IMPORTANCE Prescription opioid misuse is a national crisis. Few interventions have improved adherence to opioid-prescribing guidelines.OBJECTIVE To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk. DESIGN, SETTING, AND PARTICIPANTSCluster-randomized clinical trial among 53 primary care clinicians (PCCs) and their 985 patients receiving long-term opioid therapy for pain. The study was conducted from January 2014 to March 2016 in 4 safety-net primary care practices.INTERVENTIONS Intervention PCCs received nurse care management, an electronic registry, 1-on-1 academic detailing, and electronic decision tools for safe opioid prescribing. Control PCCs received electronic decision tools only. MAIN OUTCOMES AND MEASURESPrimary outcomes included documentation of guideline-concordant care (both a patient-PCC agreement in the electronic health record and at least 1 urine drug test [UDT]) over 12 months and 2 or more early opioid refills. Secondary outcomes included opioid dose reduction (ie, 10% decrease in morphine-equivalent daily dose [MEDD] at trial end) and opioid treatment discontinuation. Adjusted outcomes controlled for differing baseline patient characteristics: substance use diagnosis, mental health diagnoses, and language.RESULTS Of the 985 participating patients, 519 were men, and 466 were women (mean [SD] patient age, 54.7 [11.5] years). Patients received a mean (SD) MEDD of 57.8 (78.5) mg. At 1 year, intervention patients were more likely than controls to receive guideline-concordant care (65.9% vs 37.8%; P < .001; adjusted odds ratio [AOR], 6.0; 95% CI, 3.6-10.2), to have a patient-PCC agreement (of the 376 without an agreement at baseline, 53.8% vs 6.0%; P < .001; AOR, 11.9; 95% CI, 4.4-32.2), and to undergo at least 1 UDT (74.6% vs 57.9%; P < .001; AOR, 3.0; 95% CI, 1.8-5.0). There was no difference in odds of early refill receipt between groups (20.7% vs 20.1%; AOR, 1.1; 95% CI, 0.7-1.8). Intervention patients were more likely than controls to have either a 10% dose reduction or opioid treatment discontinuation (AOR, 1.6; 95% CI, 1.3-2.1; P < .001). In adjusted analyses, intervention patients had a mean (SE) MEDD 6.8 (1.6) mg lower than controls (P < .001). CONCLUSIONS AND RELEVANCEA multicomponent intervention improved guideline-concordant care but did not decrease early opioid refills.TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01909076

Background: People living with HIV (PLWH) frequently experience chronic pain and receive long-term opioid therapy (LTOT). Adherence to opioid prescribing guidelines among their providers is suboptimal. Objective: This paper describes the protocol of a cluster randomized trial, Targeting Effective Analgesia in Clinics for HIV (TEACH), which tested a collaborative care intervention to increase guideline-concordant care for LTOT among PLWH. Methods: HIV physicians and advanced practice providers (n=41) were recruited from September 2015-December 2016 from two HIV clinics in Boston and Atlanta. Patients receiving LTOT from participating providers were enrolled through a waiver of informed consent (n=187). After baseline assessment, providers were randomized to the control group or the year-long TEACH intervention involving: 1) a nurse care manager and electronic registry to assist with patient management; 2) opioid education and academic detailing; and 3) facilitated access to addiction specialists. Randomization was stratified by site and LTOT patient volume. Primary outcomes (≥2 urine drug tests, early refills, provider satisfaction) were collected at 12-months. In parallel, PLWH receiving LTOT (n=170) were recruited into a longitudinal cohort at both clinics and underwent baseline and 12-month assessments. Secondary outcomes were obtained through patient self-report among participants enrolled in both the cohort and the RCT (n=117). Conclusion: TEACH will report the effects of an intervention on opioid prescribing for chronic pain on both provider and patient-level outcomes. The results may inform delivery of care for PLWH on LTOT for chronic pain at a time when opioid practices are being questioned in the US.

Objective: To summarize the current literature to identify what research has been conducted, examine the approaches used, and determine what is presently known about prescription and nonprescription opioid receipts and use among individuals with traumatic brain injury (TBI). Data Sources: The search strategy included the following: opioid; opiate; analgesics, opioid; opiate alkaloids; or opioid-related disorders; AND brain injury; brain injuries; brain injuries, traumatic; head injury; head injuries; head injuries, closed; head injuries, penetrating; brain concussion; diffuse axonal injury; diffuse axonal injuries; brain trauma/s; head trauma/s; concussion; craniocerebral trauma/s; or TBI. Filters included English and Adults (19+ years). Study Selection: Inclusion: English language, adults with stable TBI, and prescription opioid receipt or use after TBI. Exclusion: Animal models, populations with other acquired brain injury, acute TBI management, and non-peer-reviewed articles, theses, or conference abstracts. Multiple reviewers screened abstracts and full-text articles for eligibility. In total, 771 abstracts were screened, 183 full texts were reviewed, and 21 met eligibility criteria. Data Extraction: Relevant content was independently extracted by multiple observers, including authors, design, sample identification and data source/s, TBI severity, TBI assessment, opioid assessment, study population (demographics, N), military affiliation, comparison groups, date of data collection, and summary of findings. Results: Studies were published between 1987 and 2019; most data were collected prior to 2015. The majority utilized administrative and electronic medical record data from the Department of Veterans Affairs and retrospective cohort designs, and most focused on prescription opioids. There were no studies evaluating interventions to reduce use of opioids in TBI populations. Preliminary findings suggest that prescription opioid receipt is strongly related to psychological symptoms, including comorbid depression, anxiety, and posttraumatic stress disorder. Conclusions: Despite increased awareness of opioid receipt and use following TBI, there is limited investigation on the examination of this issue. Future studies should include more varied patient populations as well as evaluate interventions to reduce opioid use following TBI.