Pain Management and Opioid Risk Mitigation in the Military
By Turner, Barbara J | |
Proquest LLC |
ABSTRACT Opioid analgesics misuse is a significant military health concern recognized as a priority issue by military leadership. Opioids are among those most commonly prescribed medications in the military for pain manage- ment. The military has implemented opioid risk mitigation strategies, including the Sole Provider Program and the Controlled Drug Management Analysis and Reporting Tool, which are used to identify and monitor for risk and misuse. However, there are substantial opportunities to build on these existing systems to better ensure safer opioid prescribing and monitor for misuse. Opioid risk mitigation strategies implemented by the civilian sector include establishing clinical guidelines for opioid prescribing and prescription monitoring programs. These strategies may help to inform opioid risk mitigation in the military health system. Reducing the risk of opioid misuse and improving quality of care for our Warfighters is necessary. This must be done through evidence-based approaches with an investment in research to improve patient care and prevent opioid misuse as well as its sequelae.
INTRODUCTION
Prescription opioid analgesics are the most misused drug class in
Opioid misuse afflicts both civilian and military commu- nities. In 2010, senior military leadership recognized the need to mitigate opioid misuse as a military health priority and recommended a more cautious approach to prescrib- ing opioids as well as more research on the surveillance, detection, and management of opioid misuse.7-9 These recommendations reflected concerns about an increase in opioid-related adverse events among active duty military personnel and those who have recently separated from the military. Growing evidence supports this concern. For example, of urine drug screen tests that were positive for prescription drugs in 2009, 21% were associated with illicit use.5 Because, there are few analgesic alternatives for the management of moderate to severe pain, it is important to develop to an opioid risk mitigation strategy that provides effective, appropriate pain management although reducing the risks for our active duty personnel, their dependents, and their beneficiaries.
To be successful, opioid risk mitigation must maintain access to opioids while addressing three priorities: (1) to ensure the safety of the patient for whom the drug is being prescribed (e.g., avoid improper or unnecessary prescribing), (2) to prevent use by persons for whom opioids were not prescribed (e.g., medication sharing, accidental poisoning), and (3) to prevent diversion (e.g., selling the drugs). Achiev- ing these goals requires a delicate balance of risks and bene- fits. An aggressive policy limiting access to opioids could harm patients who can benefit and would not misuse this therapy. Physicians are understandably concerned that exces- sive regulatory oversight may deny access to opioids for their patients with legitimate medical indications. This concern might be expected to be heightened for a military physician treating a returning combat veteran. But it is important to balance the need to address pain with the risks associated with opioid misuse that interferes with military preparedness, including combat readiness and fitness for duty. Ultimately, misuse can deplete the ranks of deployable warriors.
The following discussion offers an overview of diverse strategies that are being developed and implemented in the civilian sector as well as the
Opioid Misuse in the Civilian Sector and the Military
Opioid analgesic (OA) prescribing has become ubiquitous. OAs prescribed in 2010 to treat every American aged 19 or older with 5 mg hydrocodone every 4 hours for 1 month.10 In the civilian sector, accidental overdose from opioids has increased over four-fold nationally from 1999 to 2009.11 Overall, opioids were involved in three quarters of the more than 22,000 drug-overdose deaths in 2010 in civilian set- tings.12 In particular higher dose, long-term OA therapy has been associated with significantly increased risks of misuse and overdose.13
A 2008
Historically, systematic monitoring of substance abuse has rarely discriminated between prescription opioids or other prescription medications with abuse liability. A recent com- prehensive
Pain and Opioid Prescribing in the Military
According to the 2011
Opioids are prescribed commonly in the military to man- age chronic pain5 as in the civilian sector.21 Combat-related injuries during the wars in
The majority of individuals who are being prescribed an opioid for acute or chronic pain will not misuse their medica- tion. However, as noted previously, the risk of misuse increases with long-term opioid therapy for chronic pain. Effective strategies to reduce the risk of opioid misuse are needed to insure that this widespread use of opioids can be used more safely. The civilian sector has been struggling with rising use of opioids and well-documented problems with misuse. The civilian experience with developing strategies to address these challenges may be informative as the mili- tary develops its own initiatives to increase the safety and effectiveness of opioid prescribing.
Opioid Risk Mitigation Strategies in the Civilian Sector
Nationally, civilian expert panels have promulgated guide- lines to reduce risks associated with opioid therapy such as periodic urine drug testing, regular office visits to review treatment, and avoiding early refills.23,24 However, the civil- ian community in general has been slow to adopt these rec- ommendations. For example, in the study of 1,612 patients on long-term opioid therapy in several academic general internal medicine practices in
Another example of risk reduction guidelines were devel- oped by experts working for a
Quality of Care Metrics
In the civilian sector,25 population-based data from adminis- trative databases and electronic medical records are increas- ingly used to evaluate the quality and safety of prescribing practices with the ultimate objective of reducing adverse events. Qualities of care metrics for medication prescribing include reductions in high opioid dosing, excessive acetamin- ophen doses in combination with opioids, and concurrent benzodiazepine prescribing. Quality of care indicators in regard to patterns of care for pain management include pro- moting single physician or site prescribing, avoiding emer- gency department visits, and use of nonpharmacological pain management modalities (e.g., physical therapy, acupuncture, and chiropractic care for low back pain). Again, these are all metrics that can be used in the military sector.
Prescription Monitoring Programs
Another opioid risk mitigation strategy used in the civilian community is the Prescription Monitoring Program (PMP), a state-administered reporting system that is currently opera- tional in 41 states.30 These programs obtain data about opioid prescriptions from all pharmacies to examine prescribing trends and to characterize potentially risky behaviors includ- ing multiple prescribers and/or unusually high amounts or frequencies of prescriptions. PMPs use prescribing data to develop "algorithms" or measures to identify activity sug- gesting opioid misuse. Examples of these algorithms include five or more prescribers (i.e., doctor shopping), three or more pharmacies, or three or more early refills (i.e., before expected time of refill) within a year.30 PMPs have a number of appli- cations: (1) to monitor individual patients for patient care and safe opioid use; (2) to serve as a public health surveillance tool for detecting illicit behaviors (e.g., "doctor shopping", inap- propriate prescribing, questionable pharmacy practices, and prescription forgery and fraud); (3) to allow tracking of medi- cal and nonmedical use of opioids to inform policy (e.g., prescribing, opioid access, health disparities); and (4) to pro- vide a foundation for standardized reporting and queries for prescribers to share with their patients.
Several studies have documented the effectiveness of PMPs based on reductions in prescription sales31 and doctor shopping.30,32 In a review of recent studies, Wang and Christo33 concluded that emerging evidence supports the implementation of PMPs to reduce opioid misuse. To max- imize the benefit of this program, they note that the pro- gram needs adopted nationwide and has to be linked to electronic medical records.
Military Opioid Risk Mitigation Strategies
The need for improved approaches to ensure safe opioid prescribing in the military has been highlighted recently by the Office of
Sole Provider Program
One example of opioid risk monitoring in the military is the Warriors in Transition High-Risk Medication Review and the Sole Provider Program.34 The Sole Provider Program identifies individuals determined by health care providers or military commanders as being at increased risk for opioid misuse. Once enrolled in the program, one prescribing pro- vider monitors opioid use and assesses for potential high- risk behaviors such as unscheduled or premature medication requests. However, there are disadvantages to the existing Sole Provider Program. It currently has limited implementa- tion, primarily in the Warrior Transition Battalions. The program also lacks a systematic approach to identifying individuals at increased risk. The current approach of subjectively determining risk of misuse can result in misidentification and has not undergone a rigorous evaluation of its effectiveness in mitigating misuse.
Controlled Drug Management Analysis and Reporting Tool Currently, the DoD Pharmacoeconomic Center maintains the Controlled Drug Management Analysis and Reporting Tool (CD-
Despite its potential, CD-
There are many opportunities to enhance CD-
Shared Opportunities for Opioid Risk Mitigation in the Civilian and Military Sectors
Recent innovations in the structure of primary care practices in both the civilian sector and the MHS offer significant opportunities to incorporate clinical guidelines and quality of care metrics to reduce the risks of opioid misuse. The patient-centered medical home (PCMH) offers an integrative, comprehensive model of primary care i.e., especially valu- able for managing clinically complex patients, such as those with chronic pain and other comorbidities. The PCMH takes advantage of the complementary skills of diverse health pro- fessionals who provide evidence-based care. Accessible, comprehensive care delivered by a PCMH has been shown to improve clinical outcomes,36 reduce dependence on urgent care services,37 improve patient and provider satisfaction, and reduce costs of care.38
The PCMH takes advantage of an electronic medical record and offers case management for complex cases. For example, patients on long-term opioids could be tracked and offered support as needed to schedule and adhere to ancillary multidisciplinary care (e.g., physical therapy) and to insure that opioid prescriptions are not received in excess amounts or too soon. Some PCMH models even include onsite cogni- tive-behavioral counseling to help patients with mental health comorbidities. Overall, the PCMH uses the talents of pro- viders from multiple disciplines to complement and augment the efforts of the physician.
In 2010, the
Develop a Comprehensive Prescription Monitoring Program
The military has clear advantages over the fragmented health care system of the civilian sector because its CD-
CONCLUSION
Although the full extent of opioid misuse and its relationship to opioid-prescribing practices in the military has not been well examined, it is clear that opportunities to improve out- comes abound. Rather than taking a piecemeal approach, a multipronged evidence-based approach can take advantage of strategies from both the civilian and the military sectors to develop effective systems to care for chronic pain, manage opioid prescribing, and reduce opioid misuse. In support of this, we described several examples of risk mitigation strate- gies, military, and civilian.
The military also has a unique opportunity to serve as a leader in innovative approaches to safer opioid prescribing and more effective pain management. The MHS is a univer- sal health care system offering comprehensive, coordinated care with a history of using systematic approaches to address health problems in its active duty members and their families.
Currently, the military medical system is at a tipping point in regards to opioid prescribing and OA misuse. Opioid risk mitigation strategies provide a foundation for identifying effective solutions to the dual objectives of treating pain effectively and protecting access to opioids for those in pain while improving patient safety and reducing adverse effects.
ACKNOWLEDGMENT
Grant was provided by National Institute on Drug Abuse Clinical Trials Network Grants U10 DA0020024 (Trivedi) and K23 DA0002297 (Potter).
REFERENCES
1.
2. Compton WM, Volkow ND: Major increases in opioid analgesic abuse in
3.
4.
5. Warner M, Chen LH, Makuc DM: Increase in fatal poisonings involving opioid analgesics in
6. The TEDS Report. Substance abuse treatment admissions involving abuse of pain relievers: 1998 and 2008.
7. Army Health Promotion Risk Reduction Suicide Prevention Report.
8. National Drug Control Strategy.
9.
10.
11. Calcaterra S, Glanz J, Binswanger IA: National trends in pharmaceuti- cal opioid related overdose deaths compared to other substance related overdose deaths: 1999-2009. Drug Alcohol Depend 2013; 131(3): 263-70.
12. Jones CM, Mack KA, Paulozzi LJ: Pharmaceutical overdose deaths,
13.
14. Substance use disorders in the U.S. armed forces.
15. Technical Procedures for the Military Personnel Drug Abuse Testing Program (MPDATP).
16. 2010 Army Posture Statement. Rehabilitative Medicine. Available at https://secureweb2.hqda.pentagon.mil/vdas_armyposturestatement/ 2010/information_papers/Rehabilitative_Medicine.asp; accessed
17. The Warrior. Gains for pain. Available at http://www.natick.army .mil/about/pao/pubs/warrior/06/mayjune/index.htm; accessed
18.
19. Stecker T, Fortney J, Owen R, McGovern MP, Williams,
20. Helmer DA, Chandler HK, Quigley KS, Blatt M, Teichman R, Lange G: Chronic widespread pain, mental health, and physical role function in OEF/OIF veterans. Pain Med 2009; 10(7): 1174-82.
21.
22. Zoroya G: Abuse of pain pills by troops concerns
23. The use of opioids for the treatment of chronic pain. A consensus statement from the
24. Model policy for the use of controlled substances for the treatment of pain.
25. Starrels JL, Becker WC, Weiner MG, Li X, Heo M, Turner BJ: Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain. J Gen Intern Med 2011; 26(9): 958- 64.
26. Becker WC, Starrels JL, Heo M, Li X, Weiner MG, Turner BJ: Racial differences in primary care opioid risk reduction strategies. Ann Fam Med 2011; 9(3): 219-25.
27. Neven DE, Sabel JC, Howell DN, Carlisle RJ: The development of the
28. Jones T, Passik SD: A comparison of methods of administering the opioid risk tool. J Opioid Manag 2011; 7(5): 347 - 51.
29. Trescott CE, Beck RM, Seelig MD, Von Korff MR:
30. Katz N, Panas L, Kim M, et al: Usefulness of prescription monitoring programs for surveillance:analysis of Schedule II opioid prescription data in
31. Simeone R, Holland L: An evaluation of prescription monitoring programs. Available at www.ojp.usdoj.gov/BJA/pdf/PDMPExecSumm .pdf; accessed
32. Pradel V, Frauger E, Thirion X, et al: Impact of a prescription monitor- ing program on doctor-shopping for high dosage buprenorphine. Pharmacoepidemiol Drug Saf 2009; 18(1): 36-43.
33. Wang J, Christo PJ: The influence of prescription monitoring programs on chronic pain management. Pain Physician 2009; 12(3): 507 - 15.
34.
35. DoD Pharmacoeconomic Center. Controlled Drug Management Analy- sis and Reporting Tool. Available at http://pec.ha.osd.mil/CDMART/ default.php?submenuheader=3; accessed
36. Grumbach K, Bodenheimer T, Grundy P: The outcomes of imple- menting patient-centered medical home interventions: a review of the evidence on quality, access and costs from recent prospective evalua- tion studies, 2009. Available at http://familymedicine.medschool.ucsf .edu/cepc/pdf/outcomes%20of%20pcmh%20for%20White%20House% 20Aug%202009.pdf; accessed
37. Roby DH, Pourat N, Pirritano MJ, et al: Impact of patient-centered medical home assignment on emergency room visits among uninsured patients in a county health system. Med Care Res Rev 2010; 67(4): 412-30.
38. Reid RJ, Coleman K, Johnson EA, et al: The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (
*
[dagger]
[double dagger]Wilford Hall Ambulatory Surgical Center,
The opinions expressed do not reflect the official opinion or policy of the
doi: 10.7205/MILMED-D-13-00109
Copyright: | (c) 2014 Association of Military Surgeons of the United States |
Wordcount: | 4562 |
Advisor News
Annuity News
Health/Employee Benefits News
Life Insurance News