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

Kristin T. L. Huang, MD, Deborah Blazey-Martin, MD, MPH, Daniel Chandler, MD, Alysse Wurcel, MD, MS, Joseph Gillis, BA, Julie Tishler, MD


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 risk-stratified 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.


chronic opioid management, primary care, electronic health record (EHR)

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Levy B, Paulozzi L, Mack KA, et al.: Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007-2012. Am J Prev Med. 2015; 49(3): 409-413.

Paulozzi LJ, Jones CM, Mack KA, et al.: Vital signs: Overdoses of prescription opioid pain relievers–United States, 1999-2008. Morb Mortal Wkly Rep. 2011; 60(43): 1487-1492.

National Institute on Drug Abuse: Overdose death rates. Available at Updated August 2018. Accessed November 24, 2018.

Dowell D, Haegerich TM, Chou R: CDC guideline for prescribing opioids for chronic pain–United States, 2016. MMWR Recomm Rep. 2016; 65(1): 1-49.

Chou R, Fanciullo GJ, Fine PG, et al.: American Pain Society- American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10(2): 113-130.

Salinas GD, Susalka D, Burton BS, et al.: Risk assessment and counseling behaviors of healthcare professionals managing patients with chronic pain: A national multifaceted assessment of physicians, pharmacists, and their patients. J Opioid Manag. 2012; 8(5): 273-284.

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. 2011; 26(9): 958-964.

Kay C, Wozniak E, Koller S, et al.: Adherence to chronic opioid therapy prescribing guidelines in a primary care clinic. J Opioid Manag. 2016; 12(5): 333-345.

Krebs EE, Ramsey DC, Miloshoff JM, et al.: Primary care monitoring of long-term opioid therapy among veterans with chronic pain. Pain Med. 2011; 12(5): 740-746.

Lange A, Lasser KE, Xuan Z, et al.: Variability in opioid prescription monitoring and evidence of aberrant medication taking behaviors in urban safety-net clinics. Pain. 2015; 156(2): 335-340.

Lewis M, Herndon CM, Chibnall JT: Patient aberrant drug taking behaviors in a large family medicine residency program: A retrospective chart review of screening practices, incidence, and predictors. J Opioid Manag. 2014; 10(3): 169-175.

Chen JH, Hom J, Richman I, et al.: Effect of opioid prescribing guidelines in primary care. Medicine (Baltimore). 2016; 95(35): e4760.

Corson K, Doak MN, Denneson L, et al.: Primary care clinician adherence to guidelines for the management of chronic musculoskeletal pain: Results from the study of the effectiveness of a collaborative approach to pain. Pain Med. 2011; 12(10): 1490-1501.

Khodaee M, Deffenbacher B: A look at the burden of opioid management in primary care. J Fam Pract. 2016; 65(12): E1-E6.

Lin DH, Lucas E, Murimi IB, et al.: Physician attitudes and experiences with Maryland’s prescription drug monitoring program (PDMP). Addiction. 2017; 112(2): 311-319.

Rutkow L, Turner L, Lucas E, et al.: Most primary care physicians are aware of prescription drug monitoring programs, but many find the data difficult to access. Health Aff (Millwood). 2015; 34(3): 484-492.

Irvine JM, Hallvik SE, Hildebran C, et al.: Who uses a prescription drug monitoring program and how?. Insights from a statewide survey of Oregon clinicians. J Pain. 2014; 15(7): 747-755.

Hariharan J, Lamb GC, Neuner JM: Long-term opioid contract use for chronic pain management in primary care practice. A five year experience. J Gen Intern Med. 2007; 22(4): 485-490.

Porucznik CA, Johnson EM, Rolfs RT, et al.: Opioid prescribing knowledge and practices: Provider survey following promulgation of guidelines–Utah, 2011. J Opioid Manag. 2013; 9(3): 217-224.

Liebschutz JM, Xuan Z, Shanahan CW, et al.: Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: A cluster-randomized clinical trial. JAMA Intern Med. 2017; 177(9): 1265-1272.

Li RM, Franks RH, Dimmitt SG, et al.: Ideas and innovations: Inclusion of pharmacists in chronic pain management services in a primary care practice. J Opioid Manag. 2011; 7(6): 484-487.

Jacobs SC, Son EK, Tat C, et al.: Implementing an opioid risk assessment telephone clinic: Outcomes from a pharmacist-led initiative in a large Veterans Health Administration primary care clinic, December 15, 2014-March 31, 2015. Subst Abus. 2016; 37(1): 15-19.

Wiedemer NL, Harden PS, Arndt IO, et al.: The opioid renewal clinic: A primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Med. 2007; 8(7): 573-584.

Anderson D, Zlateva I, Khatri K, et al.: Using health information technology to improve adherence to opioid prescribing guidelines in primary care. Clin J Pain. 2015; 31(6): 573-579.

Jamison RN, Scanlan E, Matthews ML, et al.: Attitudes of primary care practitioners in managing chronic pain patients prescribed opioids for pain: A prospective longitudinal controlled trial. Pain Med. 2016; 17(1): 99-113.

Lin LA, Bohnert ASB, Kerns RD, et al.: Impact of the opioid safety initiative on opioid-related prescribing in veterans. Pain. 2017; 158(5): 833-839.

Penti B, Liebschutz JM, Kopcza B, et al.: Novel peer review method for improving controlled substance prescribing in primary care. J Opioid Manag. 2016; 12(4): 269-279.

Webster LR, Webster RM: Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool. Pain Med. 2005; 6(6): 432-442.

Butler SF, Budman SH, Fernandez KC, et al.: Development and validation of the current opioid misuse measure. Pain. 2007; 130(1-2): 144-156.

Bohnert ASB, Logan JE, Ganoczy D, et al.: A detailed exploration into the association of prescribed opioid dosage and prescription opioid overdose deaths among patients with chronic pain. Med Care. 2016; 54(5): 435-441.

Bohnert AS, Valenstein M, Bair MJ, et al.: Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011; 305(13): 1315-1321.

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.

Gomes T, Mamdani MM, Dhalla IA, et al.: Opioid dose and drug-related mortality in patients with nonmalignant pain. Ann Intern Med. 2011; 171(7): 686-691.

Lasser KE, Shanahan C, Parker V, et al.: A multicomponent intervention to improve primary care provider adherence to chronic opioid therapy guidelines and reduce opioids misuse: A cluster randomized controlled trial protocol. J Subst Abuse Treat. 2016; 60: 101-109.

Thakral M, Walker RL, Saunders K, et al.: Impact of opioid dose reduction and risk mitigation initiatives on chronic opioid therapy patients at higher risk for opioid-related adverse outcomes. Pain Med. 2018; 19(12): 2450-2458.

Losby JL, Hyatt JD, Kanter MH, et al.: Safer and more appropriate opioid prescribing: A large healthcare system’s comprehensive approach. J Eval Clin Pract. 2017; 23(6): 1173-1179.

Parchman ML, Von Korff M, Baldwin LM, et al.: Primary care clinic re-design for prescription opioid management. J Am Board Fam Med. 2017; 30(1): 44-51.



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