Opioid Prescribing In Primary Care Research Articles

The long-term impacts of opioid use before and after joint arthroplasty: matched cohort analysis of New Zealand linked register data.

Opioids are commonly used both before and after total joint arthroplasty (TJA). The objective of this study was to estimate the long-term effects of pre- and perioperative opioid use in patients undergoing TJA. We used linked population datasets to identify all (n =18,666) patients who had a publicly funded TJA in New Zealand between 2011 and 2013. We used propensity score matching to match individuals who used opioids either before surgery, during hospital stay, or immediately post-discharge with individuals who did not based on a comprehensive set of covariates. Regression analysis was used to estimate the effect of opioid use on health and socio-economic outcomes over 5 years. Opioid use in the 3 months prior to surgery was associated with significant increases in healthcare utilization and costs (number of hospitalizations 6%, days spent in hospital 14.4%, opioid scripts dispensed 181%, and total healthcare costs 11%). Also increased were the rate of receiving social benefits (2 percentage points) and the rates of opioid overdose (0.5 percentage points) and mortality (3 percentage points). Opioid use during hospital stay or post-discharge was associated with increased long-term opioid use, but there was little evidence of other adverse effects. Opioid use before TJA is associated with significant negative health and economic consequences and should be limited. This has implications for opioid prescribing in primary care. There is little evidence that peri- or post-operative opioid use is associated with significant long-term detriments.

Academic detailing to improve appropriate opioid prescribing: a mixed-methods process evaluation.

Academic detailing, an educational outreach service for family physicians, was funded by the Ontario government to address gaps in opioid prescribing and pain management. We sought to evaluate the impact of academic detailing on opioid prescribing, and to understand how and why academic detailing may have influenced opioid prescribing. In this mixed-methods study, we collected quantitative and qualitative data concurrently from 2017 to 2019 in Ontario, Canada. We analyzed prescribing outcomes descriptively for a sample of participating physicians and compared them with a matched control group. We invited physicians to participate in qualitative interviews to discuss their experiences in academic detailing. Development and analysis of qualitative interviews was informed by the Theoretical Domains Framework. We triangulated qualitative and quantitative findings to understand the mechanisms that drove changes in opioid prescribing. Physicians receiving academic detailing (n = 238) achieved a greater reduction in opioid prescribing than matched controls (n = 238). Seventeen physicians completed interviews and reported that academic detailing addressed barriers to pain care, including lack of confidence, difficult interactions with patients and prescribing and tapering decisions. Academic detailing reinforced knowledge about opioid prescribing and pain management. Discussion of complex patients and talking points to use during challenging conversations were described as key drivers of practice change. The findings of this real-world, mixed-methods evaluation explain how an academic detailing service addressed key barriers and enablers to limit high-risk opioid prescribing in primary care. This nuanced understanding will be used to inform, spread and scale academic detailing.

Digitally deployed, GP remote consultation video intervention that aims to reduce opioid prescribing in primary care: protocol for a mixed-methods evaluation

IntroductionOpioid prescribing rates are disproportionately high in the North of England. In addition to patients’ complex health needs, clinician prescribing behaviour is also a key driver. Although strategies have been...

Surfacing the causal assumptions and active ingredients of healthcare quality improvement interventions: An application to primary care opioid prescribing.

Efforts to maximize the impact of healthcare improvement interventions are hampered when intervention components are not well defined or described, precluding the ability to understand how and why interventions are expected to work. We partnered with two organizations delivering province-wide quality improvement interventions to establish how they envisaged their interventions lead to change (their underlying causal assumptions) and to identify active ingredients (behavior change techniques [BCTs]). The interventions assessed were an audit and feedback report and an academic detailing program. Both focused on supporting safer opioid prescribing in primary care in Ontario, Canada. Data collection involved semi-structured interviews with intervention developers (n = 8) and a content analysis of intervention documents. Analyses unpacked and articulated how the interventions were intended to achieve change and how this was operationalized. Developers anticipated that the feedback report would provide physicians with a clear understanding of their own prescribing patterns in comparison to others. In the feedback report, we found an emphasis on BCTs consistent with that assumption (feedback on behavior; social comparison). The detailing was designed to provide tailored support to enable physicians to overcome barriers to change and to gradually enact specific practice changes for patients based on improved communication. In the detailing materials, we found an emphasis on instructions on how to perform the behavior, for a range of behaviors (e.g., tapering opioids, treating opioid use disorder). The materials were supplemented by detailer-enacted BCTs (e.g., social support [practical]; goal setting [behavior]; review behavioral goal[s]). The interventions included a small range of BCTs addressing various clinical behaviors. This work provides a methodological example of how to apply a behavioral lens to surface the active ingredients, target clinical behaviors, and causal assumptions of existing large-scale improvement interventions that could be applied in other contexts to optimize effectiveness and facilitate scale and spread.

Using primary care data to understand opioid prescribing, policy impacts and clinical outcomes: A protocol for the OPPICO study.

Prescription opioid use in Australia has increased over the last 3 decades. The majority of opioids are prescribed and dispensed in primary care, however, there are few studies that are specific to opioid prescribing in this setting. Evidence about the impact of key government policy strategies to optimize opioid prescribing in primary care is limited. The aim of this study is to examine the impact of recent policy changes and clinical guidelines on opioid prescribing in primary care. Longitudinal analysis of people prescribed opioid analgesics using Population Level Analysis and Reporting (POLAR) data. POLAR is a primary care dataset comprising 464 primary health care practices in Victoria, Australia. People prescribed opioid analgesics between 2015 and 2020 will be included. The impact of opioid policies and guideline recommendations will be evaluated using interrupted time series models. Group- based trajectory modelling and multivariate regression will be used to identify patterns of opioid cessation and the provision of corresponding non-opioid interventions. The study has received Monash University Human Research Ethics Committee approval (ID 24139). Permission to access, collate and use POLAR data is granted from Outcome Health as the data custodians. The results of this study will be disseminated through publication in international journals, presented at national and international scientific conferences, and disseminated to consumers, policy makers, primary care providers and primary health networks. EU PAS Register (EUPAS43218).

Evidence-Based Interventions to Improve Opioid Prescribing in Primary Care: a Qualitative Assessment of Implementation in Two Studies.

The TOPCARE and TEACH randomized controlled trials demonstrated the efficacy of a multi-faceted intervention to promote guideline-adherent long-term opioid therapy (LTOT) in primary care settings. Intervention components included a full-time Nurse Care Manager (NCM), an electronic registry, and academic detailing sessions. This study sought to identify barriers, facilitators, and other issues germane to the wider implementation of this intervention. We conducted a nested, qualitative study at 4 primary care clinics (TOPCARE) and 2 HIV primary care clinics (TEACH), where the trials had been conducted. We purposively sampled primary care physicians and advanced practice providers (hereafter: PCPs) who had received the intervention. Semi-structured interviews explored perceptions of the intervention to identify unanticipated barriers to and facilitators of implementation. Interview transcripts were analyzed through iterative deductive and inductive coding exercises. We interviewed 32 intervention participants, 30 physicians and 2 advanced practice providers, who were majority White (66%) and female (63%). Acceptability of the intervention was high, with most PCPs valuing didactic and team-based intervention elements, especially co-management of LTOT patients with the NCM. Adoption of new prescribing practices was facilitated by proximity to expertise, available behavioral health care, and the NCM's support. Most participants were enthusiastic about the intervention, though a minority voiced concerns about the appropriateness in their particular clinical environments, threats to the patient-provider relationship, or long-term sustainability. TOPCARE/TEACH participants found the intervention generally acceptable, appropriate, and easy to adopt in a variety of primary care environments, though some challenges were identified. Careful attention to the practical challenges of implementation and the professional relationships affected by the intervention may facilitate implementation and sustainability.

Influence of provider type on chronic pain prescribing patterns A systematic review.

Chronic pain affects 100 million Americans and is most often treated in primary care, where the health care provider shortage remains a challenge. Nurse practitioners (NPs) represent a growing solution, yet their patterns of chronic pain management are understudied. Additionally, prescriptive authority limitations in many states limit NPs from prescribing opioids and often exist due to concerns of NP-driven opioid overprescribing. Little evidence on NP pain management prescribing patterns exists to address these issues. Systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, to examine opioid and nonopioid prescribing patterns of physicians, NPs, and physician assistants (PAs) in primary care. Eligible studies scored ≥60% on the Joanna Briggs Institute Critical Appraisal checklist. Searches within PubMed, Embase, CINAHL, and Web of Science. Three themes were elucidated: 1) opioid prescribing in primary care, 2) similarities and differences in opioid prescribing by provider type, and 3) nonopioid pain management strategies. All provider groups had similar opioid prescribing patterns, although NPs and PAs may be slightly less likely to prescribe opioids than physicians. Although some studies suggested that NPs/PAs had higher opioid prescribing rates compared with physicians, methodological flaws may undermine these conclusions. Evidence is also lacking on nonopioid prescribing patterns across disciplines. Nurse practitioner/PA prescriptive authority limitations may not be as effective of a solution for addressing opioid overprescribing as transdisciplinary interventions targeting the highest subset of opioid prescribers. Future research should examine prescribing patterns of nonopioid, including nonpharmacologic, therapies.

The Implementation of a Clinic-Based Opioid Review Board to Address High-Risk Opioid Prescribing in Primary Care.

The 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain emphasized safety risks of opioids while promoting a risk-benefit approach to opioid prescribing.1 Although the CDC focused on prescriber decision making around opioid therapy, primary care

Opioids and obstructive sleep apnea.

Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.

The effects of an evidence- and theory-informed feedback intervention on opioid prescribing for non-cancer pain in primary care: A controlled interrupted time series analysis.

The rise in opioid prescribing in primary care represents a significant international public health challenge, associated with increased psychosocial problems, hospitalisations, and mortality. We evaluated the effects of a comparative feedback intervention with persuasive messaging and action planning on opioid prescribing in primary care. A quasi-experimental controlled interrupted time series analysis used anonymised, aggregated practice data from electronic health records and prescribing data from publicly available sources. The study included 316 intervention and 130 control primary care practices in the Yorkshire and Humber region, UK, serving 2.2 million and 1 million residents, respectively. We observed the number of adult patients prescribed opioid medication by practice between July 2013 and December 2017. We excluded adults with coded cancer or drug dependency. The intervention, the Campaign to Reduce Opioid Prescribing (CROP), entailed bimonthly, comparative, and practice-individualised feedback reports to practices, with persuasive messaging and suggested actions over 1 year. Outcomes comprised the number of adults per 1,000 adults per month prescribed any opioid (main outcome), prescribed strong opioids, prescribed opioids in high-risk groups, prescribed other analgesics, and referred to musculoskeletal services. The number of adults prescribed any opioid rose pre-intervention in both intervention and control practices, by 0.18 (95% CI 0.11, 0.25) and 0.36 (95% CI 0.27, 0.46) per 1,000 adults per month, respectively. During the intervention period, prescribing per 1,000 adults fell in intervention practices (change -0.11; 95% CI -0.30, -0.08) and continued rising in control practices (change 0.54; 95% CI 0.29, 0.78), with a difference of -0.65 per 1,000 patients (95% CI -0.96, -0.34), corresponding to 15,000 fewer patients prescribed opioids. These trends continued post-intervention, although at slower rates. Prescribing of strong opioids, total opioid prescriptions, and prescribing in high-risk patient groups also generally fell. Prescribing of other analgesics fell whilst musculoskeletal referrals did not rise. Effects were attenuated after feedback ceased. Study limitations include being limited to 1 region in the UK, possible coding errors in routine data, being unable to fully account for concurrent interventions, and uncertainties over how general practices actually used the feedback reports and whether reductions in prescribing were always clinically appropriate. Repeated comparative feedback offers a promising and relatively efficient population-level approach to reduce opioid prescribing in primary care, including prescribing of strong opioids and prescribing in high-risk patient groups. Such feedback may also prompt clinicians to reconsider prescribing other medicines associated with chronic pain, without causing a rise in referrals to musculoskeletal clinics. Feedback may need to be sustained for maximum effect.

Association between opioid-related deaths and persistent opioid prescribing in primary care in England: A nested case-control study.

This study aimed to evaluate the association between opioid-related deaths and persistent opioid utilisation in the United Kingdom (UK). This nested case-control study used the UK Clinical Practice Research Datalink, linking the Office for National Statistics death registration. Adult opioid users with recorded opioid-related death between 2000 and 2015 were included and matched to four opioid users (controls) based on a disease risk score. Persistent opioid utilisation (opioid prescriptions ≥3 quarters/year and oral morphine equivalent dose ≥4500 mg/year) and psychotropic prescriptions were identified annually during the three patient-years before the date of opioid-related death. Conditional logistic regression was used to assess the association between persistent opioid utilisation and opioid-related death, and the results were reported as adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Of the 902 149 opioid users, 230 opioid-related deaths (cases) and 920 controls were identified. Persistent opioid utilisation was significantly associated with an increased risk of opioid-related deaths (aOR 1.9, 95% CI 1.2, 2.9) when persistent opioid utilisation was defined by both annual dose and number of quarters. Concurrent prescription of opioids and tricyclic antidepressants (aOR 2.0, 95% CI 1.2, 3.5) or higher dose of benzodiazepine (aOR 6.5, 95% CI 4.0, 10.4) or gabapentinoids (aOR 6.2, 95% CI 2.9, 13.5) were associated with opioid-related death. Persistent opioid prescribing and concurrent prescribing of psychotropics were associated with a higher risk of opioid-related death and should be avoided in clinical practice. An evidence-based indicator to monitor the safety of prescribed opioids during opioid deprescribing is needed.

Individualized prescribing portraits to reduce inappropriate initiation of opioid analgesics to opioid naïve patients in primary care: Protocol for a randomized controlled trial

BackgroundOpioid analgesics are frequently initiated for chronic and acute pain despite weak evidence of benefit, although prescribing rates of some analgesics decreased in the context of the epidemic. In some populations, up to a quarter of opioid naïve persons prescribed opioids for non-cancer pain develop prescription opioid use disorder (OUD). Audit and feedback interventions rely on constructive use of routinely collected data to align professional behaviours and clinical practice with best evidence. These interventions have been shown to help reduce inappropriate initiation. However, effectiveness and acceptability of individualized “portraits” of physicians' prescribing patterns, to reduce inappropriate initiation of opioid analgesics to opioid naïve persons, have not been evaluated.MethodsREDONNA is a mixed-methods randomized study testing the effectiveness of individualized prescribing Portraits to reduce inappropriate initiation of opioid analgesics. This intervention to improve safety of opioid prescribing in primary care in British Columbia (BC), Canada involves mailing individual prescribing portraits to an ‘early group’ of 2604 family physicians, followed in 6 months by a mailing to 2553 family physicians in the ‘delayed group’. Primary outcome is number of new opioid prescriptions initiated in opioid naïve people, measured using administrative data from a centralized medication monitoring database covering all prescription opioids dispensed from BC community pharmacies. Secondary endpoints will compare prescribing impact between the two groups. A qualitative sub-study will examine feasibility among a purposive sample of physicians and patients.DiscussionThis trial provides important evidence on the intervention's potential to steer policy and practice on inappropriate opioid analgesics initiation.Trial registration: The study was registered prospectively on 30 March 2020 at the ISRCTN Register (https://www.isrctn.com/ISRCTN34246811).

General practice responses to opioid prescribing feedback: a qualitative process evaluation.

BackgroundThe rise in opioid prescribing in primary care represents a significant public health challenge, associated with increased psychosocial problems, hospitalisations, and mortality. An evidence-based bimonthly feedback intervention to reduce opioid prescribing was developed and implemented, targeting 316 general practices in West Yorkshire over 1 year.AimTo understand how general practice staff received and responded to the feedback intervention.Design and settingQualitative process evaluation involving semi-structured interviews, guided by Normalisation Process Theory (NPT), of primary care healthcare professionals targeted by feedback.MethodParticipants were purposively recruited according to baseline opioid prescribing levels and degree of change following feedback. Interview data were coded to NPT constructs, and thematically analysed.ResultsInterviews were conducted with 21 staff from 20 practices. Reducing opioid prescribing was recognised as a priority. While high achievers had clear structures for quality improvement, feedback encouraged some less structured practices to embed changes. The non-prescriptive nature of the feedback reports allowed practices to develop strategies consistent with their own ways of working and existing resources. Practice concerns were allayed by the credibility of the reports and positive experiences of reducing opioid prescribing. The scale, frequency, and duration of feedback may have ensured a good overall level of practice population reach.ConclusionThe intervention engaged general practice staff in change by targeting an issue of emerging concern, and allowing adaption to different ways of working. Practice efforts to reduce opioid prescribing were reinforced by regular feedback, credible comparative data showing progress, and shared experiences of patient benefit.

The protocol of the Application of Economics & Social psychology to improve Opioid Prescribing Safety Trial 1 (AESOPS-1): Electronic health record nudges

Background:There is a lack of evidence that long-term opioid use offers benefit for noncancer pain and an abundance of evidence of harm. Despite clinical guidelines and education, prescribing continues at a higher rate than before the opioids crisis. The objective of trial 1 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-1) is to discourage unnecessary opioid prescribing in primary care by applying “behavioral insights”—empirically-tested social and psychological interventions that affect choice.Methods:AESOPS-1 randomizes primary care clinics in Illinois and California to behavioral intervention or control. Both arms receive opioid guideline education. Clinics randomized to the behavioral intervention arm receive nudges within the electronic health record (EHR) including: 1) an “accountable justification” entered in the chart, 2) a precommitment to address high-risk prescriptions, and 3) a “PainTracker” that broadens discussions about pain. The control arm receives no EHR-based intervention. The primary outcome is the change in weekly milligram morphine equivalents (MME) prescribed. The secondary outcome is the change in the proportion of patients prescribed at least 50 daily MME. To evaluate these outcomes, we will use a difference-in-differences mixed-effects regression model on clinician MME weekly or daily dose. The analysis will be “intent-to-treat.” The intervention period is 18-months, with a 6-month follow-up period to measure persistence of effects.Discussion:The AESOPS-1 trial will evaluate the effect of EHR-based interventions in reducing noncancer opioid prescribing in primary care. AESOPS-1 may demonstrate practical and scalable strategies to lower unnecessary population exposure to opioids.

Association of socioeconomic deprivation with opioid prescribing in primary care in England: a spatial analysis

BackgroundThe increasing trends in opioid prescribing and opioid-related deaths in England are concerning. A greater understanding of the association of deprivation with opioid prescribing is needed to guide policy responses...

Identification of barriers to safe opioid prescribing in primary care: a qualitative analysis of field notes collected through academic detailing.

Understanding barriers to safe opioid prescribing in primary care is critical amid the epidemic of prescription opioid abuse, misuse, and overdose in the US. Educational outreach strategies, such as academic detailing (AD), provide a forum for identification of barriers to, and strategies to facilitate, safe opioid prescribing in primary care. To identify barriers to safe opioid prescribing among primary care providers (PCPs) through AD. Qualitative analysis of data was collected through an existing AD intervention to improve safe opioid prescribing in primary care. The AD intervention was delivered from June 2018 to August 2018 to licensed PCPs with prescriptive authority within a large independent health system in the metropolitan Chicagoland area. The AD intervention involved visits by trained detailers to PCPs who contemporaneously documented details from each visit via field notes. Using qualitative analysis, field notes were analysed to identify recurring themes related to opioid prescribing barriers. Detailer-entered field notes from 186 AD visits with PCPs were analysed. Barriers to safe opioid prescribing were organised into six themes: 1) gaps in knowledge; 2) lack of prescription monitoring programme (PMP) utilisation; 3) patient pressures to prescribe opioids; 4) insurance coverage policies; 5) provider beliefs; and 6) health system pain management practices. Barriers to safe opioid prescribing in primary care, identified through AD visits among this large group of PCPs, support the need for continued efforts to enhance pain-management education, maximise PMP utilisation, and increase access to, and affordability of, non-opioid treatments.

The Balanced Opioid Initiative: protocol for a clustered, sequential, multiple-assignment randomized trial to construct an adaptive implementation strategy to improve guideline-concordant opioid prescribing in primary care

BackgroundRates of opioid prescribing tripled in the USA between 1999 and 2015 and were associated with significant increases in opioid misuse and overdose death. Roughly half of all opioids are prescribed in primary care. Although clinical guidelines describe recommended opioid prescribing practices, implementing these guidelines in a way that balances safety and effectiveness vs. risk remains a challenge. The literature offers little help about which implementation strategies work best in different clinical settings or how strategies could be tailored to optimize their effectiveness in different contexts. Systems consultation consists of (1) educational/engagement meetings with audit and feedback reports, (2) practice facilitation, and (3) prescriber peer consulting. The study is designed to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in diverse primary care clinics.Methods/designThe study is a hybrid type 3 clustered, sequential, multiple-assignment randomized trial (SMART) that randomizes clinics from two health systems at two points, months 3 and 9, of a 21-month intervention. Clinics are provided one of four sequences of implementation strategies: a condition consisting of educational/engagement meetings and audit and feedback alone (EM/AF), EM/AF plus practice facilitation (PF), EM/AF + prescriber peer consulting (PPC), and EM/AF + PF + PPC. The study’s primary outcome is morphine-milligram equivalent (MME) dose by prescribing clinicians within clinics. The study’s primary aim is the comparison of EM/AF + PF + PPC versus EM/AF alone on change in MME from month 3 to month 21. The secondary aim is to derive cost estimates for each of the four sequences and compare them. The exploratory aim is to examine four tailoring variables that can be used to construct an adaptive implementation strategy to meet the needs of different primary care clinics.DiscussionSystems consultation is a practical blend of implementation strategies used in this case to improve opioid prescribing practices in primary care. The blend offers a range of strategies in sequences from minimally to substantially intensive. The results of this study promise to help us understand how to cost effectively improve the implementation of evidence-based practices.Trial registrationNCT 04044521 (ClinicalTrials.gov). Registered 05 August 2019.

Increasing collaboration on substance use disorder research with primary care practices through the National Drug Abuse Treatment Clinical Trials Network

BackgroundThe National Drug Abuse Treatment Clinical Trials Network (CTN) called for its national nodes to promote the translation of evidence-based interventions from substance use disorder (SUD) research into clinical practices. This collaborative demonstration project engaged CTN-affiliated practice-based research networks (PBRNs) in research that describes aspects of opioid prescribing in primary care. MethodsSix PBRNs queried electronic health records from a convenience sample of 134 practices (84 participants) to identify the percent of adult patients with an office visit who were prescribed an opioid medication from October 1, 2015, to September 30, 2016, and, of those, the percent also prescribed a sedative in that year. Seven PBRNs sent an e-mail survey to a convenience sample of 108 practices (58 participants) about their opioid management policies and procedures during the project year. ResultsOf 561,017 adult patients with a visit to one of the 84 clinics in the project year, 22.9% (PBRN range 3.1%–25.4%) were prescribed opioid medications, and 52.1% (PBRN range 8.5%–60.6%) of those were prescribed a sedative in the same year. Of the 58 practices returning a survey (45.3% response rate), 98.1% had formal written treatment agreements for chronic opioid therapy, 68.5% had written opioid prescribing policies, and 43.4% provided reports to providers with feedback on opioid management. Only 24.1% were providing buprenorphine for OUD. ConclusionCTN-affiliated PBRNs demonstrated their ability to collaborate on a project related to opioid management; results highlight the important role for PBRNs in OUD treatment, research, and the need for interventions and additional policies addressing opioid prescribing in primary care practice.

Reducing the Pain Behind Opioid Prescribing in Primary Care.

To describe the efficacy of a comprehensive approach aimed at reducing opioid prescribing in an internal medicine resident clinic. Retrospective observational study. Internal medicine primary care resident clinic at a large urban academic medical center. All patients receiving opioid prescriptions from the primary care clinic. We reviewed pharmacy dispensing data for two hospital-affiliated pharmacies for resident primary care patients filling opioid prescriptions between July 2016 and July 2018. We instituted a comprehensive set of interventions that included resident education, limiting supervision of encounters for long-term opioid therapy (LTOT) to a fixed set of faculty champions, and providing alternate modalities for pain control. We calculated the change in number of opioid prescriptions dispensed, number of patients receiving opioid prescriptions, morphine milligram equivalents (MMEs) dispensed, and average per-patient daily MMEs dispensed. We observed an average monthly reduction of 2.44% (P < 0.001) in the number of prescriptions dispensed and a 1.83% (P < 0.001) monthly reduction in the number of patients receiving prescriptions. Over the two-year period, there was a 74.3% reduction in total MMEs prescribed and a 66.5% reduction in the average MMEs prescribed per patient. Our findings demonstrate a significant reduction in opioid prescribing after implementation of a comprehensive initiative. Although our study was observational in nature, we witnessed a nearly threefold decrease in opioid prescribing compared with national trends. Our results offer important insights for other primary care resident clinics hoping to engender safe prescribing practices and curb high-dose opioid prescribing.

A New Quality Improvement Toolkit to Improve Opioid Prescribing in Primary Care.

The role of opioids in managing chronic pain has evolved in light of the opioid misuse epidemic and new evidence regarding risks and benefits of long-term opioid therapy. With mounting national guidelines and local regulations, providers need interventions to standardize and improve safe, responsible prescribing. This article summarizes the evolution of an opioid management toolkit using a quality improvement (QI) approach to improve prescribing. The authors developed a list of opioid-prescribing best practices and offered in-office, team-based QI projects to ambulatory clinics, updated and tested over 3 trials in the form of a toolkit. Outcome measures included pre- and postproject surveys on provider and staff satisfaction, toolkit completion, and process measures. The toolkit supports workflow planning, redesign, and implementation. Ten clinics participated in trial 1, completing the QI project on average in 3 months, with a mean of 9.1 hours of team time. Provider satisfaction with prescribing increased from 42% to 96% and staff satisfaction from 54% to 81%. The most common strategies in trials 1 and 2 focused on regulatory compliance (35% to 36%), whereas in Trial 3 there was a strong move toward peer support (81%). Clinics responded to implementation of opioid-related best practices using QI with improved provider and staff satisfaction. Once the goals of regulatory compliance and workflow improvements were met, clinics focused on strategies supporting providers in the lead role of managing chronic pain, building on strategies that provide peer support. Using QI methods, primary care clinics can improve opioid-prescribing best practices for patients.