Opioid Dose Reduction in a VA Health Care System—Implementation of a Primary Care Population-Level Initiative

Westanmo, Anders; Marshall, Peter; Jones, Elzie; Burns, Kevin; Krebs, Erin E.

doi:10.1111/pme.12699

Cited by 55 publications

(52 citation statements)

References 21 publications

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“…Second, the levelling of dosing trends between 2006 and 2009 provides partial support for a relatively stable opioid prescribing practice during the same or subsequent time periods observed in the VA populations [11,12,13]. Our study extended those previous literatures with more thorough control of person-specific, temporal and geographic confounding.…”

Section: Discussionsupporting

confidence: 67%

“…Since mental health disorders have been associated with increased frequency and duration of opioid use [11–13,15,20], we selected three common mental health diagnoses as individual risk factors, including post-traumatic stress disorders (PTSD), major depressive disorders (MDD) and substance use disorders (SUD) (Supplementary eTable 2 shows a complete list of ICD-9 codes). Other clinical covariates were defined globally, using the Charlson Comorbidity Index (≥ 1 versus 0) for overall physical health and a binary indicator for having ≥ 1 other psychiatric diagnoses (including anxiety disorders, minor depression, bipolar disorder, schizophrenia, schizoaffective disorders and psychosis not otherwise-specified, based on ICD9-CM codes.…”

Section: Methodsmentioning

confidence: 99%

“…Two other VA studies compared opioid doses between two brief time windows. While one found comparable average morphine equivalents over a 1-year treatment course between 2004 (22.6 ME/d) and 2011 (21.6 ME/d) [12], the other observed significant decrease in both the rate of high-dose opioid prescribing (from 13.7% to 11.0%) and the mean daily dose (from 43 to 23 MED) 90-days before (year 2011) and after (year 2014) implementation of a local Opioid Safety Initiative targeting high-risk prescribing [13]. None of above studies accounted for potential confounding across opioid prescriptions due to heterogeneous patient characteristics, market changes in opioid formularies, or variation in clinical practice across geographic regions.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Opioid dosing trends over eight years among US Veterans with musculoskeletal disorders after returning from service in support of recent conflicts

Han

Allore

Goulet

et al. 2017

Annals of Epidemiology

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Purposes To examine long-term opioid dosing trends among Veterans with chronic pain. Methods We identified 79,015 Veterans with musculoskeletal disorders who were dispensed ≥ 1 opioid prescriptions between 2002–2009 after returning from recent conflicts. Opioid dosing trends were examined using a generalized estimating equation while accounting for patient characteristics, temporal and geographic confounding. Results In total 472,819 opioid prescriptions were dispensed (mean±standard deviation: 6.0±10.1 per Veteran). Both average daily morphine equivalents (ME/d) and the proportion of high-dose prescribing (>100 ME/d) increased from baseline period (2002–2004) to 2006 then remained relatively stable. Veterans with extended-persistent (≥ 40 days over 1–2 episodes) and extended-intermittent (≥ 40 days over ≥ 3 episodes) dispensing patterns received more high-dose prescriptions than those dispensed prescriptions < 40 days, with adjusted Odds Ratios (95% Confidence Interval) of 7.2 (6.0–8.8) and 3.6 (3.0–4.3), respectively. Post-traumatic Stress Disorder and other mental health diagnoses were associated with 30% increased odds of high-dose prescribing. Conclusions The average daily dose of opioid prescriptions and the likelihood of high-dose prescribing to these Veterans appeared to increase from 2002–2006 then remained relatively stable through 2009. Veterans on opioid prescriptions for extended duration or with mental health diagnoses tend to receive higher dose therapy.

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Section: Discussionsupporting

confidence: 67%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Opioid dosing trends over eight years among US Veterans with musculoskeletal disorders after returning from service in support of recent conflicts

Han

Allore

Goulet

et al. 2017

Annals of Epidemiology

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“…Other health system innovations have shown improved guideline adherence when researchers have analyzed observational data using a pre-post design or comparison of different settings. 21,32 Von Korff et al 33 compared the outcomes of their group practice physicians who received a system innovation with the outcomes of community-based clinicians in the context of stricter state policies for opioid prescribing. The study intervention standardized care for patients treated with long-term opioid therapy through changes in the EHR, enhanced clinician education, and monetary incentives for adherence.…”

Section: Discussionmentioning

confidence: 99%

Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care

et al. 2017

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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

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“…29 This report adds a new dimension to the sparse literature on primary care clinics using populationbased opioid safety initiatives. 19,22,30,31 Clinics implementing safety initiatives should consider ensuring access to evidence-based treatment for patients with an opioid use disorder in order to protect those patients from foreseeable harms when opioid prescriptions are discontinued. 11 To this end, they can encourage and arrange for their physicians to become trained and certified to prescribe buprenorphine to their patients with an opioid use disorder.…”

Section: Discussionmentioning

confidence: 99%

Problem Drug-related Behavior and Discontinuation of Opioids Following the Introduction of an Opioid Management Program

Grande¹,

Thompson²,

Au³

et al. 2016

The Journal of the American Board of Family Medicine

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Purpose: Problem drug-related behavior (PDB) among patients on chronic opioid therapy may reflect an opioid use disorder. This study assessed PDB prevalence and the relationship between PDB and ongoing prescription of opioids at a primary care clinic that implemented a multifaceted opioid management program.Methods: A chart review of patients in a chronic opioid registry assessed prevalence of different types of PDB over 2 years, and whether opioids were prescribed during the last 3 months of the 2-year study period among patients with different levels of PDB.Results: Among 233 registry patients, 84.1% exhibited PDB; 45.5% exhibited >3 types of PDB. At the end of 2 years, most registry patients were still prescribed opioids, though patients with >3 types of PDB were less likely than those without PDB to be prescribed opioids (62.3% vs. 78.4%, P ‫؍‬ 0.016).Conclusions: PDB was pervasive in this population of patients on chronic opioid therapy. Those with the most PDB, and thus with the greatest likelihood of opioid use disorder and its social and medical consequences, were the least likely to be prescribed opioids by the clinic after 2 years. Given the rising rates of illicit opioid use in the U.S., it is important that clinics work closely with their patients who display PDB, systematically assess them for opioid use disorder, and offer evidence-based treatment.

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Opioid Dose Reduction in a VA Health Care System—Implementation of a Primary Care Population-Level Initiative

Abstract: Opioid Safety Initiative implementation was associated with a substantial reduction in high-dose opioid prescribing. Factors that contributed to initiative success included leadership support and active clinical pharmacy engagement.

Cited by 55 publications

References 21 publications

Opioid dosing trends over eight years among US Veterans with musculoskeletal disorders after returning from service in support of recent conflicts

Opioid dosing trends over eight years among US Veterans with musculoskeletal disorders after returning from service in support of recent conflicts

Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care

Problem Drug-related Behavior and Discontinuation of Opioids Following the Introduction of an Opioid Management Program

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