wilsey:Yeah I think that PODS would be very useful to use in any pain clinic or even in a primary care office, because you get a listing of their pain. To that, you would add what you have noticed or what you record in your face-to-face interview. I think it is very useful and I must say I have had a number of people come to work in the pain clinic as clinicians, pain pharmacists, two nurse practitioners and several clinicians and they all insist on using PODS.

We are about to embark upon using PODS in telemedicine where we are going to put a computer kiosk in an outpatient clinic that is 90 miles from the Sacramento VA Medical Center. That will enable our pain pharmacists to collaborate with clinicians in this outpatient clinic in prescribing opioids. Therefore, I think that this is readily available and I am just giving a testimonial if you will on noting that several of my colleagues who have come to the pain clinic virtually all of them embraced it fully. 

It is a very simple thing to open up on the clinician’s desk PODS and go to the patients name and then put in some information as to whether or not they have had any aberrant behaviors that have been observed. Then, the clinician can take, within second’s, text that is formatted and insert it into CPRS with correct formatting. It is very simple to get that and then the clinician then does the face-to-face interview adding information. They change the plan down at the bottom from the last visit, but basically, it saves a lot of time getting this beforehand from patients.

Interviewer:Okay. Thank you. The next two questions I am going to put together. The first one is asking if your work has been done in the pain clinic or in primary care? The second question is have you tried implementing it in primary care?

Dr. Wilsey:It has all been done in the pain clinic. We have had as I said over 2,000 patients use it there. We are going to embark upon using it in the outpatient clinic that I presume is a primary care clinic 90 miles for Sacramento VA Medical Center. We are also interesting in having one of our pain pharmacists administer this in the Sacramento VA Medical Center in primary care. I have always envisioned this going out to primary care. 

I welcome comments and I put my email address in earlier, so I will put it back. I would welcome comments from people who desire to implement this and we will see what we can do. 

One thing that has been paramount of importance that has come about more in force today than it was when I started these seven years ago was information security and having a patient sit in front of a kiosk. We have a system whereby there are two sign-ins. First of all, we turn the computer into a kiosk and then we have to sign-in with our own names and our own sign-in. You have to work closely with your information security officers. I am working closely with mine to try to get this set up in an outpatient clinic 90 miles from our facility and that has to be done with them fully involved. Even the director of your facility perhaps being apprised of the value of this and the security measures that will be put into place so that a patient cannot get to the VA behind the firewall.

Interviewer:Okay. Next question, is there a multidisciplinary team approach to chronic pain treatment? If so, do those other team members EG, PT, OT site have access to this information and can you see their notes when the patients return to you?

Dr. Wilsey:Yes. Our pain clinic is in the Department of Physical Medicine and Rehabilitation. Therefore, we work closely with physical therapists and occupational therapists. We see their notes and they can see our notes. Now, I want to emphasis that we also work closely with our team of addictionologists. We often bring the computer printout to meetings with them to discuss particular patients so that they can see that we are apprised of their problems with prescription opioid abuse. We discuss the aberrant behaviors that have been observed. 

We are often asking Veterans to undergo substance abuse treatment while prescribing opioids or we may discontinue or taper the patient from opioids and offer them alternative treatments while they are undergoing substance abuse treatment. There would have to be valid reasons of course for tapering them, but that has to be done. One has to be willing to do that especially in this day and age of worrying about inadvertent overdoses from opioids. We do use a multidisciplinary approach and we do especially work with the addiction team here in Sacramento.

Interviewer:Next question, is your facility planning on naloxone rescue kit distribution with screening for suicidal ideation?

Dr. Wilsey:No that is something that I think is of rather avant garde and I have not looked into that. I have heard of it, but we have not done it. It is a good thought, but I do not know that it has been widely accepted as a measure. Obviously the purpose of giving somebody an opioid antagonist would be if they overdose to reverse the opioid to have somebody close by reverse the opioid. What we are doing here is we are carefully looking at the people who are taking more than 100 mg of morphine or equivalents per day that is associated with heightened incidence of inadvertent death. We are looking at people that are taking a combination of opioids and benzodiazepines and we are looking at people who are taking methadone to ensure that their QT interval is less than 500 msec. 

We have been funded for a special program to look at that and we have a nurse manager and a second pain pharmacist involved with that program. Therefore, that is what we are doing, but as far as the original question as to whether or not we are giving them an opioid antagonist, we have not embarked on that type of therapy yet or that type of prevention. I would like to learn more about that and I have not seen very much about that in the literature. It sounds intriguing, but I think there would have to be many precautions in giving people an opioid antagonist in provoking sudden withdrawal with all that is association. Well, I am sure there are instructions as to ensure that they are not just resting or sleeping, because that would be a cruel event to occur for somebody to be given that.

Interviewer: Okay. Next question, how does PODS prevent patient reporting bias over time?

Dr. Wilsey:That is a very good question and people tend to present themselves in the best light. I think what we have done with PODS is we have taken the SOAPP and the COMM; these are instruments that ask tangential questions. These were developed by inflection in Massachusetts and as you read their questions, you can see that tangential nature to determining whether or not the person has either prescription opioid abuse or prevention of opioid abuse or is currently misusing them. 

For instance, they do not say are you abusing the opioids, they will say do you have a relative who has had a problem with addiction and people are often willing to turn in Charlie rather than say that they themselves have an addition. Likewise, they ask questions such as do you smoke a cigarette early in the morning and that correlates with have prescription opioid abuse. So  I think we get around patients reluctance to report their behavior in that manner. We are also witnessing their behavior, which we document with aberrant behaviors being tallied at every visit. 

I think we get around the propensity for people to make themselves of better light. Now, there will be somebody who at the initial evaluation does not admit to having a previous history of substance abuse, but often that comes out in reviewing the past medical record or is determined by somebody in the addiction team when they are referred there for consideration of their treatments.  So I think we have some safeguards and enough is in place to prevent an overly favorable report by a patient. Of course I cannot say that somebody has not tricked us, but I will say we are clinicians and we are not policeman, we do not do sub rosas on people, we do our best though to record their behaviors and ask them these validated screens that seem to be able to get around somebody trying to deny they have a problem. 

Interviewer:Okay. Here is the next rather long question, when you have patients use the computers to enter their data in your computer lab are those VA computers on the VA network or were those purchased from another non-VA funded grant? If it is VA funded, how were you able to implement this in the VA?

Dr. Wilsey:Well our initial computers were such that I brought from home. We put them on a network and we got involved with the privacy officers I remember to bring in IT people to convert them into kiosks. Microsoft as you well know, when you walk into a library you sit down in front of a library kiosk computer and input information. Obviously, you are not getting into their network. We knew that there was such a software program and Microsoft offers that program for free. I think it is called the Shared Tool Kit or something to that affect.

Therefore, we had our IT people devise that for the computers that I brought in from home. Over the years, the VA decided to have only their own computers and I showed a shot of our more recent computers, our monitor computers with flat screens that are VA computers. As I said, we have a system whereby we first sign in with a password to convert that computer to a kiosk, but before we get to the internet or the server that houses this database we have to input our login or user name and our password that we ordinarily use to open CPRS. Therefore, we have two logins. 

Plus, when the patient is sitting there to get out of PODS, they would have to know a third password. I do not think it has been broken. By the way, the Microsoft product’s Shared Took Kit ordinarily you can press a button a keyboard to take you out to the desktop and the Microsoft Shared Took Kit disables that. I think it is a pretty safe bet that patients are not going to get to the VA networking facility where this is done in conjunction with the IT people in your facility.  

Interviewer:Right. Next question, is there a role for chain pharmacies such as Wal-Mart and etc in using PODS to assist VA prescribers trying to coordinate with Medicare non-VA prescribing in VA patients?

Dr. Wilsey:No, I would not think of putting this in Wal-Mart. It is more inclined for a physician. Now, a pharmacist in Walgreens might use the prescription-monitoring program in their state to reduce the incidence of doctor shopping and thereby that would be their activity I think to prevent inadvertent overdose. I am pretty sure that this has been shown also in epidemiological studies that doctor shopping contributes, I think it was shown by Hall etal in the CDC that doctor shopping contributes to inadvertent death from opioids. I think that is the mechanism whereby a pharmacists working at a Walgreens would thwart inadvertent overdose.

Interviewer:Okay. Next question, we have had difficulty using external software to enter information into CPRS records. Is PODS part of VISTA? Is the PODS approved for installation and use at all VA facilities?

Dr. Wilsey:Well, PODS is not part of this. The PODS is a Microsoft Access database that is housed on a VA server. I have not looked into bringing this nationwide. I would suppose we would have to either look into funding for that and perhaps conditional software either My Sequel or Sequel Server because the database now is the PODS database we have and Microsoft access is limited to I think 2 GB. Therefore, I think we only have 500 MG right now that we have used, but certainly, if we opened up this database to other facilities we would have to perhaps just limit it to the person who signs into their patients and therefore have to do more programming. However, you would also have to have more funding from the national VA to put this on a better platform. That platform would be either My Sequel or Sequel Server, but it is not part of VISTA and it is not part of CPRS it is separate.  

Interviewer:There is a significant difference among providers with respect to opioid prescribing when a patient has a positive urine drug screen for a drug not being prescribed. Some patients are discharged from chronic pain treatment and told to self-refer to addictions treatment, which may drive a patient to use more drugs available on the street. How do you handle this?

Dr. Wilsey:Let us say a patient is using another type of opioid and it is obvious that we have done a gas chromatography screen, we would confront the patient concerning this and perhaps at that point look at the CURES database, which is the California Prescription Monitoring Program. We always get permission from patients to do that as required by the Veterans Administration.

I think that they would be given a warning and then if they continued they would be tapered. We do not want people taking excessive amounts of opioids or taking the wrong opioid, so we are ready to taper people if necessary if they are continuing to use multiple providers.

Interviewer:Okay. Next question, for stable chronic pain patients do you ever write three one-month prescriptions and are patients dispensed three months of medication?

Dr. Wilsey:The way we do this... I am trying to think of the various regulations. The DEA has come out and said that you are allowed to give people three prescriptions and you can date them in the future or you can say on the prescription not to be filled until July 15th if you are writing it on June 15th and then the second prescription given one for June 15th, one for July 15th, and one for August 15th and you send them away. We have a program at the Sacramento VA Medical Center or so called Opioid Rewrite Program whereby a patient who is stable on opioids, has not had any abusive behavior that was not perhaps due to the physician or they did not provide enough or something like that where the patient calls in monthly and they will receive prescriptions for six months. 

I mentioned earlier I think the DEA allows three months, but the American Society of Pain Medicine and the American Pain Medicine published in their guidelines in 2008 I believe that three to six months was a reasonable amount of time to allow people to come in between visits. Therefore, we take the amount in that Opioid Rewrite Program all the way to six months and I think that is appropriate. I think that it might be advisable that maybe you have them check in using maybe a smartphone if we ever get that up and going and there are plans to do that. However, I think it is very appropriate to have people not have to come in and see us every month and not travel 100’s of miles to do so. As long as there is a trial period, which it is ascertained that they do not have any prescription opioid abuse they are put into this Opioid Rewrite Program. 

It is also a requirement of our Opioid Rewrite Program that they have a negative urine toxicology screen and that they have a negative assessment in the CURES database, that again being the California version of a prescription-monitoring program. Therefore, we have some safeguards to ensure that those patients are not going to abuse opioids and we allow them to come in at six-month intervals. 

Interviewer:Great. Okay this seems to be the last question, at least so far, what would you estimate to be the average face-to-face time with the provider before and after PODS, before using it and after using it?

Dr. Wilsey:That is a very good question. I do not have factual information on that. I think that we still allow people a 30-minute interval, we allow our clinicians 30-minute intervals for followup visits, and we have not changed that. However, I am sure there is more in depth review of what is going on as a result of that or maybe there is more written in the medical record as a result of having the information presented by PODS. However, I do not have a before and after assessment. I just have my experience and the fact that the numerous clinicians who have come to our pain clinic have all joined the bandwagon. They do not have to use it, but they all do. They find it convenient and helpful in the assessments. I can say from my own experience that I used to spend more than an hour on an initial assessment when I first started here, but I got it down to an hour and I am thankful that I have been able to get a lot of information using PODS. 

Interviewer:Okay, actually one question just came in and we still have a few minutes. How do you square the difference between actual practice and DEA regulations? The VA may do what it does by administrative constraint. However, prescribers DEA certificate is subject to DEA regulations.

Dr. Wilsey:I am not sure I understand that question, but we work for the VA. In pain medicine, we know that the VA for instance does not want us to run a prescription monitoring program report unless we have the patient’s permission. Therefore, we go out and get the patients permission. At our facility, we put that into the opioid contract that we want patients to allow us to use the CURES database, the prescription-monitoring program. We are of the belief that that reduces the propensity for people to have an inadvertent overdose. I do not think the VA other than that has much difference with the DEA. 

The VA opioid prescribing guidelines were last promo gated in 2010. I have been reviewing those for this grant that we are writing for the Department of Defense as I had mentioned earlier involving smartphones. I think there is very good information in there, they reviewed the literature about the problems with the propensity for prescription opioid abuse being greater in those with mental illness specifically personality disorders and anxiety disorders. I think that there is up to date information that has come out of the central VA on this problem and I think it is incumbent upon us to follow the DEA and the VA. We also have to follow our state because we are licensed by our states in this matter, so I am not sure I see a discrepancy there. I just personally believe in looking to the VA for their instructions, because I am a VA employee and I try to follow that.  

Interviewer:Okay. One more question here typed in, if the patient consents to use of the CURES database, are you allowed to provide the patients information to the database or just query it?

Dr. Wilsey:We just query it; I do not think that we are providing information. Certainly when we write a prescription here at the Veterans Administration, the pharmacist does not report it to the CURES database and we do not report it. Now, in California when you are inputting information about a specific patient you are allowed to write something, but I do not think that many of us implicate our patients. I think that is because the VA is a little bit wary of the Protected Health Information of Veterans and trying to keep Veterans safe by protecting information that is given to outside agencies and we follow that.

Interviewer:Okay it is to the top of the hour and I think we had better stop. I want to thank you very much Dr. Wilsey for taking the time to develop and present the talk. The questions have been great and I am glad we had time for them. If anybody has remaining questions, they can send them to Dr. Wilsey’s email I think. Is that okay?

Dr. Wilsey:Sure and I also have a VA email barth.wilsey@va.gov.

Interviewer:Okay and you can also always send questions to the VIReC  help desk, which is VIREC@va.gov. Our next session is scheduled for Monday July 23rd. It has been changed because of the HSR&D  meeting. It will be at 11:00 AM Eastern Time. The speaker is Dr. Ann Walia and she is presenting on Web Based Patient Portal to Directly Elicit a Comprehensive Medical History. She is an anesthesiologist and that is what she is talking about. Thank you all very much and enjoy your afternoon. 

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