Rx Summit Spotlight | Veterans Administration Takes Multi-Faceted Approach to Opioid Risk Mitigation

Since launching an opioid safety initiative nearly a decade ago, the Veterans Health Administration has employed a variety of strategies for reducing opioid prescriptions, embracing non-pharmaceutical treatment modalities for pain, and other opioid risk mitigation strategies.

At next week’s Rx Drug Abuse & Heroin Summit, VHA national program director for pain management Friedhelm Sandbrink, MD, VA national opioid overdose education and naloxone distribution coordinator Elizabeth Oliva, PhD, and Michael Harvey, PharmD, national clinical program manager for PBM Academic Detailing Service, will discuss the administration’s approach to addressing opioid safety and developing risk mitigation strategies. Ahead of their session at the Summit, the trio spoke with Addiction Professional about some of the strategies that have been implemented, keys to getting different stakeholders involved, and how their work has been impacted by the pandemic.

Editor’s note: This interview has been edited for length and clarity.

What have you identified as the most effective opioid risk mitigation strategies implemented by VHA?

Sandbrink: The opioid safety initiative was piloted in 2012 and was expanded nationwide in 2013. We knew from the beginning there were a few aspects we had to combine. We had to on one hand get a better understanding of what was the opioid prescribing under the VA system. We created a dashboard that allows us to see where prescribing happens and also informs providers and leadership where they are compared to others. Clearly, we also knew from the get-go that it wasn’t about reducing and taking away opioids. The main goal is providing better pain care. In this context, that means we have to educate patients and providers about how to optimize painkilling outcomes. And we had to specifically make sure we expanded options for pain care that are non-opioid therapeutic approaches that have buy-in from patients. … We have been moving away from a biomedical model to a biopsychosocial model that is often talked about, but is hard to implement. We do that in the VA system by supporting in the primary care setting providers with access to modalities from the whole range, primary care and mental health integration, CBT for chronic pain, access to physical therapists, access to integrated modalities at the primary care level. For the patient with more complex pain and a need to have greater resources brought to them because of risk or a failure to respond to treatment, we have to have a pain team that can support the patient and primary care providers to be successful.

If you ask me the most important aspect of better opioid care, it is non-opioid therapeutic modalities readily available with a consistent message that allows buy-in from patients and providers to realize it’s not the opioids that will help us, it’s the other modalities and a whole-health approach.

What we have learned most recently is that we have to have integration of opioid use disorder. We are concerned about patients being identified as high-risk with opioid medications, maybe even for opioid use disorder or excessive use, and then being cut off without the appropriate channeling and warm hand-off to someone who can address the OUD with evidence-based treatment. We have greatly expanded access to OUD treatment in the VA system, making sure it isn’t just in specialty mental health settings, but also in general health clinics and pain clinics.

Harvey: It has really become a comprehensive approach and has evolved over time, as providers have gotten more comfortable, more evidence came in and we identified more strategies and opportunities to improve care in general in the VA in this area. … The team I work with has a lot of people chipping in and working on this issue, but it’s specially trained clinicians who meet patients, talk to them one-on-one, build a relationship, identify their needs, meet them where they are and help bring them along as VA evolves in this area because everybody’s in a different place and a different comfort level.

You have different stakeholders involved. What is the key to getting everyone on the same page with these initiatives and pushing in the same direction?

Sandbrink: For patients, we need to have a consistent message by providers. It’s just as important that our providers hear a consistent message from their leaders. One thing providers have said is that when the opioid crisis hit, they weren’t getting a consistent message everywhere. The VA didn’t say the same as outside the VA. People had different opinions. Within our system, we had to work hard to make sure primary care and their leadership said the same message to their providers as well as pain specialty and mental health. … We have, among others, initiated a team at the agencywide level to bring VA stakeholders together—specialty care, mental health, primary care, social workers, nursing, the whole agencywide. They are aligned with what is outlined in CDC, VA and DOD clinical guidelines.

How has your work been impacted been during the pandemic? Are there changes you’ve made that you see sticking around long-term?

Harvey: For academic detailing specifically, our work is based around detailers in the field having one-on-one visits with providers. With the pandemic, that sort of interaction had to change. It has been a lot more tele-work. One of the key strategies we developed was something we call e-detailing, where we leverage technology the VA was already rolling out which enabled providers to have face-to-face visits with patients. We took that technology and had our detailers help providers get more comfortable with that and also use those for academic detailing visits. We’ve had a lot of virtual visits between academic detailers and providers. It was still a challenge because some of the messaging had to change because of COVID, and a lot of pharmacist detailers have clinics and see patients, so they had to pivot to helping with other related tasks. Long term, when it comes to what we’re doing, the detailers are starting to get more time back for detailing activities. I think the technology is going to stay. We’re already using it to do better outreach to rural locations.

Oliva: On the overdose front, you know how rates have increased after we saw rates decrease from 2017 to 2018. We have been messaging about the CDC health advisory network. We have a memo that went out this month to increase naloxone distribution to patients with opioid use disorder, and we’ve emphasized that opportunity for outreach to check in about care and if there is anything we can do to offer treatment again or get them connected with medication-assisted treatment for OUD. We emphasize that touchpoint as an important opportunity during the course of this pandemic to check in with patients.

The other thing we’ve been focusing on is given recent data about the importance of post-overdose care. We have a national note template that standardizes post-overdose care. Because any one provider may not have that much experience in addressing post-overdose care, we’ve standardized this template that walks them through the risk factors and includes consults to various services to ensure they get care. We also have a way in which if it’s not the patient’s treatment team that is recording this that there gets to be a notice in the record that says “overdose event” so their provider is aware. That’s what we’ve been trying to do—make sure that in this climate, we’re doing what we can ensure we offer services and connect with patients during the pandemic.