Implementation and Evaluation of an APRN-Led Opioid Monitoring Clinic

Primary care physicians, physician assistants, and APRNs working at VASNHS on a full-time and part-time basis were eligible for participation as PCPs in this project. Thirty of 42 eligible PCPs participated and responded to the secure online provider survey (71% response rate).

Risks and benefits were discussed, and a written informed consent was obtained for each participant. There were no apparent risks or adverse effects encountered during project implementation and evaluation. Prior to data collection, permission for the study was obtained from the VA facility. An institutional review board application through the University of Nevada, Las Vegas’ Office of Research Integrity-Human Subjects was also submitted and approved through an expedited review.

Results

Table 1 details patient data, including demographics on the veteran participants. The av

erage age was 53 years, the majority were male, and back pain was the most common source of chronic nonmalignant pain. Many used opioids and benzodiazepines concurrently. The majority had signed an opioid pain agreement (OPA) and had a UDS prior to being seen in the OMC. Positive screens were noted among 38% of the participants. The UDS included detection of illicit use, which was found in 12 participants (ie, methamphetamines, barbiturates, cocaine, heroin, and/or benzodiazepines or methadone when none were expected). A negative opioid level despite opioid prescription was found in 9 UDSs, while 2 detected both illicit substances and negative opioid levels.

Review of PDMPs revealed that 20% of the participants received controlled substances from other HCPs. Consequently, all OMC patients completed and had reinforced OPAs that served 2 purposes. First, the content in the agreement provided patient education regarding the potential hazards of opioid use. Second, the content provided specific expectations from the patient if opioid therapy is continued, including opioid risk reduction strategies (ie, random UDSs and pill counts, PDMP for controlled substance utilization review), and the consequences of lack of adherence to opioid management.

The majority of patients remained as patients and continued to be monitored after 6 months at the OMC (Table 2). However, only 64% were retained in the OMC, in large part because 36% had their opioids discontinued due to discovery of active illicit substance use, opioi

d abuse, “doctor shopping,” nonadherence with the treatment plan, self-discharge from the OMC, and/or their care was transferred to the VA pain clinic. As part of the protocol for the OMC, veterans who were found to be abusing and/or misusing their prescription opioids were referred for treatment to the VA Alcohol and Drug Treatment Program, or care was transferred to the VA Integrated Pain Clinic for nonpharmacologic interventional management as appropriate.

The mean MED/d among OMC participants was 54 mg/d before admission, which decreased gradually to 22 mg/d after 6 months of OMC care; this represented a 59% MED reduction (Table 3). Using the exact single-tailed Wilcoxon signed rank

test, before and after, MED difference was found to be highly significant; P < .001.

Primary Care Providers

Based on the survey of PCPs, 40% of respondents referred at least 1 patient to the OMC. The majority (90%) acknowledged following the VA/DoD guidelines for opioid management, with 80% using an OPA more than usual since the implementation of the OMC, and 54% routinely accessing a PDMP for controlled substance utilization review. Moreover, 93% of PCPs routinely ordered a UDS when indicated.

For 3 months prior to opening the OMC in 2013, 1,606 UDSs were ordered at VASNHS. The UDS number steadily increased, and 6 months after opening the OMC, UDSs increased to 2,293 from months 4 to 6, representing a 30% increase. This was an expected outcome from the OMC—more PCPs now were following the VA/DoD clinical practice guidelines regarding the monitoring of patients on chronic opioid therapy.

A survey assessed the level of satisfaction among PCPs who had referred their patients to the OMC. Although only 11 PCPs responded to this question, a large majority found the OMC to have a positive effect on primary care services; many noted receiving fewer complaints regarding pain medications and fewer walk-ins. The majority recognized the advantage of the OMC in facilitating more PCP time for managing other medical problems beyond opioid use, which tends to be challenging and time consuming. Overall, 100% were satisfied with the OMC service.

Finally, 82% of PCPs reported that the OMC referral process did not need improvement. Two PCPs (18%) left positive feedback, reporting that the OMC was “simple, easy and accessible” and that the referral process “so far, it is great.” Another PCP noted, “I want patients who are suicidal but still need pain control with narcotics to be addressed.”