Impact of Clinical Pharmacist Practitioner-Driven High Opioid Dose Reevaluation in Veterans with Chronic Non-Cancer Pain

Veterans Health Administration implemented the Opioid Safety Initiative (OSI) in 2013 to promote safe/rational opioid prescribing. West Palm Beach VA Healthcare System (WPBVAHCS) has been an outlier for the percentage of Veterans with chronic non-cancer pain receiving ≥90 mg Morphine Equivalent Daily Dosing (MEDD) in Veterans Integrated Service Networks (VISN) 8 since the 2016 fiscal year. The purpose was to determine the utility of a Pain Clinical Pharmacist Practitioner (CPP) identifying, reviewing, and approaching Veterans utilizing high-dose opioids for dose reevaluation and the impact on OSI metric post-opioid reevaluation. Pain CPP opioid education resulted in 28% (11/39) of Veterans undergoing an average 17.7 mg MEDD opioid dose reduction. For Veterans evaluated by Pain CPP, 83% (15/18) reported no change or improvement in average pain and PEG score. Pain CPP’s implemented 48 interventions outside of opioid dose reduction, the most common related to naloxone. No documented opioid overdose events, hospitalizations for uncontrolled pain or mental health, suicide attempts or pain-related crisis interventions were reported. Pain CPP’s are equipped to provide opioid education, address risk mitigation strategies, reassess pain regimens, and refer for non-pharmacologic modalities. Utilization of Pain CPP resources helps improve OSI metrics while providing safe comprehensive medication management (CMM) for chronic pain.

美国退伍军人事务部（Veterans Health Administration）于2013年推出阿片类药物安全倡议（Opioid Safety Initiative, OSI），旨在推广安全、合理的阿片类药物处方行为。西棕榈滩退伍军人医疗系统（West Palm Beach VA Healthcare System, WPBVAHCS）自2016财年起，在第8号退伍军人整合服务网络（Veterans Integrated Service Networks, VISN 8）范围内，慢性非癌痛退伍军人接受≥90 mg吗啡等效日剂量（Morphine Equivalent Daily Dosing, MEDD）治疗的占比始终偏离平均水平，属于异常案例。本研究旨在明确疼痛临床药师执业者（Pain Clinical Pharmacist Practitioner, CPP）识别、评估并约谈高剂量阿片类药物使用者以开展用药剂量重新评估与调整的应用价值，以及该干预措施对阿片类药物剂量重新评估后阿片类药物安全倡议相关指标的影响。经疼痛临床药师执业者开展的阿片类药物相关教育后，28%（11/39）的退伍军人的吗啡等效日剂量平均降低了17.7 mg。在接受疼痛临床药师执业者评估的退伍军人中，83%（15/18）表示其平均疼痛程度及PEG评分（PEG score）无变化或有所改善。疼痛临床药师执业者还实施了48项非阿片类药物剂量调整类干预措施，其中最常见的干预与纳洛酮相关。本研究未记录到阿片类药物过量事件、因疼痛失控或精神健康问题住院、自杀未遂或疼痛相关危机干预的相关报告。疼痛临床药师执业者可提供阿片类药物教育、落实风险缓解策略、重新评估疼痛治疗方案，并转诊至非药物疗法干预渠道。合理利用疼痛临床药师执业者的资源，有助于改善阿片类药物安全倡议相关指标，同时为慢性疼痛患者提供安全的综合药物管理（comprehensive medication management, CMM）服务。