A study of veterans with chronic noncancer pain found associations between increased opioid dosage and higher rates of adverse effects. Interviews with providers showed inconsistent practices in assessing opioid risk, obtaining written agreements, and conducting functional assessments. To improve outcomes, the presentation recommends clinical decision support with structured data entry at the point of care, periodic assessments, education on guidelines, and multidisciplinary treatment approaches that favor non-opioid therapies over chronic opioid use whenever possible.

1. Got Drugs? Structured Data, Opioids, Documentation and Outcomes in Veterans with Chronic Noncancer Pain
Lawrence Lyon, MD, Ken Hammond, MD, VA Puget Sound Healthcare System Neither this presentation, discussion of any elements therein nor the presenter reflect or represent official Department of Veterans Affairs policies or positions
• .
Statistically Significant Associations
With COT
COT AE’s Clinic ‘depress’ ‘suicid’ PTSD MD’s SU
Mg/Day
MS Eq
0 5.4 4.5 38.3 1.3 43.6 70.5 12.6
<40 13.1 13.4 58.9 3.8 72.5 89.0 20.7
41-119 24.4 12.8 66.7 5.1 83.3 94.9 25.6
>=120 27.0 10.8 67.6 8.1 91.9 100.0 35.1
Opioid Risk Assessed? 5/8 Yes 2/8 No 1/8 responded “It depends”
Written Agreement? 4/8 Yes 2/8 No 1/8 “only after 90 days” 1/8 verbal
Standard procedure to start chronic opioids? 3/8 Yes 5/8 No
Does the practitioner use it? 2/8 Yes 5/8 No 1/8 “most of the time”
Periodic functional assessment done? 7/8 Yes 1/8 “most of the time”
Chronic
Pain?
Evaluation
of Acute
Pain
Stop
Evaluation of
Prior Treatment/
Treatment Plan
Revision
Opioid Risk
Assessment;
Mental Health
Diagnoses;
Patients receive
additional
treatment?
Use Chronic
Opioid Therapy?
Non-COT Tx Plan
Chronic Opioid
Therapy
Treatment Plan
F/U Evaluation
Functional Assessment;
Primary Care Visits/Year;
F/U Frequency
Adverse Outcomes, Side
Effects, Pain Burden
Outcome OK?
Schedule II?
Refills
Pharmacy
Facilitates Rx
RenewalRevise Treatment
Plan
Keep Treatment
Plan
Narcotic
Medication Plan
(NMP)
No No
Yes
Yes
No
Use NMP? YesYes
Provider Manages
Rx
No
Time to Chronic
Opioid Therapy,
Clinic Usage,
concurrent
medications, eg BZ’s
Opioid High vs Low Dose,
eg >120mg MS Eq/day vs
<40mg MS Eq/day, Refills/
Renewals
Narcotic
Medication
Plan?
Patient Yes
No
References:
Macey TA, Morasco BJ, Duckart JP, Dobscha SK. Patterns and Correlates of Prescription Opioid Use in OEF/OIF Veterans with Chronic Noncancer Pain. Pain Medicine 2011; 12; 1502-1509.
Seal KS, Shi Y, Cohen G, Cohen BE, Maguen S, Krebs EE, Neylan TC. e-Table 1, International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9-CM) codes used to identify
pain diagnosis, Association of Mental Health Disorders With Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan, JAMA 2012; 307; 940-947.
Seal KS, Shi Y, Cohen G, Cohen BE, Maguen S, Krebs EE, Neylan TC. e-Table 2, International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9-CM) codes used to identify
and categorize adverse outcomes, Association of Mental Health Disorders With Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan, JAMA 2012; 307;
940-947.
No evidence-based structured data available/enabled at POS
48% with chronic noncancer pain; 32% treated with chronic opioids
54% of those taking chronic opioids without a pain agreement
Where now? CDS with POS input & retrieval of structured data based on guidelines,
periodic functional assessment, e-consent, provider education; concurrent
medications alerts, multi-/interdisciplinary team management; avoid refillable COT,
no COT renewals without assessment; increase combination non-opioid treatment,
automated reporting for monitoring, use data to inform evidence for care.