The Victorian Order of Nurses (VON) Chronic Pain Program provides service to the Erie St Clair LHIN and consists of two nurse practitioners (NP), a nurse case manager, two social workers and an administrative assistant. With the evolving landscape of chronic non-cancer pain and the opioid crisis, this team has grown to meet the challenging needs of this complex population.
Addressing problems with opioid use and opioid use disorder with buprenorphine/naloxone (Bup/Nal) emerged as a gap in the chronic non-cancer pain population. The VON Chronic Pain Program addressed this by developing the capacity to offer Bup/Nal as a treatment option by optimizing the scope of the NP’s expanded prescribing practices, providing case management with the nurse, and counselling support with the social workers.
Health Quality Ontario had a chance to catch up with Jennifer Burton, NP, to learn more about this community-based approach to supporting patients with chronic non-cancer pain population.
How did you identify the need for Bup/Nal in the chronic non-cancer pain population?
Many patients referred to the VON Chronic Pain Program are on long-term opioid therapy (LTOT) for chronic non-cancer pain. Some of these individuals have high pain scores, decreased function and poor quality of life. Our assessment often reveals medical complications associated with LTOT, unsuccessful attempts at tapering and at times, mild to moderate opioid use disorder.
Patients often fall through the cracks because they feel stigmatized seeking treatment at an addiction clinic, however they meet criteria for treatment with Bup/Nal.
We found this to be a gap in our community since primary care is often reluctant to offer therapy outside of addiction clinics without appropriate support. We had patients requesting rotation to Bup/Nal but were unwilling to attend an addiction clinic for treatment, primarily due to the associated stigma.
With the support of the local addiction clinics and accessible educational opportunities, Megan Miinch, RN, and I began learning more about Bup/Nal and developed a protocol for assessing and offering this therapy within our program.
How did you prepare to manage patients in your program with Bup/Nal?
Continuing education and evidence-based practices
We accessed several continuing education and evidence-based practices including:
Physician shadowing and partnership
We spent time in the local addiction clinics to shadow the physicians and gain clinical experience assessing patients. We had the opportunity to see patients prior to and during treatment with Bup/Nal.
We consult weekly with our physician partner to discuss our patient cases and determine the most appropriate plan of care for patients who have been referred to our program.
Preceptorship
We connected with a registered nurse through Project Hope for a preceptorship in assessing and monitoring the use of Bup/Nal for opioid use disorder. She spent time with us, supervising a Bup/Nal induction in person with one of our patients. She also continues to provide support and mentorship via email and phone when needed.
What is your protocol for starting and managing patients on Bup/Nal?
Patients are offered Bup/Nal when they are on opioids and have not seen success with a traditional taper or rotation, have medical complications of LTOT, or if a mild to moderate opioid use disorder is identified according to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria.
We counsel patients on the pharmacology and logistics of Bup/Nal. We work with patients to establish treatment goals and ensure patients are given plenty of time to ask questions and make informed decisions.
We collaborate with the patients’ primary care provider and the pharmacy to outline the plan of care. Written instructions are provided to the patient in advance with a planned induction date and time. Inductions occur early in the day and early in the week to ensure ease of access to our program or other service providers.
We make daily phone calls during the first week of therapy and conduct a follow up visit on day three. Subsequent visits are arranged biweekly or monthly during the maintenance phase. We frequently revisit the therapy goals as therapy continues.
We have developed and adapted assessment tools to monitor patients’ progress in our Electronic Medical Record (EMR). We assess mental health and offer counselling support with our social worker and encourage patients to regain or maintain an active lifestyle.
What are your next steps?
Our next steps are to help build capacity and confidence within primary care, with a goal of transitioning patients back to their primary care providers once in the maintenance phase of treatment with Bup/Nal.
We are facilitating educational opportunities at local family health teams and community health centres, offering to continue collaborating in the care of these patients and empowering patients to explore this as a safer option in the active treatment of their chronic pain.
The ultimate goal is to improve accessibility and remove the stigma associated with this therapy.
Need help supporting your patients in managing their pain? Visit the Ontario Pain Management Resources for a coordinated program of tools from partner organizations across the province.