VA’s Erica Sprey, host of the podcast series “Voices of VA Research,” speaks with Dr. Joseph Frank, both a primary care physician at the VA Eastern Colorado Health Care System in Denver and a researcher at the Center of Innovation for Veteran-Centered and Value-Driven Care. Dr. Frank’s research is focused on improving care for Veterans who are living with chronic pain—especially strategies for safely tapering the use of long-term opioid medication. Listen to the full discussion here — an excerpt of the discussion is below
Can you tell me about the work you are doing for VA?
As a primary care physician, I am particularly interested in how we provide chronic pain care in primary care settings. I have pursued three related lines of research that are important to me as a physician. The first of those is for patients who are taking opioid medications long term. For these patients, the process of stopping or reducing those medications—sometimes referred to as opioid tapering—can be very challenging. We need to understand how to deliver high-quality pain care during and after opioid tapering.
The second line of research focuses on who delivers this care. As with many chronic conditions, primary-care physicians are most effective when working as part of a team. I am interested in how we should design teams in primary care to deliver pain care that is patient-centered and effective.
And finally, as a primary care physician, I know it’s critical that we help patients get involved in and lead their own plans for pain management. As a researcher, I believe this means we must also help patients get involved in pain research; therefore, I am very interested in how we can better involve patients in all phases of the research process.
Can you tell me what the VA policy is for tapering or reducing opioid doses in Veterans?
VA policy is guided by the most recent guidelines released by the Departments of Veterans Affairs and Defense. The guideline was released just last year in 2017. The guideline recommends that for patients who are on long-term opioids, it is important to assess the risks and benefits of ongoing treatment with opioid medications for the individual Veteran. That guideline also notes that it is important to assess the risks and benefits of tapering. This is challenging currently because we don’t have much evidence to help providers assess those risks and benefits. So the decision-making is challenging, but importantly should focus on the individual Veterans and their unique needs.
Importantly, what that policy does not include is a recommendation to reduce opioid dose based on dose alone or without attention to individual risks and benefits. I think a place where we risk getting beyond the evidence, beyond the VA guidelines, and other related guidelines is by unilaterally making changes to medications that don’t take into consideration an individual patient’s unique needs.
In an article published in Pain Medicine, you interviewed primary care physicians to find out about their experiences with tapering opioid therapy. What did they say are the barriers and harms associated with tapering opioid therapy?
We conducted focus groups with 40 providers across three health care systems here in Denver, Colorado. We identified three key themes related to their perceived barriers to opioid tapering. First, providers that we spoke with described discussions of opioid tapering with their patients to be uniquely emotionally charged, and at times, exhausting. Health care systems are asking providers to have these conversations more often these days, and it’s important that we recognize the impact on providers as well as the impact on patients.
Second, providers described a sense that they had inadequate resources to support opioid tapering, specifically, but also chronic pain care generally. They described a lack of training specific to this process, as well as a lack of other team members and resources in their clinics and communities.
And third, they reported that opioid tapering did not go well when there was a lack of trust between their patient and themselves.
You also mentioned in that study that you identified some facilitators or best strategies that would help primary care physicians safely taper long-term opioid therapy. Can you tell me what those are?
In addition to barriers, the primary care physicians that we spoke with also identified strategies that they found helpful. They noted the importance of empathizing with their patients’ experiences—both their experience of pain and their concern about making medication changes. We have learned from patients that this process can be very anxiety-provoking. And so providers noted the importance of acknowledging that anxiety.
Providers also described opioid tapering as a long-term process that benefits from planning and preparation. They described ways in which working with individual patients to think long-term about goals as it relates to the medication was a productive process.
And finally they reported feeling supported by guidelines and local policies that sought to standardize care processes related to opioid prescribing and opioid tapering.
What types of strategies would you like to see developed to help primary care physicians work with chronic pain patients and assist them in tapering opioids?
That’s an important question. I think first it takes a team. And in a system like the VA, it will take guidance to help teams develop effective processes in their own local sites. Primary care providers, nurses, psychologists, pharmacists—the list goes on. Each provider has a unique expertise that may be helpful to patients during opioid tapering. The challenge ahead is to create systems that connect each patient with the right team at the right time during opioid tapering and chronic pain management generally.
The VA is leading in this area with some very interesting work to compare different types of teams and to understand which Veterans benefit from which team structure. It will be important that we learn from those ongoing studies and as researchers try and help leaders in VA integrate those lessons into routine care as quickly as we can.
I’ll mention two other resources that I think are potentially impactful in VA. The first is an important role for peer support. While I as a primary care physician try to help my patients know what to expect during opioid tapering, I think a fellow Veteran who has been through the process can provide practice insights and support that I just can’t match.
And finally, as we discussed, opioid medications are just one tool in the chronic pain toolkit. I think it’s important that we continue to improve Veterans’ access to the full range of treatments and continue to improve the quality of evidence that guides our approach to multimodal pain care.