Guideline recommendations included but were not limited to the following1,8-10:
- Patient education about chronic pain and opioids
- Evaluation of pain, function, opioid misuse risk at least twice yearly
- Patient-centered and driven treatment plans
- A holistic approach to chronic pain interventions
- Review of treatment plan efficacy at least twice yearly
- Enzyme multiplied immunoassay technique urine drug screening (UDS) 2 times per year
- State prescription monitoring program query annually
- Signed iMedConsent for treatment of chronic pain
- Plan for safe discontinuation of opioids
- Documentation that the above has been performed with patient understanding
The literature suggested a multimodality approach to chronic nonmalignant pain by minimizing the use of opioids over time while emphasizing nonpharmacologic therapies, such as cognitive behavioral therapy (CBT), mindfulness, meditation, yoga, and spiritual growth, to name a few.10,11 These findings are based on several studies, which suggested that passive coping strategies (eg, use of medication for immediate relief, depending on others, restricting medications) result in an increase in subjective pain among chronic nonmalignant pain patients.12 Helping patients reduce frequent use of passive coping strategies is believed to decrease pain.12 Active coping strategies (eg, engaging in therapies, staying busy or active, distracting attention from pain) have been found to decrease pain.12 The PC-CPP program shifted health care outcomes and responsibilities away from the hierarchal PCP-patient relationship toward a collaborative relationship that encourages patient-driven, patient-centered care outcomes and shared responsibilities.
Program Overview
The PC-CPP was shaped by the following hypotheses: (1) Transparent expectations and consequences would increase functional scores and decrease chronic opioid doses; (2) Treatment plans consisting of chronic opioid prescriptions linked with interactive nonpharmacologic interventions led to decreased pain and increased functional scores; (3) Transparent expectations combined with a streamlined approach to the chronic nonmalignant pain patient would improve patient and PCP satisfaction scores.
The PC-CPP was developed to provide an efficient, effective, and evidence-based approach to managing chronic nonmalignant pain and opioid therapy issues in the primary care setting. Referred patients attend 1 shared medical appointment (SMA) every 6 months with up to 19 other female veterans also referred to the PC-CPP. The group was composed of only female veterans as the pilot study for this SMA occurred in the Women’s Clinic. At each 6-month SMA, patients received education from the Taking Opioids Responsibly for Your Safety and the Safety of Others (TORYSSO) guide13 and signed the corresponding long-term opioid therapy for pain informed consent form (iMedConsent).
The patient and a staff member developed a treatment plan that was patient driven and included at least 1 nonpharmacologic treatment option. The 1-hour nonpharmacologic sessions were either group or individual and occurred weekly for 6 to 8 weeks. These options included CBT for chronic pain, Living Well With Chronic Conditions, trauma-sensitive yoga, smoking cessation, mindfulness for stress and anxiety, MOVE! weight management, Walk With Ease, and a self-help option (VA-issued Manage Stress Workbook, 2014). The workbook was included as an option for those who lived far away, were limited by work schedules, or were unable to afford the copays for a 6- to 8-session program.
Inclusion and Exclusion Criteria
Any female veteran patient enrolled in the VASLCHCS with a chronic nonmalignant pain diagnosis who received daily opioids for 3 or more consecutive months from a PCP was included. Excluded individuals were those with cognitive decline/dementia, serious mental illness, psychosis, active suicidality, disruptive behavior flag, or those excluded by PCP discretion if it was determined that the patient would do better in a one-on-one setting with the PCP (Table 1). Patients taking > 200 MED/d of opioids who were seen in the VASLCHCS specialty pain clinic were also excluded.
Patient and PCP Responsibilities
The patient was responsible for timely attendance and full participation in all SMA group classes as determined in the veteran’s Treatment Plan Agreement (TPA). In addition, the patient had to provide UDS when requested (a minimum of twice yearly) and communicate with the PCP if having a procedure requiring additional opioids. This was in line with the current standards set forth by the VA Opioid Safety Initiative (OSI) Taskforce.12
The PC-CPP provided education, evaluation, documentation, and referral and follow-up with the nonpharmacologic treatment options discussed but did not provide prescription medications. The PCP reviewed the medical documents completed in the PC-CPP, and the PCP was strongly encouraged to follow its recommendations. The expectation was that the PCP would support the PC-CPP when the care recommendation was for a pharmacist-guided opioid taper.
Lack of attendance was defined as a no-show or a reschedule. Patients were considered adherent if they missed fewer than 2 SMA appointments and 2 nonpharmacologic treatment appointments every 6 months. The patient was required to attend the SMA and nonpharmacologic treatment on the third appointment to remain adherent with PC-CPP expectations and agreements. Adherence was acknowledged after 12 and 24 months by a reduction in PC-CPP requirements.