Overcoming challenges of prescribing long-term opioid therapy in residency clinics
DOI:
https://doi.org/10.5055/jom.0869Keywords:
opioid, opioid prescribing, chronic pain, residency, family medicineAbstract
Objectives: To describe the impact of a standardized opioid prescribing intervention when implemented in three family medicine (FM) residency training clinics—environments that face operational challenges including regular resident turnover.
Design: We performed a retrospective cohort study to compare patterns of long-term opioid prescribing between residency and nonresidency clinics.
Setting: This study took place within a large, academic, health system.
Patients and participants: Three FM residency clinics were compared with three nonresidency FM clinics.
Interventions: A standardized opioid prescribing process was developed and implemented within the FM residency clinics. Nonresidency clinics used an independent process and were not exposed to the intervention.
Main outcome measures: Descriptive comparisons were performed for treatment and control clinics' opioid prescribing from 2015 to 2018. The primary outcome was a patient's annual opioid exposure supplied from these select clinics. We also examine coprescribing with high-risk medications that potentiate the overdose risk of opioid prescriptions. Difference-in-difference modeling was used to control for clinic-level variation in practice.
Results: Statistically significant decreases were observed in both residency and nonresidency clinics for the mean number of opioid prescriptions and the mean daily morphine milligram equivalent. These decreases were comparable between the residency and nonresidency clinics.
Conclusions: Residency clinics face unique challenges and require innovative solutions to keep up with best practices in opioid prescribing. Our residency clinics' implementation of a standardized intervention, including electronic health record integration, standardized processes, and metric management, suggests steps that may be valuable in achieving outcomes comparable to nonresidency clinics in large health systems.
References
Yong RJ, Mullins PM, Bhattacharyya N: Prevalence of chronic pain among adults in the United States. Pain. 2022; 163(2): e328-e332. DOI: 10.1097/j.pain.0000000000002291. DOI: https://doi.org/10.1097/j.pain.0000000000002291
Bifulco L, Anderson DR, Blankson ML, et al.: Evaluation of a chronic pain screening program implemented in primary care. JAMA Netw Open. 2021; 4(7): e2118495. DOI: 10.1001/jamanetworkopen.2021.18495. DOI: https://doi.org/10.1001/jamanetworkopen.2021.18495
Jamison RN, Scanlan E, Matthews ML, et al.: Attitudes of primary care practitioners in managing chronic pain patients prescribed opioids for pain: A prospective longitudinal controlled trial. Pain Med. 2016; 17(1). DOI: 10.1111/pme.12871. DOI: https://doi.org/10.1111/pme.12871
Guy GP, Jr, Zhang K: Opioid prescribing by specialty and volume in the US. Am J Prev Med. 2018; 55(5): e153-e155. DOI: 10.1016/j.amepre.2018.06.008. DOI: https://doi.org/10.1016/j.amepre.2018.06.008
Levy B, Paulozzi L, Mack KA, et al.: Trends in opioid analgesic– prescribing rates by specialty, US, 2007–2012. Am J Prev Med. 2015; 49(3): 409-413. DOI: 10.1016/j.amepre.2015.02.020. DOI: https://doi.org/10.1016/j.amepre.2015.02.020
CDC: Vital signs: Overdoses of prescription opioid pain relievers—United States. 2011. Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm. Accessed March 9, 2020.
Scholl L, Seth P, Kariisa M, et al.: Morbidity and Mortality weekly report drug and opioid-involved overdose death—United States, 2017. MMWR Morb Mortal Wkly Rep. 2018; 67(5152): 1419-1427. DOI: 10.15585/mmwr.mm675152e1. DOI: https://doi.org/10.15585/mmwr.mm6751521e1
Dowell D, Haegerich T, Chou R: CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016; 315(15): 1624-1645. DOI: https://doi.org/10.1001/jama.2016.1464
Diiulio J, Militello LG, Andraka-Christou BT, et al.: Factors that influence changes to existing chronic pain management plans. J Am Board Fam Med. 2020; 33(1): 42-50. DOI: 10.3122/JABFM.2020.01.190284. DOI: https://doi.org/10.3122/jabfm.2020.01.190284
Parchman ML, Von Korff M, Baldwin LM, et al.: Primary care clinic re-design for prescription opioid management. J Am Board Fam Med. 2017; 30(1): 44-51. DOI: 10.3122/JABFM.2017.01.160183. DOI: https://doi.org/10.3122/jabfm.2017.01.160183
Shoemaker-Hunt S, Childs E, Mikosz C, et al.: The effect of health systems' opioid quality improvement (QI) efforts on prescribing practices: Findings from the CDC opioid QI collaborative. Health Serv Res. 2021; 56(S2): 57-58. DOI: 10.1111/1475-6773.13777. DOI: https://doi.org/10.1111/1475-6773.13777
Cardarelli R, Weatherford S, Schilling J, et al.: Improving chronic pain management processes in primary care using practice facilitation and quality improvement: The Central Appalachia Inter-Professional pain education collaborative. J Patient Centered Res Rev. 2017; 4(4): 247-255. DOI: 10.17294/2330-0698.1457. DOI: https://doi.org/10.17294/2330-0698.1457
Weiner SS, Weiser SR, Carragee EJ, et al.: Managing nonspecific low back pain: Do nonclinical patient characteristics matter? Spine (Phila Pa 1976). 2011; 36(23): 1987-1994. DOI: 10.1097/BRS.0B013E3181FEE8EF. DOI: https://doi.org/10.1097/BRS.0b013e3181fee8ef
Finestone AS, Raveh A, Mirovsky Y, et al.: Orthopaedists' and family practitioners' knowledge of simple low back pain management. Spine (Phila Pa 1976). 2009; 34(15): 1600-1603. DOI: 10.1097/BRS.0B013E3181A96622. DOI: https://doi.org/10.1097/BRS.0b013e3181a96622
Williams CM, Maher CG, Hancock MJ, et al.: Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med. 2010; 170(3): 271-277. DOI: 10.1001/ARCHINTERNMED.2009.507. DOI: https://doi.org/10.1001/archinternmed.2009.507
Dey P, Simpson CWR, Collins SI, et al.: Implementation of RCGP guidelines for acute low back pain: A cluster randomised controlled trial. Br J Gen Pract. 2004; 54(498): 33-37.
Kroenke K, Alford DP, Argoff C, et al.: Challenges with implementing the Centers for Disease Control and Prevention opioid guideline: A consensus panel report. Pain Med. 2019; 20(4): 724-735. DOI: 10.1093/PM/PNY307. DOI: https://doi.org/10.1093/pm/pny307
Østbye T, Yarnall KSH, Krause KM, et al.: Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005; 3(3): 209-214. DOI: 10.1370/AFM.310. DOI: https://doi.org/10.1370/afm.310
McCalmont JC, Jones KD, Bennett RM, et al.: Does familiarity with CDC guidelines, continuing education, and provider characteristics influence adherence to chronic pain management practices and opioid prescribing? J Opioid Manag. 2018; 14(2): 103-116. DOI: 10.5055/JOM.2018.0437. DOI: https://doi.org/10.5055/jom.2018.0437
Raheemullah A, Andruska N, Saeed M, et al.: Improving residency education on chronic pain and opioid use disorder: Evaluation of CDC guideline-based education. Subst Use Misuse. 2019; 55(4): 684-690. DOI: 10.1080/10826084.2019.1691600. DOI: https://doi.org/10.1080/10826084.2019.1691600
Parchman ML, Penfold RB, Ike B, et al.: Team-based clinic redesign of opioid medication management in primary care: Effect on opioid prescribing. Ann Fam Med. 2019; 17(4): 319-325. DOI: 10.1370/AFM.2390. DOI: https://doi.org/10.1370/afm.2390
AAMC: Academic medicine leads efforts to address the opioid epidemic. Available at https://www.aamc.org/news-insights/academic-medicine-leads-efforts-address-opioid-epidemic. Accessed June 30, 2020.
Mezei L, Murinson BB, Johns H, et al.: Pain education in North American medical schools. J Pain. 2011; 12(12): 1199-1208. DOI: 10.1016/j.jpain.2011.06.006. DOI: https://doi.org/10.1016/j.jpain.2011.06.006
Schiel Zoberi K, Everard KM, Antoun J: Teaching chronic pain in the family medicine clerkship: Influences of experience and beliefs about treatment effectiveness: A CERA study. Fam Med. 2016; 48(5): 353-358.
Tran UE, Kircher J, Jaggi P, et al.: Medical students' perspectives of their clinical comfort and curriculum for acute pain management. J Pain Res. 2018; 11: 1479-1488. DOI: 10.2147/JPR.S159422. DOI: https://doi.org/10.2147/JPR.S159422
Bishop S, Waller R, Sicat B, et al.: Interprofessional team-based learning module: Chronic non-cancer pain. MedEdPORTAL. 2015; 11(1): 2374-8265. DOI: 10.15766/mep_2374-8265.10112. DOI: https://doi.org/10.15766/mep_2374-8265.10112
Gordon DB, Watt-Watson J, Hogans BB: Interprofessional pain education—With, from, and about competent, collaborative practice teams to transform pain care. Pain Rep. 2018; 3(3): e663. DOI: 10.1097/PR9.0000000000000663. DOI: https://doi.org/10.1097/PR9.0000000000000663
Harper PG, Van Riper K, Ramer T, et al.: Team-based care: An expanded medical assistant role-enhanced rooming and visit assistance. J Interprof Care. 2018: 37(Supp. 1): S95-S101. DOI: 10.1080/13561820.2018.1538107. DOI: https://doi.org/10.1080/13561820.2018.1538107
Berge JM, Trump L, Trudeau S, et al.: Integrated care clinic: Creating enhanced clinical pathways for integrated behavioral health care in a family medicine residency clinic serving a lowincome, minority population. Fam Syst Heal. 2017; 35: 283-294. DOI: 10.1037/fsh0000285. DOI: https://doi.org/10.1037/fsh0000285
HHS: US Department of Health & Human Services Office of Inspector General Toolkit: Using data analysis to calculate opioid levels and identify patients at risk of misuse or overdose OEI-02-17-00560. 2018. Available at https://oig.hhs.gov/oei/reports/oei-02-17-00560.pdf. Accessed March 23, 2023.
Patnode CD, Webber EM, Thomas RG, et al.: Technical brief—Primary care-relevant interventions to prevent opioid use disorder: Current research and evidence gaps. AHRQ Publication No. 21-05280-EF-1. 2021: 11-12. Available at https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/prevention-of-opioid-user-disorder-ehc-tech-brief.pdf. Accessed March 23, 2023.
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