Presentation delivered at the University of Michigan Injury Center Opioid Overdose Summit, Ann Arbor, MI, December 1, 2015

1. Improving opioid prescribing in
VA primary care
Erin E. Krebs, MD, MPH
Minneapolis VA Health Care System
University of Minnesota

2. Disclosures
• I have no commercial financial relationships
• I have received research funding from VA, NIH, FDA, and DOD
• Views expressed are mine and do not reflect the position or
policy of the VA or US government

3. “My first doctor… I trusted him all the time… and didn’t
ask him a question at all, and I [was] on almost 600 mg
of the OxyContin and that other drug together and I
mean I was just in la-la land all the time.
I never should’ve let him do that to me, but his, his—
I’m at a loss for words. He wanted to relieve my pain…
He really did care for me, but he was overly taking care
of me and didn’t think about the side effects of what he
was doing.”

4. Outline
• Barriers to improving pain management practice
• VA Opioid Safety Initiative
• Minneapolis VA Opioid Safety Initiative experience

8. Opioid prescribing in VA
• VA patients have ~2x rate of accidental poisoning
compared with the general population
– Opioid medications ~1/3 of deaths
• 50% of 1.4 million Veterans with chronic pain*
received ≥ 1 opioid prescription in 2011
– Median days’ supply: 120
– Median daily dose: 21 ME mg
Bohnert AS et al., Med Care 2011; Edlund MJ et al., Pain 2014
*Back pain, neck pain, arthritis,
headache, neuropathic pain

9. Opioid prescribing in VA
Edlund MJ et al., Pain 2014

10. VA Opioid Safety Initiative
• OSI dashboard: national, regional, & facility-level
reporting of opioid prescribing metrics
• Opioid panel report: Primary care team-level
reporting of patient risk and treatment
characteristics
• Nationwide targets for all VA facilities/health systems
– Issued April 2014
– Revised December 2014

11. National VA OSI goals
1. Educate prescribers on
use of UDT
2. Increase use of UDT
3. Facilitate use of PDMP
4. Establish tapering
programs for patients on
benzodiazepines &
opioids
5. Develop tools to identify
high-risk patients
6. Improve prescribing of
long-acting opioids
7. Review treatment plans
of patients on high-dose
opioids
8. Offer behavioral & CAM
therapies at all facilities
9. Develop collaborative PC
and MH models to
manage benzodiazepine
& opioid prescribing

12. Minneapolis VA OSI
• Primary care population-level QI initiative (2011-)
• Objectives
– Reduce dose to <200 ME mg/d for chronic non-cancer pain
– Phase out use of oxycodone SA
Westanmo A et al., Pain Med 2014

13. Minneapolis VA Health Care System
• 1 urban tertiary
care hospital +
11 suburban and
rural clinics
• 68,000 patients
enrolled in
primary care

14. Mpls OSI implementation
• Preparation phase (April 2011-January 2012)
– Leadership/stakeholder meetings
– Primary care pain/opioid seminars (6 sessions)
– Clinical pharmacist meetings/training
Westanmo A et al., Pain Med 2014

15. Mpls OSI implementation
• Implementation (February 2012)
– Chief of Staff letter to PCPs
– Patient lists and OSI action plans to PCPs
• Develop taper/conversion plan with pharmacist
• Schedule patient visit for pain medication review
• Work with pharmacist to implement plan
– OSI performance measures
– Patient pain education classes
• Phase 2 (2013): Opioid review committee
Westanmo A et al., Pain Med 2014

16. Pre-OSI PCP attitudes & beliefs
Agree
I’m satisfied with care provided for pts with chronic pain 9%
I have adequate training to care for my pts with chronic pain 32%
It is important to have a consistent standard of care for opioid rx 97%
It is reasonable to set a dose limit of 200 ME mg/day 76%
There are no good alternatives to high dose opioids 35%
If I decrease doses, my pts may be threatening or violent 62%
If I decrease doses, I will be pressured by pt representatives 59%
Keeping doses <200 will improve pt safety/reduce risk of death 85%
Keeping doses <200 will improve pts’ quality of life 59%
Keeping doses <200 will protect me as a prescriber 65%
Westanmo A et al., Pain Med 2014

17. Pre-OSI PCP concerns and hopes
• What if treatment options
have been exhausted?
• Some veterans may be left
less functional
• Suicide threats/attempts
• Long waits for specialty
referrals, etc.
• Physician burnout, stress,
extra time and extra work
• Security, especially at CBOCs
• Back-up to help us do what
we all want to do anyway—
use fewer opioids
• Hope at least some patients
will wind up better off
• Patients may become more
engaged in their own care
and healing

18. Panel-specific patient data
Adapted from slide by Peter Marshall, MD

19. PC performance measures
• Performance measure
data distributed to all
PCPs
• Number of patients on
≥ 200 ME mg/d and
receiving oxycodone SA
Adapted from slide by Peter Marshall, MD

20. Change in opioid daily doses
1256
712
342
126
811
303
65
11
0
200
400
600
800
1000
1200
1400
>50 >100 >200 >400
Pre OSI Post OSI
Number of patients receiving
daily dose above threshold
Westanmo A et al., Pain Med 2014

21. Change in long-acting opioids
831
286
94
292
770
164
94
3
0
100
200
300
400
500
600
700
800
900
Morphine SA Methadone Fentanyl TD Oxycodone SA
Pre OSI Post OSI
Number of patients
receiving drug
Westanmo A et al., Pain Med 2014

22. Post-OSI PCP attitudes & beliefs
Pre Post
I’m satisfied with care provided for pts with chronic pain 9% 26%
I have adequate training to care for my pts with chronic pain 32% 29%
It is important to have a consistent standard of care for opioids 97% 100%
It is reasonable to set a dose limit of 200 ME mg/day 76% 87%
There are no good alternatives to high dose opioids 35% 23%
If I decrease doses, my pts may be threatening or violent 62% 64%
If I decrease doses, I will be pressured by pt representatives 59% 22%
Keeping doses <200 will improve pt safety/reduce risk of death 85% 87%
Keeping doses <200 will improve pts’ quality of life 59% 55%
Keeping doses <200 will protect me as a prescriber 65% 65%
Westanmo A et al., Pain Med 2014

23. “…the VA system swung too suddenly in
the other direction after the national
spotlight on overprescribing… Veterans
should not be imprisoned by pain
because doctors are unwilling or unable
to prescribe the medications they need.”

24. Mpls OSI summary
• Accomplishments
– Altered primary care prescribing practices  lower dose,
lower risk opioid regimens
– Change in system-wide standard of pain care  more
conservative expectations for opioids
• Persistent challenges
– PCP perceptions of quality of care & adequacy of training
– Availability of non-pharm pain management options
– Patient/public perceptions
• Unknowns
– Patient outcomes

25. “99% of the conversations we ever have… is my weight,
blood pressures, what number of pain I’m in, but there
is no conversation about pain.
See my personal belief—and [my doctor] is the best I’ve
seen over these four decades—is they’re at a loss at
this.”

26. Implications
• Systematic efforts can reverse opioid prescribing
patterns
• The main challenge is to transform our
understanding of chronic pain and how it should be
prevented, assessed, and managed
IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention,
Care, Education, and Research. Washington, DC: National Academies Press

27. Questions?
erin.krebs@va.gov