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VA RESEARCH QUARTERLY UPDATE
This Issue: The Returning Veteran | Table of Contents: Winter 2018 | Download this issue

Spotlight on Career Development Awardees

Investigating ways to help Veterans safely stop long-term opioid use


Dr. Joseph Frank is a primary care physician at the VA Eastern Colorado Health Care System in Denver. He is also a health services researcher at the HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care. His research is focused on improving the safety and effectiveness of chronic pain care for Veterans. As a physician, he is particularly interested in how VA can provide chronic pain care in primary care settings.

VARQU spoke with Frank about the work he is doing to help Veterans who are living with chronic pain.

KEY POINTS:

  • Tapering or stopping long-term opioid medications in Veterans who have chronic pain can be a challenging process.
  • The scientific evidence guiding the assessment of the risks and benefits of long-term opioid therapy and/or dose reduction or discontinuation for individual patients is limited.
  • A team-based approach to multimodal pain care could help both physicians and their patients.
  • Further research is needed to identify the systems and resources that are necessary to adequately support physicians and patients as they consider opioid tapering.

               


Dr. Joseph Frank is a primary care physician who is investigating the best ways to reduce or stop opioid use in Veterans with chronic pain.
(Photo by Shawn Fury)
Dr. Joseph Frank is a primary care physician who is investigating the best ways to reduce or stop opioid use in Veterans with chronic pain. (Photo by Shawn Fury)

Dr. Joseph Frank is a primary care physician who is investigating the best ways to reduce or stop opioid use in Veterans with chronic pain. (Photo by Shawn Fury)

Welcome, Dr. Frank. Can you tell us about the three different lines of research that you are pursuing?

The first of those is for patients who are taking opioid medications long term. For these patients, the process of stopping or reducing those medications—sometimes referred to as opioid tapering—can be very challenging. We need to understand how to deliver high-quality pain care during and after opioid tapering.

The second line of research focuses on who delivers this care. As with many chronic conditions, primary-care physicians are most effective when working as part of a team. I am interested in how we should design teams in primary care to deliver pain care that is patient-centered and effective.

And finally, as a primary care physician, I know it's critical that we help patients get involved in and lead their own plans for pain management. As a researcher, I believe this means we must also help patients get involved in pain research; therefore, I am very interested in how we can better involve patients in all phases of the research process.

You have received a VA Career Development Award to study tapering opioid medications for patients on long-term therapy. What areas will you be investigating as part of this award?

We will be investigating several different areas. The first of those is a national survey of Veterans who are on long-term opioid medications to learn more about their perceptions of and experiences with opioid tapering. We know that opioid prescribing rates are decreasing over recent years within VA. But we don't know how these changes are affecting Veterans who have been on these medications long-term. And we don't know what their goals are as it relates to their own use of opioid medications.

The second aspect of this work is to engage Veterans in the development of a primary care-focused program to support opioid tapering. We will be gathering Veteran stakeholders as well as VA provider stakeholders to conduct a series of meetings and incorporate their perspectives in the development of a program to provide patient-centered opioid-tapering support.

And finally, the long-term goal is to pilot this intervention and understand what it means for Veterans. As I mentioned, pain care is changing rapidly in the VA. So I think a challenge in the years ahead will be to continue to learn quickly from research that is ongoing and to make sure that the intervention that we are developing will take advantage of the latest science in this area. With our approach to engaging Veterans early in the process, we will have a unique opportunity to incorporate both the latest science as well as Veterans’ experiences to come up with something that is valuable to the Veterans that we serve.

"I know it's critical that we help patients get involved in and lead their own plans for pain management. I believe this means we must also help patients get involved in pain research."

What is the VA policy for tapering or reducing opioid use in Veterans?

VA policy is guided by the most recent guidelines released by the departments of Veterans Affairs and Defense. The guideline was released just last year, in 2017. The guideline recommends that for patients who are on long-term opioids, it is important to assess the risks and benefits of ongoing treatment with opioid medications for the individual Veteran. That guideline also notes that it is important to assess the risks and benefits of tapering. This is challenging currently because we don't have much evidence to help providers assess those risks and benefits. So the decision-making is challenging, but importantly should focus on the individual Veterans and their unique needs.

Importantly, what that policy does not include is a recommendation to reduce opioid dose based on dose alone or without attention to individual risks and benefits. I think a place where we risk getting beyond the evidence, beyond the VA guidelines, and other related guidelines is by unilaterally making changes to medications that don't take into consideration an individual patient's unique needs.

Can you tell me about the benefits and limitations of using opioid medications long-term for chronic pain?

I think the goal of using medications, any medications, particularly opioids long-term for a condition like chronic pain, is that they improve function and quality of life. I think we are moving away from measuring pain severity on a simple zero to 10 scale, and trying to think more broadly about individual patients’ long-term goals, especially as it relates to their ability to do the things they want to do. So I think when they are beneficial, it is because they are helping patients function well and improve their quality of life.

I think important risks often travel alongside those benefits. We have seen in prior studies that people may take these medications with some ambivalence, as they experience both benefits and some side effects. Side effects differ based on the individual patient, but can include decreased energy, cognitive impairment, and some other meaningful side effects that they experience day to day.

And then I think the risk of serious harms such as overdose or a new opioid use disorder diagnosis are front and center in the minds of policymakers and providers. In our prior work talking with patients, they told us that the pain they experience day to day is more salient than the more abstract risks for future harms. And so it can be a real challenge for physicians and providers to get on the same page prioritizing goals and concerns about potential future harms.

You published a paper that discussed the scientific evidence on strategies to safely taper opioid medications. Can you tell us what you found?

This was a systematic review conducted by a great team of VA researchers doing work on this topic. Together, we identified 67 studies that examined opioid tapering and came to three key conclusions. First, the quality of evidence was very low for each of our key questions. Health care systems and health care providers are working to take urgent action to prevent opioid-related harms. However, for patients taking these medications long-term, it's important that we balance this urgency with caution, because we have so little evidence to guide opioid tapering currently.

I think the second key point is that we found very few studies that addressed the effect of opioid tapering on important adverse events such as overdose. We want to find effective strategies to prevent harms such as overdose, and we need to learn more about how tapering affects this risk.

And third, we found that opioid tapering may improve pain, function, and quality of life for some patients. Importantly, the fair-quality studies that showed these positive results examined voluntary tapering in the context of multidisciplinary pain management programs. More work is needed to better understand the effects of tapering when it occurs in primary care, which is where most of our pain management is happening in VA.

In a different study, you interviewed a group of primary care physicians to find out about their experiences with tapering opioid therapy. What did they say are their greatest challenges?

We conducted focus groups with 40 providers across three health care systems here in Denver, Colorado. We identified three key themes related to their perceived barriers to opioid tapering. First, providers that we spoke with described discussions of opioid tapering with their patients to be uniquely emotionally charged, and at times, exhausting. Health care systems are asking providers to have these conversations more often these days, and it's important that we recognize the impact on providers as well as the impact on patients.

Second, providers described a sense that they had inadequate resources to support opioid tapering, specifically, but also chronic pain care generally. They described a lack of training specific to this process, as well as a lack of other team members and resources in their clinics and communities.

And third, they reported that opioid tapering did not go well when there was a lack of trust between their patient and themselves.

You also mentioned in that study that you identified several best strategies that would help primary care physicians safely taper opioids. What are they?

In addition to barriers, the primary care physicians that we spoke with also identified strategies that they found helpful. They noted the importance of empathizing with their patients' experiences—both their experience of pain and their concern about making medication changes. We have learned from patients that this process can be very anxiety-provoking. And so providers noted the importance of acknowledging that anxiety.

Providers also described opioid tapering as a long-term process that benefits from planning and preparation. They described ways in which working with individual patients to think long-term about goals as it relates to the medication was a productive process.

And finally they reported feeling supported by guidelines and local policies that sought to standardize care processes related to opioid prescribing and opioid tapering.

What types of strategies would you like to see developed to help primary care physicians work with chronic pain patients and assist them in tapering opioids?

That's an important question. I think first it takes a team. And in a system like the VA, it will take guidance to help teams develop effective processes in their own local sites. Primary care providers, nurses, psychologists, pharmacists—the list goes on. Each provider has a unique expertise that may be helpful to patients during opioid tapering. The challenge ahead is to create systems that connect each patient with the right team at the right time during opioid tapering and chronic pain management generally.

The VA is leading in this area with some very interesting work to compare different types of teams and to understand which Veterans benefit from which team structure. It will be important that we learn from those ongoing studies and as researchers try and help leaders in VA integrate those lessons into routine care as quickly as we can.

I'll mention two other resources that I think are potentially impactful in VA. The first is an important role for peer support. While I as a primary care physician try to help my patients know what to expect during opioid tapering, I think a fellow Veteran who has been through the process can provide practice insights and support that I just can't match.

And finally, as we discussed, opioid medications are just one tool in the chronic pain toolkit. I think it's important that we continue to improve Veterans' access to the full range of treatments and continue to improve the quality of evidence that guides our approach to multimodal pain care.


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