Primary care survey of the value and effectiveness of the Washington State Opioid Dosing Guideline

Josiah S. Morse, MPH; Hal Stockbridge, MD, MPH; Kathleen B. Egan, MPH; Jaymie Mai, PharmD; Thomas Wickizer, PhD; Gary M. Franklin, MD, MPH

doi:10.5055/jom.2011.0083

Authors

Josiah S. Morse, MPH
Hal Stockbridge, MD, MPH
Kathleen B. Egan, MPH
Jaymie Mai, PharmD
Thomas Wickizer, PhD
Gary M. Franklin, MD, MPH

DOI:

https://doi.org/10.5055/jom.2011.0083

Keywords:

opioid analgesics, drug therapy, intractable pain, family physician, physician’s practice patterns, practice guideline, cross-sectional survey

Abstract

Purpose: To evaluate the acceptability and usefulness of the Washington State Opioid Dosing Guideline (Guideline) developed for primary care providers for the treatment of chronic noncancer pain. The Guideline contains innovative tools, such as an online dosing calculator, and recommendations to assist providers, including a “yellow flag” threshold of 120 mg/d morphine equivalent dose (MED) at which specialty consultation is recommended.
Methods: Using a convenience sample, an anonymous web-based survey was conducted among primary care providers in Washington (WA) state. Physician/administrative leaders in four regional and two statewide healthcare systems and associations distributed the electronic links to primary care providers in their organizations.
Results: Six hundred fifty-five (n) providers completed the survey representing 20 percent of the total number contacted. The majority (89 percent) of providers in this sample treat chronic pain patients, and more than half (54 percent) have frequent concerns about addiction, tolerance, and diversion. Forty-five percent had read and applied the Guideline in their practice. The majority of these providers found the Guideline to be helpful and 86 percent find the threshold of 120 mg/d MED dose reasonable or too high. Some key best practices such as tracking pain and function using structured instruments and use of urine drug testing are infrequently used.
Conclusions: Results from this survey suggest that the recommendations and tools given in the Guideline, including the threshold of 120 mg/day MED dose, are acceptable and useful to a large majority of primary care providers in WA state. Substantial additions to the Guideline based on needs identified in this survey were added in June 2010 and wider dissemination is planned.

Author Biographies

Josiah S. Morse, MPH

Program Director, Health Technology Assessment Program, Washington State Health Care Authority, Olympia, Washington.

Hal Stockbridge, MD, MPH

Associate Medical Director, Washington State Department of Labor and Industries, Olympia, Washington; Adjunct Faculty, Clinical Occupational Epidemiology and Health Outcomes Program, University of Washington School of Public Health and Community Medicine, Seattle, Washington.

Kathleen B. Egan, MPH

Research Coordinator, Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health and Community Medicine, Seattle, Washington.

Jaymie Mai, PharmD

Pharmacy Manager, Washington State Department of Labor and Industries, Olympia, Washington.

Thomas Wickizer, PhD

Stephen F. Loebs Professor, Division of Health Services Management and Policy, Ohio State University College of Public Health, Columbus, Ohio.

Gary M. Franklin, MD, MPH

Medical Director, Washington State Department of Labor and Industries, Olympia, Washington; Research Professor, Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health and Community Medicine, Seattle, Washington.

References

American Academy of Pain Medicine: The use of opioids for the treatment of chronic pain; 1996. Available at http://www.painmed.org/Workarea/DownloadAsset.aspx?id=3213. Accessed July 29, 2011.

Hill CS Jr: Government regulatory influences on opioid prescribing and their impact on the treatment of pain of nonmalignant origin. J Pain Symptom Manage. 1996; 11(5): 287-298.

Washington State Medical Quality Assurance Commission: Guidelines for Pain Management; MD96-07, 1996. Available at http://www.doh.wa.gov/hsqa/MQAC/painmgmt.htm. Accessed December 2, 2010.

Washington Administrative Code Chapter 246-919. Section 246-919-800 Pain Management 1999.

Paulozzi L, Annest J: Unintentional poisoning deaths—United States, 1999-2004. Morb Mortal Wkly Rep. 2007; 56(5): 93-96.

Franklin GM, Mai J, Wickizer T, et al.: Opioid dosing trends and mortality in Washington State workers’ compensation, 1996-2002. Am J Ind Med. 2005; 48(2): 91-99.

Warner MC, Chen LH, Makuc DM: Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2006; NCHS Data Brief No. 22, 2009. Hyattsville, Maryland: National Center for Health Statistics, 2009. Available at http://www.cdc.gov/nchs/data/databriefs/db22.pdf. Accessed December 2, 2010.

Washington State Department of Health: Poisoning and drug overdose. Washington State Injury and Violence Prevention Guide. 2008. Available at http://www.doh.wa.gov/hsqa/emstrauma/injury/pubs/icpg/DOH530090Poison.pdf. Accessed December 2, 2010.

Washington State Agency Medical Directors’ Group: Interagency guideline on opioid dosing for chronic non-cancer pain: An educational pilot to improve care and safety with opioid treatment; 2010. Available at http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf. Accessed July 14, 2010.

National Guideline Clearinghouse (NGC): Guideline summary: Interagency guideline on opioid dosing for chronic noncancer pain: An educational pilot to improve care and safety with opioid treatment; November 2010. Available at http://www.guideline.gov. Accessed November 9, 2010.

University of Washington: Rural-urban commuting area codes (version 2.0); 2010. Available at http://depts.washington.edu/uwruca/index.php. Accessed December 2, 2010.

Ostbye T, Yarnall KS, 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.

Rosenblatt R: Rural chronic pain and opiate addiction: The Impact on the Physician Workforce. Paper presented at the Interagency Workgroup to Prevent Prescription Opioid Misuse, Abuse and Overdose, Washington State Department of Health, Tumwater, WA, June 28, 2010; Powerpoint presentation.

Ballantyne JC, Shin NS: Efficacy of opioids for chronic pain: A review of the evidence. Clin J Pain. 2008; 24(6): 469-478.

Dunn KM, Saunders KW, Rutter CM, et al.: Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010; 152(2): 85-92.

Braden JB, Russo J, Fan MY, et al.: Emergency department visits among recipients of chronic opioid therapy. Arch Intern Med. 2010; 170(16): 1425-1432.

Centers for Disease Control and Prevention (CDC): CDC’s issue brief: Unintentional drug poisoning in the United States; 2010. Available at http://www.cdc.gov/homeandrecreationalsafety/poisoning/brief.htm. Accessed November 9, 2010.

McLellan AT, Turner BJ: Chronic noncancer pain management and opioid overdose: Time to change prescribing practices. Ann Intern Med. 2010; 152(2): 123-124.

Bhamb B, Brown D, Hariharan J, et al.: Survey of select practice behaviors by primary care physicians on the use of opioids for chronic pain. Curr Med Res Opin. 2006; 22(9): 1859-1865.

Dobscha SK, Corson K, Flores JA, et al.: Veterans affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates. Pain Med. 2008; 9(5): 564-571.

Potter M, Schafer S, Gonzalez-Mendez E, et al.: Opioids for chronic nonmalignant pain. Attitudes and practices of primary care physicians in the UCSF/Stanford Collaborative Research Network. University of California, San Francisco. J Fam Pract. 2001; 50(2): 145-151.

Upshur CC, Luckmann RS, Savageau JA: Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med. 2006; 21(6): 652-655.

Starrels JL, Becker WC, Weiner MG, et al.: Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain. J Gen Intern Med., in press.