Francine Goodman, Pharm.D ., BCPS Clinical Pharmacy Specialist, National PBM Services

1. Opioid Therapy Practiceand Policy IssuesNational Opioid Pain Care Agreementand Large Quantity Opioid Prescription Review Francine Goodman, Pharm.D., BCPS Clinical Pharmacy Specialist, National PBM Services Project Leader, National Opioid Pain Care Agreement

2. National Opioid Pain Care AgreementThree Documents DIRECTIVE THE OPCA Available via iMedConsentTM program PATIENT INFORMATION Supplements the OPCA Supports • a standard, national Opioid Pain Care Agreement • a single location (Clinical Warnings / CWAD) in VHA’s Computerized Patient Record System (CPRS)

3. TO DO LIST • Form work group • Obtain field input • Combine opioid agreements • Distill core OPCA

4. TO DO LIST • Improve readability • Pilot in patients • Build consensus (ongoing)

5. FINAL TO DO’S (FY10) • Submit to VACO for concurrence • Post Model OPCA on VHA Pain Management Web sitehttp://www1.va.gov/pain_management/index.cfm • Provider Education STILL UNDER CONSTRUCTION THANK YOU FOR YOUR PATIENCE

6. Large Quantity Opioid Rx Reviews • Goal • To evaluate appropriateness (quality and safety) of aberrant large-quantity opioid prescriptions • Extends Multi-site and Multi-VISN Opioid / CN101 Rx Reviews

7. CN101 Large Quantity Rx Reviews • National PBM identifies Large Quantity cases that are considered for Protected Peer Review • Started June 2009

8. Methods • Identify Top 10 Large Quantity patients in each VISN • 10 or fewer cases per VISN per formulation • Up to 30 cases possible per VISN • Includes multi-VISN fills • Probably represents top 0.05% or less of all CN101 patients

9. Cutoffs • Intended to reduce size of database • Tab/cap: >= 1200 / 3 mo • Patches: >= 90 / 3 mo • Oral Liquid: >= 6000 / 3 mo

10. Process for Large Quantity Cases PBM Protected Peer Review Process: 1) Multidisciplinary Peer Cmte screen VPEs CMOs COSs COPs Re-evaluation of opioidcare plan PPR Process: 2) PPR of selected cases

11. Accountability • PBM requires no follow-up; not involved in PPRs • Multidisciplinary Peer Cmtes should ensure timely feedback to providers to ensure patient and public safety • Quality Measure: • CN101 utilization by Large Quantity patients (q6mo) • National roll-up of PPRs • Process Evaluation: Dec 2009

12. Reference Guide for PPRs • Guides reviewers to potentially important aspects of care • Available through VPEs and CMOs 1 Choice of diagnostic tests and timely ordering of those diagnostic tests. 2 Performance of a procedure and / or treatment 3 Addressing abnormal results of diagnostic tests 4 Timeliness of diagnosis and appropriateness of diagnosis     5 Timing of treatment initiation and appropriateness of treatment 6 Adequacy of technique during procedures 7 Recognition and communication of critical clues to patient's condition during the period of clinical deterioration 8 Timely initiation of appropriate actions during periods of clinical deterioration 9 Medical record documentation 10 Supervision of health profession trainees 11 Other relevant aspects of care

13. Questions?