Robert Sproul


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Responsible Prescribing Practices
National Rx Drug Abuse Summit 4-11-12

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Robert Sproul

  1. 1. ResponsiblePrescribing Practices April 10-12, 2012 Walt Disney World Swan Resort
  2. 2. Learning Objectives:1. Describe how cautious, evidence-basedprescribing practices can lower opioid-relatedoverdose deaths while maintaining appropriateaccess for medically needed treatment of chronicpain.2. Identify “best practice” strategies that can beused by clinicians for pain management treatment.3. Explain evidence-based practice and policies forprovider education and patient educationprograms being utilized across the US.
  3. 3. Disclosure Statement•  All presenters for this session, Dr. Rollin M. Gallagher, Dr. Andrew Kolodny, and Robert Sproul, have disclosed no relevant, real or apparent personal or professional financial relationships.
  4. 4. Opioid-High Alert Appropriate Treatment / Risk Mitigation Robert Sproul PharmD Program Director, OVAMC Pain Management Program Manager, Pharmacy PM, Palliative Care Project Director, OVAMC E-Consult Pain Management Co-Chair, VA National Pain Management Pharmacy Work GroupCo-Chair, VA National Clinical Pharmacy Training Work Group Pain Management Member, VA National Pain Management Strategy Coordinating Committee National RX Drug Abuse Summit 2012 Orlando VA Medical Center
  6. 6. ? Where Do We Start How Do We Get There ? Tertiary Interdisciplinary Pain Centers RISK   Advanced diagnostics & interventions CARF accredited pain rehabilitation Co morbiditiesTreatmentRefractory Patient Aligned Clinical Team (PACT) Routine screening for presence & intensity of pain Comprehensive pain assessmentComplexity Management of common pain conditions MH-PC Integration, OEF/OIF, & Post-Deployment Teams Expanded care management Opioid Renewal Clinics
  7. 7. Abridged VA Quality Monitors Going Beyond DEA Regulations•  PBM High Dose Opioid (HDO) Monitor –  Multi-Site review identify patients receiving opioids from more than one site within a VISN –  Multi-VISN review identify patients receiving opioids from sites in more than one VISN•  Formulary Management –  Evidence Based Drug class and molecular reviews –  Criteria for use that address safety concerns •  MAP (Medical Advisory Panel) –  Field input and review from subject matter experts, clinical alerts –  PBM site (Public Link)
  8. 8. Abridged VA Quality Monitors Provider Education Support Programs•  VA MedSafe –  Pharmacovigilance/PostmarketingSurveillance and VA ADERS program •  National ADE reporting program for all VA –  Active surveillance •  Proactive tracking of all patients exposed to a medication and identifying adverse events using diagnostic codes or symptom•  Provider Education: It s not just about Monitors –  VA Web Programs for Providers (Example: Opioid Web Course) –  INTRANET Department of Veteran Affairs •  VHA Pain Management –  VA Methadone, Fentanyl Dosing, Safety –  Collaborative Intervention for Pain and Depression –  VA/DoD CPG: Management of Opioid Therapy for Chronic Pain –  Stepped Integrated Pain Care in the VHA
  9. 9. Managing Chronic Opioid Therapy VHA Innovations In Clinical ServicesSupport of our Veterans and their Providers
  10. 10. Helping the Bewildered Survive the Storm Gollie
  11. 11. National Clinical Pharmacy Training BOOT CAMP / Mentoring Program•  Boot Camp –  Designed •  Empower the attendees with the most fundamental knowledge •  Necessary to develop competence and confidence •  To address every day pain issues –  In the AMB Care or PACT setting•  VA Pain Management Mentoring (VAPPMM) –  Mentoring Outlook Exchange Service •  Continue this theme by providing continued support •  Solidify the skills learned in the boot camp •  Broaden the horizons of those participating in this exchange •  Safety Net (NOT SURE THEN ASK)
  12. 12. BOOT CAMP / VAPPM Mentoring Abridged Topics of Emphasis•  Opioids –  Check the "math" –  Conversions, Rotation, Titration, Taper etc. –  Choice of Opioids /Drug to Drug interactions –  Pharmacokinetic/dynamic implications –  Adjuvant or Alternatives•  Urine Drug Tests (UDT) –  Results, Implications, Caveats –  Follow up procedures •  Appropriate documentation •  Patient Safety Issues/Moderate to High Risk Patients •  Provider Coverage•  Referral Considerations –  Substance Abuse, Mental Health, Physical Therapy, Other
  13. 13. E-Consult Pain Management HELP! DIRECTIONS PLEASE-NOW? PATIENT PCP ? UDS Labs
  14. 14. Bridging The Gap OVAMC E-Consult Pain Management Primary Care Specialty Care Pain ClinicsDaily PM Issues, Support Management Services
  15. 15. OVAMC E-Consult PM
  16. 16. OVAMC E-Consult PM Fundamental Goals•  To address everyday pain management questions and patient safety issues•  To provide easy access to the service for the consulting provider –  Easy Access equates with Timely Support –  Paramount for addressing patient safety issues•  Typical concerns addressed by the E-Consult Pain –  Opioid related •  Titration, rotation, conversions, tapering •  Alternative treatment modalities –  Urine Drug Screen •  Interpretation, policy, provider recourse •  Associate opioid tapering and ethical considerations
  17. 17. Project Coordinator Pain Pharmacist E-Consult CPRS Review/Documented RecommendationsProvider EducationWeek Pain Pharmacist: Initial Responder Triage Based on Level of Complexity (LOC)Teleconference L1 Pharmcotherapy concerns L2 Pharmcotherapy /MH Comorbitity Concerns a. Multidisciplinary L3 Complex Comorbitity/High Risk Patients: Teleconferencing a. InterdisciplinaryVHAORL E-Consult Pain Management Outlook Triage MH Screen Provider Non-CPRS Follow up Pain Psychologist +Screen-Comorbitity L2 Contact Option Chart Review CPRS Clinical Review Pain Pharmacist 1.0 FTE Progress Notes OutcomesPrimary Responder-Pharmacist Pain Psychologist % FTE Quarterly/Annual Data Pain Psychologist Pain Physician % FTE
  18. 18. Recommendations / Documentation What s In A Name•  Intent –  Is not to paint a provider into a corner –  Is to provide guidance for / with options to the provider•  Wording –  How a recommendation is worded is crucial •  Stipulates the recourse the Pain Service would take •  Offers alternative to the Clinic s stance (opinion) –  Acknowledges providers discretion•  Example –  For the following patient safety issues detailed above a.b.c., the Pain Clinic would no longer prescribe opioids for this pt at this time –  However, should the provider determine opioids will be continued, then the Pain Clinic would recommend the following •  Frequent UDS •  No more than a seven day supply, etc
  19. 19. OVAMC E-Consult PM Provider Education•  OVAMC/VISN 8 E-Consult –  Chronic Pain Audio Conference•  Weekly Case-Base Provider Education (CME) –  Moderate to High Risk Patients –  Complex patients with Comorbitity•  Supporting didactics•  Provides an Interdisciplinary Forum –  Explore alternatives –  Discuss controversies –  Provider recommendations
  20. 20. Hidden Treasures Transcending the Routine E-Response•  Typical consults –  Often directly address important daily issues, such as urine drug screens, opioids, and associated concerns•  However, provider support is not limited to "treatment modalities" alone –  May directly assist the provider in resolving difficult scenarios •  Patient treatment and or ethically related issues •  Assist in coordination of care
  21. 21. E-Case Study Ethical Considerations•  Reason for Consult –  Terminally ill cancer patient –  In the ambulatory care setting –  Non-End of Life Scenario –  On significant amount of opioids –  Test positive for cocaine/alcohol•  Providers Comments..."Im concerned that the patient is going to overdose or hurt someone else… Is a second chance reasonable, or must I discontinue the opioids… I don t want to cut the opioids… I know he s in a lot of pain... What should I do
  22. 22. E-Hidden Treasures PCP Doesn t Have to Walk the Walk Alone•  Ultimately it will be the providers discretion that determines the recourse which will be taken•  However, the provider can reach out to a "team" for support and or advice –  Options with the supporting details –  To address a controversial pain / ethical issue•  Means to avoid the unilateral decision process –  An uncomfortable situation for many providers –  Due to perceived scrutiny •  From oneself or from others •  Laced in the form of legal, ethical, moral considerations/implications
  23. 23. Balancing the Benefits and Risks Personal Perspective•  Opioids CNMP: The Approach and Contingency •  Exhaust other options prior to prescribing opioids for chronic use •  Utilize all resources / tools available to ensure success •  Discuss with patient expectations, limitations, shared responsibility •  Set goals prior to implementing opioid therapy •  Monitor for success and or failure to protect our Veterans who may have an abuse problem who may not be able to help themselves•  However, we respect the rights of our Veterans to the use of these medications, •  When other options have failed •  When these medications prove affective –  Safety comes first, function is at minimum preserved •  When used responsibly•  We Do Not Sacrifice or Label our Veterans who are in need for those who would abuse, when being treated with opioids
  24. 24. VHA Pain ManagementSupport of and Care for our Veterans
  25. 25. To All of Our Veterans-Who Have Sacrificed-