An Interdisciplinary Pain Rehabilitation Program for Veterans with Chronic Pain: Description and Initial Evaluation of Outcomes.

Objective: Chronic pain conditions are prominent among Veterans. To leverage the biopsychosocial model of pain and comprehensively serve Veterans with chronic pain, the San Francisco Veterans Affairs Healthcare System has implemented the interdisciplinary pain rehabilitation program (IPRP). This study aims to (1) understand initial changes in treatment outcomes following IPRP, (2) investigate relationships between psychological factors and pain outcomes, and (3) explore whether changes in psychological factors predict changes in pain outcomes. Methods: A retrospective study evaluated relationships between clinical pain outcomes (pain intensity, pain disability, and opioid use) and psychological factors (depressive symptoms, catastrophizing, and "acceptable" level of pain) and changes in these outcomes following treatment. Multiple regression analysis explored whether changes in psychological variables significantly predicted changes in pain disability. Results: Catastrophizing and depressive symptoms were positively related to pain disability, while "acceptable" level of pain was idiosyncratically related to pain intensity. Pain disability and psychological variables showed significant changes in their expected directions. Regression analysis indicated that only changes in depressive symptoms significantly predicted changes in pain disability. Conclusion: Our results are consistent with evidence-based clinical practice guidelines for the management of chronic pain in Veterans. Further investigation of interdisciplinary treatment programs in Veterans is warranted.

Implementing an opioid risk assessment telephone clinic: Outcomes from a pharmacist-led initiative in a large Veterans Health Administration primary care clinic, December 15, 2014-March 31, 2015.

BACKGROUND: In response to the national epidemic of prescription opioid misuse and related adverse outcomes, two clinical pharmacists developed a telephone risk assessment clinic to promote safe opioid prescribing through a monthly assessment of patient medication use, aberrant behaviors, and side effects. METHODS: A pilot group of five primary care providers and their patients with chronic nonmalignant pain on chronic opioid therapy, defined as having received prescription opioid medications for ≥90 days in the last 120 days, were identified. A risk assessment evaluation based on Veterans Health Administration/Department of Defense Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain was created. Factors assessed were receipt of non-San Francisco Veterans Administration Health Care System controlled substance prescriptions through California's prescription drug monitoring program, urine drug test (UDT) results, and aberrant behaviors. Pharmacist-recommended changes to regimen and provider response to recommendation were compiled. The pilot was conducted from December 15, 2014, to March 31, 2015. RESULTS: Among 608 patients on chronic opioid therapy, 148 were assigned to pilot providers and 447 assessments were completed. Twenty-five (16.8%) patients had non-VA controlled substance prescriptions, of which 14 (56.0%) patients filled a non-VA controlled substance within 3 months of the start of pilot. Seventeen UDT results inconsistent with their prescribed regimens were identified from 12 patients (8.1%). Pharmacists recommended 66 changes to chronic opioid prescriptions in 48 patients (32.4%), including decreasing quantity of opioid(s) (33.3%), discontinuing chronic opioid therapy (22.7%), and delaying a fill (19.7%). Sixty-one of 66 (92.5%) pharmacist recommendations for regimen change were implemented by providers. Chronic opioid therapy was discontinued in 14 (9.5%) patients over the course of the pilot study. CONCLUSIONS: A pharmacist-led telephone risk assessment clinic improved adherence to clinical guidelines and changed opioid prescribing practices in more than one third of assessed patients.

Conivaptan for treatment of hyponatremia in neurologic and neurosurgical adults.

OBJECTIVE: To review the literature evaluating the clinical safety and efficacy of conivaptan in the management of hyponatremia in a neurologic and neuro-surgical adult patient population. DATA SOURCES: A literature search was conducted using MEDLINE, EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials (1966-May 2013). Search limits were English, human, and adult using the terms vasopressin receptor antagonist, conivaptan, tolvaptan, lixivaptan, neurology, neurological disorder, neurosurgery, neurointensive care, and neurocritical care. STUDY SELECTION AND DATA EXTRACTION: All case reports, case series, and clinical trials investigating the use of conivaptan in neurosurgical patients were included. DATA SYNTHESIS: Seven reports were identified using conivaptan as monotherapy or adjunctive treatment for hyponatremia in a neurosurgical patient population. One study was a prospective, randomized, controlled trial, while 6 reports were case reports or case series. The prospective randomized trial found a significant increase in serum sodium concentration over baseline with a conivaptan 20-mg intravenous bolus dose followed by a 20-mg/day continuous infusion for 24 hours compared to "usual care" at 6 hours (7.0 ± 1.7 vs -0.6 ± 2.1 mEq/L, respectively; p = 0.008) and 36 hours (8.0 ± 5.6 vs -1.7 ± 2.1 mEq/L, respectively; p = 0.05) after treatment. One case series found that the mean serum sodium remained significantly increased from baseline up to 72 hours (5.12 ± 4.0 mEq/L; p < 0.001) after a single conivaptan 20-mg intravenous bolus dose. All reports demonstrated clinical effectiveness of conivaptan in significantly increasing serum sodium concentrations following administration compared to baseline. However, the clinical significance of this finding remains debatable since some of these patients remained hyponatremic. CONCLUSIONS: Overall, conivaptan is a promising and well-tolerated agent for the management of hyponatremia in neurologic and neurosurgical patients. However, its use should be limited to patients in whom conventional therapies fail or as adjunctive therapy.