Managing Pain Together: Verona Clinic's New Opioids Protocol Benefits Clinicians and Patients

Department of Family Medicine (DFM) physicians and staff at the UW Health Verona Clinic have begun implementing a new protocol for patients who use controlled substances (i.e., opioids) for chronic pain.

By serving as a guiding framework for the opioid prescription process, the new protocol helps clinicians and patients work together to treat chronic pain efficiently, safely, and effectively.

Driving Forces

DFM Emeritus Professor John Beasley, MD provided the initial spark for the new protocol. Like all primary care physicians, he recognizes the challenges in prescribing opioids for chronic, non-malignant pain.

Dr. Beasley explained that although most patients who take opioids for chronic pain use the drugs as prescribed, there unfortunately are a few who abuse them.

Not only do physicians need a way to ensure that an individual patient is using the medication safely and appropriately, this information must be available to other physicians who may care for the patient.

At the same time, clinicians and patients need a structured way to collaboratively approach the pain management process.

"We need to make sure we're doing everything we can for patients with chronic pain," Dr. Beasley said. "This might include recommending alternate ways of relieving pain, helping patients get on a therapeutic plan, and making sure their other medical needs are met."

Protocol Design and Highlights

Dr. Beasley then formed a team of collaborators at Verona Clinic to develop the new protocol. Key members of the team included Jerri Ustby-Cruz Bye, RN, nursing supervisor; Brian Earley, DO; and Brian Arndt, MD.

According to Dr. Beasley, the goal was to create a practical, working process that codifies minimum standards without replacing individual clinician discretion. Highlights include:

• Defining which patients are eligible to participate in the protocol.
• Establishing and/or maintaining a written opioid pain management agreement between patients and clinicians.
• Documenting patients' chronic pain diagnosis and opioid pain management agreement status in their electronic medical record (EMR).
• Requiring pain management clinic follow-ups every three months, and random urine drug screens at least once a year.
• Limiting prescriptions to a three-month supply (including refills).
• Creating a Chronic Controlled Substances Review and Advisory Group (CCSRAG) for ongoing oversight.

The group has also created educational materials to help patients better understand the overall pain management process. These materials explain how opioids work, clarify roles and expectations of both the patient and the health care team, and describe the specific protocol guidelines.

Implementation and Review Processes

The clinic began implementing the protocol in March, and according to Ustby-Cruz Bye, several patients are already scheduled for follow-up visits.

A critical part of implementation is identifying all eligible patients already in the system and ensuring that they participate in the protocol—one of the first big jobs for the CCSRAG.

As chair of that group, Dr. Beasley credits Dr. Earley for helping to clearly define patient eligibility, and Dr. Arndt for using data pulled from the EMR system to create a registry of those patients.

Once the protocol is firmly in place, the CCSRAG will then perform an annual review of patients who use opioids for chronic pain. The group will also review—on a case-by-case basis—situations where patients have not followed the opioid pain management agreement.

In the future, the group hopes to identify other types of drugs at risk for misuse that could be used in similar protocols.

Right now, though, having a centralized review group and a process in place is an important step. "This protocol will help us more proactively meet our patients' needs," says Ustby-Cruz Bye. "Not only will it reduce the likelihood of opioid abuse, it will help us make sure patients receive all possible therapies for their chronic pain."