Shared Medical Appointment
Patients referred to the program and who met inclusion criteria received letters explaining the importance of SMA attendance and follow-up reminder calls. At least 30 minutes before the SMA, the patient provided an UDS sample at the laboratory. Next, the patient received an individualized program packet that included the TORYSSO guide, iMedConsent, a TPA specific to the program, a brief pain inventory (BPI) and opioid risk tool, a list of medication disposal sites, and short descriptions of available nonpharmacologic therapies.
Each SMA began with a presentation delivered by a pharmacist, a psychologist, and a medical provider, discussing TORYSSO, program expectations, and holistic approaches to pain. Each SMA also included a rotating chronic pain information topic (eg, nutrition and pain, the physiology of addiction, and the value of multiple modalities in pain treatment). Together, the staff and patients reviewed and completed the blank forms enclosed in the individualized
Each visit was entered into a Computerized Patient Record System (CPRS) template, which included a pain diagnosis, Opioid Risk Tool score, pain and functional scores, opioid fill history, last comprehensive metabolic panel, last electrocardiogram if on methadone, dates of signed agreements, patient adherence with SMA and optional therapies, and follow-up (eFigure).
Every patient enrolled in the PC-CPP had to attend a SMA every 6 months. Patients continued this indefinitely while receiving opioids, and requirements were lessened for patients who had a history of meeting program requirements. For those fully adherent after the first year, only 1 nonpharmacologic intervention was needed (instead of 1 every 6 months) yearly. After 2 years of full adherence, nonpharmacologic interventions were no longer necessary as the expectation was that the patient would continue to use the strategies that they had learned over the previous 2 years. Patients left the PC-CPP if they chose to discontinue opioids, met any of the exclusion criteria, or were nonadherent. Tapering opioid medication was recommended for patients who missed a SMA meeting or 2 nonpharmacologic treatment meetings in a 6-month period; received opioids from more than 1 provider; test positive on a UDS for substances that should not be present; consistently testing negative on a UDS for substances that should be present (indicating diversion); or exhibiting other aberrant behavior (frequent requests for early refills, medications often lost/stolen, etc).
Program Barriers
The PC-CPP took about 2 years to set up, and several barriers were encountered. A thorough understanding of the following factors is necessary for establishing a similar program.
Initially, consults were placed by a designee (someone other than the PCP currently caring for the patient). The designee was usually a member of the PC-CPP who placed consults for all patients who had opioids listed on the CPRS profile. Further, patients who had any opioids within the past 3 months were initially included as were patients who wanted pain education but were not taking opioids. After 12 months, it became apparent that the focus of the PC-CPP should center on patients taking opioids for a minimum of 3 months consecutively. Patients who wanted only education could attend other hospital education opportunities, which helped keep the patient load manageable for PC-CPP staff. Further, to lessen patient confusion and improve adherence, the PCP placed the consult and discussed the program with the patient. Class sizes of 5 to 10 patients seemed to be ideal for patient participation and provider workload.
Patient Education
Initially, the SMA did not follow a standard curriculum, but the current format is more consistent, reproducible, streamlined, and organized. This adjustment improved SMA attendance as well as patient satisfaction, as the class started and finished on time. The SMA also started with numerous handouts, including brochures for nonpharmacologic programs offered at this facility. This led to patients feeling overwhelmed, missing the important forms, and wasted paper. Handouts were simplified to 2 color-coded forms (TPA and BPI).
The take-home assessment was streamlined to a single general assessment. This assessment consisted of 2 questions that asked patients to write a summary of what they learned and then write a summary of how they applied what they learned to their pain management. The VA Manage Stress Workbook also was added to the take-home materials. There are currently 5 different take-home options, which are necessary for those who live more than 50 miles from any VA facility or for those who have transportation issues.