Table 1.
Rationale and definition of each metric
| Domain and metric | Rationale | Definition |
|---|---|---|
| Side effects management | ||
| Bowel regimen | A bowel regimen should be considered in all patients prescribed an opioid because opioid medication causes slowing of intestinal motility and untreated constipation may be a significant contributor to opioid nonadherence and patient dissatisfaction with OT (pp. 37, 54, 55). | Proportion of patients with an outpatient opioid prescription who are prescribed a bowel regimen. |
| Serious adverse effects | Increases in opioid prescribing nationally have been associated with increases in rates of opioid-related serious adverse effects such as overdose mortality (p. 26), prescription pain medication misuse, and opioid-related emergency department visits [20]. Opioids may be used in suicide attempts, and opioid-related sedation may contribute to increased accident risk. Examining rates of serious adverse effects may help facilities target efforts to decrease opioid-related risk. | Proportion of patients with evidence of a serious adverse effect that might be related to OT in the 6 months following an opioid prescription. |
| Dangerous drug interactions | ||
| Risky sedative coprescription | Co-prescribing of sedative medication with outpatient opioids is common and increases risk of overdose. Analysis of data on opioid-related overdose deaths suggests that the majority of opioid-related overdoses involve coingestion of other drugs, most commonly sedative medications [21]. Combining opioid and sedative medications may also increase risk of accidents [22]. Coprescribing is of particular concern among patients with respiratory problems and sleep apnea (pp. 18, 91–92). | Proportion of patients with overlapping prescriptions for an outpatient opioid and a barbiturate, benzodiazepine, or carisoprodol |
| Acetaminophen overprescription | Acetaminophen poisoning is a leading cause of liver toxicity [23]. Most current guidance is that patients consume no more than 4 g of acetaminophen per day, however, given concerns about opioid combination products, the FDA recommends less than 4 g/day. There are many combination opioid and acetaminophen products as well as prescription and over-the-counter acetaminophen products, and patients are often not aware and may not inform their provider about other acetaminophen use. The CPG specifically recommends (p. 52): “When using combination products, do not exceed maximum recommended daily doses of acetaminophen, aspirin, or ibuprofen.” | Proportion of patients with overlapping prescriptions that total more than 3 g/day or more than 4 g/day of acetaminophen. |
| Misuse risk: Psychiatric at-risk SUD | ||
| Chronic OT should be initiated with caution in patients receiving treatment for SUDs (p. 25). Chronic OT is absolutely contraindicated in patients with active SUDs not in treatment (p. 25). History of SUD is a strong predictor of increased risk for prescription opioid misuse [10], and patients in recovery often express concern about taking opioid medications for fear of triggering a relapse. Active, regular monitoring of illicit substance use and adherence to the prescribed opioid regimen is strongly recommended in all patients (p. 60), but crucial in this high-risk population. | Proportion of patients with a SUD diagnosis not in remission seen in a specialty SUD setting for SUD treatment AND with UDSs/labs within every 90 days supply of the opioid. | |
| Appropriate follow-up | ||
| Patients should have follow-up contact with their provider no longer than 2–4 weeks after dosage modifications, or other treatment adjustments, basing the frequency of follow-up on the clinical situation (p. 44). Opioid naive patients are at particularly high risk during initiation. | Proportion of new opioid prescriptions where patients have a clinical encounter with VA within 4 weeks. This metric is for opioid naive patients receiving their initial prescription. | |
| Avoidance of sole reliance on opioids | ||
| Psychosocial treatments | Cognitive–behavioral therapy and biofeedback for pain are mental health treatments recommended to reduce pain and improve function in chronic pain patients [24, 25]. Because it is not possible to identify cognitive–behavioral therapy for pain specifically, this measure looks over-inclusively for evidence of any type of mental health treatment in patients receiving an opioid prescription. | Proportion of OT patients who receive any of the following treatments within the year: (1) Coping skills/stress management training; (2) Psychotherapy procedures |
| Other pharmacotherapies | There are a number of other medications or medication classes that have been shown to be effective for the treatment of chronic pain or a subtype of chronic pain (e.g., neuropathic pain; p. 87). This measure assesses use of these other pharmacotherapies in patients who receive an opioid prescription. | Proportion of patients with an opioid prescription who also received any of the following within the year: (1) Non-opioid analgesics including nonsteroidal anti-inflammatory drugs and acetaminophen; (2) Tricyclic antidepressants; (3) Serotonin–norepinephrine reuptake inhibitors; (4) Anticonvulsants; and (5) Topical medications. |
| Rehabilitation medicine | Treatment of chronic pain requires care to recover or maintain physical, social, and occupational function. This metric includes physical therapy, recreational therapy, occupational therapy, chiropractic, weight loss program, and pain clinic encounters. | Proportion of OT patients who receive treatments to increase activity including: (1) physical therapy; (2) occupational therapy; (3) special populations therapy; (4) recreational therapy; (5) pain clinic; and (6) others. |
| Complementary and alternative medicine treatments | This category includes complementary and alternative medicine clinic encounters, massage, acupuncture, biofeedback, hypnotherapy, and music therapy. | Proportion of OT patients who receive treatments considered complementary and alternative therapies. |
| Safe and effective prescribing practices | ||
| Absolutely contraindicated opioid prescriptions | High-dose formulations are dangerous and can cause overdose/respiratory arrest in opioid-naive patients (pp. 37–38). They should never be prescribed to patients without an existing prescription and tolerance to another opioid formulation. | Number of new opioid prescriptions that are for a high-dose opioid formulation. |
| Medication management/pharmacy reconciliation | Pain patients frequently have complex comorbid conditions that make them more likely to be receiving multiple medications, which can interact in harmful ways with opioid medications. A review of medications by a pharmacist or other health care professional can prevent harmful interactions between these medications. | Proportion of OT patients with evidence of medication management or pharmacy reconciliation. |
| Ordering of appropriate lab tests | ||
| All patients receive UDSs/screens | The use of drug screens to assess for illicit drug use and adherence to prescribed medications is strongly recommended in all chronic pain patients prescribed opioids (pp. 60–61). | Proportion of patients receiving an opioid prescription that received the following: (1) drug screen for nonopioid abusable substances; (2) drug screen for heroin/morphine; and (3) drug screen for nonmorphine opioid compounds. |
Page numbers refer to the 2010 VA/DoD CPG
SUD substance use disorder, UDS urine drug screen, OT opioid therapy