A better approach to opioid prescribing in primary care

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Original Research

A better approach to opioid prescribing in primary care

J Fam Pract. 2014 June;63(6):E1-E8

By

Robin E. Canada, MD

Danae Dirocco, MPH

Susan Day, MD, MPH

We developed and tested a novel EMR-based protocol that fostered increased adherence to best-practice standards and resulted in improved provider attitudes toward patients taking opioids.

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References

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4. Washington State Department of Health- Medical Quality Assurance Commission. Rule-Making Order CR-103. University of Washington Web site. Available at: http://depts.washington.edu/anesth/education/forms/pain/WAC-Rules-CR-103P.pdf. Accessed February 1, 2012.

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ABSTRACT

Purpose Primary care physicians are at the center of a national prescription opioid epidemic, with little training or knowledge about the management of patients on opioids for chronic noncancer pain (CNCP). We developed an electronic medical record (EMR)-based protocol and educational intervention to standardize documentation and management of patients prescribed opioids by primary care providers. Our objective was to evaluate provider adherence to this protocol, attitudes toward the management of these patients, and knowledge of opioid prescribing.

Methods We trained providers and select staff from 3 primary care practices at the Division of General Internal Medicine at the University of Pennsylvania in the use of a protocol for managing patients taking opioids for CNCP. The following served as measures of protocol adherence: 1) the provider used a standard diagnosis (chronic pain, ICD-9 code 338.29A) in the problem list, 2) the provider ordered at least one urine drug screen (UDS) for the patient in the past year, and 3) the patient came in for at least one office visit every 6 months. We assessed physician and staff attitudes and knowledge with pre- and post-intervention surveys. Adherence to the protocol was linked to a monetary incentive.

Results Provider adherence to the protocol significantly improved measured outcomes. The number of UDSs ordered increased by 145%, and the diagnosis of chronic pain on the problem list increased by 424%. There was a statistically significant improvement in providers’ role adequacy, role support, and job satisfaction/role-related self-esteem when working with patients taking opioids. In addition, provider knowledge of proper management of these patients improved significantly. Eighty-nine percent of our physicians attained the monetary incentive.

Conclusions We developed a quality improvement intervention that addressed the need for better regulation of opioid prescribing, resulted in increased adherence to best-practice guidelines, and improved provider knowledge and attitudes.

In all 3 practices, the total number of patients prescribed >2 opioid medications declined during the year-long study period.Primary care physicians often express dissatisfaction with their competency in treating patients with opioids,¹ and at our institution, this includes residents and faculty, as well. Their concern, combined with apprehension about patient safety and the potential for addiction, can hinder appropriate opioid management.¹ We asked: Could a protocol that structures the intervention improve physician competence and performance in prescribing opioids and reduce patient risk?

Physician concerns are well-founded. Nonmedical use of prescription opioids is second only to smoking marijuana in the illicit use of drugs in the United States.² Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine combined, leading the Centers for Disease Control and Prevention to declare in 2012 that the problem was a “national epidemic.”³ The Washington State Medical Quality Assurance Commission now mandates extensive patient evaluation and documentation, the use of a Controlled Medication Agreement (CMA), and specific education requirements for physicians prescribing long-acting or high-dose opioids.⁴

Necessary adjustments going forward. As the nation moves toward more regulated prescribing of opioids, physicians will need to develop a consistent approach to this complicated task. Primary care doctors must be at the center of this effort, as they generate most opioid prescriptions for the treatment of CNCP. Currently, providers vary widely in their management of this condition,^5-7 and recommended corrective steps include increased education8 and improved adherence to national guidelines. Our contention—and the basis of our study—was that a clinical protocol for opioid prescribing could improve the care that physicians and staff were providing to CNCP patients, as well as improve the satisfaction that clinicians felt in providing this care.

Our protocol intervention. Prior to our protocol intervention, no guidelines existed for managing patients on long-term opioid therapy in the clinical practices of the University of Pennsylvania Division of General Internal Medicine. Our providers, too, varied widely in their prescribing and management. Though regular urine drug screening is known to improve detection of opioid misuse and decrease the problem in patients treated for CNCP,^9,10 a study reviewing opioid prescribing practices in our clinics from 2004 to 2007 showed that physicians ordered UDSs for only 8% of patients.¹¹ Furthermore, only half of patients (49.8%) had regular office visits—even those at high risk for opioid misuse.¹¹

TABLE 1
"Smart set" elements for EMR documntation

Cause of pain

Previous work-up

Medications or treatment tried in the past

Current alternative therapy for pain (PT/pain management/exercise)

Primary managing provider/continuity attending physician

Frequency of follow-up

Date of pain contract

Type and frequency of medications

Date of CMA

Last UDS* with results

Aberrant drug-seeking behaviors (early refills,lost medications, use of illicit drugs, etc)

Functional goals

Risk stratification/OR T Score

^{CMA, Controlled Medication Agreement; EMR, electronic medical records; ORT, opioid risk tool; PT, physical therapy; UDS, urine drug screen.}
^{*Including amphetamines, cocaine metabolite, opiates, barbiturates, benzodiazepines, phencyclidine, tetrahydrocannabinol, ethanol, methadone propoxyphene, and ecstasy.}