Organizational changes lead to a reduction in opioid consumption among chronic pain patients: A systematic review

Nina Bache, MRHL, RN; Anja Geisler, PhD, CRRN

doi:10.5055/jom.2022.0707

Authors

Nina Bache, MRHL, RN
Anja Geisler, PhD, CRRN https://orcid.org/0000-0002-2461-2672

DOI:

https://doi.org/10.5055/jom.2022.0707

Keywords:

pain, opioid, follow-up

Abstract

Objective: To investigate the literature in terms of describing new ways to organize pain treatment for patients with chronic nonmalignant pain and the effect on opioid consumption.

Design: A systematic literature search was conducted in PubMed, CINAHL, REHABDATA, PsycINFO, and EMBASE using the methodology recommended by Cochrane. The data extraction was performed by Population, Intervention, Comparison, Outcome, and Time frame. The quality of the studies was rated by the Study Quality Assessment Tool or the revised Standards for Quality Improvement Reporting Excellence when suitable.

Setting: Primary care clinics.

Patients/participants: Patients with chronic nonmalignant pain in high-dose opioid treatment connected to a primary care clinic or the employed healthcare professionals.

Main outcome measures: The primary aim of this Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review was to investigate if an organizational change in the follow-up procedures has an effect on high-dose opioid consumption in patients with long-term nonmalignant pain.

Results: Out of 2,146 articles, 11 studies met the inclusion criteria, mainly of an observational character. The majority of the studies were rated as good quality studies. As for the risk of bias, five studies were rated unclear, one study rated as high risk, and four studies as low risk of bias. One study could not be rated. All studies demonstrated a reduction in opioid consumption. Two studies investigated patients’ pain and quality of life, but no reduction was found between groups.

Conclusion: The findings indicate that it is possible to detect a reduction in opioid consumption when a new follow-up procedure has been implemented.

Author Biographies

Nina Bache, MRHL, RN

Head of Ward, The Multidisciplinary Pain Center, Zealand University Hospital, Køge, Denmark

Anja Geisler, PhD, CRRN

Head of Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark

References

Sjøgren P, Jensen NH, Opioider I: Praktisk Klinisk Smertebehandling: smerter Ved Cancer og Kroniske Ikke-Maligne Tilstande [Book chapter]. 5th ed. Denmark: Munksgaard, 2009: 122-147.

Staehelin Jensen T, Dahl JB, Arendt-Nielsen L: Smerter: Baggrund, Evidens og Behandling [Book chapter]. 4th ed. Nota: FADL's Forlag, 2014: 419.

Uhrbrand P, Simoni AH, Olesen AE, et al.: Opioid dependency as complication after surgery. Ugeskr Laeger. 2018; 31: 180.

Karmali RN, Bush C, Raman SR, et al.: Long-term opioid therapy definitions and predictors: A systematic review. Pharmacoepidemiol Drug Saf. 2020; 29(3): 252-269.

Chou R, Turner JA, Devine EB, et al.: The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a national institutes of health pathways to prevention workshop. Ann Intern Med. 2015; 162(4): 276-286.

Kidner CL, Mayer TG, Gatchel RJ: Higher opioid doses predict poorer functional outcome in patients with chronic disabling occupational musculoskeletal disorders. J Bone Jt Surg Am. 2009; 91(4): 919-927.

WHO; Dependence syndrome [Internet]. 2018. Available at https://www.who.int/substance_abuse/terminology/definition1/en/. Accessed May 1, 2020.

Birke H, Ekholm O, Sjogren P, et al.: Long-term opioid therapy in Denmark: A disappointing journey. Eur J Pain. 2017; 21(9): 1516-1527.

Schieber LZ, Guy GP, Seth P, et al.: Trends and patterns of geographic variation in opioid prescribing practices by state, United States, 2006-2017. JAMA Netw Open. 2019; 2(3): e190665.

Danish Health Organization: Mapping the opioid consumption in Denmark: With a focus on patients with non-malignant pain [Internet]. Sundhedsstyrelsen. 2016. Available in Danish at https://www.sst.dk/da/Feeds/~/media/69913B827BAA4850A9A70E0CF76CB305.ashx. Accessed May 1, 2020.

Dowell D, Haegerich TM, Chou R: CDC guideline for prescribing opioids for chronic pain—United States. JAMA. 2016; 315(15): 1624-1645.

Danish Health Organization: Focus on pain treatment [Internet]. 2018. Available in Danish at https://www.sst.dk/da/rationel-farmakoterapi/smerteindsats. Accessed May 1, 2020.

Danish Health Organization: Opioid treatment for chronic non-malignant pain: National clinical guideline. 2018. Available in Danish at https://www.sst.dk/-/media/Udgivelser/2018/NKRopioid/301440-Quick-Guide-NKR-opioidbehandling.ashx?la=da&hash=5CFC2E187940D9BD4D1AAD4780045E8BBBB0C701. Accessed December 31, 2019.

Burnes B: Managing Change: A Strategic Approach to Organisational Dynamics. 5th ed. Harlow: Financial Times Prentice Hall, 2009: xii, 620.

Moher D, Liberati A, Tetzlaff J, PRISMA Group, et al.: Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. J Clin Epidemiol. 2009; 62(10): 1006-1012.

Page MJ, McKenzie JE, Bossuyt PM, et al.: The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021; 372: N1.

Whittemore R, Knafl K: The integrative review: Updated methodology. J Adv Nurs. 2005; 52(5): 546-553.

Study Quality Assessment Tools | National Heart, Lung, and Blood Institute (NHLBI) [Internet 2021]. Available at https://www.nhlbi.nih.gov/health-topics/study-quality-assessmenttools. Accessed May 1, 2020.

Ogrinc G, Davies L, Goodman D, et al.: SQUIRE 2.0 (standards for QUality improvement reporting excellence): Revised publication guidelines from a detailed consensus process. BMJ Qual Saf. 2016; 25(12): 986-992.

CLARITY Group at McMaster University: Tools to assess risk of bias in cohort and case control studies; randomized controlled trials; and longitudinal symptom research studies aimed at the general population. 2013. Available at http://www.evidencepartners.com/resources/. Accessed December 6, 2020.

Higgins JPT, Altman DG, Gøtzsche PC, et al.: The Cochrane collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011; 343: D5928-D5928.

Weimer MB, Hartung DM, Ahmed S, et al.: A chronic opioid therapy dose reduction policy in primary care. Subst Abus. 2016; 37(1): 141-147.

Dorflinger L, Moore B, Goulet J, et al.: A partnered approach to opioid management, guideline concordant care and the stepped care model of pain management. J Gen Intern Med. 2014; 29(Suppl. 4): 870-876.

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

Von Korff M, Dublin S, Walker RL, et al.: The impact of opioid risk reduction initiatives on high-dose opioid prescribing for patients on chronic opioid therapy. J Pain. 2016; 17(1): 101-110.

Gernant SA, Bastien R, Lai A: Development and evaluation of a multidisciplinary controlled substances committee within a patient-centered medical home. J Am Pharm Assoc. 2015; 55(6): 656-663.

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.

Austin RC, Wilson FC, Fagan EB, et al.: Teaching opioid tapering through guided instruction. Fam Med. 2019; 51(5): 434-437.

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.

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.

Quanbeck A, Brown RT, Zgierska AE, et al.: A randomized matched-pairs study of feasibility, acceptability, and effectiveness of systems consultation: A novel implementation strategy for adopting clinical guidelines for opioid prescribing in primary care. Implement Sci. 2018; 13(1): 21.

Parchman ML, Penfold RB, Ike B, et al.: Team-based clinic redesign of opioid medication management in primary care: Effect on opioid prescribing. Ann Fam Med. 2019; 717(4): 319-325.

Fischer F, Lange K, Klose K, et al.: Barriers and strategies in guideline implementation—A scoping review. Healthc Basel Switz. 2016; 4(3): 36.

Ploeg J, Davies B, Edwards N, et al.: Factors influencing best-practice guideline implementation: Lessons learned from administrators, nursing staff, and project leaders. Worldviews Evid Based Nurs. 2007; 4(4): 210-219.

Kwan BM, Sills MR, Graham D, et al.: Stakeholder engagement in a patient-reported outcomes (PRO) measure implementation: A report from the SAFTINet practice-based research network (PBRN). J Am Board Fam Med. 2016; 29(1): 102-115.

Uic AS, Bastons M, Sotok P, et al.: Purpose-driven organizations: Management ideas for a better world [Internet]. 2019. Palgrave Macmillan. Available at https://www.palgrave.com/gp/book/9783030176730. Accessed September 10, 2020.

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.

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

Ekholm O, Kurita GP, Højsted J, et al.: Chronic pain, opioid prescriptions, and mortality in Denmark: A population-based cohort study. Pain. 2014; 155(12): 2486-2490.

Elwyn G, Frosch D, Thomson R, et al.: Shared decision making: A model for clinical practice. J Gen Intern Med. 2012; 27(10): 1361-1367.

Pergolizzi JV, Varrassi G, Paladini A, et al.: Stopping or decreasing opioid therapy in patients on chronic opioid therapy. Pain Ther. 2019; 8(2): 163-176.

Manhapra A, Arias AJ, Ballantyne JC: The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary. Subst Abus. 2018; 39(2): 152-161.

Poeran J, Memtsoudis SG: Chronic opioid use and long-term mortality: A global problem. Br J Anaesth. 2020; 124(1): 17-19.

Skolnick P: The opioid epidemic: Crisis and solutions. Annu Rev Pharmacol Toxicol. 2018; 658: 143-159.