Implementation and Evaluation of an APRN-Led Opioid Monitoring Clinic
Discussion
The OMC has shown great promise in identifying abuse and misuse of opioids through evidence-based guidelines and risk-mitigation strategies. In the past, VA clinics specifically focused on opioid renewal have been implemented. In 2002, the Philadelphia VAMC opened an opioid renewal clinic (ORC) to assist PCPs in the management of patients with chronic pain on chronic opioid therapy.15 The Philadelphia VAMC ORC was operated collaboratively by PCPs and Pharmacy Service. They reported that 51% of their patients initially had documented aberrant behaviors, and 45% of these patients resolved their aberrant behaviors through intensive opioid monitoring using random UDSs.14 Thirteen percent of their patients were found to have an opioid addiction disorder and eventually were referred to addiction treatment; and 4% were weaned off opioids due to consistently negative UDSs.14
In the same manner, the OMC has effectively identified patients who abused and misused their opioids and consequently referred these patients for pain interventional management or to the VASNHS alcohol and drug treatment program as appropriate, which falls under the VASNHS Mental Health Care line, a service that is vital for veterans who are suicidal and homicidal. The importance of mental health care cannot be understated, as many patients with chronic pain also experience mental health challenges.
The Malcom Randall VAMC in Gainesville, Florida, structured a nurse-led, multidisciplinary ORC in 2003.16 A retrospective review of their program showed that 33% of patients had a positive UDS for marijuana, cocaine, or alcohol. The ORC had increased patient involvement in substance abuse treatment, resulting in some patients taking lower opioid dosages than before.
The New York Harbor VAMC reduced opioid cost by effectively switching veterans on expensive long-acting opioids, such as oxycodone and fentanyl, to less expensive alternatives, such a long-acting morphine.17 A secondary purpose of the New York initiative was to reduce the potential for inappropriate use of expensive long-acting opioids. Accordingly, the initiative reduced the number of expensive long-acting and potentially inappropriate opioids from 165 to 69 prescriptions in less than 6 months (November 2007 through March 2008). Similarly, after 6 months of operation, the OMC significantly reduced opioid prescription from 54 mg to 22 MED/d. This reduction represents a significant pharmacy cost savings. The combination of the discontinuation of opioids for patients found to be abusing and misusing opioids coupled with the decrease in pill burden resulting from changes from short-acting to long-acting opioids also resulted in significant savings for VA facilities.
The impact of the OMC on PCP adherence to opioid management guidelines as well as PCP satisfaction with the OMC services was significant. Similarly, Wiedemer and colleagues found significant PCP satisfaction with the ORC.15 The ability to spend more time with patients on other medical problems while allowing the OMC to focus on opioid and pain management was found to be beneficial. Buy-in among PCPs coupled with their concerns for chronic opioid therapy for high-risk patients facilitated the success of the OMC. The commitment of the VASNHS leadership to the OMC and their support for the APRN in leading this initiative were important facilitators in the success of the OMC.
Limitations
Long-term evaluation of the OMC with a larger sample is needed to fully evaluate its impact on decreasing opioid misuse and abuse. This project was limited by a small sample size, although the results are promising. Pharmacy costs, emergency department visits, as well as patient satisfaction, physical and emotional function, and pain levels are outcomes that need to be considered over the long term. Incorporating mental health counseling, cognitive behavior therapy, self-management programs, and group educational sessions have the potential to be important OMC services. The continued success and cost-effectiveness of the OMC can be a potentially significant model for this type of service that can be applied to clinics outside the VA system.
Implications
Possible implications to practice settings that are considering an OMC or ORC include the chance that patients will want to be discharged from such a clinic and return to the PCP for opioid management. Collaborative relationships and communication between PCPs and OMC providers are important to facilitate adherence and consistency with pain care. Collaboration and effective communication can be facilitated by electronic recording and reporting. For example, the VA Computerized Patient Record System can alert PCPs to patient discharges from the OMC along with OMC provider recommendations for patient care. Another challenge for the OMC would be a lack of referrals for patients who are at high risk for opioid abuse or misuse. These challenges can be mitigated by providing in-services, educational flyers, and advertisement promotions regarding OMC services. With the high prevalence of opioid abuse and misuse as well as the subsequent exorbitant health-related costs and deaths associated with opioids, OMCs and ORCs are viable options for improving opioid management in the treatment of patients with nonmalignant chronic pain.
