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A Partnered Approach to Opioid Management, Guideline Concordant Care and the Stepped Care Model of Pain Management

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ABSTRACT

BACKGROUND

Pain is the most common presenting problem in primary care. Opioid therapy (OT) for chronic pain has increased dramatically over the past decade, as have related negative outcomes. Despite the development and dissemination of policy and clinical practice guidelines for pain management and OT, adoption has been variable. The Veterans Health Administration (VHA) has established a Stepped Care Model of Pain Management (SCM-PM) as an evidence-based framework and single standard of pain care to promote guideline-concordant care, but to date its adoption and related outcomes have not been systematically examined.

OBJECTIVE

Our aim was to examine changes in care for Veterans receiving long-term OT for management of chronic pain over a four-year study period.

DESIGN

As part of a comprehensive implementation evaluation of performance improvements, the current evaluation reports performance improvement outcomes related to pain management and OT over a four-year period.

SUBJECTS

We studied Veterans receiving long-term (90+ consecutive days) OT through primary care.

INTERVENTIONS

We engaged an interdisciplinary clinical-research team to develop and implement a multifaceted performance improvement approach that included interactive educational strategies and other organizational initiatives.

MAIN MEASURES

We measured the proportion of patients receiving long-term OT; use of opioid risk mitigation strategies; referrals to pain-related specialty services; and use of non-opioid analgesics.

KEY RESULTS

The proportion of patients receiving high-dose opioids decreased over four years (27.7 % to 24.7 %). The use of opioid risk mitigation strategies increased significantly. Referrals to physical therapy and chiropractic care and prescriptions for topical analgesics increased significantly, while referrals to the pain medicine specialty clinic decreased.

CONCLUSIONS

We demonstrate improvements in the management of veterans receiving OT that are consistent with the SCM-PM and published practice guidelines. We highlight how partnerships among funders, researchers, clinicians, and administrators contributed to the project’s design and implementation, and to the dissemination strategy and future directions for improving opioid management and pain care.

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REFERENCES

  1. Kerns RD, Otis J, Rosenberg R, Reid MC. Veterans’ reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system. J Rehabil Res Dev. 2003;40(5):371–9.

    Article  PubMed  Google Scholar 

  2. Reid MC, Engles-Horton LL, Weber MB, Kerns RD, Rogers EL, O’Connor PG. Use of opioid medications for chronic noncancer pain syndromes in primary care. J Gen Intern Med. 2002;17(3):173–9.

    Article  PubMed Central  PubMed  Google Scholar 

  3. Haskell SG, Heapy A, Reid MC, Papas RK, Kerns RD. The prevalence and age-related characteristics of pain in a sample of women veterans receiving primary care. J Wom Health. 2006;15(7):862–9. doi:10.1089/jwh.2006.15.862.

    Article  Google Scholar 

  4. Upshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med. 2006;21(6):652–5. doi:10.1111/j.1525-1497.2006.00412.x.

    Article  PubMed Central  PubMed  Google Scholar 

  5. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012;13(8):715–24. doi:10.1016/j.jpain.2012.03.009.

    Article  PubMed  Google Scholar 

  6. Tsang A, Von Korff M, Lee S, Alonso J, Karam E, Angermeyer MC, et al. Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. J Pain. 2008;9(10):883–91. doi:10.1016/j.jpain.2008.05.005.

    Article  PubMed  Google Scholar 

  7. Gironda RJ, Clark ME, Massengale JP, Walker RL. Pain among veterans of Operations Enduring Freedom and Iraqi Freedom. Pain Med. 2006;7(4):339–43. doi:10.1111/j.1526-4637.2006.00146.x.

    Article  PubMed  Google Scholar 

  8. Sites BD, Beach ML, Davis MA. Increases in the use of prescription opioid analgesics and the lack of improvement in disability metrics among users. Reg Anesth Pain Med. 2014;39(1):6–12. doi:10.1097/aap.0000000000000022.

    Article  PubMed  Google Scholar 

  9. Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician. 2010;13(5):401–35.

    PubMed  Google Scholar 

  10. Bohnert AS, Ilgen MA, Trafton JA, Kerns RD, Eisenberg A, Ganoczy D, et al. Trends and Regional Variation in Opioid Overdose Mortality Among Veterans Health Administration Patients, Fiscal Year 2001 to 2009. Clin J Pain. 2009. doi:10.1097/ajp.0000000000000011.

    Google Scholar 

  11. Seal KH, Shi Y, Cohen G, Cohen BE, Maguen S, Krebs EE, et al. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA. 2012;307(9):940–7. doi:10.1001/jama.2012.234.

    Article  CAS  PubMed  Google Scholar 

  12. Sekhon R, Aminjavahery N, Davis CN, Jr., Roswarski MJ, Robinette C. Compliance with Opioid Treatment Guidelines for Chronic Non-Cancer Pain (CNCP) in Primary Care at a Veterans Affairs Medical Center (VAMC). Pain Med. 2013. doi:10.1111/pme.12164

  13. Nuckols TK, Anderson L, Popescu I, Diamant AL, Doyle B. Di Capua P, et al. A Systematic Review and Critical Appraisal of Guidelines for Chronic Pain. Ann Intern Med: Opioid Prescribing; 2013. doi:10.7326/0003-4819-160-1-201401070-00732.

    Google Scholar 

  14. Franklin GM, Mai J, Turner J, Sullivan M, Wickizer T, Fulton-Kehoe D. Bending the prescription opioid dosing and mortality curves: impact of the Washington State opioid dosing guideline. Am J Ind Med. 2012;55(4):325–31. doi:10.1002/ajim.21998.

    Article  PubMed  Google Scholar 

  15. Agency Medical Directors’ Group. Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. Olympia, WA: Washington State Agency Medical Directors’ Group; 2010.

    Google Scholar 

  16. Kirshbaum M. The development, implementation and evaluation of guidelines for the management of breast cancer related lymphoedema. Eur J Canc Care. 1996;5(4):246–51.

    Article  CAS  Google Scholar 

  17. Aucott JN, Pelecanos E, Dombrowski R, Fuehrer SM, Laich J, Aron DC. Implementation of local guidelines for cost-effective management of hypertension. A trial of the firm system. J Gen Intern Med. 1996;11(3):139–46.

    Article  CAS  PubMed  Google Scholar 

  18. Nardella A, Farrell M, Pechet L, Snyder LM. Continuous improvement, quality control, and cost containment in clinical laboratory testing. Enhancement of physicians’ laboratory-ordering practices. Arch Pathol Lab Med. 1994;118(10):965–8.

    CAS  PubMed  Google Scholar 

  19. Management of Opioid Therapy for Chronic Pain Working Group. VA/DoD clinical practice guideline for management of opioid therapy for chronic pain. Washington (DC): Department of Veterans Affairs, Department of Defense; 2010.

  20. Rosenberger PH, Kerns R. Implementation of the Va Stepped Care Model of Pain Management. Ann Behav Med. 2012;43:S265-S.

  21. Rubenstein LV, Pugh J. Strategies for promoting organizational and practice change by advancing implementation research. J Gen Intern Med. 2006;21(Suppl 2):S58–64. doi:10.1111/j.1525-1497.2006.00364.x.

    Article  PubMed Central  PubMed  Google Scholar 

  22. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217–26. doi:10.1097/MLR.0b013e3182408812.

    Article  PubMed Central  PubMed  Google Scholar 

  23. Kerns RD, Dorflinger L, Goulet J, Moore BA, Lee A, Pellico L, et al. The Veterans Health Administration Stepped Care Model: A mixed qualitative and quantitative approach to informing and evaluating implementation. Poster Presented at the 19th Annual International Scientific Symposium on Improving the Quality and Value of Health Care; Orlando, FL2013.

  24. Lincoln LE, Pellico L, Kerns R, Anderson DK. Barriers and Facilitators to Chronic Non-cancer Pain Management in Primary Care: A Qualitative Analysis of Primary Care Providers’ Experiences and Attitudes. Palliative Care & Medicine. 2013;S3. doi: 10.4172/2165-7386.S3-001

  25. Pellico LH, Gilliam WP, Lee AW, Kerns RD. Hearing new voices: Registered Nurses and Health Technicians experience caring for chronic pain patients in primary care clinics. The Open Nursing Journal. in press.

  26. Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies—a synthesis of systematic review findings. J Eval Clin Pract. 2008;14(5):888–97. doi:10.1111/j.1365-2753.2008.01014.x.

    Article  PubMed  Google Scholar 

  27. Grimshaw J, Eccles M, Tetroe J. Implementing clinical guidelines: current evidence and future implications. The Journal of Continuing Education in the Health Professions. 2004;24(Suppl 1):S31–7. doi:10.1002/chp.1340240506.

    Article  PubMed  Google Scholar 

  28. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133(4):581–624. doi:10.1037/0033-2909.133.4.581.

    Article  PubMed  Google Scholar 

  29. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432–42. doi:10.1111/j.1526-4637.2005.00072.x.

    Article  PubMed  Google Scholar 

  30. Braden JB, Russo J, Fan MY, Edlund MJ, Martin BC, DeVries A, et al. Emergency department visits among recipients of chronic opioid therapy. Arch Intern Med. 2010;170(16):1425–32. doi:10.1001/archinternmed.2010.273.

    Article  PubMed Central  PubMed  Google Scholar 

  31. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85–92. doi:10.7326/0003-4819-152-2-201001190-00006.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171(7):686–91. doi:10.1001/archinternmed.2011.117.

    Article  CAS  PubMed  Google Scholar 

  33. Kidner CL, Mayer TG, Gatchel RJ. Higher opioid doses predict poorer functional outcome in patients with chronic disabling occupational musculoskeletal disorders. J Bone Joint Surg. Am Vol. 2009;91(4):919–27. doi:10.2106/JBJS.H.00286.

    Article  Google Scholar 

  34. Saunders KW, Dunn KM, Merrill JO, Sullivan M, Weisner C, Braden JB, et al. Relationship of opioid use and dosage levels to fractures in older chronic pain patients. J Gen Intern Med. 2010;25(4):310–5. doi:10.1007/s11606-009-1218-z.

    Article  PubMed Central  PubMed  Google Scholar 

  35. Bohnert AS, Ilgen MA, Ignacio RV, McCarthy JF, Valenstein M, Blow FC. Risk of death from accidental overdose associated with psychiatric and substance use disorders. Am J Psychiatr. 2012;169(1):64–70. doi:10.1176/appi.ajp.2011.10101476.

    Article  PubMed  Google Scholar 

  36. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4. Doi 10.1186/1748-5908-4-50

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Acknowledgements

Contributors

The authors wish to thank the large number of individuals who have contributed to Project Step. These include members of the Project Step research team and our clinical partners at VACHS: Daren Anderson, Wendy Bellmore, Lucile Burgo, Wesley Gilliam, Gerald Grass, Allison Lee, Forrest Levin, Lesiley Lincoln, Linda Pellico, and Christopher Ruser.

Funders

Drs. Becker, Dorflinger, Goulet, Moore and Kerns were supported by a Program for Research Leadership Award from the Patrick and Catherine Weldon Donaghue Medical Research Foundation and Mayday Fund. Dr. Becker was supported by a Veterans Health Administration Health Services Research & Development Career Development Award (08–276). Drs. Kerns and Heapy were supported by the Veterans Health Administration Health Services Research and Development Service Center of Innovation (CIN 13–407).

Prior presentations

Portions of this paper were presented at the 19th Annual International Scientific Symposium on Improving the Quality and Value of Health Care, Orlando, FL, and will be presented at the 33rd annual scientific meeting of the American Pain Society, Tampa, FL.

Disclaimer

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Author information

Authors and Affiliations

  1. PRIME Center/11ACSLG, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, 06516, USA

    Lindsey Dorflinger PhD, Brent Moore PhD, Joseph Goulet PhD, William Becker MD, Alicia A. Heapy PhD, John J. Sellinger PhD & Robert D. Kerns PhD

  2. Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA

    Lindsey Dorflinger PhD, Brent Moore PhD, Joseph Goulet PhD, William Becker MD, Alicia A. Heapy PhD, John J. Sellinger PhD & Robert D. Kerns PhD

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  1. Lindsey Dorflinger PhD
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Correspondence to Lindsey Dorflinger PhD.

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Dorflinger, L., Moore, B., Goulet, J. et al. A Partnered Approach to Opioid Management, Guideline Concordant Care and the Stepped Care Model of Pain Management. J GEN INTERN MED 29 (Suppl 4), 870–876 (2014). https://doi.org/10.1007/s11606-014-3019-2

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  • DOI: https://doi.org/10.1007/s11606-014-3019-2

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