VA Health Services Research & DevelopmentState of the Art Conference on Opioid SafetyWorkgroupLong-term Opioid Therapy and TaperingVETERANS HEALTH ADMINISTRATION0
Workgroup Members—Thank You!Work Group FacilitatorsJoseph Frank, MD, MPHFriedhelm Sandbrink, MDJoanna Starrels, MD, MSWork Group MembersMelissa Christopher, PharmDSteve Dobscha, MDMark Edlund, MD, PhDGary Franklin, MDKeith Humphreys, PhDTerri Jorgenson, RPH, BCPSStefan Kertesz, MD, MScVETERANS HEALTH ADMINISTRATIONWork Group RecordersCarol Sison, MPHSarah ConroyErin Krebs, MD, MPHJennifer Murphy, PhDElizabeth Oliva, PhDIlene Robeck, MDMark Sullivan, MD, PhDDavid Thomas, PhD1
Workgroup #2:Long-Term Opioid Therapy & Opioid Tapering Multidisciplinary group with expertise in Psychiatry,Psychology, Pharmacy, Neurology, Addiction Medicine,Pain Medicine, Internal Medicine Current state of VHA pain care: Fear & mistrust are common Disconnect between policy & practice Multiple ongoing initiatives, some with unintendedconsequences Multiple meanings of ‘opioid tapering’VETERANS HEALTH ADMINISTRATION2
Workgroup #2:Long-Term Opioid Therapy & Opioid Tapering Focus on distinct audiences for SOTA recommendations: Veterans Operational partners Clinicians Funders ResearchersVETERANS HEALTH ADMINISTRATION3
SOTA Goal #1: Evidence Sufficient forImplementation Focus on actionable gaps between evidence, policy and currentpractice in VA No need to emphasize all evidence-based chronic paintreatments These treatments lack strong evidence related to taperingVETERANS HEALTH ADMINISTRATION4
SOTA Goal #1: Evidence Sufficient forImplementation1. Avoid initiation of long-term, high-dose opioid therapy forchronic pain2. Recommend individualized assessment of risks & benefits andindividualized implementation of opioid dose reduction Recommend against tapering without assessment of ordiscussion with patient Recommend against abrupt opioid tapering3. Recommend ongoing assessment of OUD and referral/treatmentin patients with OUDVETERANS HEALTH ADMINISTRATION5
SOTA Goal #1: Evidence Sufficient forImplementation4. Recommend system-wide access to team-based support foropioid tapering, including engagement with Patient Aligned CareTeam resources Team-based care may not be needed for all patients5. Support programs that provide intensive, multidisciplinarytreatment to support opioid dose reductionVETERANS HEALTH ADMINISTRATION6
SOTA Goal #1: Dissemination strategies A single, consistent, clear message from National PainManagement Program to all stakeholders Veterans & families Clinicians LeadershipCommunication: VA National Pain Management website Letters to Veterans Emails to cliniciansVETERANS HEALTH ADMINISTRATION7
SOTA Goal #2: Research Agenda Brainstorming to identify full range of research questions/issues Focused discussion to prioritize top 5 (or 8) questions Expansion of individual questions Discussion of methodologic issues (i.e., study design, dataquality)VETERANS HEALTH ADMINISTRATION8
What are the benefits and harms of opioiddose reduction and discontinuation? Benefits:––––Pain severityPain-related functionQuality of lifePatient satisfaction Harms:– Overdose– Mortality– Depression, anxiety– SuicidalityVETERANS HEALTH ADMINISTRATION– Substance use– Protracted withdrawalsymptoms Other:– Healthcare utilization– Retention in primarycare9
What are the benefits and harms of opioiddose reduction and discontinuation? Other issues:– Likely require observational designs and recruitment totapering studies is increasingly challenging– Patient-reported outcome data is critical– Include long-term follow up after tapering and incorporatenon-VA data– Include patient, system and other contextual factorsVETERANS HEALTH ADMINISTRATION10
What are strategies for safe, effective opioidtapering? Multiple potential strategies that require further study– Evidence-based for chronic pain care– Evidence-based for other chronic disease managementVETERANS HEALTH ADMINISTRATION11
What are strategies for safe, effective opioidtapering? Team-based care Mental Health integration Telehealth Peer support Non-pharmacologic care Longer PCP visits Medication management– Formulation– Rate,scheduleVETERANSHEALTH ADMINISTRATION Medication rotation– Buprenorphine– Naltrexone Clinician/stakeholdereducation Technology Family engagement Policy change12
What are strategies for safe, effective opioidtapering? Other issues:– Multiple large studies relevant to opioid tapering areongoing– Limited VA system capacity to host (and fund) largepragmatic trials– Unique interventions for special populations such as ruralVeterans– Important to assess patient, system and other contextualfactors– Important to assess cost-effectivenessVETERANS HEALTH ADMINISTRATION13
Is there any role for opioids for chronic pain? Among Veterans age 65 or older, what are the benefits &harms of low-dose, intermittent opioid medications comparedto non-opioid medications?– Including buprenorphine for chronic pain What are the characteristics of patients for whom the benefitsof low-dose, intermittent opioids medications outweigh risks?VETERANS HEALTH ADMINISTRATION14
Other research needs A taxonomy of tapering Complex persistent opioid dependence Importance of patient & provider perspectivesVETERANS HEALTH ADMINISTRATION15
A taxonomy of tapering ‘Tapering’ not monolithic–––––Any dose reductionPercent dose reductionPre-specified thresholds (90mg MED, 50mg MED)Change in medication or formulationElimination of benzodiazepine co-prescribing What is a successful taper?VETERANS HEALTH ADMINISTRATION16
Patient & provider perspectives Patients:– What is your understanding of current VA policy? What arebarriers to patient-centered opioid tapering? Providers:– What is your understanding of current VA policy? What arebarriers to patient-centered opioid tapering? Challenges:– Rapidly changing policy environmentVETERANS HEALTH ADMINISTRATION17
Defining complex persistent opioiddependence Limitations of DSM-5 criteria in context of long-termopioid therapy Opportunity for Delphi process to determine criteria forevaluation in future studiesVETERANS HEALTH ADMINISTRATION18
Other considerations: Feasibility VA system capacity is limited for multi-site pragmatic trials Opportunity for HSR&D to support rapid evaluation of clinicalinnovationsVETERANS HEALTH ADMINISTRATION19
Other considerations: Data quality & opportunities VHA data offers unique opportunity to assess long-termoutcomes But, patient-reported outcomes important and will requireinvestment in data collection infrastructure Novel data collection strategies include: Friend- & family-reported outcomes Technology-based dataVETERANS HEALTH ADMINISTRATION20
SOTA Goal #2: Dissemination strategies Propose research agenda in JGIM Supplement Support development of HSR&D funding opportunityVETERANS HEALTH ADMINISTRATION21
SOTA Goal #3: Emerging Issues National data collaboration National PDMP for research Consider non-VA stakeholders MISSION Act & Community Care Application to de-prescribing of other medications/substances Cannabis Stimulants Benzodiazepines Importance of culture change in pain managementVETERANS HEALTH ADMINISTRATION22
Workgroup Members—Thank You!Work Group FacilitatorsJoseph Frank, MD, MPHFriedhelm Sandbrink, MDJoanna Starrels, MD, MSWork Group MembersMelissa Christopher, PharmDSteve Dobscha, MDMark Edlund, MD, PhDGary Franklin, MDKeith Humphreys, PhDTerri Jorgenson, RPH, BCPSStefan Kertesz, MD, MScVETERANS HEALTH ADMINISTRATIONWork Group RecordersCarol Sison, MPHSarah ConroyErin Krebs, MD, MPHJennifer Murphy, PhDElizabeth Oliva, PhDIlene Robeck, MDMark Sullivan, MD, PhDDavid Thomas, PhD23
1. Avoid initiation of long -term, high-dose opioid therapy for chronic pain 2. Recommend individualized assessment of risks & benefits and individualized implementation of opioid dose reduction Recommend against tapering without assessment of or discussion with patient Recommend against abrupt opioid tapering 3.
3. the silver pulser for making Ionic colloidal silver. 4. the water ozonator for freshly ozonated water. CoMPLete UnIt InCLUDes one (1) . Magnetic Pulser MP5 by SOTA Instruments - The Magnetic Pulser MP5 is a magnetic products that can be used for greater health. Keywords: magnetic pulser, sota magne
4 Post-op Opioid Use Study of 39,140 opioid-naïve patients having major surgery 49.2% D/C with opioid prescription 3.1% on opioids 90 days after surgery 5 Post-op Opioid Use Study of 391,139 opioid- naïve patients having short-stay surgery 7.7% were prescribed opioids 1 year after surgery
Workgroup Bridge Mode 2 OL-18375-01 Note Although it functions as a bridge, an access point in workgroup bridge mode has a limited radio range. Workgroup bridges do not support the distance setting, which enables you to configure wireless bridges to communicate across several kilometers. Figure 1 shows an access point in workgroup bridge mode.
Antennas for SOTA By Fred Maas KT5X (aka WS0TA) INTRODUCTION SOTA peaks came "on-line" during the summer of 2011, and that's when I did my first activation. I elected to use a 20 meter dipole because I had one on hand. It used an RG58 feedline. I used cords wrapped around full water bottles to toss over branches to support the ends.
Opioid use disorder — a combination of opioid dependence and opioid abuse — is a medical condition that causes clinically significant patient impairment and distress. OUD includes the misuse of a range of opioid-classified drugs,
Opioid overdose was the main cause of the estimated 99,000-253,000 deaths worldwide related to illicit drug use in 2010.1 Opioid overdose is both preventable and, if witnessed, treatable (reversible). In its resolution 55/7 on promoting measures to prevent drug overdose, in particular opioid overdose, the
Naloxone for Opioid Overdose: FAQs Background Opioid prescribing doubled from the late 1990s to 2012, when pain treatment became the subject of several quality initiatives and practice guidelines.1-3 Prescription opioid overdose deaths quadrupled between 1999 and 2010, while heroin overdoses increased by 50%.4 Now, opioid
OMIClear Instruction A02/2014 Price List Versions Index 11.Apr.2014 Initial version. Revokes OMIClear Notice 03/2010 – Price List. 1.Feb.2015 Modification of the Price List, including: modification of the structure regarding the Fees on transactions in Futures, Forwards and Swaps .which depend on the monthly traded volume (now including 3 tiers of volume instead of 2). Clarification on the .