Effect of opioid prescribing guidelines in primary care

Comprehensive Approach to Opioid Management in a Primary Care Network

In response to the opioid epidemic, the Centers for Disease Control and Prevention released best practice recommendations for prescribing, yet adoption of these guidelines has been fragmented and frequently met with uncertainty by both patients and providers. This study aims to describe the development and implementation of a comprehensive approach to improving opioid stewardship in a large network of primary care providers. The authors developed a 3-tier approach to opioid management: (1) establishment and implementation of best practices for prescribing opioids, (2) development of a weaning process to decrease opioid doses when the risk outweighs benefits, and (3) support for patients when opioid use disorders were identified. Across 44 primary care practices caring for >223,000 patients, the total number of patients prescribed a chronic opioid decreased from 4848 patients in 2018 to 3106 patients in 2021, a decrease of 36% (P < 0.001). The percent of patients with a controlled substance agreement increased from 13% to 83% (P < 0.001) and the percent of patients completing an annual urine drug screen increased from 17% to 53% (P < 0.001). The number of patients coprescribed benzodiazepines decreased from 1261 patients at baseline to 834 at completion. A total of 6.5% of patients were referred for additional support from a certified alcohol and substance abuse counselor embedded within the program. Overall, the comprehensive opioid management program provided the necessary structure to support opioid prescribing and resulted in improved adherence to best practices, facilitated weaning of opioids when medically appropriate, and enhanced support for patients with opioid use disorders.

Systematic Identification and Categorization of Opioid Prescribing and Dispensing Policies in 16 States and Washington, DC

OBJECTIVES

State policies can impact opioid prescribing or dispensing. Some state opioid policies have been widely examined in empirical studies, including prescription drug monitoring programs and pain clinic licensure requirements. Other relevant policies might exist that have received limited attention. Our objective was to identify and categorize a wide range of state policies that could affect opioid prescribing/dispensing.

METHODS

We used stratified random sampling to select 16 states and Washington, DC, for our sample. We collected state regulations and statutes effective during 2020 from each jurisdiction, using search terms related to opioids, pain management, and prescribing/dispensing. We then conducted qualitative template analysis of the data to identify and categorize policy categories.

RESULTS

We identified three dimensions of opioid prescribing/dispensing laws: the prescribing/dispensing rule, its applicability, and its disciplinary consequences. Policy categories of prescribing/dispensing rules included clinic licensure, staff credentials, evaluating the appropriateness of opioids, limiting the initiation of opioids, preventing the diversion or misuse of opioids, and enhancing patient safety. Policy categories related to applicability of the law included the pain type, substance type, practitioner, setting, payer, and prescribing situation. The disciplinary consequences dimension included specific consequences and inspection processes.

DISCUSSION

Policy categories within each dimension of opioid prescribing/dispensing laws could become a foundation for creating variables to support empirical analyses of policy effects, improving operationalization of policies in empirical studies, and helping to disentangle the effects of multiple state laws enacted at similar times to address the opioid crisis. Several of the policy categories we identified have been underexplored in previous empirical studies.

The Role of Informatics in Implementing Guidelines for Chronic Opioid Therapy Risk Assessment in Primary Care: A Narrative Review Informed by the Socio-Technical Model

Approximately 2 million Americans live with opioid use disorder (OUD), most of whom also have chronic pain. The economic burden of chronic pain and prescription opioid misuse runs into billions of dollars. Patients on prescription opioids for chronic non-cancer pain (CNCP) are at increased risk for OUD and overdose. By adhering to the Center for Disease Control and Prevention (CDC) opioid prescribing guidelines, primary care providers (PCPs) have the potential to improve patient outcomes. But numerous provider, patient, and practice-specific factors challenge adherence to guidelines in primary care. Many of the barriers may be mediated by informatics interventions, but gaps in knowledge and unmet needs exist. This narrative review examines the risk assessment and harm reduction process in a socio-technical context to highlight the gaps in knowledge and unmet needs that can be mediated through informatics intervention.

A focus on the future of opioid prescribing: implementation of a virtual opioid and pain management module for medical students

BACKGROUND

The United States opioid epidemic is a devastating public health crisis fueled in part by physician prescribing. While the next generation of prescribers is crucial to the trajectory of the epidemic, medical school curricula designated to prepare students for opioid prescribing (OP) and pain management is often underdeveloped. In response to this deficit, we aimed to investigate the impact of an online opioid and pain management (OPM) educational intervention on fourth-year medical student knowledge, attitudes, and perceived competence.

METHODS

Graduating students completing their final year of medical education at Sidney Kimmel Medical College of Thomas Jefferson University were sent an e-mail invitation to complete a virtual OPM module. The module consisted of eight interactive patient cases that introduced topics through a case-based learning system, challenging students to make decisions and answer knowledge questions about the patient care process. An identical pre- and posttest were built into the module to measure general and case-specific learning objectives, with responses subsequently analyzed using the Wilcoxon matched-pairs signed-rank test.

RESULTS

Forty-three students (19% response rate) completed the module. All median posttest responses ranked significantly higher than paired median pretest responses (p <  0.05). Comparing the paired overall student baseline score to module completion, median posttest ranks (Mdn = 206, IQR = 25) were significantly higher than median pretest ranks (Mdn = 150, IQR = 24) (p <  0.001). Regarding paired median Perceived Competence Scale metrics specifically, perceived student confidence, capability, and ability in opioid management increased from "disagree" (2) to "agree" (4) (p <  0.001), and student ability to meet the challenge of opioid management increased from "neither agree nor disagree" (3) to "agree" (4) (p <  0.001). Additionally, while 77% of students reported receiving OP training in medical school, 21% reported no history of prior training.

CONCLUSION

Implementation of a virtual, interactive module with clinical context is an effective framework for improving the OPM knowledge, attitudes, and perceived competence of fourth-year medical students. This type of intervention may be an important method for standardizing and augmenting the education of future prescribers across multiple institutions.

Opioid Naive Surgeons and Opioid-Tolerant Patients: Can Education Alter Prescribing Patterns to Total Knee Arthroplasty Patients?

Patterns of opioid overprescribing following arthroplasty likely developed given that poor pain control can diminish patient satisfaction, delay disposition, and lead to complications. Recently, interventions promoting responsible pain management have been described, however, most of the existing literature focuses on opioid naive patients. The aim of this study was to describe the effect of an educational intervention on opioid prescribing for opioid-tolerant patients undergoing primary total knee arthroplasty (TKA). As the start to a quality improvement initiative to reduce opioid overprescribing, a departmental grand rounds was conducted. Prescribing data, for the year before and after this intervention, were retrospectively collected for all opioid-tolerant patients undergoing primary TKA. Opioid prescribing data were standardized to mean morphine milligram equivalents (MME). Segmented time series regression was utilized to estimate the change in opioid prescribing associated with the intervention. A total of 508 opioid-tolerant patients underwent TKA at our institution during the study period. The intervention was associated with a statistically significant decrease of 468 mean MME (23%) from 2,062 to 1,594 (p = 0.005) in TKA patients. This study demonstrates that an educational intervention is associated with decreased opioid prescribing among opioid-tolerant TKA patients. While the effective management of these patients is challenging, surgeon education should be a key focus to optimizing their care.

Interventions to Influence Opioid Prescribing Practices for Chronic Noncancer Pain: A Systematic Review and Meta-Analysis

CONTEXT

This study is a systematic review of interventions to improve adherence to guideline recommendations for prescribing opioids for chronic noncancer pain.

EVIDENCE ACQUISITION

Investigators searched CINAHL, Embase, MEDLINE, PsycINFO, the Cochrane Library, and Joanna Briggs Institute Evid Based Pract database from inception until June 3, 2019. Interventional studies to improve adherence to recommendations made by opioid guidelines for chronic noncancer pain in North America were eligible if outcomes included adherence to guideline recommendations or change in quantity of opioids prescribed. Data were extracted independently and in duplicate. Quantitative synthesis was performed using random effects meta-analysis. Confidence in evidence was determined using the Grades of Recommendation, Assessment, Development, and Evaluation.

EVIDENCE SYNTHESIS

A total of 20 studies (8 controlled and 12 prospective cohort) involving 1,491 providers and 72 clinics met inclusion. Interventions included education, audit and feedback, interprofessional support, shared decision making, and multifaceted strategies. Multifaceted interventions improved the use of urine drug testing (n=2, or =2.31, 95% CI=1.53, 3.49, z=3.98, p<0.01; high-certainty evidence), treatment agreements (n=2, or =1.96, 95% CI=1.47, 2.61, z=4.56, p<0.01; moderate-certainty evidence), and mental health screening (n=2, 2.57-fold, 95% CI=1.56, 4.24, z=2.32, p=0.02; low-certainty evidence) when prescribing opioids for chronic noncancer pain. Very low-certainty evidence suggests that several interventions improved the use of treatment agreements, urine drug testing, and prescription drug monitoring programs.

CONCLUSIONS

Mostly very low-certainty evidence supports a number of interventions for improving adherence to risk management strategies when prescribing opioids for chronic noncancer pain; however, the effect on patient important outcomes (e.g., overdose, addiction, death) is uncertain.

Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project

Background

Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations.

Methods

Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4–6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse risk screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90 mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p < 0.05, 95% confidence intervals and/or Cohen’s d.

Results

Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1255 patients in the QI and 1632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p = 0.019) and prescribed ≥90 mg/day MED (23.0% vs 15.5%, p = 0.038). The stepped-wedge analysis did not show statistically significant changes in outcomes in the QI clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90 mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p = 0.02), but not other outcomes (p ≥ 0.05).

Conclusions

Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented.

Trial registration

Not applicable.

Health outcomes and costs in patients with osteoarthritis and chronic pain treated with opioids in Spain: the OPIOIDS real-world study

Objective:

The objective of this study was to analyze health outcomes, resource utilization, and costs in osteoarthritis patients with chronic nociceptive pain who began treatment with an opioid in real-world practice in Spain.

Methods:

We designed a non-interventional, retrospective, longitudinal study with 36 months of follow-up using electronic medical records (EMRs) from primary care centers, of patients aged 18+ years who began a new treatment with an opioid drug in usual practice for chronic pain due to osteoarthritis. Health/non-health resource utilization and costs, treatment adherence, pain change, cognitive functioning, and dependence for basic activities of daily living (BADL) were assessed.

Results:

A total of 38,539 EMRs [mean age (SD); 70.8 (14.3) years, 72.3% female; 53.3% hip/knee, 25.0% spine, and 21.7% other sites] were recruited. A total of 19.1% of patients remained on initial opioid at 36 months, without significant differences by osteoarthritis site (p = 0.125). Mean total adjusted cost was €17,915, with 27.7% corresponding to healthcare resources and 72.3% to lost productivity. Hospital admissions for osteoarthritis-related surgical interventions accounted for 15.8% of total healthcare cost. A slight mean pain reduction was observed: –1.3 points, –16.9%, p < 0.001, with increases in cognitive deficit (+3.3%, p < 0.001) and moderate to total dependence for BADL (+15.6%, p < 0.001) in a median duration of opioid use of 203 days (IQR: 89–696).

Conclusions:

In real-world practice in Spain, opioid use in osteoarthritis was high, but with low adherence. There were meaningful increases in resource use and costs for the National Health System. Pain reduction was modest, whereas cognitive impairment and dependence for BADL increased significantly.

Research and Reporting Considerations for Observational Studies Using Electronic Health Record Data

Electronic health records (EHRs) are an increasingly important source of real-world health care data for observational research. Analyses of data collected for purposes other than research require careful consideration of data quality as well as the general research and reporting principles relevant to observational studies. The core principles for observational research in general also apply to observational research using EHR data, and these are well addressed in prior literature and guidelines. This article provides additional recommendations for EHR-based research. Considerations unique to EHR-based studies include assessment of the accuracy of computer-executable cohort definitions that can incorporate unstructured data from clinical notes and management of data challenges, such as irregular sampling, missingness, and variation across time and place. Principled application of existing research and reporting guidelines alongside these additional considerations will improve the quality of EHR-based observational studies.

Strengths and weaknesses of existing data sources to support research to address the opioids crisis

Better opioid prescribing practices, promoting effective opioid use disorder treatment, improving naloxone access, and enhancing public health surveillance are strategies central to reducing opioid-related morbidity and mortality. Successfully advancing and evaluating these strategies requires leveraging and linking existing secondary data sources. We conducted a scoping study in Fall 2017 at RAND, including a literature search (updated in December 2018) complemented by semi-structured interviews with policymakers and researchers, to identify data sources and linking strategies commonly used in opioid studies, describe data source strengths and limitations, and highlight opportunities to use data to address high-priority public health research questions. We identified 306 articles, published between 2005 and 2018, that conducted secondary analyses of existing data to examine one or more public health strategies. Multiple secondary data sources, available at national, state, and local levels, support such research, with substantial breadth in data availability, data contents, and the data's ability to support multi-level analyses over time. Interviewees identified opportunities to expand existing capabilities through systematic enhancements, including greater support to states for creating and facilitating data use, as well as key data challenges, such as data availability lags and difficulties matching individual-level data over time or across datasets. Multiple secondary data sources exist that can be used to examine the impact of public health approaches to addressing the opioid crisis. Greater data access, improved usability for research purposes, and data element standardization can enhance their value, as can improved data availability timeliness and better data comparability across jurisdictions.

Targeted Intervention to Increase Awareness of Opioid Overprescribing Significantly Reduces Narcotic Prescribing Within an Academic Orthopaedic Practice

OBJECTIVE

To evaluate the impact of a targeted intervention focused on increasing awareness of opioid overprescribing within an academic orthopaedic practice.

DESIGN

Retrospective prescribing data was collected through an electronic chart review. A single time point, a departmental grand rounds titled "Opioid Use, Misuse, & Abuse in Orthopaedics," was conducted on February 8, 2017. Opioid prescribing data was analyzed for the year preceding and year immediately following this targeted intervention. Narcotics were standardized using milligram morphine equivalents (MME) for comparison, and patients were categorized as opioid naive or non-naive based on whether an opioid prescription was written within 90 days prior to surgery. A segmented time series regression model was utilized to determine statistical significance of the educational intervention.

SETTING

Academic Medical Center.

PARTICIPANTS

All patients undergoing orthopaedic procedures at our institution between January 2016 and March 2018.

RESULTS

A total of 5882 patients underwent orthopaedic procedures at our institution during the study period. Of these, 2887 were in the year preceding and 2995 were in the year immediately following the targeted intervention to increase awareness of opioid overprescribing. The interve.ntion was associated with an acute decrease of 167 mean MME from 780 to 613 in opioid naive (p = 0.028) and 154 mean MME from 1,015 to 861 in opioid non-naive patients (p = 0.010). The intervention was also associated with a favorable change in the overall mean MME prescribing trend over time in both naive (p = 0.011) and non-naive (p = 0.064) patients.

CONCLUSIONS

This study demonstrates decreased opioid prescribing within an academic orthopaedic department after a targeted intervention focused on raising the awareness of opioid overprescribing. Ongoing provider education and awareness are critical parts of any plan to continue curtail opioid overprescribing among surgeons.

A multicomponent intervention to improve adherence to opioid prescribing and monitoring guidelines in primary care

OBJECTIVE

Guidelines for appropriate management of chronic opioid therapy are underutilized by primary care physicians (PCPs). The authors hypothesized that developing a multicomponent, team-based opioid management system with electronic health record (EHR) support would allow our clinicians to improve adherence to chronic opioid prescribing and monitoring guidelines.

DESIGN

This was a retrospective pre-post study.

SETTING

The authors performed this intervention at our large, urban, academic primary care practice.

PATIENTS, PARTICIPANTS

All patients with the diagnosis of "chronic pain, opioid requiring (ICD-10 F11.20)" on their primary care EHR problem lists were included in this study.

INTERVENTION

The authors implemented a five-pronged strategy to improve our system of opioid prescribing, including (1) a patient registry with regular dissemination of reports to PCPs; (2) standardization of policies regarding opioid prescribing and monitoring; (3) development of a risk-assessment algorithm and riskstratified monitoring guidelines; (4) a team-based approach to care with physician assistant care managers; and (5) an EHR innovation to facilitate communication and guideline adherence.

MAIN OUTCOME MEASURES

The authors measured percent adherence to opioid prescribing guidelines, including annual patient-provider agreements, biannual urine drug screens (UDSs), and prescription monitoring program (PMP) verification.

RESULTS

Between September 2015 and September 2016, the percentage of patients on chronic opioid therapy with a signed controlled substances agreement within the preceding year increased from 46 to 76 percent (p < 0.0001), while the percentage of patients with a UDS done within the past 6 months rose from 23 to 79 percent (p < 0.0001). The percentage of patients whose state PMPs profile had been checked by a primary care team member in the past year rose from 45 to 97 percent (p < 0.0001).

CONCLUSION

A comprehensive strategy to standardize chronic opioid prescribing in our primary care practice coincided with an increase in adherence to opioid management guidelines.

Barriers and Facilitators to Implementation of Pharmacotherapy for Opioid Use Disorders in VHA Residential Treatment Programs

OBJECTIVE

Despite evidence of effectiveness, pharmacotherapy-methadone, buprenorphine, or naltrexone-is prescribed to less than 35% of Veterans Health Administration (VHA) patients diagnosed with opioid use disorder (OUD). Among veterans whose OUD treatment is provided in VHA residential programs, factors influencing pharmacotherapy implementation are unknown. We examined barriers to and facilitators of pharmacotherapy for OUD among patients diagnosed with OUD in VHA residential programs to inform the development of implementation strategies to improve medication receipt.

METHOD

VHA electronic health records and program survey data were used to describe pharmacotherapy provided to a national cohort of VHA patients with OUD in residential treatment programs (N = 4,323, 6% female). Staff members (N = 63, 57% women) from 44 residential programs (response rate = 32%) participated in interviews. Barriers to and facilitators of pharmacotherapy for OUD were identified from transcripts using thematic analysis.

RESULTS

Across all 97 residential treatment programs, the average rate of pharmacotherapy for OUD was 21% (range: 0%-67%). Reported barriers included provider or program philosophy against pharmacotherapy, a lack of care coordination with nonresidential treatment settings, and provider perceptions of low patient interest or need. Facilitators included having a prescriber on staff, education and training for patients and staff, and support from leadership.

CONCLUSIONS

Contrary to our hypothesis, barriers to and facilitators of pharmacotherapy for OUD in VHA residential treatment programs were consistent with prior research in outpatient settings. Intensive educational programs, such as academic detailing, and policy changes such as mandating buprenorphine waiver training for VHA providers, may help improve receipt of pharmacotherapy for OUD.

Variation in postoperative narcotic prescribing after pediatric appendectomy

BACKGROUND

Overuse of prescription opioids by both pediatric and adult patients has garnered significant attention in recent years. Educational interventions have been shown to decrease prescription opioids post-operatively in the adult population; similar data have not previously been reported in pediatrics.

METHODS

Educational interventions included staff education, institution of opioid standardization protocol, and distribution of educational materials to families. Chart review was performed pre- and post-intervention to compare prescribing practices following appendectomy in patients less than 19 years of age. Follow-up phone calls were used to assess patient satisfaction and pain control.

RESULTS

Three hundred thirteen cases were identified pre-intervention [PRE] and compared to 119 cases postintervention [POST]. 84.3% of patients were given a prescription for opioids at time of discharge in the PRE cohort compared to 6.7% (p < 0.001) POST. There was a significant increase in non-opioid analgesia (p < 0.001) POST. There was no significant variability in opioid usage by type of surgery performed, attending provider, or patients' gender or age. Of the patients in the POST cohort, 60.5% were available for telephone follow-up. More than 80% of patients were given acetaminophen and/or ibuprofen POST and 94.4% reported adequate pain control; 88.9% reported that they would agree to avoid opioids again in the future. On follow-up survey, there was no increase in emergency department visits or phone calls for poorly controlled pain following the intervention.

CONCLUSION

Low-fidelity educational interventions and creation of a standardized pathway is an effective tool to reduce opioid prescribing and promote alternative means of analgesia without an increase in readmissions or presentation for pain.

LEVEL OF EVIDENCE

III.

TRPV1 channel contributes to remifentanil-induced postoperative hyperalgesia via regulation of NMDA receptor trafficking in dorsal root ganglion

Background

Remifentanil is widely used in general anesthesia due to its reliability and rapid onset. However, remifentanil-induced postoperative hyperalgesia might be a challenge nowadays. Accumulating evidence suggests that the transient receptor potential vanilloid 1 (TRPV1) was involved in the development of neuropathic pain and hyperalgesia. However, the contribution of TRPV1 in modulating remifentanil-induced postoperative hyperalgesia is still unknown. The aim of this study is the contribution of TRPV1 to the surface expression of N-methyl-d-aspartate (NMDA) receptors in remifentanil-induced postoperative hyperalgesia.

Methods

The hot plate test and the Von Frey test were performed to evaluate thermal and mechanical hyperalgesia. Capsazepine (CPZ) was administrated intrathecally to confirm our results. TRPV1, NMDA receptors, CaMKII (calcium/calmodulin-dependent kinase II), and protein kinase C (PKC) in the dorsal root ganglion (DRG) were detected by Western blotting. Immunofluorescence assay was applied to analyze the distribution of TRPV1 and the relationship between TRPV1 and NMDA receptor subunit 1 (NR1).

Results

Remifentanil-induced both thermal and mechanical postoperative hyperalgesia. Here, we found the membrane trafficking of NR1, possibly due to the activation of TRPV1 in DRG neurons after remifentanil infusion. Furthermore, intrathecal injection of CPZ was able to relieve remifentanil-induced postoperative hyperalgesia according to a behavioral test and CPZ confirmed that TRPV1 is involved in NR1 trafficking. In addition, CaMKII/PKC but not protein kinase A (PKA) contributed to remifentanil-induced postoperative hyperalgesia.

Conclusion

Our study demonstrates that TRPV1 receptors are involved in remifentanil-induced postoperative hyperalgesia. TRPV1 contributes to the persistence of remifentanil-induced postoperative hyperalgesia through the trafficking of NMDA receptors via the activation of CaMKII-PKC signaling pathways in DRG neurons.

Barriers and Facilitators to Implementation of Pharmacotherapy for Opioid Use Disorders in VHA Residential Treatment Programs

OBJECTIVE

Despite evidence of effectiveness, pharmacotherapy-methadone, buprenorphine, or naltrexone-is prescribed to less than 35% of Veterans Health Administration (VHA) patients diagnosed with opioid use disorder (OUD). Among veterans whose OUD treatment is provided in VHA residential programs, factors influencing pharmacotherapy implementation are unknown. We examined barriers to and facilitators of pharmacotherapy for OUD among patients diagnosed with OUD in VHA residential programs to inform the development of implementation strategies to improve medication receipt.

METHOD

VHA electronic health records and program survey data were used to describe pharmacotherapy provided to a national cohort of VHA patients with OUD in residential treatment programs (N = 4,323, 6% female). Staff members (N = 63, 57% women) from 44 residential programs (response rate = 32%) participated in interviews. Barriers to and facilitators of pharmacotherapy for OUD were identified from transcripts using thematic analysis.

RESULTS

Across all 97 residential treatment programs, the average rate of pharmacotherapy for OUD was 21% (range: 0%-67%). Reported barriers included provider or program philosophy against pharmacotherapy, a lack of care coordination with nonresidential treatment settings, and provider perceptions of low patient interest or need. Facilitators included having a prescriber on staff, education and training for patients and staff, and support from leadership.

CONCLUSIONS

Contrary to our hypothesis, barriers to and facilitators of pharmacotherapy for OUD in VHA residential treatment programs were consistent with prior research in outpatient settings. Intensive educational programs, such as academic detailing, and policy changes such as mandating buprenorphine waiver training for VHA providers, may help improve receipt of pharmacotherapy for OUD.

Assessment of Opioid Prescribing Practices Before and After Implementation of a Health System Intervention to Reduce Opioid Overprescribing

IMPORTANCE

Overprescribing of opioids has generated and sustains the opioid overdose epidemic. Health systems have a responsibility to lead the effort to reduce overprescribing.

OBJECTIVE

To measure the effects of multilevel interventions on opioid prescribing within a health system.

DESIGN, SETTING, AND PARTICIPANTS

Quality improvement study comparing a 6-month preintervention baseline with a 16-month postintervention period ending in April 2018. Inpatient and outpatient clinical activity within a regional health system including an acute care hospital, same-day surgery, and outpatient clinics. Opioid prescribing activity by hundreds of clinicians involving over a million clinical encounters was measured using a health system's electronic medical record.

INTERVENTIONS

Multiple parallel interventions in different domains, including prescriber education and accountability, enhanced oversight via measurement of individual prescribers, tools to right-size postoperative discharge prescriptions, reduction of default amounts on standard opioid prescription orders, and professionally written patient and public education about opioid risks and alternatives.

MAIN OUTCOMES AND MEASURES

Morphine milligram equivalents (MME) per encounter per month, MME per opioid prescription, and rate of opioid prescriptions (opioid prescriptions per encounter per month).

RESULTS

More than 44 000 clinical encounters per month were recorded. All baseline trends were not significantly different from 0. Total health system MME per encounter decreased 1.0 MME per encounter per month. At the end of the postintervention observation period, the monthly MME per encounter was 58% lower than the average of the 6-month baseline, the MME per opioid prescription per month was 34% less than the average of the baseline, and the opioid prescription rate was 38% lower than the average of the baseline.

CONCLUSIONS AND RELEVANCE

Opioid overprescribing was reduced with multifocal interventions targeting patient and public demand, creating prescriber awareness and accountability, and creating tools for clinical leadership accountability. The interventions described are adoptable by most organized health systems. Reducing total opioid supply within communities should be given high priority by those with a mission to protect and improve public health.

Systematic Review and Meta-analysis of the Effectiveness of Implementation Strategies for Non-communicable Disease Guidelines in Primary Health Care

BACKGROUND

As clinical practice guidelines represent the most important evidence-based decision support tool, several strategies have been applied to improve their implementation into the primary health care system. This study aimed to evaluate the effect of intervention methods on the guideline adherence of primary care providers (PCPs).

METHODS

The studies selected through a systematic search in Medline and Embase were categorised according to intervention schemes and outcome indicator categories. Harvest plots and forest plots were applied to integrate results.

RESULTS

The 36 studies covered six intervention schemes, with single interventions being the most effective and distribution of materials the least. The harvest plot displayed 27 groups having no effect, 14 a moderate and 21 a strong effect on the outcome indicators in the categories of knowledge transfer, diagnostic behaviour, prescription, counselling and patient-level results. The forest plot revealed a moderate overall effect size of 0.22 [0.15, 0.29] where single interventions were more effective (0.27 [0.17, 0.38]) than multifaceted interventions (0.13 [0.06, 0.19]).

DISCUSSION

Guideline implementation strategies are heterogeneous. Reducing the complexity of strategies and tailoring to the local conditions and PCPs' needs may improve implementation and clinical practice.

Enhancing system-wide implementation of opioid prescribing guidelines in primary care: protocol for a stepped-wedge quality improvement project

Background

Systematic implementation of guidelines for opioid therapy management in chronic non-cancer pain can reduce opioid-related harms. However, implementation of guideline-recommended practices in routine care is subpar. The goal of this quality improvement (QI) project is to assess whether a clinic-tailored QI intervention improves the implementation of a health system-wide, guideline-driven policy on opioid prescribing in primary care. This manuscript describes the protocol for this QI project.

Methods

A health system with 28 primary care clinics caring for approximately 294,000 primary care patients developed and implemented a guideline-driven policy on long-term opioid therapy in adults with opioid-treated chronic non-cancer pain (estimated N = 3980). The policy provided multiple recommendations, including the universal use of treatment agreements, urine drug testing, depression and opioid misuse risk screening, and standardized documentation of the chronic pain diagnosis and treatment plan. The project team drew upon existing guidelines, feedback from end-users, experts and health system leadership to develop a robust QI intervention, targeting clinic-level implementation of policy-directed practices. The resulting multi-pronged QI intervention included clinic-wide and individual clinician-level educational interventions. The QI intervention will augment the health system’s “routine rollout” method, consisting of a single educational presentation to clinicians in group settings and a separate presentation for staff. A stepped-wedge design will enable 9 primary care clinics to receive the intervention and assessment of within-clinic and between-clinic changes in adherence to the policy items measured by clinic-level electronic health record-based measures and process measures of the experience with the intervention.

Discussion

Developing methods for a health system-tailored QI intervention required a multi-step process to incorporate end-user feedback and account for the needs of targeted clinic team members. Delivery of such tailored QI interventions has the potential to enhance uptake of opioid therapy management policies in primary care. Results from this study are anticipated to elucidate the relative value of such QI activities.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3227-2) contains supplementary material, which is available to authorized users.