Safer Opioid Prescribing - docs.lms.va.gov

Management and Opioid Safety Addressing the Opioid Crisis: Adverse Events, Opioid Overdose and Opioid Use Disorder For VHA Prescribers 2016.09.16 Each year, more Americans die from drug overdoses than in traffic accidents, and more than three out of five of these deaths involve an opioid. Since 1999, the number of overdose deaths involving opioids, including prescription opioid

pain relievers, heroin, and fentanyl, has nearly quadrupled. https://www.whitehouse.gov/the-press-office/2016/09/16/presidential-proclamation-pre scription-opioid-and-heroin-epidemic 2016.09.23 2 Opioid Overdose Epidemic From 2000 to 2014 nearly half a million people died from drug overdoses. In 2014 alone, 47,055 persons died from drug overdoses more than in any year on record before. The majority of drug overdose deaths (more than 6 out of 10) involve an opioid. 78 Americans die every day from an opioid overdose.

(source: CDC) In 2012, 80% of drug overdose deaths in the United States were unintentional. (Drug Overdose in the US: Fact Sheet, 2014) Source: National Vital Statistics System, Mortality file; CDC 3 Overdose Deaths related to Prescription Opioid Medication 72% of deaths related to

prescription medications involve an opioids. At least half of all opioid overdose deaths involve a prescription opioid. 4 Correlation of Opioid Sales with Overdose Deaths and Treatment for Opioid Use Disorder Rates of prescription painkiller sales, deaths and substance abuse treatment admissions (1999-2010)

SOURCES: National Vital Statistics System, 1999-2008; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), 1999-2010; Treatment Episode Data Set, 1999-2009; ttp://www.cdc.gov/vitalsigns/painkilleroverdoses/infographic.html Veterans are twice as likely to die from accidental overdose compared to non-Veterans. (Bohnert et al., 2011) 6 Open Letter To Americas Physicians AMA President 05/11/2016 For the past 20 years, public policies well-intended but now known to be flawed compelled doctors to treat pain more aggressively for the comfort of our patients. But todays crisis

plainly tells us we must be much more cautious with how we prescribe opioids. We must accept and embrace our professional responsibility to treat our patients' pain without worsening the current crisis. Stephen J. Stack, Emergency physician and the 170th president of the American Medical Association 7 Surgeon General campaign Turn the Tide Open letter to all Medical Providers: Years from now, I want us to look back and know that, in the face of a crisis that threatened our nation, it was our profession

that stepped up and led the way. TurnTheTideRx.org website launched Aug. 8, 2016 as a platform with resources for physicians and their patients. http://turnthetiderx.org/ 8 The Misuse Potential of Controlled Substances Prescription Opioids and

Heroin Prescription opioids and heroin are chemically similar and work through the same mechanism of action. www.drugabuse.gov accessed 10/17/16 Both Heroin and prescriptions work at the Mu-opioid receptor. Reward regions of the brain have high concentration of Muopioid receptors. Because prescription opioids are similar to and act on the same brain systems affected by heroin they present an intrinsic abuse and addiction liability.

Opioid Use Disorder (OUD) Epidemic Anyone who takes prescription opioids can become addicted to them. In 2014, nearly two million Americans either abused or were dependent on prescription opioid pain relievers. 25-41% of patients on prescription opioids meet criteria for opioid use disorder (DSM-5 criteria). The risk of developing OUD increases with the duration and with the prescribed dosage of opioid therapy. cdc Opioid Use Disorder Epidemic

Opioid Use Disorder Epidemic Among new heroin users, approximately three out of four report abusing prescription opioids prior to using heroin. Heroin-related deaths more than tripled between 2010 and 2014. 10,574 heroin deaths in 2014. cdc Risks of Opioid Therapy Mortality (of all-causes)

Hazard ratio (HR) 1.64 for long acting opioids for noncancer pain Overdose deaths (unintentional) HR 7.18-8.9 for MED > 100 mg/d Opioid use disorder For patients on long-term opioids (> 90 days) HR 15 for 1-36 mg/d MED HR 29 for 36-120 mg/d MED HR 122 for > 120 mg/d MED MED=Morphine Equivalent Daily Dose (in mg/d) Other Medical and Psychological Adverse Effects from Long-Term Opioid Therapy: Endocrine deficiencies in men and women, including sexual dysfunction from low testosterone levels in men, and osteoporosis. Cognitive impairment, sedation, and impaired judgment (including driving) Worsening of depression, anxiety, and symptoms of PTSD.

Falls and related injuries Immunosuppression and cardiovascular side effects. Disrupted and impaired sleep including with possibility of developing worsening of sleep-disordered breathing, like sleep apnea. Opioid induced hyperalgesia: opioids contribute to central sensitization and may actually worsen pain control in some patients When this occurs, the threshold to experience pain decreases, and incident pain may be more difficult to tolerate. Paradigm Shift in Pain Care There is no completely safe opioid dose threshold below which there are no risks for adverse outcomes. Even a short-term use of low dose opioids may result in addiction. Realization that any initial, short-term functional benefit will likely not be sustained in most patients.

Patients on opioids may actually experience a functional decline in the long term, measured by factors like returning to employment. Paradigm shift away from long-term opioid therapy for chronic, non-end-of-life pain management. Principles of Pain Management Pain - Overview The IASP definition describes pain as an unpleasant sensory and emotional experience (International Association for the Study of Pain, 1974) Pain is a complex multidimensional experience that involves biological, psychological, social, and spiritual domains and is made up of cognitive, emotional, and sensory components. When pain becomes persistent, biopsychosocial and behavioral influences change the brain and central nervous system, such

that circuits involved in pain processing are sensitized and circuits involved in goal-directed behavior, emotional modulation, and the embodied sense of self appear to be disrupted. As pain becomes persistent, the processing of pain in the brain shifts from nociceptive brain circuits where pain perception arises from stimulation of pain sensors to brain circuits involved with emotional and cognitive processing. Biopsychosocial Model Start with a whole person biopsychosocial assessment. Assess: sleep, psychiatric co-morbidities, psychosocial-spiritual situation, patients goals, substances, suicidal ideation, UDT, PDMP, prior records. Biopsychosocial Model: Whole

Person Assess daily function, sleep, psychosocial-spiritual situation, social support, patients goals; medical and psychiatric comorbidities, substance use/abuse, suicidal ideation, etc. Include data from urine drug testing, prescription drug monitoring programs, prior records, etc. 21 Assessing Pain and Function - Talk to the patient about the pain care plan - Set realistic goals for pain

and function - Several tools are available - PEG Pain Enjoyment of Life General activity Assessing Pain and Function - DVPRS Pain Scale : Pain Severity Interference: Function, Sleep, Mood, Stress

http://www.dvcipm.org/clinical-resources/pain-rating-scale - NIH Promis subset for pain related function - American Chronic Pain Association Quality of Life Scale 0-worst to 10-best https://www.theacpa.org/uploads/docum ents/Quality_of_Life_Scale.pdf Setting SMART Goals Specific Identifies a specific action or event

that will take place Measurable Should be quantifiable so progress can be tracked Achievable Should be attainable and realistic given resources Relevant Should be personally meaningful Time-boundState the time period for accomplishing the goal Preferred Treatments for Pain Self-Care and Active Non-Pharmacologic Therapies Enhance whole health self-care and lifestyle modification.

Provide behavioral, mindfulness, and cognitive therapies. Offer movement therapies. Use coordinated, team-based approach. Optimize treatment of co-morbidities. Bridging Therapies Safe, short-term therapies that are implemented to help patients transition to more active strategies from less safe, passive strategies. Acupuncture Spinal manipulation (e.g., chiropractic) Physical modalities (e.g., self-applied electrical stimulation, etc.) Invasive therapies that may be implemented when the benefits of facilitating active treatment strategies outweigh the potential risks of therapy.

Trigger point injections Joint injections Nerve blocks Spinal injections Pharmacological Therapies: Non-Opioids Medications are Preferred Non-steroidal anti-inflammatory drugs (NSAIDs) and Acetaminophen. - For musculoskeletal/nociceptive pain, not for neuropathic pain.

Antidepressants* : tricyclic antidepressants (TCAs), serotonin/norephinephrine reuptake inhibitors (SNRIs). - For musculoskeletal and neuropathic pain conditions. Anticonvulsants*: gabapentin/pregabalin. - For neuropathic pain conditions. Topical therapies: lidocaine, capsaicin, NSAIDs. Muscle relaxants. - Usually only short term use. *Includes off-label use, outside of FDA-approved conditions CDC Nonopioid Treatments for Chronic Pain

Best Practices for Appropriate and Effective Prescribing of Opioid Pain Medications If Initiation of Opioid Therapy is Considered The Core Challenge: Finding the Appropriate Place for Opioids in the Context of Safe and Effective Pain Care Use Caution When Opioid Therapy is Considered for Acute Pain

Start with a whole person biopsychosocial assessment. Use caution with all opioid prescribing, including for acute pain Even a single opioid prescription may increase risk for developing OUD. Often, opioid therapy for an acute pain condition unintentionally becomes long-term opioid therapy. Avoid opioids for minor injuries (e.g. acute low back pains, sprains). When opioids are required for acute pain, prescribe the lowest effective dose of immediate-release opioids for the shortest therapeutic duration. 3 days or less is often sufficient; more than seven days will rarely be needed. Combine opioids with other pharmacological and non-pharmacological modalities do NOT use opioids in isolation. Do not use long-acting opioid medication for acute pain, as-need pain or postoperatively. Discuss with the patient benefits, side effects and risks (e.g., sedation, addiction, overdose). Check patient understanding of treatment plan. Counsel patients about safe storage and disposal of unused opioids.

Use Caution When Continuation of Opioid Therapy is Considered For persistent pain: In general, opioid therapy should be used only short-term (< 90 days). Prescribe lowest effective dose. Combine opioids with other pharmacological and non-pharmacological modalities, i.e. whole person care. Ensure that risks do not outweigh potential modest short-term benefits by utilizing opioid risk assessment tools and risk mitigation strategies. Educate regarding realistic effects, risks, responsibilities, and goals of therapy. Determine realistic goals for pain and function. Set criteria for stopping or continuing opioid. Set criteria for regular progress assessment. Identify exit strategy. Reassess benefits/risks within 1 4 weeks after initial assessment.

Risk Factors for Harm from Opioids Personal or family history of substance use disorder. Psychiatric disorders, including anxiety or depression. History of aberrant behavior/non-compliance.

Age 65 or older. Young age (below 30). COPD or other underlying respiratory conditions. Renal or hepatic insufficiency. Pregnancy . http://www.cdc.gov/drugoverdose/opioids/prescribed.html Risk Assessment Stratification Tool for Opioid Risk Mitigation (STORM) risk score For all providers. Opioid Therapy Risk Report (OTRR) dashboard For Primary Care panel management, accessible from CPRS.

Comprehensive clinical assessment Biopsychosocial assessment. Opioid Risk Tool (ORT) Caution: even patients labeled low risk may be at significant risk. Opioid Risk Assessment and Mitigation: STORM Stratification Tool for Opioid Risk Monitoring - STORM Leverages VA national data and predictive modeling. States the probability of adverse event within next year (suicide and overdose) and 3 years (suicide and overdose +/- falls and accidents. When considering opioid therapy and for patients on opioids.

Key features: 1. 2. Identifies patients at-risk for drug overdose or suicide. Lists risk factors that place patients at-risk. e.g., co-Rx benzodiazepines, previous adverse events, mental health and medical diagnoses, MEDD. 3. 4. 5. Displays risk mitigation strategies, including non-pharmacological treatment options, that have been employed and/or could be considered. Displays upcoming appointments and current treatment providers to facilitate care coordination.

Updated nightly. https://spsites.cdw.va.gov/sites/OMHO_PsychPharm/Pages/Real-Time-STORM-Dashboard.aspx 36 Continuation of Opioids Use Caution If Opioid Therapy is Continued Combine opioids with other pharmacological and non-pharmacological modalities, i.e. whole person care. Keep opioid therapy at the lowest effective dosage for the shortest therapeutic duration, in general only short-term (< 90 days). Educate regarding realistic effects, risks, responsibilities, and goals of therapy. Determine/Reassess realistic goals for pain and function.

Prioritize assessment of function, quality of life, sleep, and mood over pain intensity. Reassess benefits/risks within 1 4 weeks after initial assessment. Follow-up on previously established criteria for regular progress assessment and opioid therapy. Continue opioids only after confirming clinically meaningful improvements in pain and function without significant risks or harm. Utilize opioid risk assessment and mitigation strategies/tools. Risk Mitigation Patients receiving long-term opioid therapy should be monitored and reassessed at least every 3 months, with the frequency based on risk. Innovative strategies for monitoring patients include use of shared medical appointments and utilizing the expanded patient care team. Always maintain vigilance for sedation, declining function, evidence of opioid use disorder or other opioid related harms. Each follow-up interaction with the patient is an opportunity to provide

education about self-management strategies and the risks associated with opioid therapy while optimizing whole person approaches to pain care and treatment of comorbid health conditions. Essential components of Opioid Safety include: (1) An informed consent for long-term opioid therapy. (2) Prescription drug monitoring programs (PDMPs). (3) Random urine drug testing. (4) Overdose education, and naloxone distribution as appropriate (OEND). 39 Informed Consent for LongTerm Opioid Therapy Informed Consent Informed consent (via I-Med) is required for all patients on Long Term Opioid Therapy (LTOT),

defined as > 90 days (excluding end-of-life care). Opportunity to discuss risks of and alternatives to long-term opioid therapy with the veteran. Provides some protection to provider and facility in case of harm to the patient related to opioid therapy. After obtaining the signature informed consent, a copy of the signed document including the brochure Taking Opioids Responsibly should given to the patient. VHA Directive 1005, Informed Consent for Long-Term Opioid Therapy for Pain. May 6, 2014 Prescription Drug Monitoring Programs (PDMP) PDMP is a statewide electronic database that tracks all controlled substance prescriptions.

Includes prescription data such dispensed medications and doses. All prescribing providers should register and use the PDMPs regularly. PDMPs improve patient safety by allowing clinicians to: Identify patients who are obtaining opioids from multiple providers. Identify patients who are being prescribed other substances that may increase risk of opioidssuch as benzodiazepines. Check PDMP prior to initiation of opioids and at least once every 3 months, consider check prior to every opioid prescription (CDC recommendations). State requirements vary. Urine Drug Testing

Random urine drug testing (UDT) needs to be performed prior to and routinely during opioid prescribing Frequency of UDT needs to be based on risk, but at a minimum once every 6 to 12 months for low risk and every 3 months or more frequently for high risk patients Determine compliance with prescribed medications Reveal diversion of prescribed substances Identify use of undisclosed substances Enhance patient motivation to adhere to treatment plan A verbal consent should be obtained and documented in the patients medical record by the provider (may be done in advance, at least every 12 months). Before requesting urine, always ask*: When did you take your last dose? How much? Have you taken any other pain medicine? Any drugs? *Documentation of this is crucial for interpreting UDT results

42 Urine Drug Testing Urine Drug Screening (UDS) Urine Drug Confirmation Testing* Enzyme-Multiplied Immunoassay (EMIT) Gas Chromatography-Mass Spectrometry (GC-MS) Qualitative Quantitative

Rapid, inexpensive, widely available Time consuming, expensive, usually send out High sensitivity, with exceptions Very high sensitivity Limited specificity: false positives Very high specificity Interpretation of urine drug testing should be made within the full clinical context of the patients medical situation. Confirmatory testing is usually necessary to accurately assess an unexpected positive

or negative result on UDS. *Urine Drug Confirmation Testing may also be done by Liquid Chromatography. When available, this is less expensive, has faster turn around times and allows detecting of multiple substance. 43 Urine Drug Testing Urine Drug Screening (UDS) for OPIOIDS Source of Opioid Analgesics Natural Semisynthetic (from opium) (derived from opium) Codeine

Hydrocodone Morphine Hydromorphone Oxycodone Oxymorphone Buprenorphine Immunoassay for opiates Immunoassay for opiates (UDS) (UDS) Low sensitivity High sensitivity Positive only if taken in high dosage and recently Usually positive Synthetic* (man-made) Fentanyl

Methadone Meperidine Tapentadol Tramadol Immunoassay for opiates (UDS) Inability to detect Always negative (*) Specific immunoassay tests and GCMS are necessary 1. 2. 3. Slide Compliments of Lacey J. Miller, Pharm.D 44 Gourlay DL, et al. Connecticut: PharmaCom Group, Inc;2012. Moeller KE, et al. Mayo Clin Proc. 2008;83(1):66-76.

Urine Drug Testing Detection Period After Last Dose Marijuana single use: 2-8 days Cocaine hrs Heroin < 1 hr Opiates,

Opioids BEG: 1-3 days 6-MAM 4-12 hrs Codeine/Morphine, or Oxycodone 2-3 days Methadone 3-6 days Methadone Amphetamine Benzodiazepine Barbiturate Alcohol

chronic use: 20-30 days Methamphetamine 3-4 days Amphetamine 1-2 days long-acting: 30 days short-acting: 3 days short: 1 day 7-12 hrs long-acting: 21 days Ethyl glucuronide

72 hrs 1. 2. 3. 4. 5. 6. Slide Compliments of Lacey J. Miller, Pharm.D. Tenore PL. Journal of Addictive Diseases. 2010;29:436-448. Standbridge JB, et al. Am Fam Physician. 2010;81(5):635-640. Moeller KE, et al. Mayo Clin Proc. 2008;83(1):66-76. 45 Gourlay DL, et al. Connecticut: PharmaCom Group, Inc;2012. Drug Testing: A White Paper of the American Society of Addiction Medicine. 2013.

Overdose Education and Naloxone Distribution OEND Overdose Education (OE) Provide patient education on how to prevent, recognize, and respond to an opioid overdose. Naloxone Distribution (ND) FDA approved as naloxone autoinjector and nasal spray. Dispense and train patient and caregiver/family. Target patient populations: OUD, and prescribed opioids. Offer naloxone when factors that increase risk for opioid overdose are present: h/o overdose, h/o SUD, higher opioid dosages (50 MMED), or concurrent benzodiazepine use. OEND provides opportunity to discuss risk; however, naloxone does not eliminate risk or make opioids more effective.

46 Opioid Risk Assessment and Mitigation: OTRR Opioid Therapy Risk Report OTRR Tool optimized for Primary Care. For PACT providers to review their panel for all patients on LTOT. Included in CPRS under Tools Primary Care Almanac. Veteran lookup by SSN http://go.usa.gov/3DH9g Multitude of factors that potentially increase risk incl. MH diagnoses Opioid risk mitigation parameters Individual report includes Visual display Opioid dosage Pain score (severity)

Updated nightly LTOT definition: opioid dispensed in the last 90 days and total days supply 90 days in the past 180 days 47 Opioid Risk Assessment and Mitigation: STORM Stratification Tool for Opioid Risk Monitoring - STORM Leverages VA national data and predictive modeling. States the probability of adverse event within next year (suicide and overdose) and 3 years (suicide and overdose +/- falls and accidents. When considering opioid therapy and for patients on opioids. Key features:

1. 2. Identifies patients at-risk for drug overdose or suicide. Lists risk factors that place patients at-risk. e.g., co-Rx benzodiazepines, previous adverse events, mental health and medical diagnoses, MEDD. 3. 4. 5. Displays risk mitigation strategies, including non-pharmacological treatment options, that have been employed and/or could be considered. Displays upcoming appointments and current treatment providers to facilitate care coordination. Updated nightly.

https://spsites.cdw.va.gov/sites/OMHO_PsychPharm/Pages/Real-Time-STORM-Dashboard.aspx 48 VHA Opioid Monitoring/Risk Mitigation Tools Stratification Tool for Opioid Risk Monitoring STORM Example Opioid Risk Increases with Dosage Prescription risk factors: No completely safe opioid dose. Risk increases with dose and begins to significantly increase at 20-50 mg/d MED. Generally avoid increasing above 50 mg/d MED

and if > 50 mg/d MED then MUST add additional precautions including more frequent monitoring; Avoid increasing above 90 mg/d MED. Avoid combining with benzodiazepines. Opioid Risk Increases with Dosage Washington State - Interagency Guidelines on Prescribing Opioids for Pain Dose Related Risk of Death from Opioids We know of no other medication routinely used for a nonfatal condition that kills patients so frequently. 1 in every 550 patients started on opioid therapy died a median of 2.6 years after the first opioid prescription as high as 1 in 32 among patients receiving doses of 200

MME Frieden and Houry, NEJM, 2016 MME = Morphine Milligram Equivalent dosage per day 52 Tapering and Discontinuing Opioids Indications for Opioid Tapering Source: VA PBM Academic Detailing Service, Opioid Taper Decision Tool, 2016 Tapering/Discontinuation of Opioids Indications

Process Risks outweigh benefits. Treatment goals not met. Individualize care plan. Optimize whole person care. Opioid use disorder suspected. Unsafe or illegal behaviors. Gradual taper preferred if safety allows. Non-adherence to treatment plan.

Severe side effects. Patient preference. Psychological, physical, social, spiritual support Can reduce by 5-20% per month. Frequent monitoring by team. Vigilance for unmasked opioid use disorder. Seek specialty consultation for moderate and high risk patients. Opioid Tapering Determine if the initial goal is a dose reduction or complete discontinuation. If Considerations initial goal is determined to be a dose reduction, subsequent regular

reassessment may indicate that complete discontinuation is more suitable. Several factors go into the speed of taper selected: Slower, more gradual tapers are often the most tolerable and can be completed over a several months to years based on the opioid dose The longer the duration of previous opioid therapy, the longer the taper Most commonly, tapering will involve dose reduction of 5-20% every 4 weeks More rapid tapers may be required in certain instances like drug diversion, illegal activities, or situations where the risks of continuing the opioid outweigh the risks of a rapid taper. Document the rationale for the opioid taper and the opioid taper schedule in the Veterans medical record. Strongly caution patients that it takes as little as a week to lose their tolerance and that they are at risk of an overdose if they resume their original dose. 56 Academic Detailing Examples for Opioid Tapering

57 Academic Detailing: During the taper: Follow up with the Veteran 58 Potential Substance Use Disorders Identification, Referral, and Treatment Key Points: Opioid Use Disorder and Long Term Opioid Therapy Anyone can develop opioid use disorder (OUD). Even without other known risk factors for OUD, patients receiving opioids for pain are all at risk for developing OUD.

OUD Risk increases with duration of therapy and with dosage. OUD is a chronic disease, not a moral weakness or willful choice. OUD, like other diseases (e.g. hypertension), often requires chronic treatment. Patients with OUD can achieve full remission. Using medication-assisted treatment (MAT) for OUD saves lives. MAT is always assisting core therapies for psycho-social-spiritual wholeness and well-being. DSM-5 Criteria for OUD (prescription opioids) (2 or more of the following criteria) DSM-5 Criteria

Example behaviors Craving or strong desire to use opioids Describes constantly thinking about opioids Recurrent use in hazardous situations Repeatedly driving under the influence Using more opioids than intended Repeated requests for early refills Persistent desire/unable to cut down or control opioid use

Unable to taper opioids despite safety concern or familys concern Great deal of time spent obtaining, using or recovering from the effects Spending time going to different doctors offices and pharmacies to obtain opioids Continued opioid use despite persistent opioid-related social problems Marital/family problems or divorce due to concern about opioid use Continued opioid use despite opioidrelated medical/psychological problem

Insistence on continuing opioids despite significant sedation Failure to fulfill role obligations Poor job/school performance; declining home/social function No longer active in sports/leisure activities Important activities given up Opioid Use Disorder Principles Vigilance for signs and symptoms of OUD, particularly when tapering LTOT.

MAT and behavioral treatment when OUD is identified. Pain and OUD can and often does co-exist along with psychiatric comorbidities. Toolbox Integrated SUD, pain, mental health, and primary care teams. VA/DoD 2015 SUD CPG. DSM-5 criteria for OUD. Buprenorphine waiver training. Clinical Opioid

Withdrawal Scale. Urine Drug Testing Urine drug testing can serve as a helpful diagnostic and educational tool. Interpretation of urine drug testing should be made within the full clinical context of the patients medical situation. Confirmatory testing is usually necessary to accurately assess an unexpected positive or negative result. Possible Red Flags that require further evaluation can include: Negative for opioid(s) prescribed. Positive for prescription medications not prescribed. (benzodiazepines, opioids, stimulants, etc.) Positive for illicit substances. Positive for alcohol or alcohol metabolites. Approach to Unexpected

UDT Result Obtain confirmatory drug test to follow up on the Red Flag. If testing confirms the red flag result (e.g. positive for amphetamines), further action is necessary (and must be documented). Patient takes the prescribed drug (UDT is positive for prescribed opioids): have a discussion with the patient, come up with a plan (consider a controlled taper &/or MAT, and consultation with/referral to an addiction treatment program) Patient does not take prescribed opioid ( UDT is negative): have a discussion with the patient, come up with a plan (discontinue opioids, consider consultation with/referral to an addiction treatment program ). Principles of Engaging Patient Treatment works

Treatment is more effective than no treatment; medication-assisted treatment (MAT) has been shown to be more effective than treatments without MAT for moderate to severe OUD Respect patient preference Consider the patients prior treatment experience and respect patient preference for the initial intervention Use motivational interviewing (MI) techniques Emphasize common elements of effective interventions (e.g. improving self-efficacy for change, promote therapeutic relationship, strengthen coping skills, etc.)

Emphasize predictors of successful outcomes Promote mutual help programs* Retention in formal behavioral and wellbeing treatment Adherence to medications for OUD Active involvement with community support for recovery Narcotics Anonymous (NA)

Principles of Engaging Veterans about OUD Address concurrent problems and pursue Whole Health and WellBeing (not just disease management) Coordinate addiction-focused psychosocial interventions with evidence-based intervention(s) for other biopsychosocial problems and with effective well-being strategies Promote least restrictive setting Provide intervention in the least restrictive setting necessary to promote access to care, safety, and

effectiveness Emphasize that options will remain available If unwillingness remains, maintain MI style, emphasize that options remain, determine where medical/psychiatric problems managed,** look for opportunities to engage Medication Assisted Treatment (MAT) along with Addiction Focused Medical Management and/or Addiction Treatment Is considered 1st line treatment for OUD. Allows the patient to focus more readily on recovery activities by preventing withdrawal and reducing cravings.

Helps achieve long-term goal of reducing opioid use and the associated negative medical, legal, and social consequences, including death from overdose. In patients with an active OUD, opioid withdrawal management should be followed by treatment with OUD pharmacotherapy (MAT). Do NOT provide withdrawal management alone due to high risk of relapse and overdose. Do not provide MAT as sole therapy; MAT is assisting therapies for psycho-social-spiritual wholeness and Well-being. Addiction-focused medical management management * MONITOR Self-reported use, urine drug test, consequences, adherence,

treatment response, and adverse effects Consider using a measurementbased assessment tool (e.g. BAM) E D U C ATE Educate about OUD consequences and treatments ENCOURAGE To abstain from

non-prescribed opioids and other addictive substances To attend mutual help groups (community supports for recovery) To make lifestyle changes that support recovery *Session structure varies according to the patients substance use status and treatment compliance. BAM = Brief Addiction Monitor Comparison of Methadone

and Buprenorphine/Naloxone Buprenorphine/Naloxone** Methadone Treatment setting Office-based Specially licensed OTP Mechanism of action Partial opioid agonist* Opioid agonist

FDA approved for OUD Yes Yes Reduces cravings Yes Yes Best for mild, moderate, or severe OUD? MildModerate

Mild, Moderate, and Severe Candidates and history of failed treatment attempts None/few failed attempts Many failed attempts Recommended for OUD candidates with pain conditions requiring ongoing short-acting opioids? No Yes

Psychosocial intervention recommendations Addiction-focused MM Individual counseling and/or contingency management Extended-Release Injectable Naltrexone FDA-approved for the prevention of relapse in adult patients with OUD following complete detoxification from opioids. Recommended for patients unable/unwilling to take OAT (Opioid Agonist Therapy) and have not used an opioid in the past 7-14 days). Consider Naltrexone IM in patients with comorbid OUD

and Alcohol Use Disorder. Patients with OUD and Pain Avoid Opioid analgesics. Sedative-hypnotics. Muscle relaxants. Other medications with potential for addiction. Patients with OUD and Pain Recommend Nonpharmacological therapies Cognitive behavioral therapy (CBT) and /or Acceptance and Commitment Therapy (ACT) for pain, as well as other effective trainings for empowering Whole Health and Wellbeing. Pain school or behavioral groups. Support groups/Community support. Rehabilitation therapies (e.g. physical therapy and occupational therapy).

Specialty procedures (e.g. injections, nerve blocks). Complementary and alternative therapies (e.g. acupuncture, massage, Tai Chi). Non-opioid medications SNRI or low dose TCA. Gabapentin/pregabalin Acetaminophen, NSAIDs Topicals (e.g. lidocaine, capsaicin) Assessment for and treatment of co-morbid psychiatric conditions* (e.g. PTSD, insomnia, anxiety)

Proper Methods for Disposing of Controlled Substances Medication Safety Steps You Should Take Consider writing prescriptions in smaller amounts when appropriate to prevent the accumulation of unneeded medication in the home. Educate patients about safely storing their medication. Tell patients to secure their medications in an area where others do not have ready access to them or a locked box. Studies show the majority of people misusing controlled substances get them from family and friends, often out of a medicine cabinet. Educate patients about safe disposal options. All VHA facilities should have mail back envelopes. Some facilities also have on-site receptacles.

Ask patients not to advertise to others that they are taking these types of medications and to keep their medications secure. Medication Mail-Back Programs VHA has partnered with a DEA registered reverse distributor to provide mail back envelopes to Veterans. All VA facilities should have envelopes. Check with Pharmacy if in need. Pharmacy can also mail envelopes to patients if the need is identified (e.g., by a Home Based Primary Care visit, or patient phone call). There are flyers posted on the PBM intranet that can be used to education patients. Only legally obtained, patient owned medications may be placed in mail-back envelopes and receptacles. Controlled and non-controlled medications may be comingled in mail-back envelopes and receptacles.

It is illegal for pharmacist, technicians, nurses, physicians or any health care worker to take controlled substances directly back from patients. Exception in long term care staff may assist patient or dispose of medications if patient leaves or expires. Disposal Instructions for Patients Disposal Instructions for unused medications: Mix with coffee grounds or cat litter and dispose in trash, outside the reach of any children. Drug disposal information (DEA): http://www.deadiversion.usdoj.gov/drug_disposal/index.html VHA Information for patients: http://www.pbm.va.gov/vacenterformedicationsafety/vacenterformedicationsafetyprescri ptionsafety.asp

PBM Intranet, marketing materials, staff education and other resources: https://vaww.cmopnational.va.gov/cmop/PBM/Medication Disposal for Patients Opioid Prescribing Recommendations: Summary of 2016 CDC Guidelines 78 Website Website www.va.gov/painmanagement Intranet - vaww.va.gov/painmanagement DATE 79 CDC and Turn The Tide:

Resources http:// www.cdc.gov/drugoverdose/p df/assessing_benefits_harms_ of_opioid_therapy-a.pdf http:// www.cdc.gov/drugoverdo se/pdf/pdo_checklist-a.pd f http:// turnthetiderx.org/wp-conten t/uploads/2016/08/PocketG uide_FINAL6.pdf

http:// www.cdc.gov/drugoverdos e/pdf/alternative_treatme nts-a.pdf 80 The Six Essential Elements of Good Pain Care 1. Educate Veterans / families and promote selfefficacy 2. Educate / train all team members 3. Develop non-pharmacological modalities 4. Institute safe medication prescribing, including safe opioid use 5. Develop approaches to bringing the Veterans expanded team together (virtual pain consulting and education as well as ongoing communication

between team members) 6. Establish metrics to monitor pain care End of Teaching Material 82 VA Technical Assistance VA National OEND SharePoint (Step-by-step implementation instructions; implementation models) VA OEND Videos (links to all 5 videos) Intro for People with Opioid Use Disorders https://youtu.be/-qYXZDzo3cA

Intro for People Taking Prescribed Opioids https://youtu.be/NFzhz-PCzPc How to Use the VA Naloxone Nasal Spray https://youtu.be/0w-us7fQE3s How to Use the VA Auto-Injector Naloxone Kit https://youtu.be/-DQBCnrAPBY How to Use the VA Intranasal Naloxone Kit https://youtu.be/WoSfEf2B-Ds VA OEND Naloxone Kit Distribution Report VA Academic Detailing Patient education brochures, Kit brochures, DVDs for providers and patientsorder through depot Opioid Safety Initiative (OSI) & Psychotropic Drug Safety Initiative (PDSI) Panel Management Tools

OEND Patient Risk Dashboard; Stratification Tool for Opioid Risk Mitigation; Opioid Therapy Risk Reduction Report Accredited TMS training: TMS trainings 27440 and 27441 83

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