Patient Care

Implementation and Evaluation of an APRN-Led Opioid Monitoring Clinic

Evidence-based strategies helped reduce opioid doses and identify abuse and misuse in patients referred to an opioid monitoring clinic.

Fed Pract. 2016 November;33(11):22-27

Author(s):

Richard Talusan, DNP, MSN, APRN, FNP

Jennifer Kawi, PhD, FNP-BC, CNE

Lori Candela, EdD, RN, CNE

John Filler

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References

1. Institute of Medicine (IOM). Relieving pain in America: a blueprint for transforming prevention, care, education, and research. http://iom.nationalacademies.org/~/media/Files/Report%20Files/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research/Pain%20Research%202011%20Report%20Brief.pdf. Published June 2011. Accessed August 25, 2016.

2. International Narcotics Control Board. Report of the International Narcotics Control Board on the availability of internationally controlled drugs. https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf. Published January 2011. Accessed August 25, 2016.

3. Manchikanti L, Helm S II, Fellows B, et al. Opioid epidemic in the United States. Pain Physician. 2012;15(3)(suppl):ES9-ES38.

4. Krebs EE, Ramsey DC, Miloshoff JM, Bair MJ. Primary care monitoring of long-term opioid therapy among veterans with chronic pain. Pain Med. 2011;12(5):740-746.

5. Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med. 2011;155(5):325-328.

6. Baser O, Xie L, Mardekian J, Schaaf D, Wang L, Joshi AV. Prevalence of diagnosed opioid abuse and its economic burden in the Veterans’ Health Administration. Pain Pract. 2014;14(5):437-445.

7. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. Guideline summary. http://www.va.gov/painmanagement/docs/cpg_opioidtherapy_summary.pdf. Published May 2010. Accessed August 25, 2016.

8. Centers for Disease Control and Prevention (CDC). CDC grand rounds: prescription drug overdoses—a U.S. epidemic. MMWR Morb Mortal Wkly Rep. 2012;61(1):10-13.

9. Hansen H, Noe CE, Racz GB. The evolving role of opioid treatment in chronic pain management. In: Hansen H, Racz GB, Noe CE, eds. Pain and Treatment. http://www.intechopen.com/books/pain-and-treatment/the-evolving-role-of-opioid-treatment-in-chronic-pain-management. Published July 10, 2014. Accessed October 5, 2016.

10. McAuley D. Opioids—equianalgesic dosages. http://www.globalrph.com/narcotic.htm. Updated August 5, 2016. Accessed October 5, 2016.

11. U.S. Department of Health and Human Services. Addressing prescription drug abuse in the United States: current activities and future opportunities. https://www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf. Accessed August 25, 2016.

12. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, RTI International. Results from the 2010 National survey on drug use and health: summary of national findings. http://archive.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm. Published September 2011. Accessed October 5, 2016.

13. Birnbaum HG, White AG, Schiller M, Waldman T, Cleveland JM, Roland CL. Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Med. 2011;12(4):657-667.

14. Federation of State Medical Boards. Model policy on the use of opioid analgesics in the treatment of chronic pain. http://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/pain_policy_july2013.pdf.Published July 2013. Accessed October 5, 2016.

15. Wiedemer NL, Harden PS, Arndt IO, Gallagher RM. The opioid renewal clinic: a primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Med. 2007;8(7):573-584.

16. Sampson JM, Havens S, Marsh B, Murrhee R. Managing chronic, nonmalignant pain in patients with a substance use disorder. Fed Pract. 2005;22(11):10, 16, 18, 25-26, 29.

17. Kharlamb V. (2008). VISN Opioid cost avoidance plan. New York Harbor VA, New York. Unpublished raw data.

Chronic pain, defined as pain lasting longer than 3 to 6 months in duration, affects about 100 million Americans.¹ The use of opioids in the management of chronic nonmalignant pain is common in primary care. The U.S., with only 5% of the global population, nevertheless is the world’s leading opioid consumer.² For example, it is estimated that the U.S. consumes 56% of the global supply of morphine, 99% of hydrocodone, and 83% of oxycodone; this consumption is a growing problem in the use of chronic opioid therapy in managing chronic nonmalignant pain.^2,3 The high rates of use of opioids continues, despite a lack of solid evidence on the long-term effectiveness of opioids for managing chronic nonmalignant pain and on the associated risks of opioid addiction, abuse, and misuse.^3,4 Among veterans, the prevalence of opioid abuse and misuse has been reported to be about 30%, a nearly 7-fold occurrence compared with that in the general population.^5,6

Due to the pervasiveness of opioid abuse and misuse among veterans, a project was initiated to develop, implement, and evaluate an Opioid Monitoring Clinic (OMC) as a clinical referral system within the primary care service of the VA Southern Nevada Healthcare System (VASNHS) in North Las Vegas. A health care provider (HCP) needs assessment was conducted at the facility, resulting in recommendations to improve adherence to evidence-based clinical practice guidelines in opioid management and regular monitoring of veterans on chronic opioid therapy for the identification of opioid abuse and misuse. Based on the results, an advanced practice registered nurse (APRN) in consultation with the chief of primary care at VASNHS and teamlet support (a registered nurse, licensed practical nurse, and medical support assistant) started the OMC. The OMC was developed consistent with the 2010 VA/DoD clinical practice guidelines for managing opioid therapy for chronic pain.⁷

After 6 months of OMC operation, the project also was evaluated for efficacy. First, a retrospective chart review of participants was conducted to identify the use of opioid pain agreements, prescription drug monitoring programs (PDMP) for controlled substance use review, and urine drug screens (UDSs). The chart review also included the average daily morphine equivalent dose (MED) for patients and OMC retention rates. Second, an online survey of primary care providers (PCPs) assessed their adherence to evidence-based guidelines in opioid management and satisfaction of the OMC services.

Background

In 1997, the average sales and distribution of opioids in the U.S. was 96 mg MED per individual, which increased to 710 mg per individual in 2010.^8,9 The MED is a standardized daily dose measure for all opioids.¹⁰ At VASNHS North Las Vegas, there were 5,881 patients on opioid therapy in 2013 with about 13% of patients on opioid therapy using about 100 mg MED/d. The potential for abuse and misuse was great. Almost 30% of patients on chronic opioid therapy for chronic nonmalignant pain abuse their opioid prescriptions.^5,7 Subsequently, opioid analgesics were responsible for nearly 60% of overdose deaths in 2010.¹¹

In 2010, there were about 12 million people in the U.S. who abused or misused prescription opioids, using them for nonmedical reasons; annually, the prevalence rate of Americans who abuse and misuse opioids is about 2 million people.¹² The 5-year prevalence rate of opioid abuse among veterans is at least 3%.⁶ This results in health care expenditures with an average excess medical cost of $20,546 per year for patients who misuse opioids compared with those who do not.¹³ The economic burden among veterans is even higher. Baser and colleagues reported that the annual economic cost for veterans who abused their opioid prescriptions was nearly $29,000.⁶

Unfortunately, injudicious opioid prescribing by HCPs is often cited as a contributor to the growing problem of opioid abuse and misuse in the U.S.¹⁴ Health care provider education on the proper and judicious use of opioids and adherence to clinical practice guidelines in the management of chronic pain is a crucial factor in reducing the complications of chron

ic opioid therapy.^3,14 Hence, the OMC was developed to address the prevailing problem of opioid abuse and misuse by implementing strict monitoring of high-risk veterans on chronic opioid therapy, using mitigation strategies based on the 2010 VA/DoD clinical practice guidelines to help identify abuse as early as possible. The OMC was implemented and took over opioid prescription renewal, dose adjustments, opioid substitution as appropriate, and patient opioid monitoring that was consistent with the 2010 VA/DoD guidelines (Figure).

Method

This project evaluated the APRN-led OMC with both quantitative and qualitative data from patients and PCPs. The OMC was implemented at VASNHS North Las Vegas, which serves almost 60,000 veterans. Patients referred to the OMC who were eligible for admission were veterans aged ≥ 18 years, who had chronic nonmalignant pain for at least 3 months, were receiving chronic opioid therapy, and were considered high risk for abuse or misuse of opioids. Patients were considered high risk if they had documented aberrant behaviors, such as multiple early refill requests, history of lost medications, drug screens not showing prescribed opioid(s), positive drug screens for controlled substance not prescribed, nonadherence with plan of care, or a history of substance abuse, including alcohol, cocaine, heroin, and marijuana. Veterans found to be suicidal or homicidal were excluded from the OMC and instead were referred to appropriate specialty care for further evaluation. A total of 61 veteran participants were successfully recruited.