Background: Rates 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.(Continued on next page)

Randomised double blind crossover trial comparing safety and efficacy of oral controlled release oxycodone with controlled release morphine in patients with cancer pain. J Clin Oncol 1998;16:3222-9. 23 Nicholson AB. Methadone for cancer pain. Cochrane Database Syst Rev 2004;(2):CD003971. 24 Muijsers RB, Wagstaff AJ. Transdermal fentanyl: an updated review of its pharmacological properties and therapeutic efficacy in chronic cancer pain control. Drugs 2001;61:2289-307. 25 Ahmedzai S, Brooks D. Transdermal fentanyl versus sustained release oral morphine in cancer pain: preference, efficacy and quality of life.

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significantly lower in the ulipristal acetate group compared with placebo (7 vs 12 days; P5.002). A significantly more women in the ulipristal acetate group experienced cessation of bleeding within 10 days compared with placebo (34.4% vs 9.7%; P5.03; NNT54). Limitations included the small sample size, possible recall bias in bleeding diary reports before start of trial, and having to end the study early because of FDA recall and concern for possible liver toxicity.