VA’s Pharmacists Manage Patients’ Opioid Use via Education, Interdisciplinary Care

When Timothy J. Atkinson, a clinical pharmacy specialist in pain management, has a first appointment with a veteran who has been on high-dosage opioid therapy for a long time, he shows his patient a laminated 3-by-5 card with 2 pie charts.

At the top of the card is a single-color chart and a single label: “Pain Medications.” Underneath is a multicolored chart with several pie slices representing a variety of pain control alternatives—physical rehabilitation, pain-relieving procedures, psychology, transcutaneous electrical nerve stimulation, and acupuncture—in addition to pain medications.

Atkinson called this “simple visual” the starting point in educating his patients—all of whom have been referred to him by an anesthesiologist or nurse practitioner at the Veterans Affairs (VA) Tennessee Valley Healthcare System’s pain management clinic in Murfreesboro.

Emphasizing the message “It’s not your fault” during clinic visits, Atkinson said he explains to new patients that current pain management options do not consist entirely of pain medications.

“When patients understand that they’re not being singled out [for their opioid use], that this is a national initiative, and that this is the direction that we’re going—that we want to extend these other services, we want to show them another way—then they tend not to take it personally and they’re willing to work with you in most cases,” he said.

VA’s Opioid Safety Initiative started in 2013. It seeks to help ensure safe and effective prescribing and use of opioid pain medications.

Two of the initiative’s goals are to review treatment plans for patients receiving high-dosage opioid therapy and offer complementary and alternative medicine modalities for chronic pain.

According to VA data, opioids were received by 1 in every 4 veterans who obtained prescription medication in 2012 from the pharmacy at the Nashville VA Medical Center, part of the Tennessee Valley Healthcare System. The rate is less than 1 in every 7 veterans thus far this year.

Adjusting patients’ beliefs can be difficult, Atkinson readily conceded.

People who become dependent on opioids, he said, “do tend to be pretty focused on them.”

Atkinson emphasized the need to educate patients about current pain management techniques and schedule sufficient time—an hour, for example—for the initial conversation.

“They’re not used to providers taking the time to explain why we’re doing what we’re doing and what we want for them and [that] we’re doing this because we care,” he said of patients prescribed long-term, high-dosage opioid therapy to treat pain.

Those patients need to be told that other pain management modalities are available and can be tried, Atkinson said. “But you still can’t throw it all at them at once and ask them to do 5 things when they’re used to doing just 1”—taking an opioid.

Enactment of the Comprehensive Addiction and Recovery Act of 2016 (CARA) expanded the Opioid Safety Initiative.

CARA requires every VA medical facility to have a pain management team of healthcare professionals to coordinate and oversee pain management therapy for patients with acute or chronic pain not related to cancer. Behavioral and rehabilitation medicine providers must be on the team, according to a VA memorandum.

Nicole Elharar, a clinical pharmacy specialist in posttraumatic stress disorder (PTSD) and substance abuse at West Palm Beach VA Medical Center, said her south Florida facility in March started operating a clinic that treats veterans who have both pain and substance abuse disorder.

Elharar called the new clinic a “CARA clinic” and described its work as an interprofessional effort to get veterans with pain who have been abusing opioids of any type to instead use nonopioid therapies.

She said the clinic has 2 clinical pharmacy specialists in mental health (including herself), 2 clinical pharmacy specialists in pain, an addiction psychiatrist, and a physician pain specialist.

According to a poster abstract at the ASHP 2017 Federal Forum during the Midyear Clinical Meeting in December, this clinic is a consultation service managed by some of the members of the medical center’s pain management team.

“I definitely think this CARA clinic [approach] has been a huge success and should . . . be implemented nationwide,” Elahara said in mid-June.

Managing these patients from just the perspective of substance use disorder or pain could let the other condition go untreated, perhaps resulting in the worsening of depression or PTSD symptoms, she said.

The clinic’s healthcare providers meet for an hour before seeing patients so that everyone has the opportunity to say what they believe is needed most by each patient on the schedule, Elharar said. Some patients may benefit most from a substance abuse treatment approach involving the use of buprenorphine–naloxone, which Elharar is authorized to initiate, modify, and discontinue under the superversion of a psychiatrist. Some patients express a desire to try acupuncture. Some patients want physical therapy. Some prefer a pain-relieving procedure.

During each appointment, the team invites the patient’s input, she said.

Some patients with opioid use disorder, Elharar said, have turned out to be “drug seeking,” however. “We always take what the veteran says, and we weigh our options. We look at the risk versus benefit, and from there we’re able to make a decision.”

She said she spends half a day at the CARA clinic, which operates out of 2 adjacent offices. CARA clinic patients come in every other week.

[This news story appears in the August 1, 2018, issue of AJHP.]