ADAPTING A COLLABORATIVE CARE MODEL TO FACILITATE REDUCTION OF HIGH DOSES OF PRESCRIPTION OPIOIDS IN COMMUNITY DWELLING ELDERS

Abstract

Introduction In 2008, the Pennsylvania Department of Aging (PA DoA) and its pharmacy benefits programs for low- to low-middle income older Pennsylvanians—the Pharmaceutical Assistance Contract for the Elderly (PACE) and PACE Needs Enhancement Tier (PACENET)—partnered with the University of Pennsylvania (Penn) to establish a telephone-delivered clinical service that supported geriatric patients and their primary care providers in delivering mental health care integrated within the primary care setting. This evidence-based collaborative care service improved outcomes for elderly Pennsylvanians with disorders of mood or cognition. In the context of the current opioid epidemic, PACE/PACENET and Penn agreed to pilot a new telephone-delivered collaborative care service to help geriatric patients with chronic pain who receive continuing prescriptions for very high doses of opioids. Objectives: To report preliminary findings from a pilot project that adapted an existing collaborative care service to facilitate reduction of high doses of prescription opioids in community dwelling elders. The principle aims were to measure levels of patient participation and engagement, and to determine the extent to which engaged patients and their prescribers achieve opioid dose reduction. Methods Patient Sample: From May through October 2018, a convenience sample of elderly patients receiving chronic opioid prescriptions for > 120 mg morphine-equivalent dose (MED) was referred by PACE/PACENET to the Penn collaborative care service. Clinical Intervention: Patients who agree to participate undergo comprehensive assessments of mental health, cognition, sleep, pain, and functional status by a Behavioral Health Lab (BHL) technician. Measures include the Patient Health Questionnaire-9 (PHQ-9); Generalized Anxiety Disorder -7 (GAD-7); Blessed Orientation-Memory-Concentration test (BOMC); Insomnia Severity Index (ISI); Pain intensity, interference with Enjoyment of life, and interference with General activity (PEG); pain self-efficacy questionnaire (PSEQ); and Veterans RAND 12-item Health Survey (VR-12) for mental and physical function. A follow up baseline interview with a BHL clinician (LSW or RN) includes self-reported daily opioid dose, assessment of medical-psychiatric co-morbidity, other medications and pain treatment modalities, and identification of unmet biopsychosocial needs. The BHL clinician engages the patient in individualized treatment planning, with emphasis on goals of opioid dose reduction to safer levels. Modalities of treatment offered include but are not limited to (1) behavioral pain management, (2) general medication education, (3) reinforcing positive health behaviors, (4) addressing barriers to change, (5) scheduling positive activities, and (6) relaxation techniques. Summary reports are sent to prescribers with recommendations for pain care management and opioid dose reduction. Program Evaluation: “Participation” was defined as patient agreement to participate in the initial health assessment with a BHL technician. “Engagement” was defined as completion of the baseline health assessment and at least two follow-up contacts with a BHL clinician. “Substantial dose reduction” was defined as at least 20% reduction from the self-reported baseline MED within the first 12 weeks of program engagement. Results 71 patients were referred over the first 5 months, 3 of whom were unable to participate due to communication barriers. Of the remaining 68 eligible patients, 49 (72%) participated in the initial health assessment. Of these participants, 25 (36.8% of eligibles) had at least 2 follow-up contacts with a BHL clinician and were considered “engaged” in the program. Participants’ mean age was 73.9 years (range, 65-87); 61.5% were male; 94.2% were White, 1.9% were Black; 96.2% were non-Hispanic, 1.9% were Hispanic. Participants’ mean PHQ-9 score was 8.3; mean GAD-7 score 4.3; mean BOMC score 4.1; and mean ISI score was 6.3. Mean baseline PEG and PSEQ scores were 7.1 and 6.0, respectively. Mean VR 12 mental health score was 47.4 indicating average overall functioning, and VR-12 physical score was 20.4 indicating low overall functioning. Of the 25 engaged patients, 21 (84%) achieved dose reductions, with a mean MED of 420 mg on initial assessment and 276 mg at the last contact. 36% of engaged individuals achieved dose reductions of >20%. Conclusions In this pilot program for elderly patients taking very high doses of prescription opioids, we found a high rate of participation in the initial assessment, and a moderate rate of engagement in follow-up. Although 36% of the engaged patients achieved substantial opioid dose reductions, these patients were still receiving unsafe doses. Nevertheless, these findings suggest that it is possible to adapt a collaborative care model to help some older adults achieve substantial reductions from high doses of prescription opioids. This research was funded by Pennsylvania Department of Aging