Expanded taper options, including rotation to buprenorphine, withinamulti-disciplinarypainclin-ic for patients on high-risk opioid regimens

Statement Of Problem Or Question (One Sentence): With increasing safety concerns regarding long-term opioid therapy (LTOT), balancing the potential benefits of opioids with adverse effects remains a challenge for patients, providers and health systems. Objectives Of Program/Intervention (No More Than Three Objectives): In 2011, a team of clinicians, administrators, and quality improvement specialists at VA Connecticut designed the Opioid Reassessment Clinic (ORC) to: 1. Offer team-based assessment and longitudinal multimodal treatment of patients with high-risk LTOT 2. Improve the safety of LTOT, such as by tapering to lower dosages or rotating to the partial opioid agonist buprenorphine/naloxone (bup/nx) Description Of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice Or Community Characteristics): Staffed by an internist, addiction psychiatrist, advanced-practice nurse, health psychologist, and nurse case manager, the ORC is embedded in a primary care clinic and runs one half day per week. Eligible patients include those on LTOT who demonstrate problems with safety, efficacy, or misuse. At the initial visit, the psychiatrist and internist use a biopsychosocial framework to conduct standardized assessments of pain, current functioning, and patient-generated goals. During the second visit, the clinical health psychologist assesses pain-related quality of life to determine whether psychosocial treatments are indicated. Follow-ups are carried out by the APRN or MDs until the referral issue is stabilized. Physicians in the ORC are bup/nx certified, and can facilitate referral to other pain services. Measures Of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): We conducted a quality-improvement study of Veterans referred to the ORC over a one-year period to examine clinic attendance, wait-times, engagement in various treatment options including a trial of bup/nx, and reductions in morphine equivalent daily doses (MEDDs) of opioids during engagement in the ORC. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): We reviewed medical records of Veterans for whom an ORC consult had been placed between March 1, 2016 and March 1, 2017. During this period, 114 Veterans were referred to the ORC and 61 (54%) attended an ORC visit between March 1, 2016 and January 1, 2018. Of the 61 who attended a visit, mean wait-time was 46 days (standard deviation [SD] 32 days). Mean MEDD at the time if initial visit was 161 mg morphine daily (SD 249). Thirty-eight (62%) of those engaged in the ORC opted for a trial on bup/nx and, of these, 16 (42%) continued buprenorphine for the duration of their engagement in the ORC. Twenty-one Veterans (34%) opted to taper their opioid dose, which may have involved a bup/nx rotation. For those choosing to taper, mean MEDD decreased from the initial visit (211 mg morphine, SD = 216) when compared to the final visit (110mg morphine, SD = 122, P < 0.01). Key Lessonsfordissemination(Whatcanothers Take Away For Implementation To Their Practice Or Com-Munity?): Multidisciplinary clinics can engage patients with high-risk opioid use to develop safer opioid pain regimens using multiple modalities. Patients on LTOT can effectively engage in tapers, which may involve transitioning to bup/nx. Study of less resource intensive models and models for re-engagement with primary care are warranted.