Summer 2016

In this Issue: Improving the Safety of Prescription Opioid Use among Veterans » Table of Contents

Improving Opioid Therapy among Veterans with Chronic Pain

Feature Article

Recently, VA's Quality Enhancement Research Initiative (QUERI) launched a national network of Programs designed to improve Veterans' health by more rapidly implementing research evidence into practice. One such program, Improving Pain-Related Outcomes for Veterans (IMPROVE), is working with VA national leaders to implement strategies that reduce chronic pain among Veterans and also reduce high-dose opioid therapy. Among Veterans treated in the VA healthcare system, chronic non-cancer pain is highly prevalent (up to 50% of patients) and a major contributor to poor health-related quality of life. The primary goal of IMPROVE QUERI is to improve function and quality of life – and decrease morbidity and mortality among Veterans with chronic pain. A growing body of research and expert consensus support multi-modal pain care. In this type of care, evidence-based, non-pharmacologic treatment modalities are incorporated alongside pharmacologic treatment, including a reduction in high-dose opioid therapy and avoidance of opioid-benzodiazepine combination therapy. Inappropriate opioid therapy can result in higher morbidity and mortality. For example, one recent study shows that prescription opioid use among patients with a recent history of depression increases the chance of recurrent depression, independent of pain diagnoses or pain intensity (Scherrer et al, 2016). Another recent study found that an increased dose of opioids was a marker for increased suicide risk among more than 120,000 Veterans with chronic non-cancer pain (Ilgen et al, 2016).

IMPROVE QUERI has assembled an expert team of implementation scientists, clinical researchers with expertise in pain management – and has partnered with clinical leadership, including VHA Pain Management, Primary Care Services, and Pharmacy Benefits Management (PBM) to create projects that address cross-cutting issues in pain care, particularly as they relate to opioid therapy, including:

Primary Care Integrated Pain Support (PIPS). This project is studying the implementation of a pharmacist-led care management strategy designed to decrease the number of Veterans receiving high-dose opioid and combination opioid-benzodiazepine therapy, while increasing their engagement with non-pharmacologic pain treatment. Investigators will use formative evaluation to modify and assess the effectiveness of a blended-facilitation implementation strategy at three VA facilities.

Cooperative Pain Education and Self-management (COPES). This project is focusing on reaching Veterans who currently do not have access to pain management resources by using technology to help patients use cognitive-behavioral therapy to manage their pain. An automated Interactive Voice Response (IVR) system called COPES will allow patients to engage in this evidence-based treatment from their homes. Investigators will evaluate the effectiveness of a facilitation-based approach on Veteran enrollment in COPES at community-based outpatient clinics associated with three VA facilities.

Academic Detailing Quality Improvement. In this quality improvement project, interviews are being conducted with academic detailers (offers university-based or non-commercial-based educational outreach) and VA providers from VISN 21 to evaluate the Pharmacy Benefit Management Services' opioid-prescribing practices. Findings will be used to target low-performing sites, where out­reach will be conducted to improve performance on key opioid safety metrics.

For more information about this QUERI program, please contact Leonore Okwara at Leonore.Okwara@va.gov.