March 17, 2021
ON A SPRING DAY IN 2016, a female patient walked into the Physical Medicine and Rehabilitation clinic at Virginia Mason Medical Center in Seattle. The patient, who came to Virginia Mason after her previous provider moved out of state, was receiving more than 1,300 morphine milligram equivalents (MMEs) per day for chronic low back pain.
As one of the medical center’s Ambulatory Pharmacy Managers—and one of the first pharmacists at Virginia Mason to join its innovative team-based care model for opioid stewardship — Amanda Locke, Pharm.D., M.B.A., BCACP, is well equipped to care for this patient and others receiving potentially dangerous amounts of opioids for chronic pain.
Opioid Interventions
Amanda Locke, Pharm.D., M.B.A., BCACP
Since 2012, when she helped establish the opioid stewardship program, Dr. Locke and other ambulatory care pharmacists at Virginia Mason have been meeting with patients receiving chronic opioid therapy for persistent pain. The goal is to reduce or eliminate opioid use. Under the new model, patients have an average of four routine clinic visits per year — one with both their opioid-prescribing provider and a clinic pharmacist provider, and three other appointments alternating between the pharmacist and the prescribing provider.
Prior to and during clinic visits, pharmacists review the patient’s medication regimen, assess the risk for opioid-related complications, and conduct and review urine screens. They also provide education on pain management and opioid use, and explain the medical center’s opioid use policy. The pharmacists recommend non-opioid and non-pharmacological treatments, such as physical therapy, mindfulness, and acupuncture, and they prescribe naloxone.
Lowering MMEs, Standardizing Care
According to Dr. Locke, patients partaking in the opioid stewardship program have seen their total MMEs decrease during a 32-month period. In addition, the program helps ensure that each patient receiving chronic opioid therapy is treated according to the same best practices at every visit, whether the patient is seen by a pharmacist or another provider.
“Since the program has been in place, we’ve seen prescribers adhering more closely to safe prescribing guidelines and state regulations, and using risk-assessment tools, urine screens, and patient agreements significantly more often,” Dr. Locke said.
Supporting Patients Through Life Changes
While treating patients receiving opioids for chronic pain, Dr. Locke has learned some important lessons. For example, tapering opioid doses can lead to emotional responses from many patients, and they need to feel supported and listened to within the provider-patient relationship.
“The best and most effective tapering experiences involve working with the patient and supporting them, rather than just telling them how to taper,” she said. “We have lots of discussions with the patient and try to understand their goals and concerns. We also use shared decision-making tools and motivational interviewing to make sure they have the goal of reaching that lower dose.”
Non-pharmaceutical care — such as physical therapy, mindfulness, and acupuncture — during the opioid-tapering process has also been an important component, Dr. Locke said, noting that opioid use and persistent pain can be driven by unmet needs like uncontrolled depression, anxiety, and sleep deprivation. “Our clinic pharmacist providers are trained to address behavioral health concerns and sleep care, and we’re also getting more involved in substance use disorder management,” she said.
Word Is Spreading
The success of the opioid stewardship program has inspired a growing list of departments at Virginia Mason, such as rheumatology and neurology, to include pharmacists in the management of their patients receiving opioids for chronic pain.
Because managing opioid treatment in patients with neurological and movement disorders patients presents unique challenges, Virginia Mason brought Lorifel Nabong, Pharm.D., BCACP, on to its neurology clinic in early 2017. “It can be a challenge to manage medications. Patients may lose their prescriptions or tablets, so coming to the clinic to see a provider once a month or every three months for refills can reduce the likelihood of that happening,” said Dr. Nabong. “Meeting with patients more often also means they can be monitored more closely than they might be, if they were to have access only to their primary care provider.”
Lorifel Nabong, Pharm.D., BCACP, talks to a patient about how opioids affect brain function. Photo credit: Bob Riedlinger, Medical Photography Department at Virginia Mason
In addition to being an invaluable opioid management resource at the neurology clinic, Dr. Nabong has also seized upon other opportunities for medication therapy management. “I’ve been helping the team with a variety of conditions, including managing seizure medications for epilepsy, symptom relief medications for patients with multiple sclerosis, and finding financial assistance for patients with Parkinson’s disease who cannot afford the newer, more expensive medications,” said Dr. Nabong.
Both Dr. Nabong and Dr. Locke feel that greater pharmacist involvement in the opioid and pain management process has been an opportunity for health-system pharmacists to provide the high-level clinical care they are trained for. Moreover, their work has also freed other providers to practice at the top of their licenses.
“For example, two days a week of having a pharmacist see patients in the Physical Medicine and Rehabilitation Clinic has meant physicians can see an additional 1,200 patients annually,” said Dr. Locke. “And taking on some medication-heavy tasks that nurses were frequently called on to do — like creating a drug-tapering schedule — has allowed them to focus on providing the care that best fits their skill set.”
Group Sessions to Meet High Demand
Demand for pharmacist involvement in the care of patients receiving chronic opioid therapy has been so high at Virginia Mason that, at some clinics, offering group meetings has been the most effective way to reach as many patients as possible.
Emily Sullivan, Pharm.D.
Emily Sullivan, Pharm.D., Primary Care Pharmacist at Virginia Mason, meets with groups of six to 12 patients for 20 to 40 minutes, twice a month. “During the sessions, I talk about pain and opioids, and emphasize the effectiveness of complementary and non-opioid pain treatments,” she explained.
Despite the group format, Dr. Sullivan individualizes care by checking each patient’s prescription drug monitoring program record prior to a session and scouring their medical record for potential drug interactions. She also reviews their drug screens and writes naloxone prescriptions for patients receiving high-risk doses of opioids.
Dr. Sullivan said the group format offers patients an opportunity to ask questions, share their experiences, and learn about approaches that have been effective for others with persistent pain. “Something I like about the group format is that patients can see that they’re not alone. Pain can be very isolating, and meeting others who are in similar situations can alleviate some of that isolation,” she said. “Caring for patients using chronic opioids can be challenging, but the experience has been extremely rewarding.”
The results have also been rewarding for patients, including the woman who walked into Dr. Locke’s office receiving 1,300 MMEs per day. “Initially, as we were lowering her opioid dose, she said her pain was increasing, but after a while she also began noticing other things, like not dozing off on the couch as much at the end of the day, sleeping better, and being more active,” recalled Dr. Locke. “Now, two years after the initial visit, we’ve cut her opioid dose to 300 MMEs, and we plan to keep going until we reach 90 MMEs.”
By David Wild
