Associate Professor of Pallative Medicine at the University of Michigan
About
Dr. Silveira is an associate professor in palliative medicine at the University of Michigan and a clinical scientist at the Ann Arbor Veterans Affairs Medical Center (VAMC). Dr. Silveira was moved to become a pioneer in palliative care after witnessing the unaddressed suffering of countless patients during her medical school training in the 1990's. After completing her clinical training, she studied health services research through the Robert Wood Johnson Clinical Scholars Program. Early in her research career, Dr. Silveira conducted observational studies to document the high symptom burden among patients at the end of life, examine the use of advance directives, and demonstrate the relationship between economic status and symptom control. Inspired to improve the lives of the patients Dr. Silveira studied and saw in clinic, she has devoted the last 10 years to developing information technology to support patients with symptoms so that they may access safe and effective symptom management advice, communicate more efficiently and effectively with their clinicians, and involve their family caregivers.
Current Work:
Thousands of veterans are prescribed opioids every year to manage pain. Opioids carry significant risks, including side effects, addiction, overdose, and death. Despite this risk, most would agree that in the setting of severe cancer pain, the risk/benefit analysis favors the use of opioids. The question then becomes, "How can we help veterans with cancer pain take their opioids safely?" Dr. Silveira hypothesizes that targeted, clinical pharmacist support for veterans taking opioids for cancer pain can reduce pain severity, opioid-related side effect burden, and the number of moderate to severe adverse events. Dr. Silveira proposes to test this hypothesis through a randomized controlled trial of a program that monitors veterans' pain, side effects, and opioid use in order to alert a clinical pharmacist when veterans are non-adherent to opioids, or experience side effects or poorly controlled pain in order for the clinical pharmacist to target those veterans for additional support.
Veterans age >=65 with a "solid tumor" who are receiving an opioid (e.g. morphine) for cancer pain will be invited to enroll in the study; those who demonstrate regular opioid use during a 1-week monitoring-only period will be entered into the 10-week, randomized, controlled trial. Dr. Silveira will use automated telephonic symptom assessment technology to measure pain and side effects (weekly), and electronic pill caps to measure opioid use (daily), in order to enhance patient monitoring without burdening patients with face-to-face or telephone encounters to report data, and focus clinical pharmacist time upon those patients with demonstrable difficulties. Clinical pharmacist activities related to the intervention will be tracked in order to determine which tasks might be able to be accomplished by other clinicians. Costs of the intervention will be tracked to inform future implementation. There will be an additional 2 weeks of monitoring after the trial is completed to determine if effects are lasting. Dr. Silveira's specific aims are: 1) To test in a randomized, controlled trial whether 10 weeks of targeted clinical pharmacist support to veterans taking opioids for cancer pain can reduce pain, side effects, and adverse events; 2) To test the mediating effect of opioid adherence on the efficacy of a of clinical pharmacist intervention to manage pain and side effects in cancer patients taking opioids for pain; 3) To calculate the per patient costs of each study arm, using service use, medication costs and clinical pharmacist time as inputs; 4) To evaluate the validity of self-reported adherence to opioids and pill counts against real time data obtained from electronic pill caps.
Dr. Silveira's team is the first to test the efficacy of clinical pharmacist support for patients taking opioids for cancer pain in a rigorous fashion. They are the first to use electronic monitoring of symptoms and medication use to target the activities of a clinical pharmacist to patients with demonstrated need for support. The results of this study will yield an evidence-based intervention to address the needs of older veterans taking opioids for cancer pain, cost estimates to inform implementation of the intervention, and process data that can be used to adapt the intervention for administration by other types of providers. Their long-term goal is to develop a cost-effective intervention that can be implemented throughout veterans affairs to assist in its ongoing efforts to curb the epidemic of opioid-related morbidity and mortality by providing a mechanism for intensely monitoring and supporting veterans taking opioids. In this study, Dr. Silveira's team focuses on older veterans with cancer because they are a population who is especially at risk for medication non-adherence, opioid-related side effects, and adverse events.
Research Area Keyword(s):
Palliative care, caregiving, symptom management, pain, opioids
