The Impact of Opioid Risk Reduction Initiatives on High-Dose Opioid Prescribing for Patients on Chronic Opioid Therapy

Korff, Michael Von; Dublin, Sascha; Walker, Rod; Parchman, Michael L.; Shortreed, Susan M.; Hansen, Ryan N.; Saunders, Kathleen

doi:10.1016/j.jpain.2015.10.002

Cited by 51 publications

(57 citation statements)

References 24 publications

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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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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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“…Themes and concepts were also compared and contrasted to a Group Health opioid improvement initiative to identify common elements and strategies. 8,9 As descriptive phrases and definitions were developed, examples of activities used by the clinics to make the necessary changes were identified from the LEAP data sources.…”

Section: Data Coding and Analysismentioning

confidence: 99%

“…Systematic changes to make opioid prescribing safer have been evaluated in large integrated health care delivery systems such as Veteran's Administration clinics and other large group practice settings. [7][8][9] Less is known about systems approaches to improve address the overuse of COT across a diversity of primary care settings.…”

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confidence: 99%

Primary Care Clinic Re-Design for Prescription Opioid Management

et al. 2017

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Background:The challenge of responding to prescription opioid overuse within the United States has fallen disproportionately on the primary care clinic setting. Here we describe a framework comprised of 6 Building Blocks to guide efforts within this setting to address the use of opioids for chronic pain.Methods: Investigators conducted site visits to thirty primary care clinics across the United States selected for their use of team-based workforce innovations. Site visits included interviews with leadership, clinic tours, observations of clinic processes and team meetings, and interviews with staff and clinicians. Data were reviewed to identify common attributes of clinic system changes around chronic opioid therapy (COT) management. These concepts were reviewed to develop narrative descriptions of key components of changes made to improve COT use.Results: Twenty of the thirty sites had addressed improvements in COT prescribing. Across these sites a common set of 6 Building Blocks were identified: 1) providing leadership support; 2) revising and aligning clinic policies, patient agreements (contracts) and workflows; 3) implementing a registry tracking system; 4) conducting planned, patient-centered visits; 5) identifying resources for complex patients; and 6) measuring progress toward achieving clinic objectives. Common components of clinic policies, patient agreements and data tracked in registries to assess progress are described.Conclusions: In response to prescription opioid overuse and the resulting epidemic of overdose and addiction, primary care clinics are making improvements driven by a common set of best practices that address complex challenges of managing COT patients in primary care settings. (J Am Board Fam Med 2017;30:44 -51.)

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“…Finally, health systems should consider the use of coordinated care plans to optimize evidence-based care. Coordinated care plans structure and coordinate care by increasing precautions for patients taking high dosages, codifying treatment agreements with patients, monitoring patients with urine drug tests and prescription drug monitoring program checks, and avoiding prescribing opioids in conjunction with benzodiazepines; coordinated care plans have been shown to reduce risk factors for opioid-related harm (10), and might be especially effective with older patients.…”

Section: What Are the Implications For Public Health Practice?mentioning

confidence: 99%

Trends in Methadone Distribution for Pain Treatment, Methadone Diversion, and Overdose Deaths — United States, 2002–2014

Jones¹,

Baldwin²,

Manocchio³

et al. 2016

MMWR Morb. Mortal. Wkly. Rep.

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The Impact of Opioid Risk Reduction Initiatives on High-Dose Opioid Prescribing for Patients on Chronic Opioid Therapy

Cited by 51 publications

References 24 publications

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

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

Primary Care Clinic Re-Design for Prescription Opioid Management

Trends in Methadone Distribution for Pain Treatment, Methadone Diversion, and Overdose Deaths — United States, 2002–2014

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