A look at the burden of opioid management in primary care

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Original Research

A look at the burden of opioid management in primary care

J Fam Pract. 2016 December;65(12):E1-E6

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References

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4. Watkins A, Wasmann S, Dodson L, et al. An evaluation of the care provided to patients prescribed controlled substances for chronic nonmalignant pain at an academic family medicine center. Fam Med. 2004;36:487-489.

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8. Wenghofer EF, Wilson L, Kahan M, et al. Survey of Ontario primary care physicians’ experiences with opioid prescribing. Can Fam Physician. 2011;57:324-332.

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We reviewed, one by one, all tasks created from November 1 to 30, 2010. One of the study’s investigators categorized each task according to the following descriptors: who created the task, who addressed the task, what day of the week the task was created, urgency of the task, whether the task required a follow-up phone call, and whether the task was related to opioid/controlled-substance issues. The task was categorized as acute if the issue was related to a condition that had been present for fewer than 3 weeks. Chronic tasks were created for conditions present for ≥3 weeks. At the time the study was completed, our EHR had no portal through which we could communicate with patients.

ANALYSIS

We conducted statistical analyses with the IBM SPSS, version 22.0 (SPSS, Inc, Chicago, Illinois). We used descriptive statistics to examine the frequency and percentage for all variables. We used a chi-squared (χ2) test to assess the differences between the 2 clinics, and used a binary multiple logistic regression model to determine possible factors related to opioid-related tasks. P values <.05 were considered statistically significant. The Colorado Multiple Institutional Review Board approved this study.

RESULTS

Clinics 1 and 2, respectively, saw 2007 and 1186 patients during the study period (TABLE 1). The additional 1028 tasks generated by phone calls were almost equally distributed among the 3 pods of Clinic 1 (290, 202, and 260) and Clinic 2 (276). For data analysis, we compared Clinic 1 with Clinic 2 and also compared the 3 pods of Clinic 1 individually with Clinic 2. Both approaches produced similar results.

Most tasks (54% for Clinic 1 and 99% for Clinic 2) were created by MAs and CTAs. At Clinic 1, tasks were also created by residents (17%), PA/NPs (8%), attending physicians (7%), and others/clinical nurses (14%). Tasks at Clinic 1 were addressed by attending physicians (49%), residents (25%), PA/NPs (25%), and others (1%). At Clinic 2, tasks were addressed by attending physicians (75%) and PA/NPs (25%). Approximately half of the tasks (51%) in both clinics were created during weekdays, compared with the day after weekends/holidays (28%), the day before weekends/holidays (17%), and during weekends/holidays (4%). Chronic patient issues, acute patient issues, and other issues accounted for 54%, 29%, and 17% of tasks, respectively. Follow-up phone calls to patients, pharmacies, or others occurred in 37% of tasks. Two hundred twenty tasks (21%) in the clinics combined were related to opioids and controlled substances.

Multiple logistic regression analysis of data from both clinics (TABLE 2) showed more opioid-related tasks in Clinic 1 compared with Clinic 2 (P<.001), and that these tasks were more often related to chronic issues than to acute issues (P<.001). Tasks created by MAs, CTAs, clinical nurses, and others were more likely to be opioid-related compared with the tasks created by attending physicians, residents, NPs, or a PA (25% vs 15%; P<.05). Compared with non-opioid-related tasks, opioid-related tasks required more follow-up phone calls (P<.001). Follow-up phone calls to pharmacies occurred more often with opioid-related tasks than with non-opioid tasks (11% vs 5%), while follow-up phone calls to patients occurred more often for non-opioid related tasks than opioid-related tasks (28% vs 18%). No correlations with task creation were found for who addressed the opioid-related task or the day the task was created.

DISCUSSION

This study demonstrated that our process of handling patient issues related to opioids accounts for a large proportion of all tasks. Dealing with tasks is time consuming, not only for attending physicians and residents but also for clinic nurses and staff. Almost a quarter of clinic tasks were opioid related. As has been shown in previous studies,^5-8 chronic pain management with opioids is an unsatisfying task for staff and care providers at our clinics. We also found that tasks created by non-providers were more likely to be opioid-related than were tasks created by providers. This is most likely due to the fact that non-providers cannot write prescriptions and they have to ask providers for further reviews.

In this study, the larger urban practice with residents had proportionately more opioid-related tasks than the smaller suburban practice. Despite their different locations, these 2 clinics have relatively similar patient populations with relatively similar insurance coverage (TABLE 3). One reason for the difference noted in opioid-related tasks could be the composition of the provider pools (ie, part-time vs full-time) at each clinic. About half of the providers at Clinic 1 were residents; no residents served at Clinic 2. The variable and part-time nature of a resident’s clinic schedule could have led to discrepancies in opioid management, possibly leading in turn to an increase in phone calls and tasks. However, this finding could also be due to patients’ preferences for seeing less experienced providers for opioid management issues.^12,13

Khalid et al found that, compared with attending physicians, residents had more patients on chronic opioids who displayed concerning behaviors, including early refills and refills from multiple providers.¹³ The higher number of part-time providers at Clinic 1 in our study may have also caused insufficient continuity of care at that site. Nevertheless, this model of practice is used in many academic primary care institutions.⁴ Another possible reason for the difference could be a lack of resident training on current guidelines for managing opiates for chronic pain.^3,13,14 Again, this was a pilot study and we drew no solid conclusion about the reasons for differences between these 2 clinics.

It is obvious, however, that we spend a significant amount of time and resources dealing with chronic pain management. Our institution created an opioid/controlled-substance patient registry about 3 years ago. The data for 2014 showed that 22.8% and 18% of patients seen at least once at Clinic 1 and Clinic 2, respectively, were prescribed opioids/controlled substances (TABLE 3).

Possible solutions to reduce tasks related to opioid management. For both small and large practices, one way to reduce the number of tasks related to opioid management and, therefore, the time allocated to completing those tasks, would be to have a clear protocol to follow.^{3,4,8,11,14,15} The protocol may include the creation of an opioid/controlled-substance registry and the development and implementation of clinical decision support programs.

We also recommend the dissemination of tools for clinical management at the point of care. These can include a controlled-substance risk assessment tool for aberrant behaviors, a controlled-substance informed consent form, a functional and quality-of-life assessment, electronic clinical-note templates in the EHR, urine drug screening, and routine use of existing state pharmacy prescription drug monitoring programs. Also essential would be the provision of routine educational programs for clinicians regarding chronic pain management based on existing evidence and guidelines. (See “Opioids for chronic pain: The CDC’s 12 recommendations.”) It has been demonstrated that an EHR opioid dashboard or an EHR-based protocol improved adherence to guidelines for prescribing opiates.¹⁶

This study has several limitations. First, this was a small pilot study completed over a short period of time, although we believe the findings are likely representative of the prescribing practices in the 2 clinics we evaluated. Second, it was a retrospective study, which was appropriate for evaluating our questions. Third, we were unable to account for other factors that could potentially confound the results, including, but not limited to, the amount of time allocated to each task, and the total number of patients at each clinic who were on opioids for management of chronic pain during the study period. However, due to our recent addition of an opioid/controlled-substance patient registry, we were able to add information for the year 2014 (TABLE 3). Multi-center large scale studies are required to evaluate this further.

ACKNOWLEDGEMENTS
We thank Dr. Corey Lyon for his editorial assistance.

CORRESPONDENCE
Morteza Khodaee, MD, AFW Family Medicine Clinic, 3055 Roslyn Street, Denver, CO 80238; morteza.khodaee@ucdenver.edu.