Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care

Liebschutz, Jane M.; Xuan, Ziming; Shanahan, Christopher W.; Larochelle, Marc R.; Keosaian, Julia; Beers, Donna; Guara, George; O'Connor, Kristen; Alford, Daniel P.; Parker, Victoria A.; Weiss, Roger D.; Samet, Jeffrey H.; Crosson, Julie; Cushman, P; Lasser, Karen E.

doi:10.1001/jamainternmed.2017.2468

Cited by 115 publications

(115 citation statements)

References 43 publications

(98 reference statements)

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“…A recent cluster RCT among primary care clinicians sought to improve guideline adherence while decreasing opioid misuse risk in chronic pain using a multicomponent intervention (nurse care management, an electronic registry, one‐on‐one academic detailing, and electronic decision tools for safe opioid prescribing). The intervention improved adherence to guideline‐concordant care compared with a control using electronic decision tools only; however, the intervention did not decrease early opioid refills .…”

Section: Managementmentioning

confidence: 80%

Best Practices in the Management of Nonmedical Opioid Use in Patients with Cancer-Related Pain

Ulker

Fabbro

2019

The Oncologist

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Introduction Nonmedical opioid use (NMOU) in patients with cancer is a term covering a spectrum of nonprescribed opioid use. The extent to which an individual uses opioids in a nonprescribed manner will influence propensity for adverse effects such as neurotoxicity, substance use disorder, overdose, and death. Objectives The objectives of this study were to (A) evaluate current literature regarding management of NMOU in patients with cancer‐related pain; (B) provide best practice recommendations based on evidence; and (C) integrate practices derived from the management of noncancer pain, where clinically appropriate or when the oncology literature is limited. Methods This study is a narrative review. Implications Although harm from NMOU was thought to be rare among oncology patients, about one in five patients with cancer is at risk of adverse outcomes including prolonged opioid use, high opioid doses, and increased health care utilization. The management of NMOU can be challenging because pain is a multidimensional experience encompassing physical, psychological, and spiritual domains. An interdisciplinary team approach is most effective, and management strategies may include (A) education of patients and families; (B) harm reduction, including opioid switching, decreasing the overall daily dose, avoiding concurrent sedative use, and using adjuvant medications for their opioid‐sparing potential; (C) managing psychological and spiritual distress with an interdisciplinary team and techniques such as brief motivational interviewing; and (D) risk mitigation by pill counts, frequent clinic visits, and accessing statewide prescription drug monitoring plans. Conclusion Although many of the management strategies for NMOU in patients with cancer‐related pain are modeled on those for chronic non–cancer‐related pain, there is emerging evidence that education and harm‐reduction initiatives specifically for cancer‐related pain are effective. Implications for Practice Nonmedical opioid use (NMOU) in patients with cancer is a term covering a broad spectrum of nonprescribed opioid use. The extent to which an individual uses opioids in a nonprescribed manner will influence propensity for adverse effects such as neurotoxicity, substance use disorder, overdose, and death. This review evaluates the evidence for best practices in oncology and addresses limitations in the literature with supplemental evidence from noncancer chronic pain. Management recommendations for NMOU are provided, based on a combination of literature‐based evidence and best clinical practice. Effective management of NMOU in oncology has the potential to improve quality of life, decrease health utilization, and improve survival.

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Section: Managementmentioning

confidence: 80%

Best Practices in the Management of Nonmedical Opioid Use in Patients with Cancer-Related Pain

Ulker

Fabbro

2019

The Oncologist

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“…In a more recent trial of academic detailing, which used a registry and decision-support tools across 4 safety-net clinics, LtOT patients at intervention clinics were more likely to have a ≥10% decrease in MED. 22 In a similar trial of academic detailing, which used audit and feedback as well as external facilitation, the average MED was decreased significantly at 12 months for intervention clinic patients compared with the comparison control group. 24 These studies used blended implementation strategies similar to the ones used in the present study, suggesting that this approach can be effective in improving opioid-prescribing behaviors.…”

Section: Discussionmentioning

confidence: 98%

“…Several clinicians at the study sites mentioned to study team members that some patients self-tapered their opioid dose in response to conversations about risks and harms. 22 In addition, monitoring and reporting on prescribing behaviors by individual clinicians within these organizations created opportunities for discussions and peer comparisons that may have influenced subsequent prescribing behaviors. In a systematic review of dose reduction or discontinuation of LtOT, a common theme in studies with positive outcomes was team-based, multidisciplinary support of clinicians and staff.…”

Section: Discussionmentioning

confidence: 99%

Team-Based Clinic Redesign of Opioid Medication Management in Primary Care: Effect on Opioid Prescribing

et al. 2019

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PURPOSE Six key elements of opioid medication management redesign in primary care have been previously identified. Here, we examine the effect of implementing these Six Building Blocks on opioid-prescribing practices. METHODS Six rural-serving organizations with 20 clinic locations received support for 15 months during the period October 2015 to May 2017 to implement the Six Building Blocks. Patients undergoing long-term opioid therapy (LtOT) at these study sites were compared with patients undergoing LtOT enrolled in a regional health plan who did not receive care at the study sites but who resided in the same primary care service areas (control group). Outcomes were monthly trend in the proportion of patients undergoing LtOT prescribed a ≥100 morphine equivalent dose (MED) of opioids daily and the total number of patients receiving an opioid prescription. An interrupted time series using difference-indifference analysis was used for tests of significance. RESULTS The proportion of patients prescribed a ≥100 MED of opioids daily decreased 2.2% (11.8% to 9.6%) among patients at the intervention clinics and 1.3% (14.0% to 12.7%) among patients in the control group. The rate of decrease was significantly greater among study patients than among patients in the control group (P = .018). The rate of decrease in the number of patients on LtOT at intervention clinics increased during the intervention period compared with the preintervention period (P <.001). CONCLUSIONS Efforts to redesign opioid medication management in primary care resulted in a significant decrease in opioid prescribing. Future research is needed to determine if these results are generalizable to other settings and to assess implications for patient-reported outcomes.

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“…Our findings provide priority areas that clinicians, policymakers, medicine regulators, and commissioners can use in their plight to manage the growing opioid crisis. Monitoring the prescribing of opioids via clinical dashboards or electronic medical records has improved adherence to guidelines, reduced opioid doses, and improved physicians' knowledge and attitudes towards managing people on opioids in primary care [40][41][42]. Strategies that promote the safe prescribing of opioids and enable prescribers to effectively manage factors such as benzodiazepine co-prescription and depression are needed.…”

Section: Implications For Practice and Policymentioning

confidence: 99%

Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis

Richards

Mahtani

Muthee

et al. 2020

BMC Med

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Background: The risks of harms from opioids increase substantially at high doses, and high-dose prescribing has increased in primary care. However, little is known about what leads to high-dose prescribing, and studies exploring this have not been synthesized. We, therefore, systematically synthesized factors associated with the prescribing of high-dose opioids in primary care. Methods:We conducted a systematic review of observational studies in high-income countries that used patientlevel primary care data and explored any factor(s) in people for whom opioids were prescribed, stratified by oral morphine equivalents (OME). We defined high doses as ≥ 90 OME mg/day. We searched MEDLINE, Embase, Web of Science, reference lists, forward citations, and conference proceedings from database inception to 5 April 2019. Two investigators independently screened studies, extracted data, and appraised the quality of included studies using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. We pooled data on factors using random effects meta-analyses and reported relative risks (RR) or mean differences with 95% confidence intervals (CI) where appropriate. We also performed a number needed to harm (NNT H ) calculation on factors when applicable. Results:We included six studies with a total of 4,248,119 participants taking opioids, of whom 3.64% (n = 154,749) were taking high doses. The majority of included studies (n = 4) were conducted in the USA, one in Australia and one in the UK. The largest study (n = 4,046,275) was from the USA. Included studies were graded as having fair to good quality evidence. The co-prescription of benzodiazepines (RR 3.27, 95% CI 1.32 to 8.13, I 2 = 99.9%), depression (RR 1.38, 95% CI 1.27 to 1.51, I 2 = 0%), emergency department visits (RR 1.53, 95% CI 1.46 to 1.61, I 2 = 0%, NNT H 15, 95% CI 12 to 20), unemployment (RR 1.44, 95% CI 1.27 to 1.63, I 2 = 0%), and male gender (RR 1.21, 95% CI 1.14 to 1.28, I 2 = 78.6%) were significantly associated with the prescribing of high-dose opioids in primary care.Conclusions: High doses of opioids are associated with greater risks of harms. Associated factors such as the coprescription of benzodiazepines and depression identify priority areas that should be considered when selecting, identifying, and managing people taking high-dose opioids in primary care. Coordinated strategies and services that promote the safe prescribing of opioids are needed. Study registration: PROSPERO, CRD42018088057

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Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care

Cited by 115 publications

References 43 publications

Best Practices in the Management of Nonmedical Opioid Use in Patients with Cancer-Related Pain

Best Practices in the Management of Nonmedical Opioid Use in Patients with Cancer-Related Pain

Team-Based Clinic Redesign of Opioid Medication Management in Primary Care: Effect on Opioid Prescribing

Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis

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