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Opioid Use Review Clinic

Pharmacist explaining prescription medicine to attentive senior couple
During a one-time, hourlong session, Opioid Use Review clinic staff talk with Veterans about their pain, discuss ways to improve quality of life and provide opioid safety education, either in person in Pittsburgh or via telehealth at regional VA outpatient clinics.

Since 2014, more than 55 people* who may have otherwise overdosed and died have been saved with naloxone rescue kits issued to Veterans by VA Pittsburgh Healthcare System.

While that is an amazing fact, it is a small number compared to the more than 70,000* people in the U.S. who died from drug overdoses in 2017. Naloxone may have helped to save lives in many of those cases.

Also known by the brand name Narcan, naloxone is a medication with the potential to reverse opioid overdoses. It is sometimes prescribed by VA Pittsburgh's Opioid Use Review (OUR) Clinic.

Primary Care Chief Dr. Walter Clark, who is certified in addiction medicine, and two doctors of pharmacy started the clinic in 2017. The clinic helps other VA providers care for Veterans whose prescribed opioid use meets specific criteria. That criteria, Clark said, includes: "Any veteran on an opioid regimen for whom there is even the slightest concern. Any veteran who has not been fully evaluated in a standard manner as advised by the Centers for Disease Control and Prevention and Veterans Affairs/Department of Defense clinical guidelines for chronic (long-term) opioid therapy for chronic non-cancer pain." 

Veterans on long-term opioid therapy who are newly enrolled or haven't been seen at VA in a while should also be evaluated in accordance with the Comprehensive Addiction and Recovery Act (CARA), Clark said. 

Signed into law by Congress, CARA was introduced by Congress in 2016 in response to the U.S. opioid epidemic. The law addresses education, intervention, prevention and expanded access to naloxone. 

During a one-time, hourlong session, OUR clinic staff talk with Veterans about their pain, discuss ways to improve quality of life and provide opioid safety education. Veterans speak with Clark and a pharmacist either in person in Pittsburgh or via telehealth at regional VA outpatient clinics. 

According to pharmacist Amy Plumley, many Veterans are concerned VA will take away their opiates. 

"It's a review clinic," Plumley said. "It may be totally appropriate for them to be on what they're on. But we know for some patients, keeping them on these medications is potentially dangerous."

VA providers often point Veterans in this category toward additional alternative therapies, including acupuncture and yoga, and more intensive therapies, like VA Pittsburgh's 12-week Interdisciplinary Pain Rehabilitation Program

Plumley said the OUR clinic uses quality of life assessments to see how each Veteran's pain/medication affects their activities. 

"What are their goals? Are they trying to run a marathon? Or do they just want to play with their grandkids?" Plumley said. 

Some Veterans want to be on the least amount of medication possible so they can do basic chores and hobbies, like car repairs or cutting the grass, said Beth Desanzo, the other clinic pharmacist.

"They want to be able to hunt and fish," Desanzo said. "Maybe their hunting goal is not going to do a full deer drive like they did when they were 20. Maybe it's getting from the truck over to the tree stand." 

Safety considerations, like whether the Veteran is using drugs and alcohol, and other factors also come to light during sessions.

"We know things can get into the wrong hands. With Narcan, if you are in a situation where you can use this on someone else to save their life, do so," Plumley stressed. "We do have Veterans with grandkids or nieces or nephews who have a drug abuse problem, and the Veteran is concerned about that. We'll replace it if they use it on someone else." 

Both Plumley and Desanzo said they believe the clinic can be easily replicated at other VA health care systems nationwide.

*Naloxone rescue data provided by VA Pittsburgh's Center for the Treatment of Addictive Disorders. National overdose death data is from the Centers for Disease Control and Prevention.

Writer's notes: The most commonly used opioids at VA Pittsburgh include codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine and oxycodone. Veterans who are prescribed naloxone by any VA Pittsburgh provider must complete training on safely using the device.

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