Opioid Monitoring Clinic Improved Practice Guideline Compliance

LAS VEGAS — A nurse practitioner-led opioid monitoring clinic (OMC) implemented at the VA-Las Vegas improved primary care provider compliance with Department of Veterans Affairs (VA)/Department of Defense (DoD) clinical practice guidelines for opioid prescribing and participation with the Nevada Prescription Monitoring Program (PMP). 

Richard Talusan, DNP, FNP-BC, NEA-BC, surveyed all 40 primary care providers (PCPs) at the VA-Las Vegas to determine whether they felt they would benefit from an OMC to assist in identifying opioid abuse, misuse, and diversion. 

In the initial needs assessment, slightly more than half of respondents indicated that they were aware that VA/DoD clinical practice guidelines for opioid prescribing existed, and a similar number indicated that they adhered to the guidelines.

After implementation of the OMC, the percentage of PCPs who completed the user survey (n=30) and reported following the VA/DoD clinical practice guidelines increased from 58% at baseline to 90%. Furthermore, more than half of survey respondents indicated that they routinely accessed the PMP to check for doctor shopping among patients on opioid therapy after participating in the OMC (54%). 

“By accessing the PMP to screen their patients on opioid therapy, PCPs can help identify and stop abuse and misuse of opioids as early as possible with subsequent referral for treatment as indicated,” said Dr. Talusan.

All PCPs who referred patients to the OMC (n=11) reported overall satisfaction in having the OMC co-manage their patients on chronic opioid therapy.

Overall, 114 patients were seen and evaluated in the OMC from July 1, 2013 to February 18, 2014, and 61 patients agreed to participate in the study (average age 53 years; 4 women, 57 men). 

To be eligible to participate in the study, participants needed to have provider-diagnosed chronic noncancer pain and be prescribed chronic opioid therapy, have a history of substance abuse (ie, heroin, cocaine, alcohol), and/or demonstrate provider-identified and documented aberrant behaviors (ie, report of medication loss, request for early refills).

Unexpected urine drug screen results indicating substance misuse or abuse were identified among 23 study participants (38%) at the initial or at a subsequent OMC visit. A total of 12 participants (20%) were found to be “doctor shopping.” Types of misuse and abuse included:

  • Illicit substance abuse but negative opioid level, despite an active prescription for opioid therapy (n=1; 2%)
  • Consistently negative opioid levels in the urine despite an active prescription for opioid therapy (n=9; 15%)
  • Illicit substance in the urine (n=12; 20%)
  • Having an opioid identified on urine drug screen that was different from the one they were prescribed or having hospital admissions related to opioid overdose (n=3; 5%).

Opioids were discontinued in 22 participants (36%) due to discovery of active illicit substance abuse, doctor shopping, opioid abuse, noncompliance with the treatment plan, or self-decision to discontinue therapy (2%). Among those whose opioid therapy was discontinued, 12 were referred to an alcohol and drug treatment program (20%) for illicit drug abuse or doctor shopping and 9 were referred to an integrated pain clinic for non-opioid pain management (15%). 

Other encouraging findings included decreases in the average morphine equivalent dose per day (from 96 mg/d at baseline to 46 mg/d; 52%; P<.001), decreases in functional pain assessment scores on the Brief Pain Inventory (6.3 at baseline to 5.8; P=.389), and an increase in the number of drug screens ordered at the VA-Las Vegas (from 1849 in July 2013 to 2293 in December 2013; 30%) 

“This is very encouraging,” Dr. Talusan said. “Although there are increased costs associated with ordering more urine drug screens, this is offset by the potential cost saving from preventing even one patient from experiencing an opioid overdose and from associated opioid pharmacy cost-savings from discontinuing opioids that are being abused and misused.”

The OMC program implemented at the VA-Las Vegas is a clinic specific to the needs of the PCPs at that location and may not be representative of other primary care clinics in the VA system nationwide, Dr. Talusan warned. However, he noted that encouraging initial findings support developing similar specialized clinics to assist clinicians in managing complicated and high-risk patients on opioid therapy.