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Decision Support for the Management of Opioid Therapy in Chronic Pain
Jodie A. Trafton, PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: July 2005 - June 2008
It is estimated that one out of two Veterans are diagnosed with at least one type of chronic pain and approximately one-third of them are prescribed at least one opioid. The management of opioid therapy for chronic pain in the VA by primary care physicians presents a significant clinical problem due to under-trained providers in opioid therapy and the high prevalence of substance use disorders and other psychiatric comorbidities that complicate opioid therapy. Physician best practice must balance the need for pain relief against risks of over treatment and opioid misuse.
The objectives of the proposed research project were: (1) To modify an existing VA DSS (used in managing hypertension) for new use in managing opioid therapy in chronic pain; (2) To assess and iteratively improve the new Chronic Pain DSS based on three types of testing: basic quality assurance and system testing, accuracy of practice recommendations testing, and provider usability testing; and (3) To evaluate and iteratively improve the DSS in a single-site pilot based on evaluations of: patient acceptability, provider feedback, and impact on provider behaviors and patient outcomes.
An expert panel of pain specialists, primary care physicians, a pharmacist, and a DSS expert met to guide and approve user specifications, operationalize the clinical practice guideline, and design system tools. We updated and revised the ATHENA-DSS technology to create an.automated DSS based on the VA/DoD Clinical Practice Guide that makes customized recommendations based on patient data during a primary care visit. This initial system was iteratively tested for accuracy, usability, and clinical utility in both laboratory-based and clinic-based use by VA clinicians and pain experts. Volunteer clinicians were given access to the developing system in their clinical practice during a pilot period. Administrative records from a period before and during the testing were examined to explore the impact on care practices.
A new DSS, ATHENA-Opioid Therapy, was designed and implemented for volunteer clinicians in VA Palo Alto primary care clinics. Assessment of the system rules indicate that ATHENA-Opioid Therapy provides recommendations that meet the intent of the VA/DoD Clinical Practice Guideline. Volunteer providers rated the system as highly usable, and useful for clinical practice. However, clinicians raised concerns that they would not be able to follow all system/guideline recommended care practices within the time constraints of their clinical practice. Observation of volunteer clinicians indicated that the clinics were well set-up to allow use of the system, ATHENAOpioid Therapy appeared and was occasionally accessed during patient visits, and time restraints did not appear to preclude use of the system. Nevertheless, logs of clinicians interactions with ATHENA-Opioid Therapy in clinic indicate that clinicians made detailed use of the system far less frequently than would be expected given the prevalence of chronic pain and opioid prescribing with the patient population. Preliminary analysis of data on care practices suggest that rates of prescription of short-acting opioids to patients with a history of substance use disorders tended to decline during the implementation period, suggesting that the system may encourage safer prescribing practices.
This project developed a highly usable clinical decision support system to assist VA primary care physicians with opioid prescribing. Pilot testing suggests that the system has positive effects on use of safe opioid prescribing practice. Use of this system may help clinicians reduce opioid medication misuse and adverse events, and improve chronic pain management.
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DRA: Substance Use Disorders, Health Systems
Keywords: Decision support, Drug abuse, Pain
MeSH Terms: none