Outcomes Associated With Pharmacist- Led Consult Service for Opioid Tapering and Pharmacotherapy
Background: In response to the growing opioid epidemic, the US Department of Veterans Affairs created the Opioid Safety Initiative to monitor opioid prescriptions and reduce the risk of opioid misuse through electronic consults (eConsult). The primary objective of this study was to assess the outcomes of the pain pharmacist recommendations for opioid tapering and opioid pharmacotherapy by quantifying the number of recommendations accepted/implemented by the prescribers.
Methods: Data gathered include patient demographics, pain scores, and morphine equivalent daily doses. Additional data included pain regimens, the reason for opioid taper request, the number of actionable recommendations made and implemented, and adverse events (AEs) related to opioid dose decrease or taper. A feedback assessment was completed to assess health care provider (HCP) satisfaction with the eConsult service.
Results: We identified 464 eConsults placed with 89% having at least 1 recommendation accepted/implemented. Eleven patients experienced 32 AEs likely associated with opioid dose decrease or tapering. HCP satisfaction with the pharmacy eConsult service was 83%, with 90% planning to use the service in the future and would recommend the service to other HCPs.
Conclusions: A pain pharmacy eConsult service managed by pharmacists assisted HCPs with opioid therapy recommendations in a safe and timely manner, reducing risk of overdose secondary to high-dose opioid therapy and with limited patient harms.
At 6 months, 6 patients were receiving no pain medications from the VA, and 24 of the patients were tapered from their opiate to discontinuation. It is unclear whether patients are no longer taking opioids or switched their care to non-VA providers to receive medications, including opioids, privately. This is difficult to verify, though a prescription drug monitoring program (PDMP) could be used to assess patient adherence. As many of the patients that were tapered due to identification of aberrant behaviors, lack of continuity of care across health care systems may result in future patient harm.
The results of this analysis highlight the importance of checking PDMP databases and routine UDSs when prescribing opioids—there can be serious safety concerns if patients are taking other prescribed or illicit medications. However, care must be taken; there were 2 instances of patients’ chronic opioid prescriptions discontinued by their VA provider after a review of the PDMP showed they had received non-VA opioids. In both cases, the quantity and doses received were small (counts of ≤ 12) and were received more than 6 months prior to the check of the PDMP. While this constitutes a breach of the Informed Consent for long-term opioid use, if there are no other concerning behaviors, it may be more prudent to review the informed consent with the patient and discuss why the behavior is a breach to ensure that patients and PCPs continue to work as a team to manage chronic pain.
Limitations
The study population was one limitation of this project. While data suggest that chronic pain affects women more than men, this study’s population was only 13% female. Thirty percent of the women in this study had an AE compared with only 8% of the men. Additional limitations included use of problem list for comorbidities, as lists may be inaccurate or outdated, and limiting the monitoring of AE to only 6 months. As some tapers were not initiated immediately and some taper schedules can last several months to years; therefor, outcomes may have been higher if patients were followed longer. Many of the patients with AEs had increased ED visits or unscheduled primary care visits as the tapers went on and their pain worsened, but the visits were outside the 6-month time frame for data collection. An additional weakness of this review included assessing a pain score, but not functional status, which may be a better predictor of the effectiveness of a patient’s pain management regimen. This assessment is needed in future studies for more reliable data. Finally, PCP survey results also should be viewed with caution. The current survey had only 29 respondents, and the 2014 survey had only 10 respondents and did not include CBOC providers.
Conclusion
A pain eConsult service managed by CPSs specializing in pain management can assist patients and PCPs with opioid therapy recommendations in a safe and timely manner, reducing risk of overdose secondary to high dose opioid therapy and with limited harm to patients.
