VCSQI SAN 2.0

Opioid Management Workgroup (OMW)

Minutes – February 22, 2018 -1- 2 P.M. EST

Appendix A- invitees; Appendix B- Resources; Appendix C- Metrics

RECORDING OF MEETING AS A YOUTUBE AVAILABLE HERE:

Invited Attendees: (See attachment A for names/emails of practices’ primary contacts in attendance on this call)

VCSQI Staff in attendance: Ivan Berkel, Jayna Eller, Eddie Fonner, Rick Koss, Debbie Melnyk

Objectives of this workgroup include:

-To commit to review opioid prescribing practices within each participating practice

-To review, understand, and adapt several tools already available toward improving opioid prescribing practices (e.g. the CDC Opioid Prescribing Guidelines for Chronic Pain, opioid risk assessment tools/methods, opioid treatment agreement, monitoring and follow up with patients)

-To implement an opioid prescribing protocol in each participating practice and encourage clinicians to “take the pledge”

-To share resources and learn from each other (see Appendix B for links to relevant resources), including sharing of stories within VCSQI and TCPi.

Agenda/Discussion Item / Discussion Points / Action
Review of Agenda (2”) / Are there any other discussion items to be added?
Update from CMS Quality Conference – Debbie (5”) / Debbie shared that at the CMS Quality Conference, there continued to be strong attention on improving opioid prescribing practices. One session she attended included speakers from CDC, SAMHSA (a unit of the U.D. Department of Health and Human Services), and University of New Mexico. Recent statistics were provided, including that over 63,000 overdose deaths occurred in 2016 and is the leading cause of death for men between 40 and 50 years old now. Dr. Jan Losby (CDC) encouraged all to review the CDC guidelines for prescribing opioids for chronic, non-cancer pain, and to visit the CDC’s website for additional resources ( and
Dr. Tony Campbell from Substance Abuse and Mental Health Services Administration (SAMHSA - also spoke about the 5 strategies SAMHSA has related to opioid misuse:
  1. Increase public health awareness
  2. Advance the practice of pain management
  3. Increase access to treatment and recovery services
  4. Targeting availability and distribution of overdose-reversal agents
  5. Supporting cutting edge research.
He shared that the Comprehensive Addiction and Recovery Act (CARA) of 2016 also expanded who is legally able to prescribe buprenorphine, to now include NPs, PA, and APNs. Buprenorphine is used to treat addiction on an outpatient basis. He welcomed questions be sent to him at
Dr. Judy Bartlett from the University of Mexico spokes about Project ECHO ( She stated that medication-assisted treatment is the cornerstone to treatment and encouraged all to review the use of methadone and buprenorphine. She quoted a recent study in Baltimore that showed a 66% drop in heroin overdose deaths as the use of buprenorphine increased. / VCSQI will share links to CMS presentations once available.
Review of CDC’s opioid prescribing guidelines for chronic pain (15”) / For chronic pain:
How can these recommendations be applied to your practice and patients?
We reviewed the guideline. There is significant detail about the process used to develop the guidelines, followed by discussion of each of the 12 recommendations. The 12 recommendations fall into 3 categories; each recommendation is described with a rationale. The 3 categories are:
1. When to prescribe opioids
2. How to prescribe opioids (type, dose, duration, etc.)
  1. Assessing the patients risk when taking opioids.
Recommendation 6 (in Category 2) has relevance to treating acute pain and may be interest to several prescribers. It reads:
Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed. / All prescribers are encouraged to review the guideline and 12 recommendations to consider applicability to their own practice.
A brief fact sheet that may be helpful for posting is available at:
Information about the mobile prescribing app is available at

Update from Cardiovascular Surgery PA, in Orlando – Steve Dickson (15”) / Cardiovascular Surgery, PA has started to address opioid prescribing practices. He will share how this process is unfolding.
Steve shared that when they completed the VCSQI survey on opioid prescribing practices, he found that the practice did not have a protocol for similar practice. Sometimes the hospitalist prescribed for the surgeons’ patients too. It appeared disjointed to him. This was not something, as an administrator, was on his radar in the past. The survey findings and hearing more from some of the surgeons about the number of “re-do’s” of valve replacements on IV drug users, opened his eyes to this issue. Re-do’s are happening within a couple months of each other on the same patient. The surgeons do lose sight of how the patients are being followed since the patients return to PCPs and cardiologists.
A site visit was planned; Ivan and Eddie spent time talking with Steve and the office nurses to discuss the prescribing practices of the surgeons and learn what the nurses were hearing from patients. Key take-aways and action items were written up following this meeting.
It was important to consider the type of surgery the patient underwent, to determine recommended pain management and opioid prescribing plan. The nurses also saw the prescribing practices beginning with the type of incisional entry into the surgical procedure (sternotomy, thoracotomy, subcutaneous). They are developing a decision tree that begins with that, and then also considers age as well. Older patients don’t seem to task for opioids, but the younger patients do.
Ivan added that one of the biggest eye-openers for him was that it could not be done quickly since there was more to learn about patient-differences, and about pain management. There are different parts to this puzzle, which means that getting input form the several stakeholders is important to understanding the full picture.
Steve continued saying that the nurses felt it was important to work with the hospital and pharmacists to understand the hospital’s protocols. Post-surgical prescriptions was the final topic of discussion: what happens after the patient leaves the ICU? The stepdown unit? The hospital? So they have set up a group with the hospital to review and discuss the protocol, beginning this coming Monday. The group will include a hospital pharmacist, a hospital pain management clinician, a hospital care coordinator, and staff from the surgical practice.
Steve will continue to provide updates to this group.
Updates (5”) / Dr. Rich, Debbie, Ivan and Eddie met with STS staff at the annual STS meeting last month. There is interest in working together to develop a position paper on opioid prescribing for cardiothoracic and thoracic surgery patients. Stay tuned for more about you can participate on the workgroup.
Do you have a story to tell? We’ll help you write them up to share with national TCPi partners. Stories are entered online, but we’ve made a Word document of the data fields, so you can review and edit them in advance of online data entry (sent in email with this agenda). The online link is below and included in the Word document.
Plan for next meeting (5”)-
March 22nd, 1-2 PM ET / Topic of focus:
-Assessing the patient’s risk of opioid misuse
-Securing and documenting patient’s treatment agreement
-Conducing follow up monitoring with patients

From University of Virginia – VCSQI member

Narcotic Smartphrase for AVS

This is in our d/c instructions and it has really cut down on the phone calls to the clinic.

Pain Medication & Refills:

Virginia has changed their opioid (pain medication) prescribing laws due to the abuse of these types of medication. Most insurances are changing their regulations so that they cover only one week of prescription pain medication.

  1. Due to these changes, we are able to give you only a 7-10 day supply of pain medication.
  2. Your pharmacy may inform us that we can only give 7 days of pain medication. If that is the case, it will change the amount of pills we can prescribe to you.
  3. The prescription you are given is to last you for 1-2 weeks after going home.
  4. Wecannotcall, fax, or mail in a prescription for pain medications any longer.
  5. If you need a refill, you will need to be seen by your PCP, or our clinic, for evaluation.
  6. Please take Tylenol 650mg by mouth 4 times daily for 1-2 weeks, and then as needed. Do not exceed 4g (4000mg) daily. If you have a liver conditions please do not take Tylenol unless otherwise directed.
  7. With the Tylenol you can also takeoxyCODONE(ROXICODONE) 5 MG tablet 1 OR 2 tablets EVERY 4 to 6 hours AS NEEDED for pain.
  8. Do not drive, drink alcohol, or operate heavy machinery while taking this medication.
  9. Take an OVER THE COUNTERstool softener (Colace 100 MG capsule, or senna 8.6 MG tablet) to prevent constipation. Stop if having loose stools/diarrhea.

Chronic Pain Patients (Already on Pain Medication):

  1. If you have chronic pain, we will give you one week of pain medication.
  2. Once you have exhausted that supply you will be required to see whoever issues your monthly supply of pain medication.

Attachment A

VCSQI 2.0 Participating Practices

Primary Contact Persons in Attendance (highlighted)

Susan Warriner – Winchester Medical Center (Virginia – original VCSQI member)

Steve Dickson <>,
Dr. Pankaj Kulshrestha <>
Ryan Dougherty <>
Dr. Denise Cox <>, John Honey <>
Brenda Campbell <>, Vishal Thaker >
Becca Eckert <>
Dr. Vince Wood <>
Maggie Yanan <>
Mrs. Monk <>
Tari Higgins <>
Brigette Jackson <>
Wakeeda Morgan <>
Maria Ramirez <>
Stephanie Dresback <>, Rhonda Byerly <>
Suzanne King <>
Samara Clurman <>
Andrea Moreno <>
Richard Boyd <>
Dr. Gary McLeod <>
Dr. Tim Frost <>
Janet Rodriguez <>
Dr. NP Patel <>
Thang Tran <>
Victoria Betz <>
Dianne Garino <>
Debbie McNamara <>
Darleen Sutcliffe <>
John Pispidikis <>
Trish Richardson <>
Dr. Frederick Hasty <>
Maureen Moldovan and Dr. John Gump <>
Rosemary Donald <>
Cathy Picillo <>, Cathy Picillo <>
Lauren Raabe <>
Amy Davis <>
Dawn Fitzgerald <>
Billie Jo Robbins <>
Bakula K. Dave <>
David Salonga <>
Roberta Killeen <>
Von Stepp <>
Janelle Cox <>
Dr. Jeffrey Hurwitz <>
Tammie Robinette
Dr. Sam Kahlam <>
Dr. Alan
Ginny Elzinga <>
Nicolette Shameer <>
Dr. John Morris <>
Denise Zahares <>
Dr. Julie Chao <>
Mariam Bashkoei <>
Geri Hing <>
Dr. John Douglas <>
Ann Tran <>
Doris Barzas <>
Attachment B
Resources
GUIDELINES
From Centers for Disease Control
(full guidelines document)
(brief summary)
Chou et al. Clinical Guidelines for Use of Opioids in Chronic Noncancer Pain. The Journal of Pain, Vol 10, No 2 (February), 2009: pp 113-130.
- Comprehensive article that also discusses and includes risk assessment tools and treatment agreements. Full pdf of article posted on VCSQI website in “Resources” tab. Also sent with this agenda.
Jamison, Serraillier,andMichna. Assessment and Treatment of Abuse Risk in Opioid Prescribing for Chronic Pain. Pain Res Treat. 2011; 2011: 941808. Published online 2011 Oct 11. doi: 10.1155/2011/941808 – General article. Includes list of risk tools and samples of treatment agreement and monitoring tool.

RISK ASSESSMENT
Copies of Opioid Risk Tool (ORT)


– online tool and
calculator
- article about various risk tools.
TREATMENT AGREEMENTS
- article about treatment agreements with samples

Appendix C

Opioid Management Metrics- For quarterly monitoring by VCSQI

  1. Practice has standardized opioid prescribing protocol (yes/no/in development)
  1. Evaluation or Interview for Risk of Opioid Misuse(QPP quality measure 414)
  2. All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record
  3. NOTE: this measure will be tracked as yes/no for VCSQI SAN 2.0quality data monitoring purposes. A practice can use it to measure their rate of evaluation of risk and use this as one of their QPP/MIPS measures.
  1. Opioid Therapy Follow-up Evaluation(QPP quality measure 408)
  2. All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record
  3. NOTE: this measure will be tracked as yes/no for VCSQI SAN 2.0 quality data monitoring purposes. A practice can use it to measure their rate of evaluation of risk and use this as one of their QPP/MIPS measures.
  1. Documentation of Signed Opioid Treatment Agreement(QPP quality measure 412)
  2. All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record.
  3. NOTE: this measure will be tracked as yes/no for VCSQI SAN 2.0quality data monitoring purposes. A practice can use it to measure their rate of evaluation of risk and use this as one of their QPP/MIPS measures.